Social determinants of health influence clinical outcomes of patients undergoing rotator cuff repair: a systematic review.

BACKGROUND: Social determinants of health (SDOH) are the collection of environmental, institutional, and intrinsic conditions that may bias access to, and utilization of, health care across an individual's lifetime. The effects of SDOH are associated with disparities in patient-reported outcomes after hip and knee arthroplasty, but its impact on rotator cuff repair (RCR) is poorly understood. This study aimed to investigate the influences that SDOH have on accessing appropriate orthopedic treatment, as well as its effects on patient-reported outcomes following RCR. METHODS: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and guidelines outlined by the Cochrane Collaboration. A search of PubMed, the Cochrane Library, and Embase from inception until March 2022 was conducted to identify studies reporting at least 1 SDOH and its effect on access to health care, clinical outcomes, or patient-reported outcomes following RCR. The search term was created with reference to the PROGRESS-Plus framework. Methodological quality of included primary studies was appraised using the Newcastle-Ottawa Scale (NOS) for nonrandomized studies, and the Cochrane Risk of Bias Tool for randomized studies. RESULTS: Thirty-two studies (level I-IV evidence) from 18 journals across 7 countries, published between 1999 and 2022, met inclusion criteria, including 102,372 patients, 669 physical therapy (PT) clinics, and 71 orthopedic surgery practices. Multivariate analysis revealed female gender, labor-intensive occupation and worker's compensation claims, comorbidities, tobacco use, federally subsidized insurance, lower education level, racial or ethnic minority status, low-income place of residence and low-volume surgery regions, unemployment, and preoperative narcotic use contribute to delays in access to health care and/or more severe disease state on presentation. Black race patients were found to have significantly worse postoperative clinical and patient-reported outcomes and experienced more pain following RCR. Furthermore, Black and Hispanic patients were more likely to present to low-volume surgeons and low-volume facilities. A lower education level was shown to be an independent predictor of poor surgical and patient-reported outcomes as well as increased pain and worse patient satisfaction. Patients with federally subsidized insurance demonstrated significantly worse postoperative clinical and patient-reported outcomes CONCLUSIONS: The impediments created by SDOH lead to worse clinical and patient-reported outcomes following RCR including increased risk of postoperative complications, failed repair, higher rates of revision surgery, and decreased ability to return to work. Orthopedic surgeons, policy makers, and insurers should be aware of the aforementioned SDOH as markers for characteristics that may predispose to inferior outcomes following RCR.

Indication matters: effect of indication on clinical outcome following reverse total shoulder arthroplasty-a multicenter study.

BACKGROUND: As the utilization and success of reverse total shoulder arthroplasty (RTSA) have continued to grow, so have its surgical indications. Despite the adoption of RTSA for the treatment of glenohumeral osteoarthritis (GHOA) with an intact rotator cuff and irreparable massive rotator cuff tears (MCTs) without arthritis, the literature remains sparse regarding the differential outcomes after RTSA among these varying indications. Thus, the purpose of this study was to examine the postoperative clinical outcomes of RTSA based on indication. METHODS: A retrospective review of 2 large institutional databases was performed to identify all patients who underwent RTSA between 2015 and 2019 with minimum 2-year follow-up. Patients were stratified by indication into 3 cohorts: GHOA, rotator cuff tear arthropathy (CTA), and MCT. Baseline demographic characteristics were collected to determine differences between the 3 cohorts. Clinical outcomes were measured preoperatively and postoperatively, including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation score, and visual analog scale pain score. Multivariate linear regression was performed to determine the factors independently predictive of the postoperative ASES score. RESULTS: A total of 625 patients (383 with GHOA, 164 with CTA, and 78 with MCTs) with a mean follow-up period of 33.4 months were included in the analysis. Patients with GHOA had superior ASES scores (85.6 ± 15.7 vs. 76.6 ± 20.8 in CTA cohort [P < .001] and 75.9 ± 19.9 in MCT cohort [P < .001]), Single Assessment Numeric Evaluation scores (86 ± 20.9 vs. 76.7 ± 24.1 in CTA cohort [P < .001] and 74.2 ± 25.3 in MCT cohort [P < .001]), and visual analog scale pain scores (median [interquartile range], 0.0 [0.0-1.0] vs. 0.0 [0.0-2.0] in CTA cohort [P < .001] and 0.0 [0.0-2.0] in MCT cohort [P < .001]) postoperatively. Postoperative active forward elevation (P < .001) and improvement in active external rotation (P < .001) were greatest in the GHOA cohort compared with other indications. Multivariate linear regression demonstrated that the factors independently associated with the postoperative ASES score included a diagnosis of GHOA (ß coefficient, 7.557 [P < .001]), preoperative ASES score (ß coefficient, 0.114 [P = .009]), female sex (ß coefficient, -4.476 [P = .002]), history of surgery (ß coefficient, -3.957 [P = .018]), and postoperative complication (ß coefficient, -13.550 [P < .001]). CONCLUSION: RTSA for the treatment of GHOA generally has superior patient-reported and functional outcomes when compared with CTA and MCTs without arthritis. Long-term follow-up is needed to identify the lasting implications of such outcome differences.

