Body Mass Index Improvement Reduces Total Knee Arthroplasty Complications Among Patients Who Have Extreme, but Not Severe, Obesity.

BACKGROUND: While morbid obesity has been associated with increased complication risk in primary total knee arthroplasty (TKA), limited evidence is available to attribute decreased surgical complication rates with body mass index (BMI) reduction. METHODS: We retrospectively assessed 464 unilateral TKAs performed in morbidly obese patients, including 158 extremely obese (BMI ≥ 45) and 306 severely obese patients (BMI 40 to 44.9). A detailed medical record review identified concurrent modifiable risk factors and successful preoperative BMI reduction, reaching either a contemporary risk target (BMI < 40) or an institutionally accepted threshold (BMI < 45). Postoperative blood glucose levels and 1-year adverse outcomes (periprosthetic joint infection, wound dehiscence, knee manipulation, periprosthetic fracture) were compared to 557 contemporary control subjects with expected slightly lower (moderate obesity, BMI 35 to 39.9) or sufficiently lower complication risk (overweight, BMI 25 to 29.9). RESULTS: Periprosthetic joint infection and postoperative hyperglycemia were identified more frequently among morbidly obese patients in comparison with a moderately obese control group. Extremely obese patients (BMI ≥ 45) whose BMI improved below 45 had no measurable difference in infection risk from the control group (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.04 to 16.88), while those with a nonimproved BMI had a significantly higher risk (OR 7.70, 95% CI 1.89 to 31.41). No significant differences in the risk for infection were observed between severely obese patients (BMI 40 to 44.9) with preoperative BMI improvement (1.5% rate, OR 1.70, 95% CI 0.17 to 16.57) or nonimprovement (1.7% rate, OR 1.87, 95% CI 0.41 to 8.43). CONCLUSIONS: Preoperative medical optimization may decrease postoperative TKA complications. The findings of this study support BMI improvement for extremely obese patients (BMI ≥ 45). The assignment of 40 BMI as a threshold for otherwise healthy patients may exclude patients from potential surgical benefits without realizing risk reduction.

Telehealth Visits have Lower Non-attendance than Traditional Orthopaedic Clinic Visits.

The use of telemedicine has rapidly expanded in the wake of the COVID pandemic, but its effect on patient attendance remains unknown for different clinicians. This study compared traditional in-clinic visits with telehealth visits by retrospectively reviewing all scheduled orthopaedic clinic visits. Results demonstrated lower rates of cancellations in patients scheduled for telehealth visits as compared to in-clinic visits, during the initial COVID pandemic. In general, physicians can expect a lower cancellation rate than non-physician practitioners.

Do Patients Living in Rural Areas Report Inferior 1-Year Outcomes After Total Knee Arthroplasty? A Matched Cohort Analysis.

BACKGROUND: Rural status has been associated with poor outcomes for several health problems, but its relationship and outcomes following total knee arthroplasty (TKA) has not been fully characterized. Patient-reported outcomes (PROs) are key measures of success following TKA. Therefore, this matched cohort study was designed to test the hypothesis that patients who live in rural settings will report significantly worse PRO scores 1 year after TKA when compared to those who live in urban or suburban settings. METHODS: Patients undergoing TKA at our institution were categorized into urban, suburban, and rural cohorts based on Rural Urban Commuting Area scores using reported living setting zip codes. Cohorts were matched for body mass index classification. Demographic data were extracted from the medical records, and PRO data (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR), Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health and Mental Health, University of California, Los Angeles (UCLA) Activity Score, and Visual Analog Scale Pain were collected preoperatively and 1-year postoperatively. Comparisons across living settings were made using analysis of variance (ANOVA) tests or Chi-square tests. A total of 882 TKA patients (n = 294 per cohort) were analyzed. RESULTS: Patients living in urban areas had significantly lower preoperative pain scores compared to suburban and rural residents. All measured PROs significantly improved from preoperative levels at 1 year post-TKA with no significant differences among living setting cohorts. CONCLUSIONS: In cohorts matched for body mass index, living in a rural setting was not associated with inferior PROs 1 year after TKA. LEVEL OF EVIDENCE: Level 4, retrospective cohort study.

