Zinc oxide nanoparticles mediate bacterial toxicity in Mueller-Hinton Broth via Zn2.

As antibiotic resistance increases and antibiotic development dwindles, new antimicrobial agents are needed. Recent advances in nanoscale engineering have increased interest in metal oxide nanoparticles, particularly zinc oxide nanoparticles, as antimicrobial agents. Zinc oxide nanoparticles are promising due to their broad-spectrum antibacterial activity and low production cost. Despite many studies demonstrating the effectiveness of zinc oxide nanoparticles, the antibacterial mechanism is still unknown. Previous work has implicated the role of reactive oxygen species such as hydrogen peroxide, physical damage of the cell envelope, and/or release of toxic Zn2+ ions as possible mechanisms of action. To evaluate the role of these proposed methods, we assessed the susceptibility of S. aureus mutant strains, ΔkatA and ΔmprF, to zinc oxide nanoparticles of approximately 50 nm in size. These assays demonstrated that hydrogen peroxide and electrostatic interactions are not crucial for mediating zinc oxide nanoparticle toxicity. Instead, we found that Zn2+ accumulates in Mueller-Hinton Broth over time and that removal of Zn2+ through chelation reverses this toxicity. Furthermore, we found that the physical separation of zinc oxide nanoparticles and bacterial cells using a semi-permeable membrane still allows for growth inhibition. We concluded that soluble Zn2+ is the primary mechanism by which zinc oxide nanoparticles mediate toxicity in Mueller-Hinton Broth. Future work investigating how factors such as particle morphology (e.g., size, polarity, surface defects) and media contribute to Zn2+ dissolution could allow for the synthesis of zinc oxide nanoparticles that possess chemical and morphological properties best suited for antibacterial efficacy.

Medical education during the COVID-19 pandemic: a reflection on the JHUSOM experience.

BACKGROUND: We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students. METHODS: An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors. RESULTS: 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants. CONCLUSIONS: Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students.

Investing in school systems: conceptualising returns on investment across the health, education and social protection sectors.

Public policies often aim to improve welfare, economic injustice and reduce inequality, particularly in the social protection, labour, health and education sectors. While these policies frequently operate in silos, the education sphere can operate as a cross-sectoral link. Schools represent a unique locus, with globally hundreds of millions of children attending class every day. A high-profile policy example is school feeding, with over 400 million students worldwide receiving meals in schools. The benefits of harmonising interventions across sectors with a common delivery platform include economies of scale. Moreover, economic evaluation frameworks commonly used to assess policies rarely account for impact across sectors besides their primary intent. For example, school meals are often evaluated for their impact on nutrition, but they also have educational benefits, including increasing attendance and learning and incorporating smallholder farmers into corporate value chains. To address these gaps, we propose the introduction of a comprehensive value-for-money framework for investments toward school systems that acknowledges the return to a common delivery platform-schools-and the multisectoral returns (eg, education, health and nutrition, labour, social protection) emerging from the rollout of school-based programmes. Directly building on benefit-cost analysis methods, this framework could help identify interventions that yield the highest gains in human capital per budget expenditure, with direct implications for finance ministries. Given the detrimental impact of COVID-19 on schoolchildren and human capital, it is urgent to build back stronger and more sustainable welfare systems.

The Advanced C.A.R.E. Suicide Prevention Gatekeeper Training Questionnaire for medical lecturers and specialists: A psychometric evaluation in a Malaysian sample.

Given the high prevalence rate of suicidal ideation amongst medical students, medical lecturers and specialists as gatekeepers should be well-trained in suicide prevention. There is a need for validated measures to assess gatekeeper training gains for suicide prevention. The psychometric properties of the Advanced C.A.R.E. Suicide Prevention Gatekeeper Training Questionnaire (AdCARE-Q) were evaluated for a sample of medical lecturers and specialists in Malaysia. A total of 120 participants completed 24 items in the AdCARE-Q. Analysis of variance of perceived knowledge scores was performed. Exploratory factor analysis (EFA) was conducted. Reliability was calculated. The AdCARE-Q was reduced to 15 items that fit into two factors, "self-efficacy" and "declarative knowledge." Overall internal consistency was good with Cronbach's alpha = 0.84. The intraclass correlation coefficient between groups from the psychiatry department and non-psychiatry departments was good at 0.80. The oldest age group and participants from the Psychiatry department scored significantly higher than other groups in perceived knowledge of suicide prevention. This study found that the AdCARE-Q has adequate psychometric properties to assess suicide prevention gatekeeper training gains amongst medical lecturers and specialists. Confirmatory factor analysis is recommended for future studies.

