Tuning the mechanical impedance of disordered networks for impact mitigation.

Disordered-Network Mechanical Materials (DNMM), comprised of random arrangements of bonds and nodes, have emerged as mechanical metamaterials with the potential for achieving fine control over their mechanical properties. Recent computational studies have demonstrated this control whereby an extremely high degree of mechanical tunability can be achieved in disordered networks via a selective bond removal process called pruning. In this study, we experimentally demonstrate how pruning of a disordered network alters its macroscopic dynamic mechanical response and its capacity to mitigate impact. Impact studies with velocities ranging from 0.1 m s-1 to 1.5 m s-1 were performed, using a mechanical impactor and a drop tower, on 3D printed pruned and unpruned networks comprised of materials spanning a range of stiffness. High-speed videography was used to quantify the changes in Poisson's ratio for each of the network samples. Our results demonstrate that pruning is an efficient way to reduce the transmitted force and impulse from impact in the medium strain rate regime (101 s-1 to 102 s-1). This approach provides an interesting alternative route for designing materials with tailored impact mitigating properties compared to random material removal based on open cell foams.

Auxetic metamaterials from disordered networks.

Recent theoretical work suggests that systematic pruning of disordered networks consisting of nodes connected by springs can lead to materials that exhibit a host of unusual mechanical properties. In particular, global properties such as Poisson's ratio or local responses related to deformation can be precisely altered. Tunable mechanical responses would be useful in areas ranging from impact mitigation to robotics and, more generally, for creation of metamaterials with engineered properties. However, experimental attempts to create auxetic materials based on pruning-based theoretical ideas have not been successful. Here we introduce a more realistic model of the networks, which incorporates angle-bending forces and the appropriate experimental boundary conditions. A sequential pruning strategy of select bonds in this model is then devised and implemented that enables engineering of specific mechanical behaviors upon deformation, both in the linear and in the nonlinear regimes. In particular, it is shown that Poisson's ratio can be tuned to arbitrary values. The model and concepts discussed here are validated by preparing physical realizations of the networks designed in this manner, which are produced by laser cutting 2D sheets and are found to behave as predicted. Furthermore, by relying on optimization algorithms, we exploit the networks' susceptibility to tuning to design networks that possess a distribution of stiffer and more compliant bonds and whose auxetic behavior is even greater than that of homogeneous networks. Taken together, the findings reported here serve to establish that pruned networks represent a promising platform for the creation of unique mechanical metamaterials.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

BACKGROUND: Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. METHODS: Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. RESULTS: Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. CONCLUSIONS: Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty?

BACKGROUND: In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear. QUESTIONS/PURPOSES: (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively? METHODS: Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance. RESULTS: After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066). CONCLUSIONS: The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively. LEVEL OF EVIDENCE: Level III, therapeutic study.

Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy.

PURPOSE: To determine the effect prescription-limiting legislation passed in Rhode Island has had on opioids prescribed following arthroscopic knee and shoulder surgery at various time points, up to 90 days postoperatively. METHODS: All patients undergoing the 3 most common arthroscopic procedures at our institution (anterior cruciate ligament reconstruction, partial meniscectomy, and rotator cuff repair) were included. Patients were selected from 2 6-month study periods (prepassage and postimplementation of the law). The state's Prescription Drug Monitoring Program database was queried for controlled substances filled in the perioperative period (from 30 days preoperatively to 90 days postoperatively). Multiple logistic regressions were used to identify predictors of chronic (>30 days) opioid use. RESULTS: The morphine milligram equivalents (MMEs) prescribed in the initial postoperative script decreased from 319.04 (∼43 5-mg oxycodone tablets) in the prepassage to 152.45 MMEs (∼20 5-mg oxycodone tablets) in the postimplementation group (P < .001). The total MMEs filled in the first 30 days decreased from 520.93 to 299.94 MMEs (∼70 to ∼40 5-mg oxycodone tablets) (P < .001). MMEs filled between 30 and 90 days fell by 22.5% for all patients in this study; however, this change was not statistically significant (P = .263). Preoperative opioid use (odds ratio, 10.85; P < .001) and preoperative benzodiazepine use (odds ratio, 2.13; P = .005) predicted chronic opioid use postoperatively. CONCLUSIONS: State opioid-limiting legislation reduced cumulative MMEs following arthroscopic knee and shoulder surgery in the first 30 days. Further research assessing the impact of this legislation on postoperative pain control, patient satisfaction, and functional outcomes following surgery is warranted. LEVEL OF EVIDENCE: Level III, case-control study.