Obesity Severity Predicts Patient Dissatisfaction After Total Knee Arthroplasty.

BACKGROUND: Patient dissatisfaction has been reported in 15 to 20% of traditional total knee arthroplasty (TKA) procedures. While contemporary improvements may have positive effects on patient satisfaction, these may be offset by increasing obesity prevalence among patients who have knee osteoarthritis. We performed this study to determine whether obesity severity impacts patient-reported TKA satisfaction. METHODS: We compared patient demographic characteristics, preoperative expectations, preoperative and minimum 1-year postoperative patient-reported outcome measures as well as postoperative satisfaction level among 229 patients (243 TKAs) who had World Health Organization (WHO) Class II or III obesity (group A), and 287 patients (328 TKAs) who had WHO classifications of normal weight, overweight, or Class I obesity (group B). RESULTS: Group A patients were younger and had more severe preoperative back and contralateral knee pain, more frequent preoperative opioid medication use, and lower preoperative and postoperative patient-reported outcome measures (P < .01). A similar proportion of patients in both groups expected at least 75% improvement (68.5 versus 73.2%, P = .27). While satisfaction was higher than traditional reporting for both groups (89.4 versus 92.6%, P = .19), group A patients were less likely to be highly satisfied (68.1 versus 78.5%, P = .04) and were more likely to be highly dissatisfied (5.1 versus 0.9%, P < .01). CONCLUSIONS: Patients who have Class II and III obesity report greater TKA dissatisfaction. Additional studies should help determine whether specific implant designs or surgical techniques may improve patient satisfaction or whether preoperative counseling should incorporate lower satisfaction expectations for patients who have WHO Class II or III obesity.

Lumbar spine intervertebral disc desiccation is associated with medical comorbidities linked to systemic inflammation.

INTRODUCTION: Symptomatic disc degeneration is a common cause of low back pain. Recently, the prevalence of low back pain has swiftly risen leading to increased patient disability and loss of work. The increase in back pain also coincides with a rapid rise in patient medical comorbidities. However, a comprehensive study evaluating a link between patient's medical comorbidities and their influence on lumbar intervertebral disc morphology is lacking in the literature. METHODS: Electronic medical records (EMR) were retrospectively reviewed to determine patient-specific medical characteristics. Magnetic resonance imaging (MRI) was evaluated for lumbar spine intervertebral disc desiccation and height loss according to the Griffith-modified Pfirrmann grading system. Bivariate and multivariable linear regression analyses assessed strength of associations between patient characteristics and lumbar spine Pfirrmann grade severity (Pfirrmann grade of the most affected lumbar spine intervertebral disc) and cumulative grades (summed Pfirrmann grades for all lumbar spine intervertebral discs). RESULTS: In total, 605 patients (304 diabetics and 301 non-diabetics) met inclusion criteria. Bivariate analysis identified older age, diabetes, American Society of Anesthesiologists (ASA) class, hypertension, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, and hypothyroidism as being strongly associated with an increasing cumulative Pfirrmann grades. Multivariable models similarly found an association linking increased cumulative Pfirrmann grades with diabetes, hypothyroidism, and hypertension, while additionally identifying non-white race, heart disease, and previous lumbar surgery. Chronic pain, depression, and obstructive sleep apnea (OSA) were associated with increased Pfirrmann grades at the most affected level without an increase in cumulative Pfirrmann scores. Glucose control was not associated with increasing severity or cumulative Pfirrmann scores. CONCLUSION: These findings provide specific targets for future studies to elucidate key mechanisms by which patient-specific medical characteristics contribute to the development and progression of lumbar spine disc desiccation and height loss. LEVEL OF EVIDENCE: III (retrospective cohort).

Household Income and Parental Educational Level Affect Post-Operative Opioid Usage in Pediatric Orthopaedic Patients.

