Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Plasmonic enhancement of stability and brightness in organic light-emitting devices.

The field of plasmonics, which studies the resonant interactions of electromagnetic waves and free electrons in solid-state materials1, has yet to be put to large-scale commercial application2 owing to the large amount of loss that usually occurs in plasmonic materials3. Organic light-emitting devices (OLEDs)4-7 have been incorporated into billions of commercial products because of their good colour saturation, versatile form factor8 and low power consumption9, but could still be improved in terms of efficiency and stability. Although OLEDs incorporating organic phosphors achieve an internal charge-to-light conversion of unity10, their refractive index contrast reduces the observable fraction of photons outside the device to around 25 per cent11-13. Further, during OLED operation, a localized buildup of slow-decaying14 triplet excitons and charges15 gradually reduces the brightness of the device in a process called ageing16,17, which can result in 'burn-in' effects on the display. Simultaneously improving device efficiency and stability is of paramount importance for OLED technology. Here we demonstrate an OLED that uses the decay rate enhancement18 of a plasmonic system to increase device stability, while maintaining efficiency by incorporating a nanoparticle-based out-coupling scheme to extract energy from the plasmon mode. Using an archetypal phosphorescent emitter, we achieve a two-fold increase in operational stability at the same brightness as a reference conventional device while simultaneously extracting 16 per cent of the energy from the plasmon mode as light. Our approach to increasing OLED stability avoids material-specific designs19-22 and is applicable to all commercial OLEDs that are currently used for lighting panels, televisions and mobile displays.

Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014.

Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified. PURPOSE: To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time. METHODS: Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time. RESULTS: The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities. CONCLUSIONS: When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified.

Clinic follow-up of orthopaedic trauma patients during and after the post-surgical global period: a retrospective cohort study.

BACKGROUND: Insurance status is important as medical expenses may decrease the likelihood of follow-up after musculoskeletal trauma, especially for low-income populations. However, it is unknown what insurance factors are associated with follow-up care. In this study, we assessed the association between insurance plan benefits, the end of the post-surgical global period, and follow-up after musculoskeletal injury. METHODS: This is a retrospective cohort study of 394 patients with isolated extremity fractures who were treated at three level-I trauma centers over four months in 2018. Paired t-tests were utilized to assess the likelihood of follow-up in relation to the 90-day post-surgical global period. Regression analysis was used to assess factors associated with the likelihood of follow-up. Supervised machine learning algorithms were used to develop predictive models of follow-up after the post-surgical global period. RESULTS: Our final analysis included 328 patients. Likelihood of follow-up did not significantly change while within the post-surgical global period. When comparing follow-up within and outside of the post-surgical global period, there was a 20.1% decrease in follow-up between the 6-weeks and 6-month time points (68.3% versus 48.2%, respectively; p < 0.0001). Medicaid insurance compared to Medicare (OR 0.27, 95% confidence interval (CI) = [0.09, 0.84], p = 0.02) was a predictor of decreased likelihood of follow-up at 6-months post-operatively. CONCLUSIONS: Our study demonstrates a statistically significant decrease in follow-up for orthopaedic trauma patients after the post-surgical global period, particularly for patients with Medicaid or Private insurance.

Outcomes of fixation of Vancouver B periprosthetic fractures around cemented versus uncemented stems.

BACKGROUND: The incidence of periprosthetic femur fracture (PPFF) in the setting of total hip arthroplasty (THA) is steadily increasing. We seek to address whether there is a difference in outcomes between Vancouver B fracture types managed with ORIF when the original stem was a press-fit stem versus a cemented stem. METHODS: In this retrospective cohort study at a level 1 trauma center, we identified 136 patients over 65 years-of-age with Vancouver B-type fractures sustained between 2005 and 2019. Patients were treated by ORIF and had either cemented or press-fit stems prior to their injury. Outcomes were subsidence of the femoral implant, time to full weight bearing, rate of the hip implant revision, estimated blood loss (EBL), postoperative complications, and the one-year mortality rate. RESULTS: A total of 103 (75.7%) press-fit and 33 (24.3%) cemented patients were reviewed. Patient baseline characteristics, Vancouver fracture sub-types, and implant characteristics were not found to be significantly different between groups. The difference in subsidence rates, postoperative complications, and time to weight bearing were not significantly different between groups. EBL and one-year mortality rate were significantly higher in the cemented group. CONCLUSIONS: In geriatric patients with Vancouver B type periprosthetic fractures managed with ORIF, patients with an originally press fit stem may have lower mortality, lower estimated blood loss, and similar subsidence and hospital length of stays when compared to those with a cemented stem.

