Pediatric Urinary Stone Disease in the United States: The Urologic Diseases in America Project.

OBJECTIVE: To examine the recent epidemiology of pediatric urinary stone disease (USD) in the United States. METHODS: We utilized the 2004-2016 Optum© Clinformatics® Data Mart database, a de-identified adjudicated administrative health claims database that includes 15-18 million individuals covered annually by commercial insurance in all 50 US states. The analysis included 12,739,125 children aged 0-18 years. We calculated annual rates of USD, ambulatory visits, and procedures, and the prevalence of prescription fills. RESULTS: The 2005-2016 USD rate was 59.5 cases per 100,000 person-years. The annual rate rose gradually from 2005 to a peak of 65.2 cases per 100,000 person-years in 2011. The USD rate increased with increasing age, and was highest among females compared to males, non-Hispanic Whites compared to other race/ethnic groups, and those residing in the South compared to other geographic regions. The overall 2005-2016 rate in the 120 days following a USD episode was 1.9 for ambulatory visits, 0.24 for surgical procedures, and 1.1 for imaging procedures. Ureteroscopy was the most common surgical procedure and CT scan was the most common imaging procedures, although ultrasound utilization increased over time. Medications were filled in 46.9% of cases, and use was lowest among males (43.1%), Asians (34.8%), and in the Northeast (34.3%). Opiate agonists were the most prevalent prescription (39.9%). CONCLUSION: Our study provides one of the most comprehensive examinations of pediatric USD to date, demonstrating shifting rates and treatment patterns over time, as well as differences by age, gender, race/ethnicity, and geographic region.

Residential eating disorder outcomes associated with screening positive for substance use disorder and borderline personality disorder.

OBJECTIVE: We examined whether eating disorder (ED) outcome trajectories during residential treatment differed for patients screening positive for comorbid borderline personality disorder (BPD) and/or substance use disorders (SUDs) than those who do not. METHOD: We examined data from patients in a residential ED treatment program. Patients completed validated self-report surveys to screen for SUDs and BPD on admission, and the ED Examination-Questionnaire (EDE-Q) on admission and every 2 weeks until discharge (N = 479 females). RESULTS: Fifty-four percent screened positive for at least one co-occurring condition. At admission, patients screening positive for SUD and/or BPD had significantly greater eating pathology than patients screening negative for both (t[477] = 8.23, p < .001). Patients screening positive for SUD (independent of BPD screening status) had a significantly faster rate of symptom improvement during the initial 4 weeks than patients screening positive for BPD only and those with no comorbidities. DISCUSSION: Screening positive for SUD and/or BPD was common in residential ED treatment, and associated with more severe ED symptoms. Screening positive for SUD was associated with faster ED symptom improvement than screening positive for BPD. These findings suggest that intensive ED treatment, even in the absence of intensive SUD treatment, may enhance patient outcomes for those with SUDs.

Acute Phase Treatment Outcomes of Electroconvulsive Therapy in Adolescents and Young Adults.

OBJECTIVE: Electroconvulsive therapy (ECT) is a highly efficacious, well-tolerated treatment in adults. Little is known, however, about its effectiveness in adolescents and young adults. Our objectives were to assess clinical outcomes after acute phase ECT in adolescents and young adults and determine whether screening positive or negative for a substance use disorder (SUD) is associated with differences in treatment outcomes. METHODS: Study sample consisted of all patients 16 to 25 years old who received ECT from May 2011 to August 2016 and who completed self-reported SUD screens and the Behavior and Symptom Identification Scale-24 (BASIS-24) initially and completed the BASIS-24 again after the fifth ECT treatment. For 5 BASIS-24 domains, longitudinal changes in mean domain scores were assessed; mean changes by SUD screening status were also examined using linear mixed models. RESULTS: One hundred ninety adolescents and young adults, with mean age 21.0 ± 2.6 years, met inclusion criteria. Electroconvulsive therapy was associated with significant clinical improvement (score decreases) in all 5 BASIS-24 domains during the acute phase treatment (P < 0.001). Sixty-four percent (122/190) screened positive for SUD. Compared with adolescents and young adults screening negative for SUD, those screening positive for co-occurring SUD had greater improvement in depression/functioning (-0.37 ± 0.14, P = 0.009), interpersonal relationships (-0.27 ± 0.13, P = 0.045), and emotional lability (-0.27 ± 0.14, P = 0.044) domains after the fifth ECT treatment. CONCLUSIONS: Electroconvulsive therapy in adolescents and young adults was associated with significantly improved clinical outcomes during acute phase treatment. Adolescents and young adults screening positive for SUD had better acute phase ECT outcomes in self-reported depression/functioning, interpersonal relationships, and emotional lability than those screening negative. More research is needed to clarify adolescents and young adult patient characteristics that may be associated with differential ECT outcomes.