Medical Education during the COVID-19 Pandemic: A Reflection on the JHUSOM Experience.

Background: We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students. Methods: An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for the presence of antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors. Results: 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants. Conclusions: Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students.

Rotavirus genotypes in the post-vaccine era: A systematic review and meta-analysis of global, regional, and temporal trends in settings with and without rotavirus vaccine introduction.

BACKGROUND: Even moderate differences in rotavirus vaccine effectiveness against non-vaccine genotypes may exert selective pressures on circulating rotaviruses. Whether this vaccine effect or natural temporal fluctuations underlie observed changes in genotype distributions is unclear. METHODS: We systematically reviewed studies reporting rotavirus genotypes from children <5 years of age globally between 2005 and 2023. We compared rotavirus genotypes between vaccine-introducing and non-introducing settings globally and by World Health Organization (WHO) region, calendar time, and time since vaccine introduction. RESULTS: Crude pooling of genotype data from 361 studies indicated higher G2P[4], a non-vaccine genotype, prevalence in vaccine-introducing settings, both globally and by WHO region. This difference did not emerge when examining genotypes over time in the Americas, the only region with robust longitudinal data. Relative to non-introducing settings, G2P[4] detections were more likely in settings with recent introduction (e.g. 1-2 years post-introduction aOR: 4.39 (95% CI: 2.87-6.72)) but were similarly likely in settings with more time elapsed since introduction, (e.g. 7 or more years aOR (1.62 95% CI: 0.49-5.37)). CONCLUSIONS: When accounting for both regional and temporal trends, there was no substantial evidence of long-term vaccine-related selective pressures on circulating genotypes. Increased prevalence of G2P[4] may be transient after rotavirus vaccine introduction.

Women With Large Vessel Occlusion Acute Ischemic Stroke Are Less Likely to Be Routed to Comprehensive Stroke Centers.

Background Prehospital routing of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) to centers capable of performing endovascular therapy may improve clinical outcomes. Here, we explore whether distance to comprehensive stroke centers (CSCs), stroke severity, and sex are associated with direct-to-CSC prehospital routing in patients with LVO AIS. Methods and Results In this cross-sectional study, we identified consecutive patients with LVO AIS from a prospectively collected multihospital registry throughout the greater Houston area from January 2019 to June 2020. Primary outcome was prehospital routing to CSC and was compared between men and women using modified Poisson regression including age, sex, race or ethnicity, first in-hospital National Institutes of Health Stroke Scale score, travel time, and distances to the closest primary stroke center and CSC. Among 503 patients with LVO AIS, 413 (82%) were routed to CSCs, and women comprised 46% of the study participants. Women with LVO AIS compared with men were older (73 versus 65, P<0.01) and presented with greater National Institutes of Health Stroke Scale score (14 versus 12, P=0.01). In modified Poisson regression, women were 9% less likely to be routed to CSCs compared with men (adjusted relative risk [aRR], 0.91 [0.84-0.99], P=0.024) and distance to nearest CSC ≤10 miles was associated with 38% increased chance of routing to CSC (aRR, 1.38 [1.26-1.52], P<0.001). Conclusions Despite presenting with more significant stroke syndromes and living within comparable distance to CSCs, women with LVO AIS were less likely to be routed to CSCs compared with men. Further study of the mechanisms behind this disparity is needed.

Investigating Maternal Stress, Depression, and Breastfeeding: A Pregnancy Risk Assessment Monitoring System (2016-2019) Analysis.