Trends in cannabis use in New Jersey: Effects of COVID-19 and cannabis legalization.

Objectives: With the legalization of cannabis in New Jersey on April 21, 2022, including the licensing of cannabis dispensaries, concerns have arisen about potential adverse events related to cannabis use. Here, we explore temporal trends and risk factors for cannabis-related harm in both adult and pediatric cannabis-related visits at a tertiary care academic institution. Methods: We performed a retrospective chart review and temporal trend analysis via the electronic health record from May 1, 2019 to October 31, 2022, covering 2 years before, and 6 months after, cannabis legalization in New Jersey. The pediatric charts identified were analyzed for root causes of adverse events, and changes in the frequency of specific unsafe practices since cannabis legalization were tracked. Results: We found that adult cannabis ED-related visits significantly increased during the COVID-19 pandemic and remained higher than pre-pandemic levels for the remainder of the study periods, without a significant change upon legalization. Pediatric rates of cannabis-related ED visits did not vary significantly during the study period. The vast majority of visits for children aged 0-12 years were related to accidental cannabis exposures-often a household member's edibles-whereas most visits for older children stemmed from intentional cannabis use. Conclusion: This project highlights the unintended consequences of wider cannabis access in New Jersey. Notably, cannabis use increased even before its legalization, presumably in response to the COVID-19 pandemic and its attendant mental health effects. Rates of cannabis use disorder and its highlight of other concurrent psychiatric disorders are important topics for both clinicians and lawmakers to consider.

Relationship of Subtalar Joint Range of Motion to Ankle Injuries in NBA G League and Collegiate Basketball Players.

BACKGROUND: This study sought to determine whether range of motion (ROM) of the ankle and subtalar joint complex (STJ) is correlated with ankle injuries in National Basketball Association (NBA) G-league and collegiate basketball players to identify an at-risk population that may benefit from participation in an ankle injury prevention program. METHODS: This prospective cohort study encompassed 103 player-seasons (68 collegiate, 35 NBA G-League). Patient demographics, passive ankle and STJ range of motion measurements, anterior drawer, and talar tilt tests were collected at preseason physicals along with plain radiographs. Subtalar eversion and inversion measurements were added to assess the Combination Motion (CM) of the STJ and subtracted to calculate the Subtalar Difference (SD). We defined the ratio of CM to SD as Subtalar Mobility Index (SMI=CM/SD). RESULTS: Twenty-one ankle injuries occurred with 10 405 player exposures yielding an incidence of 2.11/1000 exposures, resulting in 113 days of missed playing time. No direct measures of ankle, subtalar, or combined motion were associated with risk of injury, rejecting our original hypothesis that increased STJ ROM would predispose to ankle injuries. However, we did find that athletes with CM >16 degrees in combination with either SD <6 degrees (P = .025) or SMI >3.75 (P = .032) were nearly 3 times more likely to have an ankle injury (3.14 vs 2.97, respectively). CONCLUSION: Using the predictive subtalar mobility thresholds found in this study may help identify at-risk players that may benefit from targeted ankle injury prevention programs. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Gluteus Maximus Tendon Reference: A Novel Method to Restore Leg Length in Total Hip Arthroplasty With Femoral Bone Loss.