Opioid medications are commonly prescribed after pediatric orthopaedic surgery, but there is a critical need to optimize prescribing practice. This study identifies socio-economic characteristics, surgical characteristics, and patient reported psychological factors influencing postoperative opioid use in this population and found that post-operative opioid use in this pediatric orthopaedic population is multifactorial. Physicians should consider implementing protocols for initial opioid prescriptions to cover two to three days following common orthopaedic surgeries for most pediatric patients.

Distribution of cardiomyocyte-selective adeno-associated virus serotype 9 vectors in swine following intracoronary and intravenous infusion.

Limited reports exist regarding adeno-associated virus (AAV) biodistribution in swine. This study assessed biodistribution following antegrade intracoronary and intravenous delivery of two self-complementary serotype 9 AAV (AAV9sc) biologics designed to target signaling in the cardiomyocyte considered important for the development of heart failure. Under the control of a cardiomyocyte-specific promoter, AAV9sc.shmAKAP and AAV9sc.RBD express a small hairpin RNA for the perinuclear scaffold protein muscle A-kinase anchoring protein ß (mAKAPß) and an anchoring disruptor peptide for p90 ribosomal S6 kinase type 3 (RSK3), respectively. Quantitative PCR was used to assess viral genome (vg) delivery and transcript expression in Ossabaw and Yorkshire swine tissues. Myocardial viral delivery was 2-5 × 105 vg/µg genomic DNA (gDNA) for both infusion techniques at a dose ∼1013 vg/kg body wt, demonstrating delivery of ∼1-3 viral particles per cardiac diploid genome. Myocardial RNA levels for each expressed transgene were generally proportional to dose and genomic delivery, and comparable with levels for moderately expressed endogenous genes. Despite significant AAV9sc delivery to other tissues, including the liver, neither biologic induced toxic effects as assessed using functional, structural, and circulating cardiac and systemic markers. These results indicate successful targeted delivery of cardiomyocyte-selective viral vectors in swine without negative side effects, an important step in establishing efficacy in a preclinical experimental setting.

Regional Differences in Serious Psychological Distress and Overall Physical and Mental Health.

To determine regional differences in the prevalence of overall physical health, overall mental health, and serious psychological distress (SPD). Data from the 2004 to 2016 Medical Expenditure Panel Survey were used for weighted analysis across region. Relationship modifiers considered were sociodemographic factors, health factors, and measures of health expenditures. A higher burden ratio of health care expenditures is negatively associated with health outcomes, across all US regions and insurance. Compared to 2004 values, SPD, overall physical health, and mental health are significantly improved after 2014. This research supports the whole health paradigm, indicating that overall mental and physical health are closely related. The burden of health care costs is an important consideration and related to overall health outcomes, regardless of insurance status or region. These considerations are likely increasingly important to consider with recent global events.

DXA2: An Automated Program for Extraction of Dual-Energy X-Ray Absorptiometry Data.

INTRODUCTION/BACKGROUND: Since the 1970s imaging devices have been rapidly advancing to provide researchers, clinicians, radiologists, and practitioners greater capabilities to image bone. Today, dual-energy X-ray absorptiometry (DXA) has emerged as the gold standard for the assessment of bone and body composition. Despite recent improvements in DXA image quality and reduced radiation dosages and scan times, the data extraction process has yet to be streamlined. The objective of this study was to design an application to allow DXA users to quickly and accurately transfer DXA report data directly into a user-friendly format. METHODOLOGY: Initial development of the DXA Data Xtraction Assistant (DXA2) included processing 485 DXA reports from a previous study. Using Python script, numeric data from these DXA reports were converted to .csv files and then merged into one file, effectively compiling and organizing all table data from each report, by participant and visit number. A graphical user interface was then developed and beta tested using multiple DXA manufacturers, models, and software versions. To compare the effectiveness of the DXA2 to the current standard of manual extraction, all 485 reports were manually transcribed into Microsoft Excel. The time required per report and the error rates were compared. RESULTS: Manual transcription, by an experienced researcher, took over 10 h with an error rate of 0.6% and average error magnitude of 51%. Data extraction from DXA2 took less than 25 min to retrospectively reformat all DXA reports for the DXA2 and transcribe all 485 reports with 100% accuracy. CONCLUSION: The DXA2 application automates DXA report data extraction and aggregation for clinical, research, and applied settings and drastically reduces manual data entry time and eliminates transcription errors.

Geometric morphometric analysis of growth patterns among facial types.

INTRODUCTION: Extreme patterns of vertical facial divergence are of great importance to clinicians because of their association with dental malocclusion and functional problems of the orofacial complex. Understanding the growth patterns associated with vertical facial divergence is critical for clinicians to provide optimal treatment. This study evaluates and compares growth patterns from childhood to adulthood among 3 classifications of vertical facial divergence using longitudinal, lateral cephalograms from the Craniofacial Growth Consortium Study. METHODS: Participants (183 females, 188 males) were classified into 1 of 3 facial types on the basis of their adult mandibular plane angle (MPA): hyperdivergent (MPA >39°; n = 40), normodivergent (28° ≤ MPA ≤ 39°; n = 216), and hypodivergent (MPA <28°; n = 115). Each individual had 5 cephalograms between ages 6 and 20 years. A set of 36 cephalometric landmarks were digitized on each cephalogram. Landmark configurations were superimposed to align 5 homologous landmarks of the anterior cranial base and scaled to unit centroid size. Growth trajectories were calculated using multivariate regression for each facial type and sex combination. RESULTS: Divergent growth trajectories were identified among facial types, finding more similarities in normodivergent and hypodivergent growth patterns than either share with the hyperdivergent group. Through the use of geometric morphometric methods, new patterns of facial growth related to vertical facial divergence were identified. Hyperdivergent growth exhibits a downward rotation of the maxillomandibular complex relative to the anterior cranial base, in addition to the increased relative growth of the lower anterior face. Conversely, normodivergent and hypodivergent groups exhibit stable positioning of the maxilla relative to the anterior cranial base, with the forward rotation of the mandible. Furthermore, the hyperdivergent maxilla and mandible become relatively shorter and posteriorly positioned with age compared with the other groups. CONCLUSIONS: This study demonstrates how hyperdivergent growth, particularly restricted growth and positioning of the maxilla, results in a higher potential risk for Class II malocclusion. Future work will investigate growth patterns within each classification of facial divergence.

What Are the Risk Factors for an Upper Extremity Deep Venous Thrombosis After Orthopaedic Irrigation and Debridement and Peripherally Inserted Central Catheter Placement?

BACKGROUND: Peripherally inserted central catheter (PICC) placement is necessary for delivery of intravenous (IV) antibiotics to treat bone and soft tissue infections. Upper extremity deep venous thrombosis (DVT) after PICC placement is a complication with unknown incidence in the orthopaedic literature. The major objectives of this study are Identifying the rate of upper extremity PICC-associated DVTs after orthopaedic procedures;Which orthopaedic subspecialties are most likely to encounter an upper extremity PICC-associated DVT?What surgeries or medical comorbidities are risk factors for upper extremity PICC-associated DVTs?Does type of DVT chemoprophylaxis decrease the risk of an upper extremity PICC-associated DVT? METHODS: A retrospective review of electronic medical records (EMR) was performed to include all patients undergoing irrigation and debridement (I&D) for treatment of orthopaedic surgery-related infections over a 10-year period. All patients with PICC placement were included for analyses. Age, sex, and medical comorbidities were extracted from the EMR. Mann-Whitney non-parametric tests, Fisher's exact tests, Chi-square tests, and Cochran-Mantel-Haenszel (CMH) tests were used to determine associations with DVT events for those with PICCs based on medical comorbidities, PICC lumen size, team placing the PICC, impact of implant removal, and protective effect of DVT chemoprophylaxis. Significance was set at p<0.05. RESULTS: Twenty-one of 660 patients (3.18% rate) were found to have an upper extremity PICC-associated DVT. A history of DVT (OR=8.99 [95% CI: 3.39, 49.42]) was significantly associated with an upper extremity PICC-associated DVT. The greatest risk for an upper extremity PICC-associated DVT was intramedullary implant removal (OR=12.43 [95% CI: 3.13, 49.52]). The type of DVT chemoprophylaxis did not significantly affect the likelihood of an upper extremity PICC-associated DVT. CONCLUSION: Intramedullary implant removal and a history of DVT are risk factors for an upper extremity PICC-associated DVT. The results of this study should be of particular interest to surgeons who do not typically give DVT prophylaxis and plan to perform surgery on patients with CHF, a history of a DVT, or plan to manipulate the intramedullary canal.

Tissue-specific small heat shock protein 20 activation is not associated with traditional autophagy markers in Ossabaw swine with cardiometabolic heart failure.

The small heat shock protein 20 (HSPB6) emerges as a potential upstream mediator of autophagy. Although autophagy is linked to several clinical disorders, how HSPB6 and autophagy are regulated in the setting of heart failure (HF) remains unknown. The goal of this study was to assess the activation of the HSPB6 and its association with other well-established autophagy markers in central and peripheral tissues from a preclinical Ossabaw swine model of cardiometabolic HF induced by Western diet and chronic cardiac pressure overload. We hypothesized HSPB6 would be activated in central and peripheral tissues, stimulating autophagy. We found that autophagy in the heart is interrupted at various stages of the process in a chamber-specific manner. Protein levels of HSPB6, Beclin 1, and p62 are increased in the right ventricle, whereas only HSPB6 was increased in the left ventricle. Unlike the heart, samples from the triceps brachii long head showed only an increase in the protein level of p62, highlighting interesting central versus peripheral differences in autophagy regulation. In the right coronary artery, total HSPB6 protein expression was decreased and associated with an increase in LC3B-II/LC3B-I ratio, demonstrating a different mechanism of autophagy dysregulation in the coronary vasculature. Thus, contrary to our hypothesis, activation of HSPB6 was differentially regulated in a tissue-specific manner and observed in parallel with variable states of autophagy markers assessed by protein levels of LC3B, p62, and Beclin 1. Our data provide insight into how the HSPB6/autophagy axis is regulated in a preclinical swine model with potential relevance to heart failure with preserved ejection fraction.NEW & NOTEWORTHY Our study shows that the activation of HSPB6 is tissue specific and associated with variable states of downstream markers of autophagy in a unique preclinical swine model of cardiometabolic HF with potential relevance to HFpEF. These findings suggest that targeted approaches could be an important consideration regarding the development of drugs aimed at this intracellular recycling process.

Metabolic responses of meniscal tissue to focal collagenase degeneration.

Purpose: The objective of this study was to determine the responses of normal meniscus to collagenase activity. It was hypothesized that meniscal explants exposed to collagenase would significantly increase release of pro-inflammatory cytokines and degradative enzymes, in a dose-dependent manner, compared to control.Methods: Menisci were harvested from adult dogs (n = 6) euthanized for reasons unrelated to this study. Meniscal explants were created from the central portion of lateral and medial meniscus. Explants were injected with 100 µl collagenase at a concentration of 50 µg/ml, 5 µg/ml, or 0 µg/ml of collagenase. Explants were cultured for 12 days, and media were changed and collected every 3 days for biomarker analyses. Differences among collagenase concentrations were determined by a three factor ANOVA with adjustment for multiple comparisons, with pre-adjustment statistical significance set at p < 0.05.Results: When data from all explants were compared, the 50 µg group released significantly higher IL-6 and PGE2, and the 5 µg group released significantly higher levels of MMP-3 and CTX-II compared to the 0 µg group. Explants from the medial meniscus released significantly more MMP-1, MMP-2, MMP-3, and MMP-13 in response to stimulation with 5 µg/ml of collagenase compared to explants from the lateral meniscus.Discussion: The data from this study indicate that in response to localized degradative enzyme activity, the meniscus increases the release of pro-inflammatory and degradative biomarkers in a dose-dependent manner. Further, these data indicate potential differences in metabolic responses of lateral versus medial menisci to collagenase insult.

Clinical implications of age-related change of the mandibular plane angle.

OBJECTIVE: To identify trajectories of ontogenetic change in the mandibular plane angle (MPA) and to describe the influence of sex and other factors on MPA during growth. SETTING/SAMPLE: The data consisted of 7026 MPA measurements from lateral cephalographs representing longitudinal series from ages 6 to 21 for 728 individuals from the Craniofacial Growth Consortium Study (CGCS). MATERIALS AND METHODS: Facial type was determined from MPA for each assessment, with the assessment closest to age 18 representing the adult facial type. The sample includes 366 males and 362 females, each with between 2 and 15 cephalographs. The mean number of cephalographs per individual is 10. Variation in childhood MPA (earliest assessment between 6 and 9 years of age) and adult MPA (closest assessment to age 18 between 15 and 21 years of age), and change in MPA from childhood to adulthood were compared by sex and adult facial type using ANOVA and post hoc t tests. RESULTS: Mandibular plane angle decreased from childhood to adulthood in 92% of males and 81% of females, yet increased in 36% of males and 50% of females with the hyper-divergent adult facial type. Childhood MPA and overall change in MPA were significantly different by adult facial type. CONCLUSIONS: Adult facial type is associated with differences in childhood MPA and change in MPA during growth. There are multiple ontogenetic pathways by which an individual can achieve a normo-divergent adult facial type, and an individual's childhood MPA does not necessarily correspond to his or her adult facial type.

A Surgical Mouse Model for Advancing Laryngeal Nerve Regeneration Strategies.

Iatrogenic recurrent laryngeal nerve (RLN) injury is a morbid complication of anterior neck surgical procedures. Existing treatments are predominantly symptomatic, ranging from behavioral therapy to a variety of surgical approaches. Though laryngeal reinnervation strategies often provide muscle tone to the paralyzed vocal fold (VF), which may improve outcomes, there is no clinical intervention that reliably restores true physiologic VF movement. Moreover, existing interventions neglect the full cascade of molecular events that affect the entire neuromuscular pathway after RLN injury, including the intrinsic laryngeal muscles, synaptic connections within the central nervous system, and laryngeal nerve anastomoses. Systematic investigations of this pathway are essential to develop better RLN regenerative strategies. Our aim was to develop a translational mouse model for this purpose, which will permit longitudinal investigations of the pathophysiology of iatrogenic RLN injury and potential therapeutic interventions. C57BL/6J mice were divided into four surgical transection groups (unilateral RLN, n = 10; bilateral RLN, n = 2; unilateral SLN, n = 10; bilateral SLN, n = 10) and a sham surgical group (n = 10). Miniaturized transoral laryngoscopy was used to assess VF mobility over time, and swallowing was assessed using serial videofluoroscopy. Histological assays were conducted 3 months post-surgery for anatomical investigation of the larynx and laryngeal nerves. Eight additional mice underwent unilateral RLN crush injury, half of which received intraoperative vagal nerve stimulation (iVNS). These 8 mice underwent weekly transoral laryngoscopy to investigate VF recovery patterns. Unilateral RLN injury resulted in chronic VF immobility but only acute dysphagia. Bilateral RLN injury caused intraoperative asphyxiation and death. VF mobility was unaffected by SLN transection (unilateral or bilateral), and dysphagia (transient) was evident only after bilateral SLN transection. The sham surgery group retained normal VF mobility and swallow function. Mice that underwent RLN crush injury and iVNS treatment demonstrated accelerated and improved VF recovery. We successfully developed a mouse model of iatrogenic RLN injury with impaired VF mobility and swallowing function that can serve as a clinically relevant platform to develop translational neuroregenerative strategies for RLN injury.

Estimating peak height velocity in individuals: a comparison of statistical methods.

BACKGROUND: Estimates pertaining to the timing of the adolescent growth spurt (e.g. peak height velocity; PHV), including age at peak height velocity (aPHV), play a critical role in the diagnosis, treatment, and management of skeletal growth and/or developmental disorders. Yet, distinct statistical methodologies often result in large estimate discrepancies. AIM: The aim of the present study was to assess the advantages and disadvantages of three modelling methodologies for height as well as to determine how estimates derived from these methodologies may differ, particularly those that may be useful in paediatric clinical practice. SUBJECTS AND METHODS: Height data from 686 individuals of the Fels Longitudinal Study were modelled using 5th order polynomials, natural cubic splines, and SuperImposition by Translation and Rotation (SITAR) to determine aPHV and PHV for all individuals together (i.e. population average) by sex and separately for each individual. Estimates within and between methodologies were calculated and compared. RESULTS: In general, mean aPHV was earlier, and PHV was greater for individuals when compared to estimates from population average models. Significant differences between mean aPHV and PHV for individuals were observed in all three methodologies, with SITAR exhibiting the latest aPHV and largest PHV estimates. CONCLUSION: Each statistical methodology has a number of advantages when used for specific purposes. For modelling growth in individuals, as one would in paediatric clinical practice, we recommend the use of the 5th order polynomial methodology due to its parameter flexibility.

Predicting adult facial type from mandibular landmark data at young ages.

OBJECTIVES: To assess the potential of predicting adult facial types at different stages of mandibular development. SETTING AND SAMPLE POPULATION: A total of 941 participants from the Bolton-Brush, Denver, Fels, Iowa, Michigan and Oregon growth studies with longitudinal lateral cephalograms (total of 7166) between ages 6-21 years. MATERIAL AND METHODS: Each participant was placed into one of three facial types based on mandibular plane angle (MPA) from cephalograms taken closest to 18 years of age (range of 15-21 years): hypo-divergent (MPA < 28°), normo-divergent (28°≤ MPA ≤ 39°) and hyper-divergent (MPA > 39°). Cephalograms were categorized into 13 age groups 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18-21. Twenty-three two-dimensional anatomical landmarks were digitized on the mandible and superimposed using generalized Procrustes analysis, which projects landmarks into a common shape space. Data were analysed within age categories using stepwise discriminant analysis to identify landmarks that distinguish adult facial types and by jackknife cross-validation to test how well young individuals can be reclassified into their adult facial types. RESULTS: Although each category has multiple best discriminating landmarks among adult types, three landmarks were common across nearly all age categories: menton, gonion and articulare. Individuals were correctly classified better than chance, even among the youngest age category. Cross-validation rates improved with age, and hyper- and hypo-divergent groups have better reclassification rates than the normo-divergent group. CONCLUSIONS: The discovery of important indicators of adult facial type in the developing mandible helps improve our capacity to predict adult facial types at a younger age.

Dual-Agent Antibiotic Prophylaxis Using a Single Preoperative Vancomycin Dose Effectively Reduces Prosthetic Joint Infection Rates With Minimal Renal Toxicity Risk.

BACKGROUND: We performed this study to compare prosthetic joint infection (PJI) and renal toxicity rates following hip and knee total joint arthroplasty (TJA) when a first-generation cephalosporin was administered either alone or in combination with a single preoperative vancomycin dose, whether vancomycin administration timing potentially influenced dual-antibiotic PJI prophylaxis approach effectiveness, and whether single-dose vancomycin use increased risk of renal impairment. METHODS: This was a retrospective study of 1997 consecutive primary TJAs (1871 patients) treated with cefazolin alone (1044 TJAs) or cefazolin with single-dose vancomycin (953 TJAs). The vancomycin group included 476 TJAs (450 patients) with infusion started at least 45 minutes before the skin incision and 477 TJAs (464 patients) with infusion started less than 45 minutes before the skin incision. RESULTS: The addition of a single dose of vancomycin did not significantly reduce PJI rates when compared with cefazolin alone (1.6% vs 2.1%, P = .32). However, the PJI rate was significantly lower following primary TJA when vancomycin administration was initiated at least 45 minutes before incision (0.2%) when compared with other TJA procedures performed using cefazolin and vancomycin (2.9%, P < .01) or cefazolin alone (2.1%, P < .01). We observed no difference in renal toxicity between treatment groups. CONCLUSION: In our institution, the addition of vancomycin to cefazolin at least 45 minutes before incision reduced PJI infection rates in primary hip and knee TJA with a low risk of renal impairment.

Social engagement and survival in people aged 50 years and over living with HIV and without HIV in Uganda: a prospective cohort study.

This study examined the association between social engagement and survival in people with or without HIV aged 50 years and over in Uganda. We analysed two waves of a survey from two sites in Uganda to assess predictors of mortality between waves. The first wave was conducted between 2009 and 2010 while the second wave was conducted between 2012 and 2013. A standardised questionnaire adapted from the World Health Organization study on global AGEing and adult health (SAGE) was administered through face-to-face interviews at both survey waves. Cox proportional hazards models and Nelson-Aalen cumulative hazards functions were used to investigate associations between the strength of participants' social ties, using distance and intimacy metrics, and their social engagement with mortality between waves. Of the original 510 participants, 63 (12.3%) died between waves. Being more socially engaged and able to provide in-kind or financial contributions to family or friends were protective. After adjusting for covariates neither social tie measure was predictive of mortality. There were no significant differences in social engagement and survival by HIV status. Further research is needed in African settings on the relationship between social relationships and subsequent mortality in older adults to assess if improved social relationships could moderate mortality.

The association of catastrophizing with quality-of-life outcomes in patients with irritable bowel syndrome.

BACKGROUND: Catastrophizing is a cognitive process characterized by a propensity to concentrate on and magnify the value of an actual or anticipated painful stimulus and negatively assesses one's ability to cope. Catastrophizing is an important predictor of pain-related outcomes. A cornerstone symptom of irritable bowel syndrome (IBS) is abdominal pain or discomfort. Also individuals with IBS have been reported to have a tendency to catastrophize. In a sample of individuals who suffer from IBS, we hypothesized that those individuals who catastrophize (catastrophizers) would have worse outcomes as compared to those who do not catastrophize (non-catastrophizers). METHODS: One hundred and one adults with IBS (79% female, mean age 42 years, 97% Caucasian) were recruited from outpatient clinics and data were collected through self-report measures. Catastrophizing was measured with the catastrophizing subscale of the Coping Strategies Questionnaire, illness representations were measured with The Revised Illness Perception Questionnaire (IPQ-R), psychological distress was measured with the Brief Symptom Inventory 18 (BSI-18), and health-related quality of life was measured using the Irritable Bowel Syndrome-Quality of Life (IBS-QOL) measure. Descriptive statistics, correlations, and multiple linear regression analyses were completed to describe participants, the associations of the variables of interest, and the unique relationship between psychosocial variables and HRQOL. RESULTS: Overall, participants reported poor HRQOL (M = 63.32, range 0-100). Catastrophizers differed significantly on IBS-QOL from non-catastrophizers (M = 48.98 vs. non-catastrophizers M = 78.53; p < 0.001), BSI-18 (M = 21.35 vs. non-catastrophizers M = 6.76; p < 0.001), and IPQ-R, specifically the consequences (M = 21.75 vs. non-catastrophizers M = 17.20; p < 0.001) and emotional representations (M = 20.90 vs. non-catastrophizers M = 15.43; p < 0.001). Catastrophizing was positively correlated with the consequences (r = .54; p < 0.01) and emotional representations (r = .65; p < 0.01) and negatively correlated with total HRQOL (r = -0.76; p < 0.01). CONCLUSION: The findings indicated that participants who catastrophized reported worse psychosocial and functional outcomes. Thus, catastrophizing, in addition to psychological distress variables, may be an important factor to address in optimizing health outcomes in individuals with IBS. In addition, illness perceptions were strongly related to catastrophizing and HRQOL; assessment and integration of illness perceptions as well as catastrophizing into the management of individuals who suffer with IBS may maximize the health outcomes.