Risk of Revision Shoulder Surgery, Complications, and Prolonged Opioid Use in Patients Undergoing Shoulder Arthroscopy Who Have Previously Undergone Anterior Cervical Discectomy and Fusion.

PURPOSE: To compare postoperative complications, rates of revision, and opioid use of those who undergo shoulder arthroscopy with and without previous anterior cervical discectomy and fusion (ACDF). METHODS: The PearlDiver database from 2007 to 2017 was used to query all patients who underwent shoulder arthroscopy as determined by Current Procedural Terminology (CPT). Patients were then separated among those who had a previous instance of ACDF and those who did not as filtered by CPT. Postoperative complications within 30 days, readmission rates, opioid use, and revision procedures were assessed for each cohort using a mix of International Classification of Diseases Ninth and Tenth Revision Clinical Modification codes, CPT, as well as generic drug codes. RESULTS: A total of 91,029 patients undergoing shoulder arthroscopy were identified, of whom 1,267 (1.4%) had a history of ACDF. Compared with patients without previous ACDF, patients with a history of ACDF had significantly greater respiratory complication rates (1.3% vs 0.5%: adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI]1.30-3.59, P = .003), 30-day complication rates (3.7% vs 2.2%: aOR 1.48, 95% CI 1.10-1.99, P = .011), 1-year revision rates (15.2% vs 7.7%: aOR 2.00, 95% CI 1.71-2.33, P < .0001), and greater opioid use at 1 month, 3 months, 6 months, and 12 months (P < .0001). CONCLUSIONS: This study revealed that patients who undergo shoulder arthroscopy with a history of ACDF are twice as likely to undergo revision arthroscopy within 2 years of surgery and are at an increased risk of complications within 30 days postoperatively as well as prolonged opioid use compared with those without a history of ACDF. With these findings, both spine and shoulder surgeons should aim to be more aware of surgical history, especially of the cervical spine, to better counsel patients' clinical course and expected outcomes following shoulder arthroscopy. LEVEL OF EVIDENCE: III, retrospective cohort study.

Ideal isotropic auxetic networks from random networks.

Auxetic materials are characterized by a negative Poisson's ratio, ν. As the Poisson's ratio approaches the lower isotropic mechanical limit of ν = -1, materials show enhanced resistance to impact and shear, making them suitable for applications ranging from robotics to impact mitigation. Past experimental efforts aimed at reaching the ν = -1 limit have resulted in highly anisotropic materials, which show a negative Poisson's ratio only when subjected to deformations along specific directions. Isotropic designs have only attained moderately auxetic behavior or have led to solutions that cannot be manufactured in 3D. Here, we present a design strategy to create isotropic structures from disordered networks, which result in Poisson's ratios as low as ν = -0.98. The materials conceived through this approach are successfully fabricated in the laboratory and behave as predicted. ν depends on network structure and bond strengths; this sheds light on the motifs which lead to auxetic behavior. The ideas introduced here can be generalized to 3D, a wide range of materials, and a spectrum of length scales, thereby providing a general platform that could impact technology.

Solvent Treatment of Wet-Spun PEDOT: PSS Fibers for Fiber-Based Wearable pH Sensing.

There is a growing desire for wearable sensors in health applications. Fibers are inherently flexible and as such can be used as the electrodes of flexible sensors. Fiber-based electrodes are an ideal format to allow incorporation into fabrics and clothing and for use in wearable devices. Electrically conducting fibers were produced from a dispersion of poly (3,4-ethylenedioxythiophene)-poly (styrenesulfonate) (PEDOT: PSS). Fibers were wet spun from two PEDOT: PSS sources, in three fiber diameters. The effect of three different chemical treatments on the fibers were investigated and compared. Short 5 min treatment times with dimethyl sulfoxide (DMSO) on 20 µm fibers produced from Clevios PH1000 were found to produce the best overall treatment. Up to a six-fold increase in electrical conductivity was achieved, reaching 800 S cm-1, with no loss of mechanical strength (150 MPa). With a pH-sensitive polyaniline coating, these fibers displayed a Nernstian response across a pH range of 3.0 to 7.0, which covers the physiologically critical pH range for skin. These results provide opportunities for future wearable, fiber-based sensors including real-time, on-body pH sensing to monitor skin disease.

SSAGES: Software Suite for Advanced General Ensemble Simulations.