A longitudinal rat model for assessing postoperative recovery and bone healing following tibial osteotomy and plate fixation.

BACKGROUND: Rodent models are commonly employed to validate preclinical disease models through the evaluation of postoperative behavior and allodynia. Our study investigates the dynamic interplay between pain and functional recovery in the context of traumatic osteotomy and surgical repair. Specifically, we established a rat model of tibial osteotomy, followed by internal fixation using a 5-hole Y-plate with 4 screws, to explore the hypothesis that histological bone healing is closely associated with functional recovery. OBJECTIVE: Our primary objective was to assess the correlation between bone healing and functional outcomes in a rat model of tibial osteotomy and plate fixation. METHODS: Seventeen male Sprague-Dawley rats underwent a metaphyseal transverse osteotomy of the proximal tibia, simulating a fracture-like injury. The resultant bone defect was meticulously repaired by realigning and stabilizing the bone surfaces with the Y-plate. To comprehensively assess recovery and healing, we performed quantitative and qualitative evaluations at 2, 4, 6, and 8 weeks post-surgery. Evaluation methods included micro-CT imaging, X-ray analysis, and histological examination to monitor bone defect healing. Concurrently, we employed video recording and gait analysis to evaluate functional recovery, encompassing parameters such as temporal symmetry, hindlimb duty factor imbalance, phase dispersion, and toe spread. RESULTS: Our findings revealed complete healing of the bone defect at 8 weeks, as confirmed by micro-CT and histological assessments. Specifically, micro-CT data showed a decline in fracture volume over time, indicating progressive healing. Histological examination demonstrated the formation of new trabecular bone and the resolution of inflammation. Importantly, specific gait analysis parameters exhibited longitudinal changes consistent with bone healing. Hindlimb duty factor imbalance, hindlimb temporal symmetry, and phase dispersion correlated strongly with the healing process, emphasizing the direct link between bone healing and functional outcomes. CONCLUSIONS: The establishment of this tibia osteotomy model underscores the association between bone healing and functional outcomes, emphasizing the feasibility of monitoring postoperative recovery using endpoint measurements. Our overarching objective is to employ this model for assessing the local efficacy of drug delivery devices in ameliorating post-surgical pain and enhancing functional recovery.

Sociodemographic Factors and Intestinal Microbiome Development in Preterm, Very Low Birth Weight Infants.

OBJECTIVE: Preterm very low birth weight (VLBW) infants are at risk for intestinal morbidities and dysbiotic development of the intestinal microbiome. Despite the influence of sociodemographic factors on premature infant health outcomes, whether they shape the intestinal microbiome early in life is not clear. The objective was to explore the associations between race, sex, and socioeconomic status and the intestinal microbiome of VLBW infants during the first 4 weeks of life. STUDY DESIGN: This was a secondary analysis of data from an ongoing randomized trial of 79 infants ≤30 weeks' gestation and ≤1,500 g. Stool samples were collected at week 1 through week 4, frozen to -80°C and analyzed by 16S rRNA sequencing of the V4 region using Illumina MiSeq. Reads were analyzed to measure α and ß diversity as well as relative abundance of bacteria in the intestinal microbiome. RESULTS: Of the 79 infants, 63 had at least one sample available. Twenty-three (37%) of infants were African American, 30 (48%) were male, and 44 (71%) had Medicaid insurance. There were no statistically significant (<0.05) differences in α diversity or ß diversity, and the differential abundance analysis suggests limited patterns of distinction in the intestinal microbiome between non-African American and African American infants, male and female infants, and infants with maternal private or Medicaid insurance. CONCLUSION: Our results suggest race, sex, and socioeconomic status shape colonization of specific microorganisms to a limited extent. Future studies should confirm these findings and determine clinical relevance through further study of differentially abundant microorganisms and additional factors contributing to colonization patterns. KEY POINTS: · Diversity of the gut microbiome was similar between infants of varying race, sex, and socioeconomic status.. · We observed sociodemographic-linked differences in colonization of individual taxa.. · Further study is required to confirm these results and the clinical relevance of these findings..