BACKGROUND: Accurate restoration of leg length and proximal femoral geometry is essential for achieving satisfactory outcomes in both primary and revision total hip arthroplasty. Although common landmarks such as the greater trochanter and the lesser trochanter (LT) may be used to measure limb length intraoperatively in primary cases, these landmarks may be absent or disrupted in fractures and revision procedures. We propose the distance between the gluteus maximus tendon gluteal sling (GS) and the center of the femoral head (FHC) as a novel anatomic landmark beyond the zone of injury, which can be used to restore limb length in the setting of proximal femoral bone loss or fracture. METHODS: One hundred healthy hips were retrospectively reviewed using MRI to determine the distance between the proximal edge of the GS and the FHC. Additional measurements were collected including the distance between the GS and the greater trochanter and LT, as well as the FHC to the LT and greater trochanter.Results: The distance between the GS and the femoral head was consistent and measured 8.0 cm (±1.88 cm, SD = 0.66). A moderate positive correlation (r = 0.37, P < 0.001) was observed between patient height and GS to FHC distance. DISCUSSION: The distance between the GS and the center of the femoral head consistently measures 8 cm and can be used to set implant height to restore proximal femoral geometry and leg length in total hip arthroplasty with proximal femoral bone loss.

A Simple Ventilator Designed To Be Used in Shortage Crises: Construction and Verification Testing.

BACKGROUND: The COVID-19 pandemic has demonstrated the possibility of severe ventilator shortages in the near future. OBJECTIVE: We aimed to develop an acute shortage ventilator. METHODS: The ventilator was designed to mechanically compress a self-inflating bag resuscitator, using a modified ventilator patient circuit, which is controlled by a microcontroller and an optional laptop. It was designed to operate in both volume-controlled mode and pressure-controlled assist modes. We tested the ventilator in 4 modes using an artificial lung while measuring the volume, flow, and pressure delivered over time by the ventilator. RESULTS: The ventilator was successful in reaching the desired tidal volume and respiratory rates specified in national emergency use resuscitator system guidelines. The ventilator responded to simulated spontaneous breathing. CONCLUSIONS: The key design goals were achieved. We developed a simple device with high performance for short-term use, made primarily from common hospital parts and generally available nonmedical components to avoid any compatibility or safety issues with the patient, and at low cost, with a unit cost per ventilator is less than $400 US excluding the patient circuit parts, that can be easily manufactured.

Association between interleukin­33 and ovarian cancer.

Ovarian cancer is the leading cause of cancer­ associated mortality in the female reproductive system. Interleukin (IL)­33 and its receptor IL 1 receptor like 1 (also termed ST2) are expressed by many cell types including epithelial cells. The role of IL­33 in the pathogenesis of neoplasia remains controversial. The authors previously demonstrated that IL­33 inhibits the growth of pancreatic cancer cells. The present study was performed to explore if IL­33 has any direct effects on ovarian cancer cells. A clonogenic survival assay, immunohistochemistry (IHC), proliferation kit and caspase­3 activity kit were all used to evaluate the direct effects of IL­33 on cell proliferation and apoptosis of a widely studied ovarian cancer cell line, A2780. The possible molecular mechanisms were further evaluated with reverse transcription­polymerase chain reaction and IHC. It was demonstrated that the percentage of colonies and the optical density value of cancer cells were all increased in the presence of IL­33; however, the relative caspase­3 activity in cancer cells was decreased in the presence of IL­33. Molecular mechanism studies revealed that the pro­proliferative effect of IL­33 on cancer cells was associated with decreased levels of p27, and the anti­apoptotic effect of IL­33 was associated with levels of Fas cell surface death receptor (Fas) and tumor necrosis factor­related apoptosis­inducing ligand receptor 1 (TRAILR1). Therefore, IL­33 promoted proliferation and inhibited apoptosis of ovarian cancer cells by downregulation of p27, Fas and TRAILR1. Contrary to previous studies demonstrating an anti­tumor effort in pancreatic cancer, the results of the present study indicated that IL­33 exhibited a significant onco­promoting effect on ovarian cancer. Accordingly, the inhibition of IL­33 may be a promising therapeutic strategy for ovarian cancer.

Pain management in paediatric trauma patients with long bone fracture.

OBJECTIVES: This study was done to review and describe the care of paediatric trauma patients with respect to pain assessment and medication administration. METHODS: A retrospective review of paediatric trauma patients, age <16 with a long bone fracture and GCS=15, cared for by our paediatric trauma response team (January 1998-August 2002). A single trained abstractor reviewed all records. Data were descriptively analysed. RESULTS: Fifty-six children were included. All but three received pain medication during resuscitation. The median time to first dose of pain medication after arrival was 20 min (95% CI: 14-29 min). The median pre- and post-treatment pain scores, on a 5-point scale, were 4 and 2, respectively. Vital signs were unaffected. CONCLUSIONS: As a group, our paediatric trauma resuscitation team did a much better job managing pain, in this segment of the population, than the preponderance of existing literature would predict.