Molecular simulation has emerged as an essential tool for modern-day research, but obtaining proper results and making reliable conclusions from simulations requires adequate sampling of the system under consideration. To this end, a variety of methods exist in the literature that can enhance sampling considerably, and increasingly sophisticated, effective algorithms continue to be developed at a rapid pace. Implementation of these techniques, however, can be challenging for experts and non-experts alike. There is a clear need for software that provides rapid, reliable, and easy access to a wide range of advanced sampling methods and that facilitates implementation of new techniques as they emerge. Here we present SSAGES, a publicly available Software Suite for Advanced General Ensemble Simulations designed to interface with multiple widely used molecular dynamics simulations packages. SSAGES allows facile application of a variety of enhanced sampling techniques-including adaptive biasing force, string methods, and forward flux sampling-that extract meaningful free energy and transition path data from all-atom and coarse-grained simulations. A noteworthy feature of SSAGES is a user-friendly framework that facilitates further development and implementation of new methods and collective variables. In this work, the use of SSAGES is illustrated in the context of simple representative applications involving distinct methods and different collective variables that are available in the current release of the suite. The code may be found at: https://github.com/MICCoM/SSAGES-public.

Pediatric Orthopedic Hoverboard Injuries: A Prospectively Enrolled Cohort.

Hoverboards pose a significant risk of musculoskeletal injury to pediatric riders. A prospectively enrolled cohort yielded 9 pediatric patients injured while riding hoverboards in 2016. Eight of the injuries involved the upper extremity, and one involved the lower extremity. No riders wore any safety equipment and injury patterns modeled those seen in skateboard riders.

Inherent structure energy is a good indicator of molecular mobility in glasses.

Glasses produced via physical vapor deposition can display greater kinetic stability and lower enthalpy than glasses prepared by liquid cooling. While the reduced enthalpy has often been used as a measure of the stability, it is not obvious whether dynamic measures of stability provide the same view. Here, we study dynamics in vapor-deposited and liquid-cooled glass films using molecular simulations of a bead-spring polymer model as well as a Lennard-Jones binary mixture in two and three dimensions. We confirm that the dynamics in vapor-deposited glasses is indeed slower than in ordinary glasses. We further show that the inherent structure energy is a good reporter of local dynamics, and that aged systems and glasses prepared by cooling at progressively slower rates exhibit the same behavior as vapor-deposited materials when they both have the same inherent structure energy. These findings suggest that the stability inferred from measurements of the energy is also manifested in dynamic observables, and they strengthen the view that vapor deposition processes provide an effective strategy for creation of stable glasses.

Planarity and multiple components promote organic photovoltaic efficiency by improving electronic transport.

Establishing how the conformation of organic photovoltaic (OPV) polymers affects their electronic and transport properties is critical in order to determine design rules for new OPV materials and in particular to understand the performance enhancements recently reported for ternary blends. We report coupled classical and ab initio molecular dynamics simulations showing that polymer linkage twisting significantly reduces optical absorption efficiency, as well as hole transport rates in donor polymers. We predict that blends with components favoring planar geometries contribute to the enhancement of the overall efficiency of ternary OPVs. Furthermore, our electronic structure calculations for the PTB7-PID2-PC71BM system show that hole transfer rates are enhanced in ternary blends with respect to their binary counterpart. Finally, our results point at thermal disorder in the blend as a key reason responsible for device voltage losses and at the need to carry out electronic structure calculations at finite temperature to reliably compare with experiments.

Patient Perspectives on EMS Alternate Destination Models.

INTRODUCTION: Studies have shown that a large number of ambulance transports to emergency departments (ED) could have been safely treated in an alternative environment, prompting interest in the development of more patient-centered models for prehospital care. We examined patient attitudes, perspectives, and agreement/comfort with alternate destinations and other proposed innovations in Emergency Medical Services (EMS) care delivery and determined whether demographic, socioeconomic, acuity, and EMS utilization history factors impact levels of agreement. METHODS: We conducted a cross-sectional study on a convenience sample of patients and caregivers presenting to an urban academic ED between July 2012 and May 2013. Respondents were surveyed on levels of agreement with 13 statements corresponding to various aspects of a proposed patient-centered emergency response system including increased EMS access to healthcare records, shared decision making with the patient and/or primary care physician, transport to alternative destinations, and relative importance of EMS assessment versus transportation. Information on demographic and socioeconomic factors, level of acuity, and EMS utilization history were also determined via survey and chart review. Responses were analyzed descriptively and compared across patient characteristics using chi-square and regression analyses. RESULTS: A total of 621 patients were enrolled. The percentage of patients who agreed or strongly agreed with each of the 13 statements ranged from 48.2 to 93.8%. About 86% agreed with increased EMS access to healthcare records; approximately 72% agreed with coordinating disposition decisions with a primary physician; and about 58% supported transport to alternative destinations for low acuity conditions. No association was found between levels of agreement and the patient's level of acuity or EMS utilization history. Only Black or Hispanic race showed isolated associations with lower rates of agreement with some aspects of an innovative EMS care delivery model. CONCLUSION: A substantial proportion of patients surveyed in this cross sectional study agreed with a more patient-centered approach to prehospital care where a 9-1-1 call could be met with a variety of treatment and transportation options. Agreement was relatively consistent among a diverse group of patients with varying demographics, levels of acuity and EMS utilization history. MeSH Key words: emergency medical services; triage; telemedicine; surveys and questionnaires; transportation of patients.