A Single-Incision Technique for Distal Biceps Repair Using a Flexible Reamer.

Distal biceps tendon ruptures are rare injuries that usually occur in middle-aged men. Most of these injuries are repaired acutely to restore preinjury function and strength. There is concern regarding the higher prevalence of certain complications with the double-incision technique. As such, the single-incision technique has also been studied to determine if it may produce superior safety and efficacy. In addition, the point of fixation may be created with either a rigid or a flexible reamer. The authors describe a technique that uses a single-incision cortical fixation achieved with a flexible reamer. [Orthopedics. 2017; 40(4):e744-e748.].

Arthroscopic Piriformis Release-A Technique for Sciatic Nerve Decompression.

Various techniques for piriformis muscle release have been published previously. However, it is imperative we continue to improve on existing techniques as well as develop new ones that may further optimize outcomes. Therefore, we aimed to describe an endoscopic technique for the release of the piriformis muscle in those with symptoms of sciatic nerve compression. Using the posterolateral portal, we are able to perform a complete release of the piriformis from the greater trochanter and the piriformis fossa with care to protect the external rotators and the sciatic nerve. It is our belief that this technique can be easily replicated by practitioners who read this technical note.

Total Shoulder Arthroplasty Demographics, Incidence, and Complications-A Nationwide Inpatient Sample Database Study.

INTRODUCTION: Total shoulder arthroplasty (TSA) has become a popular and successful surgery to treat advanced glenohumeral arthritis, rotator cuff arthropathy, and proximal humerus fractures. Historical data is available investigating the epidemiology of total shoulder arthroplasty with regard to patient characteristics, outcomes, and complications; however, there is a lack of studies investigating the most recent and up to date national trends related to shoulder replacement. The purpose of this study was to evaluate changes in the annual incidence, various demographics, and complications of TSA in America. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS) was assessed to identify all patients who were admitted for TSA in the United States between 1998 and 2010. National trends in patient demographics, incidence, and length-of-stay (LOS) were analyzed for correlations. The impacts of contributing factors to each outcome were assessed using adjusted multivariable regression analysis. These were used to calculate odds ratios of cohort demographics and their association with complications and LOS. RESULTS: Admissions for TSA have risen (8,041 to 39,072 admissions). The majority of the cohort consisted of Caucasian men between the ages of 64 and 79 years. The incidence rate of complications has remained consistent. Female gender, age > 80 years, and higher Deyo Comorbidity scores were risk factors for higher complications. The LOS has decreased (2.96 to 2.21 days) during the study time period. Female gender, African-American race, Medicaid insurance, and higher Deyo Comorbidity scores were associated with longer stays. DISCUSSION: Our study demonstrates a rapid increase in incidence rates of TSAs within the 13-year period in the United States. An increased risk of complications was noted with older age, female gender, and increased Deyo score. CONCLUSION: Our findings may help health care providers identify ways to better manage this procedure and select patients.

Accuracy of Prospective Predictions of 30-Day Hospital Readmission.

OBJECTIVE: This study examined how accurately inpatient case managers predicted 30-day readmission and whether objective patient characteristics improved prediction accuracy. METHODS: In this prospective study, inpatient case managers at a psychiatric hospital rated their concern (1, not concerned; 5, very concerned) about readmission after discharge of 282 privately insured patients. Sensitivity and specificity of the ratings were calculated. Logistic regression identified whether patient characteristics that could affect 30-day readmission improved prediction accuracy. RESULTS: Concern levels ≥3 yielded 86% sensitivity, 37% specificity, and a positive predictive value (PPV) of 13%; levels ≥4 yielded 39% sensitivity, 78% specificity, and a PPV of 17%. Concern level independently predicted readmission; appointments within seven days postdischarge further improved model accuracy (p=.03) (area under the curve=.67, 95% confidence interval=.58-.78). CONCLUSIONS: Although not highly accurate, case manager concern identified some patients at higher risk of 30-day readmission. Appointments within seven days of discharge improved prediction accuracy.

