The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair.

BACKGROUND: In the United States, the use of testosterone therapy has increased over recent years. Anabolic steroid use has been associated with tendon rupture, although there is a paucity of evidence evaluating the risk of biceps tendon injury (BTI) with testosterone therapy. The aim of this study was to quantify the risk of BTI after the initiation of testosterone therapy. METHODS: This was a retrospective cohort study using the PearlDiver database. Records between 2011 and 2018 were queried to identify patients aged 35-75 years who filled a testosterone prescription for a minimum of 3 months. A control group was created, comprising patients aged 35-75 years who had never filled a prescription for exogenous testosterone. International Classification of Diseases, Ninth Revision, International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes were used to identify patients with distal biceps injuries and those undergoing surgical repair. Three matching processes were completed: one for the overall cohort, one for the cohort comprising only male patients, and one for the cohort comprising only female patients. Each cohort was matched to its control on age, sex, Charlson Comorbidity Index, diabetes, tobacco use, and osteoporosis. Multivariate logistic regression was used to compare rates of distal BTI and subsequent surgical repair in the testosterone groups with their control groups. RESULTS: A total of 776,974 patients had filled a prescription for testosterone for a minimum of 3 consecutive months. In the overall matched analysis between the testosterone and control groups (n = 291,610 in both), the mean age of the patients was 53.9 years and 23.1% were women. Within 1 year of filling exogenous testosterone prescriptions for a minimum of 3 consecutive months, 650 patients experienced a distal BTI compared with 159 patients in the control group (odds ratio [OR], 4.10; 95% confidence interval [CI], 3.45-4.89; P < .001). At any time after testosterone therapy, patients with testosterone use were more than twice as likely to experience a distal BTI as their matched controls (OR, 2.07; 95% CI, 1.94-2.38). Patients who filled prescriptions for testosterone were more likely to undergo surgical repair within a year of the injury compared with the control group. A similar trend was seen in the cohort comprising male patients (OR, 1.63; 95% CI, 1.29-2.07). CONCLUSION: Patients with prior prescription testosterone exposure have an increased rate of BTI and biceps tendon repair compared with patients without such exposure. This finding provides insight into the risk profile of testosterone therapy, and doctors should consider counseling patients about this risk, particularly male patients.

Characterization of the Epidemiology and Risk Factors for Hand Fractures in Patients Aged 1 to 19 Presenting to United States Emergency Departments: A Retrospective Study of 21,031 Cases.

BACKGROUND: Hand fractures are among the most common injuries presenting in pediatric emergency departments (EDs) with incidence reported as high as 624 hand fractures per 100,000 person-years. If gone untreated, these injuries can lead to pain, loss of function, and psychological trauma. The purpose of this study was to identify risk factors and characterize pediatric hand fractures over a 5-year period. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for all hand fractures in patients aged 1 to 19 years presenting to US EDs between 2016 and 2020. Incidence was calculated using US census data. Cases were retrospectively analyzed using age, location of the injury, sex, coronavirus disease-2019 (COVID-19) era, and etiology of injury. Bivariate logistic regression was used where appropriate. RESULTS: A total of 21,031 pediatric hand fractures were identified, representing an estimated 565,833 pediatric hand fractures presenting to EDs between 2016 and 2020. The mean incidence of pediatric hand fractures was 138.3 fractures for 100,000 person-years [95% confidence interval (CI): 136.2-140.4], with a 39.2% decrease in incidence occurring between 2019 and 2020. It was found that 42.2% of the fractures were in patients aged 10 to 14. The incidence of hand fractures for males and females was 97.9 (95% CI: 96.2-99.7) and 40.4 (95% CI: 39.2-41.5), respectively, with the male rate peaking at age 14 and the female rate peaking at age 12. Age, sex, location of the injury, and injury during the COVID-19 pandemic were demonstrated to influence the frequency and etiology of the fracture. CONCLUSION: This study determined the incidence of pediatric hand fractures presenting to EDs across the United States. In addition, it identified risk factors for common hand fracture etiologies (sports-related, falling, crush, punching) and demonstrated the change in rates of different etiologies of pediatric hand fractures that presented to US EDs during the COVID-19 pandemic. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases.

BACKGROUND: Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF. METHODS: Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant. RESULTS: Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988). CONCLUSIONS: There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

Testosterone replacement therapy is associated with increased odds of Achilles tendon injury and subsequent surgery: a matched retrospective analysis.

BACKGROUND: Prescription of testosterone replacement therapy (TRT) has increased in the United States in recent years, and though anabolic steroids have been associated with tendon rupture, there is a paucity of literature evaluating the risk of Achilles tendon injury with TRT. This study aims to evaluate the associative relationship between consistent TRT, Achilles tendon injury, and subsequent surgery. METHODS: This is a one-to-one matched retrospective cohort study utilizing the PearlDiver database. Records were queried for patients aged 35-75 who were prescribed at least 3 consecutive months of TRT between January 1, 2010 and December 31, 2019. Achilles tendon injuries and subsequent surgeries were identified using ICD-9, ICD-10, and CPT billing codes. Multivariable logistic regression was used to compare odds of Achilles tendon injury, Achilles tendon surgery, and revision surgery, with a p-value < 0.05 representing statistical significance. RESULTS: A sample of 423,278 patients who filled a TRT prescription for a minimum of 3 consecutive months was analyzed. The 2-year incidence of Achilles tendon injury was 377.8 (95% CI, 364.8-391.0) per 100,000 person-years in the TRT cohort, compared to 245.8 (95% CI, 235.4-256.6) in the control (p < 0.001). The adjusted analysis demonstrated TRT to be associated with a significantly increased likelihood of being diagnosed with Achilles tendon injury (aOR = 1.24, 95% CI, 1.15-1.33, p < 0.001). Of those diagnosed with Achilles tendon injury, 287/3,198 (9.0%) of the TRT cohort subsequently underwent surgery for their injury, compared to 134/2,081 (6.4%) in the control cohort (aOR = 1.54, 95% CI, 1.19-1.99, p < 0.001). CONCLUSIONS: There is a significant association between Achilles tendon injury and prescription TRT, with a concomitantly increased rate of undergoing surgical management. These results provide insight into the risk profile of TRT and further research into the science of tendon pathology in the setting of TRT is an area of continued interest.

Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients.

BACKGROUND: Psychiatric comorbidities have been shown to influence outcomes of various orthopedic pathologies. This study aimed to compare rates of delayed scaphoid union and surgical intervention for fractures in patients with and without comorbid psychiatric diagnoses. METHODS: A matched retrospective cohort study was performed using the PearlDiver database to determine the association of depression, anxiety, bipolar disorder, and schizophrenia with delayed union rates within 3 and 6 months and rates of nonacute surgical intervention (fixation or grafting) within 6 and 12 months of scaphoid fracture. Analyses were completed using multivariate logistic regression. RESULTS: Among 20 340 patients, a comorbid psychiatric diagnosis was associated with increased rates of delayed scaphoid union at 3 months (odds ratio [OR] = 1.29; 95% confidence interval [CI], 1.14-1.45) and 6 months (OR = 1.23; 95% CI, 1.10-1.38). At 3 months, women with any psychiatric disorder (OR = 1.58; 1.29-1.66), depression (OR = 1.68; 1.31-2.17), and schizophrenia (OR = 5.32; 95% CI, 1.06-26.79) were more likely to experience delayed union, with similar results at 6 months. Men with bipolar disorder experienced increased delayed union rates at 6 months (OR = 1.40; 1.03-1.91). A comorbid psychiatric diagnosis (OR = 1.10; 1.01-1.20) was associated with increased rates of surgical intervention, whereas schizophrenia was associated with decreased rates (OR = 0.58; 0.34-0.99). CONCLUSION: Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. These results underscore the importance of understanding factors that may place patients at risk of impaired recovery.

A Comparison of the Rates of Postoperative Infection Following Distal Radius Fixation Between Pediatric and Young Adult Populations: An Analysis of 32 368 Patients.

BACKGROUND: Infection following surgical fixation of a distal radius fracture can markedly compromise a patient's functional outcome. This study aimed to compare infection rates in pediatric (5-14 years) and adolescent (15-17 years) patients undergoing fixation of a distal radius fracture to a cohort of young adult (18-30 years) patients. METHODS: A matched retrospective study was performed using PearlDiver to determine the rates of postoperative infection following distal radius fixation. χ2 and logistic regression were used to assess differences in rates, while linear regression was used to analyze rates of infection over time. RESULTS: In 32 368 patients, young adults experienced postoperative infection at a significantly increased rate (odds ratio [OR] = 1.81; 95% confidence interval [CI], 1.45-2.27). This trend was consistent among the male (OR = 1.96; 1.49-2.57) and female (OR = 2.11, 1.37-3.27) cohorts. In the multivariate model, the adult cohort remained at increased risk (OR = 1.40; 95% CI, 1.04-1.89), with open fracture (OR = 4.99; 3.55-6.87), smoking (OR = 1.76; 1.22-2.48), hypertension (OR = 1.69; 1.20-2.33), and obesity (OR = 1.37; 1.02, 1.80) identified as other significant risk factors. There was no significant change in the rate of postoperative infections over the 11-year study period. CONCLUSION: This study demonstrated that although surgical site infections following distal radius fixation are low in patients aged 30 years or younger (0.97%), young adults develop infections at a significantly increased rate. This is important for surgeons to recognize when counseling patients on the risks of surgical fixation.

Impact of medical school responses during the COVID-19 pandemic on student satisfaction: a nationwide survey of US medical students.

PURPOSE: Medical schools have faced various challenges in preparing their clinical students for the frontlines of a pandemic. This study investigated medical students' satisfaction with their institutions during the coronavirus disease 2019 (COVID-19) pandemic with the intention of guiding educators in future public health crises. METHODS: In this cross-sectional study surveying students in clinical rotations, the primary outcome was overall satisfaction regarding medical schools' responses to the pandemic, and the four secondary outcomes were school communication, exposure to COVID-19, availability of personal protective equipment, and access to COVID-19 testing. RESULTS: The survey was distributed to ten medical schools, of which 430 students responded for a response rate of 13.0%. While most students were satisfied (61.9%, n=266) with their schools' response, more than one in five (21.9%, n=94) were dissatisfied. Among the four secondary outcomes, communication with students was most predictive of overall satisfaction. CONCLUSION: In future crises, schools can best improve student satisfaction by prioritizing timely communication.

Field carcinogenesis for risk stratification of colorectal cancer.

Colorectal cancer (CRC) is characterized by genetic-environmental interplay leading to diffuse changes in the entire colonic mucosa (field carcinogenesis or field of injury) and to a pro-neoplastic genetic/epigenetic/physiological milieu. The clinical consequences are increased risk of synchronous and metachronous neoplasia. Factors such as genetics, race, ethnicity, age, and socioeconomic status are thought to influence neoplasia development. Here, we explore the potential improvement to CRC screening through exploiting field carcinogenesis, with particular focus on racial disparities and chemoprevention strategies. Also, we discuss future directions for field carcinogenesis/risk stratification using molecular and novel biophotonic techniques for personalized CRC screening.

The Role of Clinical Characteristics in Stratifying Sedation Risk: A Cohort Study.

BACKGROUND: Determination of sedation type during gastrointestinal procedures is generally based on risk assessment via the American Society of Anesthesiologists (ASA) classification system, but the reliance of anesthesia risk on clinical factors remains largely uninvestigated. We aim to determine the association between various clinical factors and choice of sedation type during gastrointestinal procedures. METHODS: This single-center, retrospective cohort study used electronic medical records to identify patients receiving colonoscopy or endoscopy at Rhode Island Hospital. The electronic medical record was queried for history of alcohol abuse, opioid abuse, polysubstance abuse, prescriptions for psychotropic or opioid medications and ASA classification. Logistic regression was used to measure how patient characteristics correlated with sedation type. RESULTS: Totally, 2,033 patients were included in the study; 1,080 patients received moderate sedation and 853 received monitored anesthesia care (MAC). Three hundred fifty-four (60.2%) MAC patients had a history of alcohol abuse compared to 234 (39.8%) moderate sedation patients (P < 0.2334); 178 (62.9%) MAC and 105 (37.1%) moderate sedation patients had a history of opioid abuse (P < 0.001); 203 (73.6%) MAC and 73 (26.4%) moderate sedation patients had a history of polysubstance abuse (P < 0.001); and 815 (75.1%) MAC patients had psychiatric comorbidities versus 270 (24.9%) in the moderate sedation group (P < 0.001). In the MAC cohort, alcohol, opioid, polysubstance abuse and psychiatric history were associated with previous failure of moderate sedation (P < 0.0001). CONCLUSIONS: For a subset of patients, clinical factors including alcohol, opioid, polysubstance abuse and psychiatric history, in addition to ASA classification, play an important role in sedation management.

Performance in Real World- and Virtual Reality-Based Spatial Navigation Tasks in Patients With Vestibular Dysfunction.

OBJECTIVE: This study evaluated whether vestibular dysfunction is associated with reduced spatial navigation performance. STUDY DESIGN: Cross-sectional study. SETTING: Otolaryngology Clinic in the Johns Hopkins Outpatient Center and an analogous virtual reality (VR) environment. PATIENTS: Eligible patients had diagnosis of unilateral or bilateral vestibular loss. Matched healthy controls were recruited at 1:1 ratio. INTERVENTIONS: The navigation task involved a route-based or place-based strategy in both real world and VR environments. MAIN OUTCOME MEASURES: Navigation performance was measured by distance travelled relative to optimal distance (i.e., path ratio) and the Judgments of Relative Direction (JRD) task, whereby participants had to recall relative angular distances between landmarks. RESULTS: The study sample included 20 patients with vestibular loss (mean age: 61 yrs, SD: 10.2 yrs) and 20 matched controls (mean age: 60 yrs, SD: 10.4 yrs). Patients with vestibular loss travelled significantly greater distance using both route-based (path ratio 1.3 vs. 1.0, p = 0.02) and place-based (path ratio 2.6 vs. 2.0, p = 0.03) strategies in the real world. Overall, participants performed worse in virtual reality compared to real world in both path ratio (2.2 vs. 1.7; p = 0.04) and JRD error (78° vs. 67°; p < 0.01). Furthermore, while controls exhibited significant positive correlations between real world and VR performance in place-based (ß = 0.75; p < 0.001) and JRD tasks (ß = 0.70; p < 0.001), patients with vestibular loss exhibited no similar correlations. CONCLUSIONS: The vestibular system appears to play a role in navigation ability during both actual and virtual navigation, suggesting a role for static vestibular signals in navigation performance.

Vestibular function and cortical and sub-cortical alterations in an aging population.

While it is well known that the vestibular system is responsible for maintaining balance, posture and coordination, there is increasing evidence that it also plays an important role in cognition. Moreover, a growing number of epidemiological studies are demonstrating a link between vestibular dysfunction and cognitive deficits in older adults; however, the exact pathways through which vestibular loss may affect cognition are unknown. In this cross-sectional study, we sought to identify relationships between vestibular function and variation in morphometry in brain structures from structural neuroimaging. We used a subset of 80 participants from the Baltimore Longitudinal Study of Aging, who had both brain MRI and vestibular physiological data acquired during the same visit. Vestibular function was evaluated through the cervical vestibular-evoked myogenic potential (cVEMP). The brain structures of interest that we analyzed were the hippocampus, amygdala, thalamus, caudate nucleus, putamen, insula, entorhinal cortex (ERC), trans-entorhinal cortex (TEC) and perirhinal cortex, as these structures comprise or are connected with the putative "vestibular cortex." We modeled the volume and shape of these structures as a function of the presence/absence of cVEMP and the cVEMP amplitude, adjusting for age and sex. We observed reduced overall volumes of the hippocampus and the ERC associated with poorer vestibular function. In addition, we also found significant relationships between the shape of the hippocampus (p = 0.0008), amygdala (p = 0.01), thalamus (p = 0.008), caudate nucleus (p = 0.002), putamen (p = 0.02), and ERC-TEC complex (p = 0.008) and vestibular function. These findings provide novel insight into the multiple pathways through which vestibular loss may impact brain structures that are critically involved in spatial memory, navigation and orientation.