Maternal Voice Exposure and Its Effect on Premature Infants' Feeding Milestones: A Systematic Review.

BACKGROUND: Premature infants experience alterations in maternal stimulation (including auditory sensory alteration such as talking or singing to the infant in the neonatal intensive care unit) due to admission to the neonatal intensive care unit. Because of their physiological and neurobehavioral immaturity, infants are at an increased risk of delays in reaching feeding milestones (a key developmental milestone), which often need to be achieved before discharge. PURPOSE: This systematic review evaluated the literature regarding the effect of maternal speech on achievement of feeding milestones in premature infants. DATA SOURCES: A systematic search of CINAHL, PubMed, Web of Science, and Google Scholar from 2010 to 2021. STUDY SELECTION: Studies were selected if they examined the effect of maternal voice interventions on premature infants' feeding milestones. DATA EXTRACTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. RESULTS: Six studies were identified. This systematic review of the literature on the effects of maternal voice on feeding milestones in premature infants found equivocal results. IMPLICATIONS FOR PRACTICE: Given the inconsistent results, this systematic review does not support a change in clinical practice. However, encouragement of maternal visits is highly recommended as the additional benefits of the mother's presence may extend beyond exposure to maternal voice. IMPLICATIONS FOR RESEARCH: More research is needed including use of more homogenous samples, application of recommended decibel levels, and utilization of an adequately powered randomized controlled trial to further examine the effects of maternal voice on feeding milestones.

The association of wound factors and symptoms of fatigue and pain with wound healing in chronic venous leg ulcers.

The purpose of this study was: (1) to characterise the association of wound area, wound exudate C-reactive protein (CRP), broad-spectrum matrix metalloprotease protein (MMPs), and symptoms of fatigue and pain in individuals with chronic venous leg ulcers (CVLUs) over time and (2) to identify factors associated with the wound healing trajectory in CVLUs. Seventy four participants with CVLU who received weekly sharp debridement were recruited from a wound care clinic during the 8-week study period. To examine associations among wound CRP, MMPs, pain, fatigue, and wound healing trajectory over time, we calculated Bayes factors (BF) based on a linear mixed model. The mean age of participants was 71.8 (SD = 9.8) and the mean wound area was 2278 mm2 (SD = 7085 mm2 ) at baseline. Higher fatigue was strongly associated with higher MMPs (BF = 9, 95% HDI: [-.05, .43]), lower CRP (BF = 11, 95% HDI: [-.02, .002]), and large areas of wound (BF = 20, 95% HDI: [-.001, .01]). Higher CRP and MMPs activity in wound exudate and higher fatigue were associated with a larger wound area. To facilitate wound healing, clinicians need to utilise the multifactorial approach, which includes wound treatment and management of symptoms such as pain and fatigue, because of the molecular and psycho-behavioural factors involved in wound healing.

Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort.

BACKGROUND: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort. METHODS: A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. RESULTS: Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs. CONCLUSIONS: In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.

Unusually High Prevalence of Stroke and Cerebral Vasculopathy in Hemoglobin SC Disease: A Retrospective Single Institution Study.