Improving the efficiency of drug use disorder screening in psychiatric settings: validation of a single-item screen.

BACKGROUND: Co-occurring drug use disorders are under-detected in psychiatrically ill populations highlighting the need for more efficient screening tools. OBJECTIVES: This study compares a single-item screening tool, previously validated in a primary care setting, to the 10-item Drug Abuse Screening Test (DAST-10) for identifying co-occurring drug use disorders among patients with severe psychiatric illness. METHODS: A total of 395 patients attending a psychiatric partial hospital program completed both the single-item screen and DAST-10. A subsample of consecutive patients (n = 67) was also administered the Structure Clinical Interview for DSM-IV (SCID-IV) as a diagnostic reference standard. RESULTS: Concordance between screening measures was moderate (κ = 0.4, p < 0.01). Sensitivity and specificity of the single-item screen and DAST-10 as compared to the SCID-IV were comparable, while area under the receiver operating curve showed better discriminatory power for the identification of drug use disorders with the single-item screen. CONCLUSIONS: In comparison to the DAST-10, the single-item screen appears to be a more efficient tool to identify co-occurring drug use disorders in a psychiatric treatment setting among patients with a range of psychiatric diagnoses.

Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics.

BACKGROUND: Complete radial tears near the medial meniscus posterior root attachment site disrupt the circumferential integrity of the meniscus (similar to a posterior root avulsion). These tears can compromise the circumferential integrity, and they have been reported in biomechanical studies to be comparable with the meniscectomized state. PURPOSE: To quantify the tibiofemoral contact pressure and contact area changes that occur in cadaveric knees from complete posterior horn radial tears and subsequent repairs of the medial meniscus adjacent to the posterior root attachment site. STUDY DESIGN: Controlled laboratory study. METHODS: Six nonpaired fresh-frozen human cadaveric knees each underwent 45 different testing conditions: 9 medial meniscus conditions (intact, root avulsion, root repair, serial radial tear at 3, 6, and 9 mm from the root attachment site, and in situ repair at the same 3 distances from the root attachment site) at 5 flexion angles (0°, 30°, 45°, 60°, and 90°), under a 1000-N axial load. Tekscan sensors were used to measure contact area and pressure in the medial and lateral compartments. RESULTS: The medial meniscus root avulsion and all radial tear conditions resulted in significantly decreased contact area and increased mean contact pressure compared with the intact state for knee flexion angles beyond 0° (P < .05). The root repair and in situ repairs restored contact area and pressure to levels statistically indistinguishable from those of the intact meniscus and increased contact area and decreased contact pressure compared with the corresponding tear conditions. CONCLUSION: Posterior horn radial tears adjacent to the medial meniscus root that extend to the meniscocapsular junction can lead to derangement of the loading profiles of the medial compartment that are similar to a root avulsion. Repair of these radial tears with an in situ pull-out technique restored joint mechanics to the intact state. CLINICAL RELEVANCE: Complete radial tears of the posterior horn of the medial meniscus, which occur relatively frequently, are biomechanically equivalent to root avulsions and could potentially lead to medial compartment arthrosis. An in situ repair offers an alternative treatment to meniscectomy and can reestablish the posterior anchor point, thus improving load distribution in the medial compartment. Future clinical studies of these repairs are recommended.

Ice hockey goaltender rehabilitation, including on-ice progression, after arthroscopic hip surgery for femoroacetabular impingement.

