A Novel Model for Predicting Rehospitalization Risk Incorporating Physical Function, Cognitive Status, and Psychosocial Support Using Natural Language Processing.

BACKGROUND: With the increasing focus on reducing hospital readmissions in the United States, numerous readmissions risk prediction models have been proposed, mostly developed through analyses of structured data fields in electronic medical records and administrative databases. Three areas that may have an impact on readmission but are poorly captured using structured data sources are patients' physical function, cognitive status, and psychosocial environment and support. OBJECTIVE OF THE STUDY: The objective of the study was to build a discriminative model using information germane to these 3 areas to identify hospitalized patients' risk for 30-day all cause readmissions. RESEARCH DESIGN: We conducted clinician focus groups to identify language used in the clinical record regarding these 3 areas. We then created a dataset including 30,000 inpatients, 10,000 from each of 3 hospitals, and searched those records for the focus group-derived language using natural language processing. A 30-day readmission prediction model was developed on 75% of the dataset and validated on the other 25% and also on hospital specific subsets. RESULTS: Focus group language was aggregated into 35 variables. The final model had 16 variables, a validated C-statistic of 0.74, and was well calibrated. Subset validation of the model by hospital yielded C-statistics of 0.70-0.75. CONCLUSIONS: Deriving a 30-day readmission risk prediction model through identification of physical, cognitive, and psychosocial issues using natural language processing yielded a model that performs similarly to the better performing models previously published with the added advantage of being based on clinically relevant factors and also automated and scalable. Because of the clinical relevance of the variables in the model, future research may be able to test if targeting interventions to identified risks results in reductions in readmissions.

Targeted Reminder Phone Calls to Patients at High Risk of No-Show for Primary Care Appointment: A Randomized Trial.

BACKGROUND: No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients. OBJECTIVE: To determine whether telephone reminder calls targeted to patients at high risk of no-show can reduce no-show rates. DESIGN: Single-center randomized controlled trial. PARTICIPANTS: A total of 2247 primary care patients in a hospital-based primary care clinic at high risk of no-show (>15 % risk) for their appointment in 7 days. INTERVENTION: Seven days prior to their appointment, intervention arm patients were placed in a calling queue to receive a reminder phone call from a patient service coordinator. Coordinators were trained to engage patients in concrete planning. All patients received an automated phone call (usual care). MAIN MEASURES: Primary outcome was no-show rate. Secondary outcomes included arrival rate, cancellation rate, reschedule rate, time to cancellation, and change in revenue. KEY RESULTS: The no-show rate in the intervention arm (22.8 %) was significantly lower (absolute risk difference -6.4 %, p < 0.01, 95 % CI [-9.8 to -3.0 %]) than that in the control arm (29.2 %). Arrival, cancellation, and reschedule rates did not differ significantly. In the intervention arm, rescheduling and cancellations occurred further in advance of the appointment (mean difference, 0.35 days; 95 % CI [0.07-0.64]; p = 0.01). Reimbursement did not differ significantly. CONCLUSIONS: A phone call 7 days prior to an appointment led to a significant reduction in no-shows and increased reimbursement among patients at high risk of no-show. The use of targeted interventions may be of interest to practices taking on increased accountability for population health.

Patient navigation based on predictive modeling decreases no-show rates in cancer care.

BACKGROUND: Patient adherence to appointments is key to improving outcomes in health care. "No-show" appointments contribute to suboptimal resource use. Patient navigation and telephone reminders have been shown to improve cancer care and adherence, particularly in disadvantaged populations, but may not be cost-effective if not targeted at the appropriate patients. METHODS: In 5 clinics within a large academic cancer center, patients who were considered to be likely (the top 20th percentile) to miss a scheduled appointment without contacting the clinic ahead of time ("no-shows") were identified using a predictive model and then randomized to an intervention versus a usual-care group. The intervention group received telephone calls from a bilingual patient navigator 7 days before and 1 day before the appointment. RESULTS: Over a 5-month period, of the 40,075 appointments scheduled, 4425 patient appointments were deemed to be at high risk of a "no-show" event. After the patient navigation intervention, the no-show rate in the intervention group was 10.2% (167 of 1631), compared with 17.5% in the control group (280 of 1603) (P<.001). Reaching a patient or family member was associated with a significantly lower no-show rate (5.9% and 3.0%, respectively; P<.001 and .006, respectively) compared with leaving a message (14.7%: P = .117) or no contact (no-show rate, 21.6%: P = .857). CONCLUSIONS: Telephone navigation targeted at those patients predicted to be at high risk of visit nonadherence was found to effectively and substantially improve patient adherence to cancer clinic appointments. Further studies are needed to determine the long-term impact on patient outcomes, but short-term gains in the optimization of resources can be recognized immediately.