INTRODUCTION: Unlike homozygous hemoglobin SS (HbSS) disease, stroke is a rare complication in hemoglobin SC (HbSC) disease. However, recent studies have demonstrated a high prevalence of silent stroke in HbSC disease. The factors associated with stroke and cerebral vasculopathy in the HbSC population are unknown. METHODS: We conducted a retrospective study of all patients with sickle cell disease treated at the University of Missouri, Columbia, over an 18-year period (2000-2018). The goal of the study was to characterize the silent, overt stroke, and cerebral vasculopathy in HbSC patients and compare them to patients with HbSS and HbS/ß thalassemia1 (thal) in this cohort. We also analyzed the laboratory and clinical factors associated with stroke and cerebral vasculopathy in the HbSC population. RESULTS: Of the 34 HbSC individuals, we found that the overall prevalence of stroke and cerebral vasculopathy was 17.7%. Only females had evidence of stroke or cerebral vasculopathy in our HbSC cohort (33.3%, p = 0.019). Time-averaged means of maximum velocities were lower in the HbSC group than the HbSS group and did not correlate with stroke outcome. Among HbSC individuals, those with stroke and cerebral vasculopathy had a marginally higher serum creatinine than those without these complications (0.77 mg/dL vs. 0.88 mg/dL, p = 0.08). Stroke outcome was associated with recurrent vaso-occlusive pain crises (Rec VOCs) (75 vs. 25%, p = 0.003) in HbSC patients. The predominant cerebrovascular lesions in HbSC included microhemorrhages and leukoencephalopathy. CONCLUSION: There is a distinct subset of individuals with HbSC who developed overt, silent stroke, and cerebral vasculopathy. A female predominance and association with Rec VOCs were identified in our cohort; however, larger clinical trials are needed to identify and confirm specific clinical and laboratory markers associated with stroke and vasculopathy in HbSC disease.

Exploring the relationship between DNA methylation age measures and psychoneurological symptoms in women with early-stage breast cancer.

PURPOSE: The epigenetic clock has been acknowledged as an indicator for molecular aging, but few studies have examined possible associations of DNA methylation (DNAm) age or age acceleration (AA) with symptom burden in individuals who are treated for cancer. This study explored the association of DNAm age or AA with psychoneurological (PN) symptoms, including cognitive impairment, fatigue, sleep disturbances, pain, and depressive symptoms, in breast cancer survivors over a 2-year period. METHODS: We measured PN symptoms using reliable instruments and DNAm levels by Infinium HumanMethylation450K BeadChip (N = 72). DNAm age was calculated by the Horvath, Grim, and Hannum-based intrinsic and extrinsic age estimations. AA was defined by the residual regressing estimated epigenetic age on chronological age. Mixed regression models were fitted for AA and changes in AA to study the association over time. Separate linear regression models and a mixed-effects model were fitted for AA at each time point. RESULTS: Horvath-AA, Grim-AA, and extrinsic epigenetic AA were significantly changed over time, while intrinsic epigenetic AA did not exhibit any temporal changes. Increased AA was associated with greater anxiety and fatigue, as well as worse cognitive memory, adjusting for race, BMI, income, chemotherapy, radiation therapy, and chronological age. Increased DNAm age was associated with greater anxiety over 2 years. CONCLUSION: Our findings suggest DNAm age and AA may be associated with PN symptoms over the course of cancer treatment and survivorship. Some PN symptoms may be amenable to preventive interventions targeted to epigenetic clocks that influence aging-associated processes.

Validation of choledocholithiasis predictors from the "2019 ASGE Guideline for the role of endoscopy in the evaluation and management of choledocholithiasis."