Breastfeeding is invaluable for postpartum physical healing and mental wellbeing, but psychosocial stress and depression impede such recovery processes. To inform future interventions and policies, associations between breastfeeding, maternal stress, and depression were examined. Data from the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed (2016-2019). Logistic regression models were used to calculate adjusted odds ratios with 95% confidence intervals. Of the total sample (n = 95,820), approximately 88% of participants attempted breastfeeding. Our findings indicate that participants who experienced any form of stress had a slightly higher likelihood of breastfeeding compared to those without stress. Specifically, partner-related and financial-related stressors were significantly associated with increased odds of breastfeeding. However, no significant associations were observed trauma-related or emotional-related stressors and breastfeeding. Additionally, no significant association was found between depression at different stages (preconception, prenatal, and postpartum) and breastfeeding. A significant interaction effect was noted between having experienced any of the 13 stressors and Black race/ethnicity on breastfeeding odds. Similarly, significant interaction effects were observed between partner-related, trauma, financial, or emotional stressors and Black race/ethnicity. These findings emphasize the importance of considering various factors when promoting breastfeeding in diverse populations, and screening for psychosocial stress during postpartum visits. Our study recommends tailoring breastfeeding interventions to address the needs of Black mothers which could significantly improve maternal health and breastfeeding outcomes.

Ichthyosis vulgaris: An updated review.

Ichthyosis vulgaris is an inherited, non-syndromic form of ichthyosis that presents with skin problems. Making up more than 95% cases of ichthyosis, ichthyosis vulgaris is caused by heterozygous loss-of-function mutation of the filaggrin gene, raising the fragility and permeability of the stratum corneum. It typically presents in infancy as xerosis, skin lesions, keratosis pilaris, palmoplantar hyper linearity, scaly dermatosis, and erythroderma, clearly identifiable by age 5. Although majority of patients have a normal lifespan, possible complications include a vitamin D deficiency and auditory problems due to scaling in the ears, besides a drop in quality of life due to dermatological changes. Urea-based creams with 10% urea, ceramides, and other ceramides are often the first line therapy in ichthyosis vulgaris. There is no known curative treatment for ichthyosis vulgaris, but lifelong treatment can alleviate the symptoms. Urea-based creams are highly therapeutic, whereas ammonium lactate 12% lotion with a physiological lipid-based repair cream can help with scaling and dryness. There is also evidence in favour of propylene glycol solutions. Risankizumab, an anti-interleukin-23 drug, and enhancement of natural moisturizing factors are also two highly promising solutions that require additional research. This review aims to provide updates on the manifestation, evaluation, and treatment of ichthyosis vulgaris.

Green synthesis and characterization of silver nanoparticles for reducing the damage to sperm parameters in diabetic compared to metformin.

The present study used physics to synthesize silver nanoparticles using aqueous extract of fresh garlic as reducing and as a stabilizing agent silver nitrate solution. This method has proven to be environmentally friendly and safe for the synthesis of stable silver nanoparticles. The acquisition of silver nanoparticles was confirmed by optical detection, that is, by changing the color of the liquid to transparent orange and then blackish brown. Then, the characterization was confirmed using other assays. In this study, it was found that the absorption peak of silver nanoparticles was at a wavelength of 420 nm and the particle size ranged between [50-350] nm. The surface roughness of silver oxide/silver nanoparticles was 9.32 nm with an average square roughness of 21.19 nm, and the energy dispersive spectra showed that the absorption peak was in the region of 3 keV, indicating that the nanoparticles contained crystalline silver. In this study, the stability of the silver nanoparticles was good, as ZP reached (- 19.5). The results confirm that the conductivity increases with the increase in frequency due to the high energy of the photons, which causes the electrons to vibrate in the energy levels and thus increase the energy in the mitochondria and increase the movement of sperm in the Diabetic mice treated with doses of silver nanoparticles. The toxic effect of silver nanoparticles has been evaluated in other studies, in addition to evaluating antioxidants, antifungals, treating cancer cells, regulating cholesterol levels, the effect of these nanoparticles on sex cells in pregnant female mice, heart tension, and many other tests. In this study, the activities and efficacy of silver nanoparticles on sperms were determined in male mice with diabetes caused by STZ, and the treatment period was long (35 days) so that the evaluation period was a complete life cycle of male sex cells and within a long period of time and at an average nano size. This has not been studied in other previous studies. The results indicate that the biosynthesis of silver nanoparticles using garlic plant led to positive results on sperm treatments by contributing to an increase in the number of sperm with reactivation and a decrease in abnormalities in addition to a decrease in mortality due to diabetes. This is evidence that the synthesis of silver nanoparticles using garlic plant size (50-350 nm) can treat impotence and be used in the future in the treatment of many diseases without side effects.