Appointment "no-shows" are an independent predictor of subsequent quality of care and resource utilization outcomes.

BACKGROUND: Identifying individuals at high risk for suboptimal outcomes is an important goal of healthcare delivery systems. Appointment no-shows may be an important risk predictor. OBJECTIVES: To test the hypothesis that patients with a high propensity to "no-show" for appointments will have worse clinical and acute care utilization outcomes compared to patients with a lower propensity. DESIGN: We calculated the no-show propensity factor (NSPF) for patients of a large academic primary care network using 5 years of outpatient appointment data. NSPF corrects for patients with fewer appointments to avoid over-weighting of no-show visits in such patients. We divided patients into three NSPF risk groups and evaluated the association between NSPF and clinical and acute care utilization outcomes after adjusting for baseline patient characteristics. PARTICIPANTS: A total of 140,947 patients who visited a network practice from January 1, 2007, through December 31, 2009, and were either connected to a primary care physician or to a primary care practice, based on a previously validated algorithm. MAIN MEASURES: Outcomes of interest were incomplete colorectal, cervical, and breast cancer screening, and above-goal hemoglobin A1c (HbA1c) and low-density lipoprotein (LDL) levels at 1-year follow-up, and hospitalizations and emergency department visits in the subsequent 3 years. KEY RESULTS: Compared to patients in the low NSPF group, patients in the high NSPF group (n=14,081) were significantly more likely to have incomplete preventive cancer screening (aOR 2.41 [2.19-.66] for colorectal, aOR 1.85 [1.65-.08] for cervical, aOR 2.93 [2.62-3.28] for breast cancer), above-goal chronic disease control measures (aOR 2.64 [2.22-3.14] for HbA1c, aOR 1.39 [1.15-1.67] for LDL], and increased rates of acute care utilization (aRR 1.37 [1.31-1.44] for hospitalization, aRR 1.39 [1.35-1.43] for emergency department visits). CONCLUSIONS: NSPF is an independent predictor of suboptimal primary care outcomes and acute care utilization. NSPF may play an important role in helping healthcare systems identify high-risk patients.

Subsidence in Nonexpandable, Single-Plane Expandable, and Dual-Plane Expandable TLIFs A Propensity-Matched Cohort Study.

BACKGROUND: Transforaminal lumbar interbody fusion (TLIF) has become a common tool to achieve interbody fusion in lumbar spine surgery while avoiding the time, expense, and morbidity associated with an anterior approach. Nonexpandable (NE) devices have excellent fusion results but are limited to implant size by spinal anatomy; conversely, expandable implants have been associated with increased intraoperative subsidence. Dual-plane expandable (DPE) devices are theorized to have reduced subsidence risk, but DPE cages have not been directly compared to NE and single plane expandable (SPE) implants in vivo. STUDY DESIGN: A retrospective review of patients who underwent TLIF at a single metropolitan academic medical center from 2018 through 2021 was conducted to compare intraoperative subsidence between NE versus SPE or DPE devices. Patients were propensity score matched (PSM) by age and bone density according to implant type. A second PSM cohort comparing DPE with SPE devices was performed. RESULTS: A total of 402 patients underwent PSM with 46 NE and 49 DPE cases matched, and 103 SPE patients were matched with 24 DPE cases. The average age was 59 years with 52.5% female patients. Mean body mass index was 29. Nonexpandable TLIF was the most common device implanted 62%, followed by SPE (26%) and DPE (12.2%). Dual-plane expandable devices had a significantly greater intraoperative subsidence than NE devices (12% vs. 0%). Nonexpandable and SPE devices had significantly larger implant lordosis when compared to DPE (10.93 SPE vs. 6. 17 NE vs. 3.83 DPE). Single plane expandable devices had a significantly greater discrepancy between implant lordosis and interbody level lordosis compared to DPE. CONCLUSIONS: Dual-plane expandable cages are associated with increased intraoperative subsidence compared to NE and SPE implants. Additionally, SPE devices have greater discrepancy between stated implant lordosis and interbody level lordosis compared with DPE devices.

State of the art and prospects of zeolites and metal organic frameworks (MOFs) for nitrogen and phosphorus removal in dairy wastewater.

Water is an essential resource for humans, animals, and plants. Water is also necessary for the manufacture of many products such as milk, textiles, paper, and pharmaceutical composites. During manufacturing, some industries generate a large amount of wastewater containing numerous contaminants. In the dairy industry, for each litre of drinking milk produced, about 10 L of wastewater is generated. Despite this environmental footprint, the production of milk, butter, ice cream, baby formula, etc., are essential in many households. Common contaminants in dairy wastewater include high biological oxygen demand (BOD), chemical oxygen demand (COD), salts as well as nitrogen and phosphorus derivatives. Nitrogen and phosphorus discharges are one of the leading causes in the eutrophication of rivers and oceans. Porous materials have long held significant potential as a disruptive technology for wastewater treatment. However, thus far they have been understudied for use in dairy wastewater treatment. Ordered porous materials, such as zeolites and metal organic frameworks (MOFs), represent classes of porous materials with significant potential for the removal of nitrogen and phosphorus. This review explores the different zeolites and MOFs applied in the removal of nitrogen and phosphorus from wastewater and the prospect of their potential for use in wastewater management in the dairy industry.

Albinterferon Alfa-2b was not inferior to pegylated interferon-α in a randomized trial of patients with chronic hepatitis C virus genotype 1.

BACKGROUND & AIMS: The current standard of care for patients with chronic hepatitis C virus (HCV) genotype 1 is once-weekly pegylated interferon-α (Peg-IFNα) plus daily ribavirin for 48 weeks. We evaluated the efficacy/safety of albinterferon alfa-2b (albIFN), a novel, long-acting, genetic fusion polypeptide of albumin and IFNα-2b. METHODS: In the phase 3 ACHIEVE-1 trial, 1331 patients were assigned equally to 3 open-label, 48-week treatment groups: Peg-IFNα-2a 180 µg every week, or albIFN 900 or 1200 µg every 2 weeks administered subcutaneously, with weight-based oral ribavirin 1000-1200 mg/day. During the study, the data monitoring committee recommended dose modification for all patients receiving albIFN 1200 µg to 900 µg because of increased pulmonary adverse events (AEs) in the 1200-µg arms of both ACHIEVE studies. Main outcome measure was sustained virologic response (SVR; undetectable serum HCV RNA at week 72). RESULTS: Intention-to-treat SVR rates were 51.0% (225/441), 48.2% (213/442), and 47.3% (208/440) with Peg-IFNα-2a, and albIFN 900 and 1200 µg, respectively. The primary objective of showing noninferiority of albIFN 900 µg (P < .001) and 1200 µg (P = .003) vs Peg-IFNα-2a for SVR was achieved. Multivariate modeling indicated consistency of treatment effect across subgroups. Serious/severe AE rates were 23.1%, 24.0%, 28.2%; treatment discontinuation rates because of AEs were 4.1%, 10.4%, 10.0%; discontinuation rates because of respiratory AEs were 0%, 0.9%, 1.6%; with Peg-IFNα-2a, and albIFN 900 and 1200 µg, respectively. Hematologic abnormality rates were comparable across the Peg-IFNα-2a and albIFN 900-µg groups. CONCLUSIONS: albIFN 900 µg every 2 weeks showed comparable efficacy, with similar serious/severe AE rates, although with a higher discontinuation rate, vs Peg-IFNα-2a in patients with chronic HCV genotype 1.

Albinterferon Alfa-2b was not inferior to pegylated interferon-α in a randomized trial of patients with chronic hepatitis C virus genotype 2 or 3.

BACKGROUND & AIMS: A phase 3 active-controlled study was conducted to assess the efficacy/safety of albinterferon alfa-2b (albIFN), a novel, long-acting, genetic fusion polypeptide of recombinant human albumin and interferon alfa-2b, in patients with chronic hepatitis C virus (HCV) genotype 2/3. METHODS: In all, 933 patients were randomized to open-label subcutaneous treatment with pegylated interferon-alfa-2a (Peg-IFNalfa-2a) 180 µg/wk, or albIFN 900 or 1200 µg every 2 weeks for 24 weeks, each administered with oral ribavirin 800 mg/day. The primary end point of the study was sustained virologic response (SVR) (HCV-RNA level, <15 IU/mL at week 48). During the study, the data monitoring committee recommended dose modification for all patients receiving albIFN 1200 µg to 900 µg, impacting 38% of this treatment arm. RESULTS: By intention-to-treat analysis, SVR rates were 84.8% (95% confidence interval, 80.4%-88.6%), 79.8% (95% confidence interval, 74.9%-84.1%), and 80.0% (95% confidence interval, 75.1%-84.3%) with Peg-IFNalfa-2a, and albIFN 900 and 1200 µg, respectively. The primary hypothesis of noninferiority of SVR was established for albIFN 900 µg (P = .009) and 1200 µg (P = .006). Independent positive predictors of SVR by multivariate regression analysis were pretreatment HCV-RNA level less than 400,000 IU/mL, age younger than 45 years, body mass index less than 30 kg/m(2), genotype 2, normal γ-glutamyl transpeptidase and increased alanine aminotransferase levels at baseline, fibrosis stage F0-F2, no steatosis, and Asian geographic region (Peg-IFNalfa-2a only). The 3 treatment groups showed similar rates of serious (7%-8%) and severe (13%-16%) adverse events, and discontinuations owing to adverse events (3.6%-5.5%). CONCLUSION: Albinterferon alfa-2b 900 µg every 2 weeks provides an alternative efficacious treatment option in patients with chronic HCV genotype 2 or 3.

Facilitating the iterative design of informatics tools to advance the science of autism.

This paper describes a usability evaluation study of an innovative first generation system (Data Dig) designed to retrieve phenotypic data from the large SFARI data set of 2700 families each of which has one child affected with autism spectrum disorder. The usability methods included a cognitive walkthrough and usability testing. Although the subjects were able to learn to use the system, more than 50 usability problems of varying severity were noted. The problems with the greatest frequency resulted from users being unable to understand meanings of variables, filter categories correctly, use the Boolean filter, and correctly interpret the feedback provided by the system. Subjects had difficulty forming a mental model of the organizational system underlying the database. This precluded them from making informed navigation choices while formulating queries. Clinical research informatics is a new and immensely promising discipline. However in its nascent stage, it lacks a stable interaction paradigm to support a range of users on pertinent tasks. This presents great opportunity for researchers to further this science by harnessing the powers of user-centered iterative design.

Role of Robotics in Adult Spinal Deformity.

Robotic-assisted adult deformity surgery has played a rapidly expanding role since its introduction. As robotic spine technologies improve, the potential to limit complications and morbidity is vast. The improvements in instrumentation accuracy combined with the ability to maintain that accuracy in multiple positions allow creative surgical approaches and techniques that can limit operative time, blood loss, and improve outcomes. In the years to come, robotic-assisted spine surgery and navigation will likely play an expanding role that continues to be defined. LEVEL OF EVIDENCE: 5, expert opinion.

Comparative Studies in the Shoulder Literature Lack Statistical Robustness: A Fragility Analysis.

PURPOSE: Evidenced-based decision-making is rooted in comparative clinical studies; however, a small number of outcome event reversals have the potential to change study significance. The purpose of this study was to determine the utility of applying fragility analysis to comparative studies in the published orthopaedic shoulder literature. METHODS: Comparative clinical shoulder research studies reporting 1:1 dichotomous categorical data were analyzed in 6 leading orthopaedic journals between 2006 and 2016. Statistical significance was defined as a P value of less than .05. The fragility index (FI) for each study outcome was determined by the number of event reversals required to change the P value to either greater or less than 0.05, thus changing the study conclusions. The associated fragility quotient (FQ) was determined by dividing the FI by the total population comprising a particular outcome. RESULTS: Of the 23,897 studies screened, 3,591 met search criteria, with 198 comparative studies ultimately included for analysis, 67 of which were randomized controlled trials. There were 357 total outcome events with 74 reported as significant and 283 as not significant. The FI was 4 (IQR 2-6) with an associated FQ of 0.066 (interquartile range [IQR] 0.038-0.102). There was no difference in statistical fragility between randomized and nonrandomized trials with both revealing a FI of 4 and FQ of 0.068 (IQR 0.044-0.107) and 0.065 (IQR 0.031-0.101), respectively. CONCLUSIONS: This current analysis reveals that comparative shoulder studies published in six leading orthopaedic journals are at risk of statistical fragility. As such, contemporary clinical shoulder literature may not be as robust as traditionally perceived with the reversal of only a few outcome events required to change study significance. Therefore, we advocate the reporting of both FI and FQ in addition to the P value as statistical complements to all comparative investigations to provide a more comprehensive understanding of trial stability and significance in the published shoulder literature. CLINICAL RELEVANCE: Comparative study designs are commonly employed in shoulder research. Several studies in both the general medical and orthopaedic literature have identified a lack of statistical robustness through comprehensive fragility analysis. Our findings demonstrate the P value may be an inadequate independent statistical metric requiring the complement of a FI and FQ to aid in the interpretation and understanding of study significance for clinical decision-making.

Temporal artery vasculitis in young: a report of two cases.

Temporal (giant cell) arteritis is a chronic vasculitis of large and medium sized vessels which usually occurs in individuals above 50 years of age. In patients less than 50 years temporal artery vasculitis is extremely rare. The clinical presentations of the vasculitis in younger patients appear to be different from the older patients. We present two case reports of temporal artery vasculitis in patients less than 50 years, one of them with human immunodeficiency virus infection. Both the cases had variable clinical presentations and good response to treatment.

Medial tenderness revisited: Is medial ankle tenderness predictive of instability in isolated lateral malleolus fractures?

INTRODUCTION: Determining deltoid ligament incompetence in supination external rotation (SER) injuries commonly relies on stress radiography, given several studies demonstrating low predictive value of physical examination. Stress radiography can be difficult to obtain and may result in suboptimal radiographs with equivocal determination of stability. This study revisits the concept of medial ankle tenderness and its association with mortise instability. METHODS: Patients who presented with an isolated lateral malleolus fracture underwent prospective data collection. VAS scores were recorded with palpation at the lateral malleolar fracture site, anterior deltoid ligament, and posterior deltoid ligament. Three non-weightbearing radiographs of the ankle and a gravity stress view were obtained. Statistical analysis was performed to determine a correlation between tenderness and instability defined as MCS widening > 4 mm on gravity stress x-ray. RESULTS: 51 patients met inclusion criteria. Group I (stable) and Group II (unstable) demonstrated no difference in tenderness over the lateral malleolus (p = 0.94) or anterior deltoid (p = 0.12), but patients in Group II reported significantly more tenderness over the posterior deltoid (p = 0.03). Taking the higher pain score from either anterior or posterior deltoid palpation, patients with unstable ankle fractures reported significantly more tenderness with medial palpation (p = 0.02). The relative risk of having an unstable ankle fracture with any tenderness to palpation over either the anterior or posterior deltoid ligament was 1.77 (95% CI 1.03 - 3.06, P = 0.039). When comparing no pain versus the presence of any pain with palpation medially, the sensitivity for any medial tenderness to detect an unstable ankle fracture was 0.76 (specificity 0.59, PPV 0.79, NPV 0.56). CONCLUSION: Patients with any medial tenderness were at significantly higher risk of having an unstable SER ankle fracture in this study, but strict reliance on the presence or absence of medial tenderness without stress radiographs would lead to an unacceptable number of both false positive and false negative determinations of instability. However, our findings suggest that medial tenderness is associated with instability. The 0.79 PPV of any medial tenderness for instability may be useful to cast doubt on equivocal stress radiography and prompt surgeons to repeat stress radiography or shorten the interval for radiographic follow up. LEVEL OF EVIDENCE: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]).

Implant Removal Matrix for the upper Extremity Orthopedic Surgeon.

Orthopedic implant removal is a commonly performed procedure. While implant removal can be associated with improved symptoms, risks of the surgery are notable. Stripped screws, broken and retained hardware, and morbidity associated with soft tissue compromise during difficult removal are all common. Familiarity with the instruments is critical to procedure success. The purpose of this study is to assist removal of unfamiliar screws in upper extremity surgery by offering a reference for screw and driver compatibility across manufacturers. Inclusion of device manufacturers was determined by market share. Screw size, drive configuration, and screw removal system compatibility data was collected and recorded. Screw, guide-wire, and screwdriver compatibility was assessed and compared to two commonly utilized universal implant-removal sets. Eight upper extremity implant vendors were included. The data was compiled in table format according to manufacturer and sub-categorized to facilitate screw identification according to radiographically identifiable characteristics. The diversity of orthopaedic implants in upper extremity surgery requires careful preoperative planning to identify the appropriate equipment for implant removal. The goal of this work is to provide a centralized reference of commonly implanted screws, guide-wires, and drivers for the upper extremity to facilitate removal.

Severe aortic stenosis is associated with perioperative mortality in proximal femur fracture patients.

OBJECTIVES: Evaluate the correlation between aortic stenosis and perioperative mortality in patients following surgical fixation of proximal femur fractures. DESIGN: Retrospectively reviewed case series. SETTING: Two Academic, Level 1 Trauma Centers. PATIENTS/PARTICIPANTS: One hundred fifty-eight patients, definitively diagnosed with aortic stenosis by means of echocardiogram, who underwent surgical fixation for an isolated proximal femur fracture (OTA/AO 31-A, 31-B, 32-A, 32-B, and 32-C fractures) between January 2000 and June 2015. The severity of the aortic stenosis was based upon accepted echocardiographic hemodynamic parameters designated by the 2014 American Heart Association guidelines. MAIN OUTCOME MEASURES: Post Injury mortality, 30-day mortality, and 1-year mortality. SECONDARY OUTCOME MEASURES: Postoperative mortality stratified by severity of aortic stenosis based on aortic valve area (AVA) and ejection fracture (EF) as determined by preoperative echocardiography. RESULTS: One hundred fifty-eight patients were available for final analysis. Kaplan-Meier survival analysis revealed a significantly longer time to mortality among Non-severe aortic stenosis patients compared to Severe aortic stenosis patients, P value .006. Twenty-three percent of patients with Severe aortic stenosis and 10% of patients with Non-severe aortic stenosis died within 30 days of surgery. No significant difference was observed in mean survival among AS patients who underwent surgery within 48 hours of injury (34.5 months) and those delayed more than 48 hours after injury (25.0 months), P value .116. Among the commonly measured hemodynamic parameters of aortic stenosis, only AVA and EF were significantly associated with mortality, P value .015, and P value < .001, respectively. There were no significant effects for Aortic Vmax, Peak ΔP, and Mean ΔP. An AVA of 0.8 cm2 or less is associated with a significantly shorter (22 months) postinjury mortality than patients with an AVA > 0.8 cm2. (37 months), P value .009. CONCLUSIONS: Severe aortic stenosis is associated with a shorter postoperative time to mortality after surgical fixation of hip fractures compared to patients with Non-severe stenosis. Aortic valve area and Ejection Fraction are the only hemodynamic parameters significantly associated with postoperative mortality.Level of Evidence: Prognostic Level III.

Getting the Starting Point Right: Prevention of Skiving and Fibular Cortical Breach During Suture Button Placement for Syndesmotic Ankle Injuries.

The use of suture button (SB) devices in the treatment of syndesmotic ankle injuries is increasing. These constructs have demonstrated better syndesmotic reduction, improved clinical outcomes, and lower rates of hardware removal compared with screw fixation. However, placing a SB device without a fibular plate can be technically challenging. In this technique tip, we use an illustrative case to demonstrate a technique tip that minimizes the risk of anterior or posterior cortical breach of the fibula and helps facilitate more accurate placement of a SB device.Levels of Evidence: Level V: Expert opinion.

Syndesmotic Fixation Utilizing a Novel Screw: A Retrospective Case Series Reporting Early Clinical and Radiographic Outcomes.

Background. Syndesmotic disruption occurs in 20% of ankle fractures and requires anatomical reduction and stabilization to maximize outcomes. Although screw breakage is often asymptomatic, the breakage location can be unpredictable and result in painful bony erosion. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw designed with a controlled break point. Methods. We performed a retrospective review of all patients who underwent syndesmotic fixation utilizing the R3lease Tissue Stabilization System (Paragon 28, Denver, CO) over a 12-month period. Demographic and screw-specific data were obtained. Postoperative radiographs were reviewed, and radiographic parameters were measured. Screw loosening or breakage was documented. Results. 18 patients (24 screws) met inclusion criteria. The mean follow-up was 11.7 months (range = 6.0-14.7 months). 5/24 screws (21%) fractured at the break point. No screw fractured at another location, nor did any fracture prior to resumption of weight bearing; 19 screws did not fracture, with 8/19 intact screws (42.1%) demonstrating loosening. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow-up. No screws required removal during the study period. Conclusion. This study provides the first clinical data on a novel screw introduced specifically for syndesmotic fixation. At short-term follow up, there were no complications and the R3lease screw provided adequate fixation to allow healing and prevent diastasis. Although initial results are favorable, longer-term follow-up with data on cost comparisons and rates of hardware removal are needed to determine cost-effectiveness relative to similar implants.Level of Evidence: Level IV: Retrospective case series.

Does Surgical Approach Influence the Risk of Postoperative Infection After Surgical Treatment of Tibial Pilon Fractures?

OBJECTIVES: To determine whether a particular surgical approach or combination of approaches is a risk factor for infection. DESIGN: Retrospective review. SETTING: Two Level-1 trauma centers. PATIENTS/PARTICIPANTS: Five hundred ninety pilon fractures in 581 patients (66% male) with a median age of 45 years were identified. INTERVENTION: Open reduction internal fixation of pilon fractures. MAIN OUTCOME MEASURES: Postoperative deep surgical site infection and risk factors for postoperative deep infection. RESULTS: The most common primary surgical approach was medial (54%), followed by anterolateral (25%), anteromedial (11%), posterolateral (8%), and posteromedial (2%). A dual approach to the distal tibia was used in 18% of the cases. The overall deep infection rate was 19%. There was no association between primary surgical approach and development of infection (P = 0.19-0.78). Independent risk factors for infection were smoking (hazard ratio, 2.1; P < 0.001) and need for soft tissue coverage (hazard ratio, 6.9; P < 0.001). CONCLUSIONS: Surgical approach does not appear to be a significant risk factor for postoperative infection after open reduction internal fixation of distal tibial pilon fractures. When treating tibial plafond fractures, surgeons should select the approach they feel best addresses the specific fracture pattern. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess. SUMMARY OF BACKGROUND DATA: Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored. METHODS: We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement. RESULTS: We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43). CONCLUSION: We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling. LEVEL OF EVIDENCE: 3.

Metal-Organic Material Polymer Coatings for Enhanced Gas Sorption Performance and Hydrolytic Stability under Humid Conditions.

Physisorbent metal-organic materials (MOMs) have shown benchmark performance for highly selective CO2 capture from bulk and trace gas mixtures. However, gas stream moisture can be detrimental to both adsorbent performance and hydrolytic stability. One of the most effective methods to solve this issue is to transform the adsorbent surface from hydrophilic to hydrophobic. Herein, we present a facile approach for coating MOMs with organic polymers to afford improved hydrophobicity and hydrolytic stability under humid conditions. The impact of gas stream moisture on CO2 capture for the composite materials was found to be negligible under both bulk and trace CO2 capture conditions with significant improvements in regeneration times and energy requirements.