BACKGROUND AND AIMS: Identifying patients likely to have CDL is an important clinical dilemma because endoscopic retrograde cholangiopancreatography (ERCP), carries a 5-7% risk of adverse events. The purpose of this study was to compare the diagnostic test performance of the 2010 and 2019 ASGE criteria used to help risk stratify patients with suspected CDL. METHODS: Consecutive patients evaluated for possible CDL from 2013 to 2019 were identified from surgical, endoscopic, and radiologic databases at a single academic center. Inclusion criteria included all patients who underwent ERCP and/or cholecystectomy with intraoperative cholangiogram (IOC) for suspected CDL. We calculated the diagnostic test performance of criteria from both guidelines and compared their discrimination using the receiver operator curve. Univariate and multivariate analysis was used to identify the strongest component predictors. RESULTS: 1098 patients [age 57.9 ± 19.0 years, 62.8% (690) F] were included. 66.3% (728) were found to have CDL on ERCP and/or IOC. When using the 2019 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 65.8, 78.9, 86.3, 54.1, and 70.4%, respectively. Using the 2010 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 50.5, 78.9, 82.5, 44.8, and 60.1%, respectively. The AUC for high-risk criteria using the 2019 guidelines [0.726 (0.695, 0.758)] was greater than for the 2010 guidelines [0.647 (0.614, 0.681)]. The key difference providing the increased discrimination was the inclusion of stones on any imaging modality, which increased the sensitivity to 55.0% from 29.1%. Not including CDL on imaging or cholangitis, a dilated CBD was the strongest individual predictor of CDL on multivariate analysis (OR 3.70, CI 2.80, 4.89). CONCLUSION: Compared to 2010, the 2019 high-risk criterion improves diagnostic test performance, but still performs suboptimally. Less invasive tests, such as EUS or MRCP, should be considered in patients with suspected CDL prior to ERCP.

Conflicts of Interest Among Authors of Systematic Reviews Regarding the Management of Chronic Non-Cancer Pain with Opioids Analgesics.

OBJECTIVE: We sought to determine whether author conflict of interest (disclosed or undisclosed) or industry sponsorship influenced the favorability of reporting of systematic reviews and meta-analyses investigating the use of opioid analgesics for the management of chronic non-cancer pain. METHODS: Our search included the MEDLINE (Ovid) and Embase (Ovid) databases. Study sponsorship was determined using the funding statement provided in each systematic review. Author COI information was extracted from the COI disclosure statement. This information was cross-referenced with information available on the CMS Open Payments Database, Dollars for Profs, Google Patents, the United States Patent and Trademark Office (USPTO), and previously published COI disclosures. RESULTS: Eight systematic reviews authored by 83 authors were included. Of these authors, 19 (23.0%) were found to have a COI, of which the majority (17/19; 89.5%) had at least one undisclosed COI. Despite nearly one-quarter of authors having a COI, we found no association between the presence of a COI and the favorability of results (P = 0.64) or conclusions (P = 0.07). CONCLUSIONS: COI are common and frequently undisclosed among systematic review authors investigating opioid analgesics for the management of chronic non-cancer pain. Despite a high prevalence of COI, we did not find that these author-industry relationships had a significant influence on the favorability of results and conclusions; however, our findings should be considered a lower bound estimate of the true influence author COI have on outcomes of pain medicine systematic reviews secondary to the low sample size included in the present study.

Computed tomography-based body composition profile as a screening tool for geriatric frailty detection.

OBJECTIVE: To assess prevalence of CT imaging-derived sarcopenia, osteoporosis, and visceral obesity in clinically frail and prefrail patients and determine their association with the diagnosis of frailty. MATERIALS AND METHODS: This cross-sectional study was constructed using our institution's pelvic trauma registry and ambulatory database registry. The study included all elderly pelvic trauma patients and ambulatory outpatients between May 2016 and March 2020 who had a comprehensive geriatric assessment and CT abdomen/pelvis within 1 year from the date of the assessment. Patients were dichotomized in prefrail or frail groups. The study excluded patients with history of metastatic disease or malignancy requiring chemotherapy. RESULTS: The study cohort consisted of 151 elderly female and 65 male patients. Each gender population was subdivided into frail (114 female [75%], 51 male [78%]) and prefrail (37 female [25%], 14 male [22%]) patients. CT-imaging-derived diagnosis of osteoporosis (odds ratio, 2.5; 95% CI: 1.2-5.5) and sarcopenia (odds ratio, 2.6; 95% CI: 1.2-5.6) were associated with frailty in females, but did not reach statistical significance in males. BMI and subcutaneous adipose tissue at L3 level were statistically lower in the frail male group compared to the prefrail group. BMI showed strong correlation with the subcutaneous area at the L3 level in both genders (Spearman's coefficient of 0.8, p < 0.001). Hypoalbuminemia and visceral obesity were not associated with frailty in either gender. CONCLUSION: This proof-of-concept study demonstrates the feasibility of using CT-derived body-composition parameters as a screening tool for frailty, which can offer an opportunity for early medical intervention.