SYNOPSIS: Ice hockey goaltenders, especially those who employ the butterfly technique, are a specialized population of athletes because of the unique physical demands that the position places on their lower extremities, specifically at the hip. It is no surprise that hip injuries are a common occurrence among goalies. A review of the biomechanical literature has demonstrated that stresses on the hip while in flexion and end-range internal rotation, the position goaltenders commonly use, put the hip at risk for injury and are likely a major contributing factor to overuse hip injuries. The stress on a goaltender's hip can potentially be further intensified by the presence of bony deformities, such as cam- or pincer-type femoroacetabular impingement, which can lead to chondrolabral junction and articular cartilage injuries. There have been few published reports of goaltenders' functional outcomes following femoroacetabular impingement surgery, and, to our knowledge, no studies have yet identified the specific challenges presented in the rehabilitation of goaltenders following femoroacetabular impingement surgery. The present clinical commentary describes a 6-phase return-to-skating program developed as part of a rehabilitation protocol to aid hockey goaltenders recovering from surgery.

Posterior cruciate ligament tears: functional and postoperative rehabilitation.

PURPOSE: Historically, the results of posterior cruciate ligament (PCL) reconstructions are not as favourable as anterior cruciate ligament (ACL) reconstructions, and it is well recognized that nonoperative treatment and postoperative rehabilitation for PCL injuries must be altered compared to those for ACL injuries. The purpose of this article was to review current peer-reviewed PCL rehabilitation programmes and to recommend a nonoperative and postoperative programme based on basic science and published outcomes studies. METHODS: To discover the current practices being used to rehabilitate PCL injuries, we conducted a search of PubMed with the terms "posterior cruciate ligament" and "rehabilitation" from 1983 to 2011. All articles within the reference lists of these articles were also examined to determine their rehabilitation programmes. RESULTS: A review of peer-reviewed PCL rehabilitation protocols revealed that the treatment of PCL injuries depends on the timing and degree of the injury. Rehabilitation should focus on progressive weight bearing, preventing posterior tibial subluxation and strengthening of the quadriceps muscles. General principles of proper PCL rehabilitation, whether nonoperative or postoperative, should include early immobilization (when necessary), prone passive range of motion to prevent placing undue stress on grafts or healing tissue, and progression of rehabilitation based on biomechanical, clinical, and basic science research. CONCLUSIONS: An optimal set of guidelines for the nonoperative or postoperative management of PCL injuries has not yet been defined or agreed upon. Based on the current review study, suggested guidelines are proposed. LEVEL OF EVIDENCE: IV.

Double-Bundle Posterior Cruciate Ligament Reconstruction Technique with Use of Endoscopic Femoral Graft Placement.

INTRODUCTION: As the varied results seen after posterior cruciate ligament (PCL) reconstructions might be due to surgical techniques that fail to reconstruct both functional bundles of the PCL and that injure the vastus medialis obliquus muscle, we developed a technique to address these problems and thus improve patient outcomes. STEP 1 EXAMINE UNDER ANESTHESIA: Assess range of motion and patellofemoral stability; perform stress tests, Lachman and pseudo-Lachman tests, pivot shift test, drawer tests, reverse pivot shift test, and dial test. STEP 2 PERFORM ARTHROSCOPY: Preserve any remnants of PCL at anterolateral and posteromedial bundle attachment sites to promote vascular healing. STEP 3 DRILL TIBIAL GUIDEPIN: Guidepin enters tibia at, roughly, 45° angle and 6 cm distal to joint line, midway between anterior tibial crest and posteromedial tibial border. STEP 4 PREPARE GRAFTS: Use Achilles tendon allograft for anterolateral bundle and semitendinosus or tibialis anterior allograft for posteromedial bundle. STEP 5 DRILL TUNNELS: Guidepin position should be slightly lateral to midline between apices of medial and lateral tibial eminences on anteroposterior radiograph and approximately 7 mm proximal to "champagne-glass drop-off" on lateral radiograph. STEP 6 PLACE AND SECURE GRAFTS IN FEMUR AND TIBIA: Tug hard on grafts through anterolateral arthroscopic portal to verify that they are secured within the femoral tunnel. STEP 7 POSTOPERATIVE CARE: Manage knee motion for first six weeks by prone knee flexion to counteract deleterious effects of gravity on reconstruction. RESULTS: In a cohort of thirty-nine total patients, thirty-three males and six females, with an average age of thirty-three years, seven isolated PCL reconstructions and thirty-two combined knee reconstructions were performed. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

A reporting tool for real-time assessment of study data availability.

A simple framework for assessing and reporting data availability in an ongoing clinical trial is described. Protocol requirements, visit schedules and data availability are combined into a simple report to track the progress of a study.