Predicting MSSA in Acute Hematogenous Osteomyelitis in a Setting With MRSA Prevalence.

BACKGROUND: Increased severity of illness in patient with acute hematogenous osteomyelitis (AHO) with methicillin-resistant Staphylococcus aureus (MRSA) necessitates prompt intervention, but overtreatment of methicillin-sensitive S. aureus (MSSA) may contribute to antibiotic resistance. Therefore, predicting methicillin sensitivity in suspected AHO is desirable. A previously published prediction algorithm has not performed well in settings with high prevalence of MRSA. We sought to develop a predictive equation using presenting factors to predict MRSA in our patient population with a predominance of MRSA. METHODS: A retrospective chart review was performed. Consecutive cases of AHO with positive blood or bone cultures were identified at a single children's hospital. Presenting features were recorded including duration of symptoms, weight-bearing, prior antibiotic use, vital signs, complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Univariate comparison was made between the groups with MRSA and MSSA. Continuous variables were compared with t tests and discrete variables were compared using the Fischer exact test. Logistic regression was performed using a forward stepwise regression to develop a model to predict MRSA. RESULTS: A total of 68 patients formed the study group, and 60% had MRSA (41 MRSA, 27 MSSA). Temperature, respiratory rate, heart rate, white blood cell count, absolute neutrophil count (ANC), ESR), and CRP were significantly higher in MRSA cases, whereas platelets were lower. Logistic regression resulted in a model utilizing temperature, ANC, and CRP. This model correctly predicted 87% of cases (92% of MRSA and 79% of MSSA) with an area under the curve of 0.919±0.035 with a 95% confidence interval of 0.851, 0.987. CONCLUSION: A logistic regression model incorporating temperature, ANC, and CRP correctly predicts methicillin resistance of S. aureus in 87% of cases. The model differs from one developed at an institution with a low rate of MRSA. Prediction of MRSA could help direct antibiotic management, whereas prediction of MSSA could help prevent overuse of antibiotics directed against MRSA. LEVEL OF EVIDENCE: Diagnostic study level IV.

Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover.

OBJECTIVE: To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. METHODS: Department heads were invited to complete a questionnaire about departmental discharge summary practices. RESULTS: Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. CONCLUSIONS: The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation's practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice.

Managing facility risk: external threats and health care organizations.

Clinicians and clinical administrators should have a basic understanding of physical and financial risk to mental health facilities related to external physical threat, including actions usually viewed as "terrorism" and much more common sources of violence. This article refers to threats from mentally ill persons and those acting out of bizarre or misguided "revenge," extortionists and other outright criminals, and perpetrators usually identified as domestic or international terrorists. The principles apply both to relatively small and contained acts (such as a patient or ex-patient attacking a staff member) and to much larger events (such as bombings and armed attack), and are relevant to facilities both within and outside the U.S. Patient care and accessibility to mental health services rest not only on clinical skills, but also on a place to practice them and an organized system supported by staff, physical facilities, and funding. Clinicians who have some familiarity with the non-clinical requirements for care are in a position to support non-clinical staff in preventing care from being interrupted by external threats or events such as terrorist activity, and/or to serve at the interface of facility operations and direct clinical care. Readers should note that this article is an introduction to the topic and cannot address all local, state and national standards for hospital safety, or insurance providers' individual facility requirements.

Successful Fracture Healing for Femoral Neck Nonunion with Bone Marrow Aspirate Concentrate.

INTRODUCTION: Femoral neck fractures in the young patient require prompt anatomic reduction and stabilization to preserve the vascular supply to the femoral head and minimize future need for arthroplasty. Secondary to unique biomechanical and vascular considerations, these injuries are prone to nonunion. CASE REPORT: A 29-year-old male with a chronic femoral neck fracture nonunion who experienced successful fracture healing and symptom resolution following Bone Marrow Aspirate Concentrate (BMAC) administration. DISCUSSION: Femoral neck nonunion in young patients is a challenging problem with treatment strategies aimed at improving the biological and biomechanical fracture environment. While the use of both vascularized and nonvascularized bone grafting has shown promising results, they have high complication rates and substantial donor site morbidity. BMAC has demonstrated multiple uses throughout orthopedic surgery and may result in an improved fracture healing environment with minimal patient morbidity. CONCLUSION: The success of the BMAC procedure for this patient is promising and may be considered in similar patients, with or without revision internal fixation methods.

Is Opioid-Limiting Legislation Effective for Hand Surgery Patients?

BACKGROUND: The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. METHODS: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. RESULTS: A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. CONCLUSIONS: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.

Analysis of Patients' Online Reviews of Orthopaedic Surgeons.

INTRODUCTION: Physician rating websites (PRWs) are an increasingly popular interface between patient and surgeon. Despite the growing popularity of PRWs, little guidance exists for orthopaedic surgeons regarding online reviews. We analyzed online ratings and comments to provide a better understanding of patients' values and expectations so that surgeons can tailor their practice accordingly to enhance their clinical care and online reputation. METHODS: Three common PRWs (Vitals, HealthGrades, and RateMDs) were queried from January 1, 2006, to May 18, 2020. Publicly available ratings, both quantitative (1 to 5 stars) and qualitative (free text comments), were collected. Comments were qualitatively tabulated as having positive or negative assessments for categories including outcome, personality, staff, surgical skill, visit time, bedside manner, wait time, diagnosis, knowledge, treatment, and advanced practice providers and analyzed using chi square goodness of fit. Quantitative comparisons of star ratings were made across surgeon years in practice, sex, practice setting, and PRW and compared using chi square independence testing. RESULTS: In total, 81% of patient comments were found to have a positive assessment. Comments regarding outcome (P < 0.001), staff (P = 0.001), surgical skill (P < 0.001), or knowledge (P = 0.001) were more likely to be positive. Reviews regarding bedside manner (P < 0.001), wait time (P < 0.001), diagnosis (P < 0.001), treatment (P < 0.001), or advanced practice providers (P < 0.001) were more likely to be negative. Surgeon sex was not associated with a difference in quantitative ratings (P = 0.131), unlike practice setting (P < 0.001) and PRW (P < 0.001). DISCUSSION: PRWs are a growing interface between surgeon and patient with a considerable effect on surgeon marketability. This study reveals a statistical association between certain patient-centered medical practices and positive patient reviews. This emphasizes the importance of ensuring that high standards are maintained throughout a physician's practice of maintaining a constant awareness of the fundamentals for effective patient care and of taking care to curate a physician's online presence.

Next-generation SELEX identifies sequence and structural determinants of splicing factor binding in human pre-mRNA sequence.

Many splicing factors interact with both mRNA and pre-mRNA. The identification of these interactions has been greatly improved by the development of in vivo cross-linking immunoprecipitation. However, the output carries a strong sampling bias in favor of RNPs that form on more abundant RNA species like mRNA. We have developed a novel in vitro approach for surveying binding on pre-mRNA, without cross-linking or sampling bias. Briefly, this approach entails specifically designed oligonucleotide pools that tile through a pre-mRNA sequence. The pool is then partitioned into bound and unbound fractions, which are quantified by a two-color microarray. We applied this approach to locating splicing factor binding sites in and around approximately 4000 exons. We also quantified the effect of secondary structure on binding. The method is validated by the finding that U1snRNP binds at the 5' splice site (5'ss) with a specificity that is nearly identical to the splice donor motif. In agreement with prior reports, we also show that U1snRNP appears to have some affinity for intronic G triplets that are proximal to the 5'ss. Both U1snRNP and the polypyrimidine tract binding protein (PTB) avoid exonic binding, and the PTB binding map shows increased enrichment at the polypyrimidine tract. For PTB, we confirm polypyrimidine specificity and are also able to identify structural determinants of PTB binding. We detect multiple binding motifs enriched in the PTB bound fraction of oligonucleotides. These motif combinations augment binding in vitro and are also enriched in the vicinity of exons that have been determined to be in vivo targets of PTB.