Milk Volume Outcomes in Pump-Dependent Mothers of Critically Ill Infants.

INTRODUCTION: Mother's own milk improves health outcomes in infants of all gestational ages. Although pump-dependent mothers of extremely premature infants are at risk of insufficient milk production, whether mother's milk production is impacted by gestational age and pump dependency in mothers of more mature critically ill infants is unknown. PURPOSE: To determine whether there is a relationship between gestational age, milk production, and time to secretory activation in mothers delivering a critically ill infant. METHODS: A convenience sample of 136 pump-dependent mothers whose infants were admitted to the neonatal intensive care unit was enrolled between 2013 and 2016 as part of a quality improvement project. Group 1 (early preterm) delivered infants at 30 to 33 weeks of gestation (n = 41), group 2 (late preterm) 34 to 36 weeks (n = 48), and group 3 (term) 37 weeks and more (n = 47). Milk volume on days 1 to 7 was measured by weighing each vial of expressed milk and compared using general linear mixed-model analysis. Time to the onset of secretory activation was compared using censored regression analysis. RESULTS: Main effect for gestational age controlling for day was statistically significant (P = .0234). The early preterm group produced more milk over the 7-day study than the term (P = .01) and late preterm (P = .02) groups. The early preterm group achieved secretory activation earlier than the late preterm group (adjusted P = .039). IMPLICATIONS FOR PRACTICE: Pump-dependent mothers of all infants admitted to the neonatal intensive care unit may be at risk of inadequate milk production and delayed secretory activation and may therefore benefit from early milk production monitoring and lactation support. IMPLICATIONS FOR RESEARCH: Further studies should examine targeted interventions to increase milk production in pump-dependent mothers.

Evaluating the relationship between industry sponsorship and conflicts of interest among systematic review authors on treatments for cannabis use disorder.

Background: Cannabis is the most commonly used illicit drug worldwide. In addition to potential adverse effects, an estimated 9% consistent cannabis users are likely to become dependent and may develop a cannabis use disorder (CUD). Methods: This cross-sectional study developed a search strategy using Ovid, MEDLINE, and Ovid Embase for systematic reviews and meta-analyses focused on CUD treatment in June 2020. These reviews were evaluated for conflicts of interest (COIs) per previously developed classification scheme. Our primary objectives were to (1) evaluate the presence of disclosed or undisclosed COI of systematic review authors, regarding treatment of CUD; and (2) determine whether overall summary effect estimates, narrative results and conclusions were influenced by the presence of disclosed or undisclosed COIs among systematic review authors. Results: Our systematic search returned 560 articles which 9 systematic reviews were eligible for data extraction. We found 77.8% (7/9) contained at least one author with a COI. From the 51 authors included, 29.4% (15/51) were found to have a COI. Forty-four percent (4/9) were funded, 22.2% (2/9) were not funded, and 33.3% (3/9) had no funding statements. Out of the 7 systematic reviews with one or more authors containing COI, 14.2% (1/7) included results favoring the treatment group and 28.6% (2/7) included conclusions favoring the treatment group. Our results showed no significance between funding source and results (p = 0.429) or conclusions. Additionally, we found no significance between the presence of COIs with the favorability of results (p = 0.56) or conclusions. Conclusion: Multiple studies favored the treatment of cannabis-containing products, even though COIs were found in the majority of the systematic reviews. COIs have the ability to sway results of a study, which can affect clinical decision-making. Stricter guidelines should be enforced among authors displaying COIs in systematic reviews studying CUD treatment.

Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly.