Helping Patients With Chronic Conditions Overcome Challenges of High-Deductible Health Plans: Mixed Methods Study.

BACKGROUND: A growing number of Americans are enrolled in high-deductible health plans (HDHPs). Enrollees in HDHPs, particularly those with chronic conditions, face high out-of-pocket costs and often delay or forgo needed care owing to cost. These challenges could be mitigated by the use of cost-conscious strategies when seeking health care, such as discussing costs with providers, saving for medical expenses, and using web-based tools to compare prices, but few HDHP enrollees engage in such cost-conscious strategies. A novel behavioral intervention could enable HDHP enrollees with chronic conditions to adopt these strategies, but it is unknown which intervention features would be most valued and used by this patient population. OBJECTIVE: This study aimed to assess preferences among HDHP enrollees with chronic conditions for a novel behavioral intervention that supports the use of cost-conscious strategies when planning for and seeking health care. METHODS: In an exploratory sequential mixed methods study among HDHP enrollees with chronic conditions, we conducted 20 semistructured telephone interviews and then surveyed 432 participants using a national internet survey panel. Participants were adult HDHP enrollees with diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, or asthma. The interviews and survey assessed participants' health care experiences when using HDHPs and their preferences for the content, modality, and frequency of use of a novel intervention that would support their use of cost-conscious strategies when seeking health care. RESULTS: Approximately half (11/20, 55%) of the interview participants reported barriers to using cost-conscious strategies. These included not knowing where to find information and worrying that the use of cost-conscious strategies would be very time consuming. Most (18/20, 90%) interviewees who had discussed costs with providers, saved for medical expenses, or used web-based price comparison tools found these strategies to be helpful for managing their health care costs. Most (17/20, 85%) interviewees expressed interest in an intervention delivered through a website or phone app that would help them compare prices for services at different locations. Survey participants were most interested in learning to compare prices and quality, followed by discussing costs with their providers and putting aside money for care, through a website-based or email-based intervention that they would use a few times a year. CONCLUSIONS: Regular use of cost-conscious strategies could mitigate financial barriers faced by HDHP enrollees with chronic conditions. Interventions to encourage the use of cost-conscious strategies should be delivered through a web-based modality and focus on helping these patients in navigating their HDHPs to better manage their out-of-pocket spending.

Immunochemistry-Based Diagnosis of Extrapulmonary Tuberculosis: A Strategy for Large-Scale Production of MPT64-Antibodies for Use in the MPT64 Antigen Detection Test.

Tuberculosis (TB) is a global health problem. The immunohistochemistry (IHC)-based MPT64 antigen detection test has shown promising results for diagnosing extrapulmonary TB in previous studies. However, the anti-MPT64 antibody currently used in the test is in limited supply, and reproduction of a functional antibody is a prerequisite for further large-scale use. Various antigen-adjuvant combinations and immunisation protocols were tested in mice and rabbits to generate monoclonal and polyclonal antibodies. Antibodies were screened in IHC, and the final new antibody was validated on clinical human specimens. We were not able to generate monoclonal antibodies that were functional in IHC, but we obtained multiple functional polyclonal antibodies through careful selection of antigen-adjuvant and comprehensive screening in IHC of both pre-immune sera and antisera. To overcome the limitation of batch-to-batch variability with polyclonal antibodies, the best performing individual polyclonal antibodies were pooled to one final large-volume new anti-MPT64 antibody. The sensitivity of the new antibody was in the same range as the reference antibody, while the specificity was somewhat reduced. Our results suggest that it possible to reproduce a large-volume functional polyclonal antibody with stable performance, thereby securing stable supplies and reproducibility of the MPT64 test, albeit further validation remains to be done.

Microscale ZnO with controllable crystal morphology as a platform to study antibacterial action on Staphylococcus aureus.

Nano- and microcrystalline ZnO is an inexpensive, easily synthesized material with a multitude of applications. Its usefulness in the present and future stems from its exceptional optoelectronic, structural, and chemical characteristics as well as a broad range of production techniques. One application comes from its ability to inhibit bacterial growth. Despite the well-documented, vigorously studied antimicrobial action of ZnO particles, the most fundamental physical and chemical mechanisms driving growth inhibition are still not well identified. Particularly, the nature of interactions between ZnO surfaces and extracellular material is not totally clear. This is important given the anisotropic lattice of ZnO leading to two characteristically different lattice terminations: polar and nonpolar, polar being electrically charged with many defect sites and nonpolar being electrically neutral while remaining relatively defect-free. In this work, we employ a hydrothermal growth protocol that allows us to produce ZnO microcrystals with dependable control of morphology and, particularly, the relative abundances of polar and nonpolar free surfaces. This functions as a platform for our investigations into surface-surface interactions behind the antibacterial action of ZnO microcrystals. In our studies, we produced ZnO crystals comparable in size or larger than Staphylococcus aureus bacteria. This was done intentionally to ensure that the ZnO particles would not internalize into the bacterial cells. Our experiments were performed in conjunction with surface photovoltage studies of ZnO crystals to characterize electronic structure and charge dynamics that might be contributing to the antibacterial properties of our samples. We report on the interactions between ZnO microcrystalline surfaces and extracellular material of Staphylococcus aureus bacteria.

Drug shortage management: A qualitative assessment of a collaborative approach.

Drug shortages frequently and persistently affect healthcare institutions, posing formidable financial, logistical, and ethical challenges. Despite plentiful evidence characterizing the impact of drug shortages, there is a remarkable dearth of data describing current shortage management practices. Hospitals within the same state or region may not only take different approaches to shortages but may be unaware of shortages proximate facilities are facing. Our goal is to explore how hospitals in Michigan handle drug shortages to assess potential need for comprehensive drug shortage management resources. We conducted semi-structured interviews with diverse stakeholders throughout the state to describe experiences managing drug shortages, approaches to recent shortages, openness to inter-institutional engagement, ideas for a shared resource, and potential obstacles to implementation. To solicit additional feedback on ideas for a shared resource gathered from the interviews, we held focus groups with pharmacists, physicians, ethicists, and community representatives. Among participants representing a heterogeneous sample of institutions, three themes were consistent: (1) numerous drug shortage strategies occurring simultaneously; (2) inadequate resources and lead time to proactively manage shortages; and (3) interest in, but varied attitudes toward, a collaborative approach. These data provide insight to help develop and test a shared drug shortage management resource for enhancing fair allocation of scarce drugs. A shared resource may help institutions adopt accepted best practices and more efficiently access or share finite resources in times of shortage.

Do local liposomal bupivacaine and interscalene nerve block provide similar pain control after shoulder arthroplasty? A dual-center randomized controlled trial.

BACKGROUND: Interscalene nerve block (INB) has become a popular technique for shoulder anesthesia. However, INB is associated with complication rates as high as 20%. Local liposomal bupivacaine (LLB) is an alternative to INB that potentially offers extended pain control with fewer adverse effects. METHODS: We conducted a dual-center randomized controlled trial of 108 participants who were treated with LLB (n = 54) or INB (n = 54) to control pain after shoulder arthroplasty. We assessed visual analog scale pain scores at 6-hour intervals from 6 to 96 hours postoperatively and at the first postoperative visit. We assessed opioid medication consumption intraoperatively and on days 1, 2, 3, and 4 postoperatively, as well as the duration of hospital and postanesthesia care unit (PACU) stays. RESULTS: At 6 hours postoperatively, the mean visual analog scale pain score was lower in the INB group (2.9 ± 3.1) than in the LLB group (5.1 ± 2.9, P < .01). The INB group consumed less opioid medication during the first 24 hours postoperatively (18 ± 12 morphine milligram equivalents) than did the LLB group (36 ± 48 morphine milligram equivalents, P = .01). The PACU stay was shorter in the INB group (102 ± 53 minutes) compared with the LLB group (139 ± 77 minutes, P < .01). CONCLUSIONS: Compared with LLB, INB provides better pain control immediately after shoulder arthroplasty as evidenced by shorter PACU stays, lower pain scores at 6 hours postoperatively, and less opioid medication consumption during the first 24 hours postoperatively. However, no differences in outcomes were observed between groups beyond 24 hours.

Racial Disparity in Time to Surgery and Complications for Hip Fracture Patients.

BACKGROUD: Racial and ethnic disparities in orthopedic surgery may be associated with worse perioperative complications. For patients with hip fractures, studies have shown that early surgery, typically within 24 to 48 hours of admission, may decrease postoperative morbidity and mortality. Our objective was to determine whether race is associated with longer time to surgery from hospital presentation and increased postoperative complications. METHODS: We queried the National Surgical Quality Improvement Program database from 2011 to 2017 for patients (> 65 years) with hip fractures who underwent surgical fixation. Patients were identified using Current Procedural Terminology codes (27235, 27236, 27244, and 27245). Delayed surgery was defined as time to surgery from hospital admission that was greater than 48 hours. Time to surgery was compared between races using analysis of variance. A multivariate logistic regression analysis adjusting for comorbidities, age, sex, and surgery was performed to determine the likelihood of delayed surgery and rate of postoperative complications. RESULTS: A total of 58,456 patients who underwent surgery for a hip fracture were included in this study. Seventy-two percent were female patients and the median age was 87 years. The median time to surgery across all patients was 24 hours. African Americans had the longest time to surgery (30.4 ± 27.6 hours) compared to Asians (26.5 ± 24.6 hours), whites (25.8 ± 23.4 hours), and other races (22.7 ± 22.0 hours) (p < 0.001). After adjusting for comorbidities, age, sex, and surgery, there was a 43% increase in the odds of delayed surgery among American Africans compared to whites (odds ratio, 1.43; 95% confidence interval, 1.29-1.58; p < 0.001). Despite higher odds of reintubation, pulmonary embolism, renal insufficiency or failure, and cardiac arrest in African Americans, mortality was significantly lower compared to white patients (4.41% vs. 6.02%, p < 0.001). Asian Americans had the lowest mortality rate (3.84%). CONCLUSIONS: A significant disparity in time to surgery and perioperative complications was seen amongst different races with only African Americans having a longer time to surgery than whites. Further study is needed to determine the etiology of this disparity and highlights the need for targeted strategies to help at-risk patient populations.

Nonoperative Treatment of Periprosthetic Humeral Shaft Fractures After Reverse Total Shoulder Arthroplasty.

Few studies report on periprosthetic humeral shaft fractures after reverse total shoulder arthroplasty (RTSA). The authors evaluated outcomes of 5 patients with this complication who were initially treated nonoperatively. Of 152 patients who underwent RTSA at the authors' institution from 2012 to 2017, 4 experienced periprosthetic humeral shaft fractures. One patient was referred to the authors for fracture treatment. All 5 patients were initially treated nonoperatively. The mean duration of follow-up was 11.5 months (range, 1.5-26 months). The authors analyzed time to fracture union, Single Assessment Numeric Evaluation (SANE) score, visual analog scale (VAS) score for pain, and active shoulder range of motion. Fracture union occurred in 4 patients treated nonoperatively at a mean of 4.4 months. Mean SANE score was 55 of 100 (range, 20-85). Mean VAS score was 3.4 of 10 (range, 0-8). Mean forward elevation was 83° (range, 45°-110°); mean abduction was 65° (range, 45°-80°); and mean external rotation with the arm at the side was 15° (range, 0°-30°). Many factors must be considered when customizing treatment for patients with periprosthetic fracture after RTSA. This case series indicates that nonoperative treatment of postoperative periprosthetic humeral shaft fractures can be successful. [Orthopedics. 2020;43(6):e553-e560.].

Association Between Delays in Radiography and Surgery With Hip Fracture Outcomes in Elderly Patients.

Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is "surgery delay" (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609-e615.].