PURPOSE: Prompt identification of traumatic pelvic fractures in the elderly is critical to guide clinical management; however, the accuracy of pelvic radiographs is often compromised by multiple factors. The purpose of this study is to examine the diagnostic accuracy of radiographs for the detection of pelvic fractures, with CT as the standard of reference. METHODS: A retrospective review was performed of patients ≥ 65 years with traumatic pelvic fractures evaluated with both pelvic radiography and computed tomography (CT) from May 2016 to October 2019. Pelvic fractures were classified into fractures of the pubis, ilium, ischium, sacrum, and acetabulum. All pelvic radiographs were independently reviewed by two emergency radiologists. Original CT reports were utilized for the reference standard. RESULTS: 177 patients were included, with a total of 555 fractures. The mean age was 81 years and 68% were female. The most common mechanism of injury was fall (62%), followed by motor vehicle accidents (18%). The most fractured bone was the pubis (314/555 fractures). Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity for the detection of pelvic fractures is classified by the following types: pubis 61%, acetabulum 60%, ilium 41%, sacrum 20%, and ischium 17%. Eighteen patients (10%) required surgical fixation. Mortality was 8%. CONCLUSION: Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.

School Health Infrastructure and Students' Elevated Body Mass Index.

School-age children with overweight or obesity continue to be problematic in the United States, and are associated with many health, social, and financial problems. Schools provide an excellent venue in which to promote healthy weight in students, and school nurses are well-positioned to play an essential role in controlling obesity. The number of studies reporting relationships among school health infrastructure and prevalence of elevated Body Mass Index (BMI) is limited. The present study explored associations between three components of school health infrastructure (staff, services, budget) and the proportion overweight or obese 1st, 3rd, and 6th grade students, after controlling for selected factors (race, county education level, county poverty level, rurality). Study results supported an independent association between elevated BMI and school health staff. Additionally, independent associations between elevated BMI and the following covariates were supported: household income, race, and parents' educational level. There is an ultimate need for well-designed studies addressing these associations.

Treatment modalities and outcomes following acetabular fractures in the elderly: a systematic review.

PURPOSE: The treatment of geriatric acetabular fractures remains controversial. Treatment options include nonoperative management, open reduction and internal fixation (ORIF), total hip arthroplasty (THA) with or without internal fixation, and closed reduction with percutaneous pinning (CRPP). There is currently no consensus on the optimal treatment strategy for geriatric patients with acetabular fractures. The purpose of this study is to compare adverse event rates, functional and radiographic outcomes, and intraoperative results between the various treatment modalities in order to help guide surgical decision making. METHODS: We performed a systematic review (registration number CRD42019124624) of observational and comparative studies including patients aged ≥ 55 with acetabular fractures. RESULTS: Thirty-eight studies including 3,928 patients with a mean age of 72.6 years (range 55-99 years) and a mean follow-up duration of 29.4 months met our eligibility criteria. The pooled mortality rate of all patients was 21.6% (95% confidence interval [CI] 20.9-22.4%) with a mean time to mortality of 12.6 months, and the pooled non-fatal complication rate was 24.7% (95% CI 23.9-25.5%). Patients treated with ORIF had a significantly higher non-fatal complication rate than those treated with ORIF + THA, THA alone, CRPP, or nonoperative management (odds ratios [ORs] 1.87, 2.24, 2.15, and 4.48, respectively; p < 0.01). Patients that underwent ORIF were significantly less likely to undergo subsequent THA than these treated with CRPP (OR 0.49, 95% CI 0.32-0.77) but were more likely to require THA than patients treated nonoperatively (OR 6.81, 95% CI 4.63-10.02). CONCLUSION: Elderly patients with acetabular fractures tend to have favorable functional outcomes but suffer from high rates of mortality and complications. In patients treated with internal or percutaneous fixation, there was a high rate of conversion to THA. When determining surgical treatment in this population, THA alone or concurrent with ORIF should be considered given the significantly lower rate of non-fatal complications and similar mortality rate. Nonoperative management remains a viable option and was associated with the lowest non-fatal complication rate. LEVEL OF EVIDENCE: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .