Long-Term Hand and Shoulder Function in Children following Early Surgical Intervention for a Birth-Related Upper Brachial Plexus Injury.

Purpose To better understand the long-term hand and shoulder outcomes of upper brachial plexus birth injuries. Methods We evaluated shoulder and hand function in 32 patients (13 males; 19 females) with a C5/C6 birth injury history). All patients had undergone primary nerve surgery as infants, and 12 underwent a simultaneous shoulder procedure as they presented with a fixed internal rotation contracture of the shoulder. On average, all patients were evaluated and examined 15 years postoperatively. The shoulder function was evaluated using the Miami Shoulder Scale. Hand function was measured by the 9-hole peg test (9-HPT) and statistical analysis included comparison of 9-HPT time against normative data using the Student's t -test. Results The cohort includes 22 right-hand-dominant and 10 left-hand-dominant patients. Mean age at surgery was 10 months; mean age at follow-up was 15 years ± 2 years 2 months. Cumulative shoulder function was "good" or "excellent" (Miami score) in 23 patients. For 9-HPT, 23 out of 32 patients seen had an involved hand with a significant alteration in function. Conclusion Early nerve surgery in cases of upper brachial plexus birth injuries result in the desired outcome. To ensure timely and targeted therapy for any residual deficits, it is imperative that limitations in hand function among children with an Erb's palsy.

Long-Term Results of Isolated Latissimus Dorsi to Rotator Cuff Transfer in Brachial Plexus Birth Injury.

Background Brachial plexus birth injury results in deficits in strength and motion, occasionally requiring surgery to restore power to the deficient external rotators of the shoulder in these patients. This is a retrospective analysis of the long-term results of an isolated latissimus dorsi transfer to the rotator cuff in patients with brachial plexus birth injury. Methods This is a retrospective review of prospectively collected data for patients undergoing isolated latissimus dorsi transfer into the infraspinatus in addition to release of the internal rotation contracture of the shoulder with greater than 5 years' follow-up. Preoperative and postoperative shoulder elevation and external rotation were documented. Failure of surgery was defined as a return of the internal rotation contracture and a clinically apparent clarion sign. Results A total of 22 patients satisfied the inclusion criteria: 9 global palsies and 13 upper trunk palsies. The average follow-up was 11 years, ranging from 7.5 to 15.9 years. There was a trend for improved external rotation in the global palsy cohort at final follow-up ( p = 0.084). All nine global palsies maintained adequate external rotation without a clarion sign. Five of the 13 upper trunk palsies failed the latissimus dorsi transfer and subsequently required either teres major transfer and/or rotational osteotomy. In these five failures, the period from initial transfer to failure averaged 6.6 years, ranging from 3.4 to 9.5 years. Conclusion The results of this study indicate that patients with global palsy have sustained long-term improved outcomes with isolated latissimus dorsi transfer while patients with upper trunk palsy have a high rate of failure. Based on these results, we recommend isolated latissimus dorsi transfer for global palsy patients who have isolated infraspinatus weakness. Level of Evidence: Case series - Level IV.

Evaluation of peer recovery services for substance use disorder in Minnesota: Impact of peer recovery initiation on SUD treatment and recovery.

Substance use disorder (SUD) remains one of the most persistent public health challenges across the nation and in Minnesota. One intervention to help people with SUD is peer recovery services (PRS). PRS is a form on non-clinical support where trained individuals who are more established in recovery come alongside people currently in the recovery journey and provide guidance in the treatment process, help in accessing resources, and offer an empathetic ear. In combination with other services in the continuum of care, PRS seeks to reduce harm from disordered use. In 2018, Minnesota made PRS for SUD a Medicaid reimbursable service. While prior literature demonstrates promising effects of PRS for SUD, especially in treatment retention and participant experience, most studies evaluated PRS in limited settings, rather than in a large-scale implementation. Our retrospective, matched-cohort study used administrative data to estimate the impact of initiating Medicaid-reimbursable PRS for SUD on treatment, overdose, and mortality. Our results align, in some dimensions, with prior literature evaluating smaller-scale programs with positive impacts on treatment completion. We also find, however, that PRS at scale did not produce other positive outcomes that past studies have documented, particularly around overdose and inpatient treatment. This suggests that PRS follows a common challenge of implementing promising ideas at scale.

Efficacy of National Comprehensive Cancer Network Guidelines in Identifying Pathogenic Germline Variants Among Unselected Patients with Prostate Cancer: The PROCLAIM Trial.

BACKGROUND: Prostate cancer (PCa) patients with pathogenic/likely pathogenic germline variants (PGVs) in cancer predisposition genes may be eligible for U.S. Food and Drug Administration-approved targeted therapies, clinical trials, or enhanced screening. Studies suggest that eligible patients are missing genetics-informed care due to restrictive testing criteria. OBJECTIVE: To establish the prevalence of actionable PGVs among prospectively accrued, unselected PCa patients, stratified by their guideline eligibility. DESIGN, SETTING, AND PARTICIPANTS: Consecutive, unselected PCa patients were enrolled at 15 sites in the USA from October 2019 to August 2021, and had multigene cancer panel testing. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Correlates between the prevalence of PGVs and clinician-reported demographic and clinical characteristics were examined. RESULTS AND LIMITATIONS: Among 958 patients (median [quartiles] age at diagnosis 65 [60, 71] yr), 627 (65%) had low- or intermediate-risk disease (grade group 1, 2, or 3). A total of 77 PGVs in 17 genes were identified in 74 patients (7.7%, 95% confidence interval [CI] 6.2-9.6%). No significant difference was found in the prevalence of PGVs among patients who met the 2019 National Comprehensive Cancer Network Prostate criteria (8.8%, 43/486, 95% CI 6.6-12%) versus those who did not (6.6%, 31/472, 95% CI 4.6-9.2%; odds ratio 1.38, 95% CI 0.85-2.23), indicating that these criteria would miss 42% of patients (31/74, 95% CI 31-53%) with PGVs. The criteria were less effective at predicting PGVs in patients from under-represented populations. Most PGVs (81%, 60/74) were potentially clinically actionable. Limitations include the inability to stratify analyses based on individual ethnicity due to low numbers of non-White patients with PGVs. CONCLUSIONS: Our results indicate that almost half of PCa patients with PGVs are missed by current testing guidelines. Comprehensive germline genetic testing should be offered to all patients with PCa. PATIENT SUMMARY: One in 13 patients with prostate cancer carries an inherited variant that may be actionable for the patient's current care or prevention of future cancer, and could benefit from expanded testing criteria.

Detailed Management of Brachial Plexus Birth Injuries: The Miami Protocol at Nicklaus Children's Hospital.

The management of children with brachial plexus birth injuries is complex and requires a multidisciplinary approach. In the following article, we describe our approach to evaluation and management at Nicklaus Children's Hospital. It is our aim is to elucidate nuances in management.

Impact of delaying high school start times on weight and related behaviors - the START study.

In the US, few adolescents get adequate school night sleep, largely due to early school start times. In the START study we aimed to test the following hypothesis: That following the implementation of later high school start times students have lesser longitudinal increases in body mass index (BMI) and shift to more healthful weight-related behaviors relative to students attending schools that retain early start times. The study enrolled a cohort of students (n = 2426) in five high schools in the Twin Cities, MN metro. Heights and weights were measured objectively, and surveys were administered annually from 9th through 11th grades (2016-2018). All study schools started early (either 7:30 am or 7:45 am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), two schools delayed their start times by 50-65 min, while three comparison schools started at 7:30 am throughout the observation period. Using a difference-in-differences natural experiment design, we estimated differences in changes in BMI and weight-related behaviors over time between policy change and comparison schools. Students' BMIs increased in parallel in both policy change and comparison schools over time. However relative to changes in comparison schools after the start time shift, students in policy change schools had a modestly more healthful profile of weight-related behaviors - for instance they had a relatively greater probability of eating breakfast, having supper with their family, getting more activity, eating fast food less frequently, and eating vegetables daily. Later start times could be a durable, population-wide strategy that promotes healthful weight behaviors.

The impact of delayed school start time on adolescent beverage consumption, findings from the START study.

OBJECTIVES: We sought to examine the effects of high school start time delay, a proven sleep-promoting intervention, on sugary beverage (SB) consumption among U.S. adolescents. METHODS: In the Spring of 2016 (baseline), the START study recruited 2134 ninth grade students who were enrolled high schools in the Twin Cities, MN metropolitan area. These participants were surveyed again in their 10th and 11th grade years, in Spring 2017 and 2018 (follow-ups 1 and 2). All five high schools started early (7:30 or 7:45 a.m.) at baseline. By follow-up 1, two "policy change" schools shifted their start times later (8:20 or 8:50 a.m.) and maintained these later start times through follow-up 2 while three "comparison schools" retained an early start time at all time points. Generalized estimating equations using a negative binomial distribution were used to obtain estimates of the number of sugary beverages consumed per day at each wave as well as the difference in difference (DiD) estimates between baseline and each follow-up period comparing policy change to comparison schools. RESULTS: Mean baseline sugary beverage consumption was 0.9 (1.5) beverages per day in policy change schools and 1.2 (1.7) beverages per day in the comparison schools. While there was no evidence of impact of start time change on total SB consumption, DiD estimates revealed a small decrease in the number of caffeinated sugary beverages consumed between baseline and the second follow-up period in students attending the policy change schools relative to comparison schools in both crude (0.11/day reduction, p-value = 0.048) and adjusted analyses (0.11/day reduction, p-value = 0.028). CONCLUSION: Although the differences in this study were quite modest, a population-wide reduction in sugary beverage consumption could have public health benefit.

Deep learning-based assessment of body composition and liver tumour burden for survival modelling in advanced colorectal cancer.

BACKGROUND: Personalized therapy planning remains a significant challenge in advanced colorectal cancer care, despite extensive research on prognostic and predictive markers. A strong correlation of sarcopenia or overall body composition and survival has been described. Here, we explore whether automated assessment of body composition and liver metastases from standard of care CT images can add to clinical parameters in personalized survival risk prognostication. METHODS: We retrospectively analysed clinical imaging data from 85 patients (50.6% female, mean age 58.9 SD 12.2 years) with colorectal cancer and synchronous liver metastases. Pretrained deep learning models were used to assess body composition and liver metastasis geometry from abdominal CT images before the initiation of systemic treatment. Abdominal muscle-to-bone ratio (MBR) was calculated by dividing abdominal muscle volume by abdominal bone volume. MBR was compared with body mass index (BMI), abdominal muscle volume, and abdominal muscle volume divided by height squared. Differences in overall survival based on body composition and liver metastasis parameters were compared using Kaplan-Meier survival curves. Results were correlated with clinical and biomarker data to develop a machine learning model for survival risk prognostication. RESULTS: The MBR, unlike abdominal muscle volume or BMI, was significantly associated with overall survival (HR 0.39, 95% CI: 0.19-0.80, P = 0.009). The MBR (P = 0.022), liver metastasis surface area (P = 0.01) and primary tumour sidedness (P = 0.007) were independently associated with overall survival in multivariate analysis. Body composition parameters did not correlate with KRAS mutational status or primary tumour sidedness. A prediction model based on MBR, liver metastasis surface area and primary tumour sidedness achieved a concordance index of 0.69. CONCLUSIONS: Automated segmentation enables to extract prognostic parameters from routine imaging data for personalized survival modelling in advanced colorectal cancer patients.

Oceans of plenty? Challenges, advancements, and future directions for the provision of evidence-based fisheries management advice.

Marine population modeling, which underpins the scientific advice to support fisheries interventions, is an active research field with recent advancements to address modern challenges (e.g., climate change) and enduring issues (e.g., data limitations). Based on discussions during the 'Land of Plenty' session at the 2021 World Fisheries Congress, we synthesize current challenges, recent advances, and interdisciplinary developments in biological fisheries models (i.e., data-limited, stock assessment, spatial, ecosystem, and climate), management strategy evaluation, and the scientific advice that bridges the science-policy interface. Our review demonstrates that proliferation of interdisciplinary research teams and enhanced data collection protocols have enabled increased integration of spatiotemporal, ecosystem, and socioeconomic dimensions in many fisheries models. However, not all management systems have the resources to implement model-based advice, while protocols for sharing confidential data are lacking and impeding research advances. We recommend that management and modeling frameworks continue to adopt participatory co-management approaches that emphasize wider inclusion of local knowledge and stakeholder input to fill knowledge gaps and promote information sharing. Moreover, fisheries management, by which we mean the end-to-end process of data collection, scientific analysis, and implementation of evidence-informed management actions, must integrate improved communication, engagement, and capacity building, while incorporating feedback loops at each stage. Increasing application of management strategy evaluation is viewed as a critical unifying component, which will bridge fisheries modeling disciplines, aid management decision-making, and better incorporate the array of stakeholders, thereby leading to a more proactive, pragmatic, transparent, and inclusive management framework-ensuring better informed decisions in an uncertain world. Supplementary Information: The online version contains supplementary material available at 10.1007/s11160-022-09726-7.

Impact of Thermophysical Properties of High-Alloy Tool Steels on Their Performance in Re-Purposing Applications.

Resource efficiency and circularity in the context of sustainability are rapidly gaining importance in the steel industry. One concept regarding circular economy is "repurposing". In the context of this work, worn-out machine circular knives are used to produce new chisels for woodturning. The chisels can be extracted parallel or perpendicular to the rolling direction of the primary production process, resulting in an associated carbide orientation of the repurposed tool. The rolling direction, and therefore carbide alignment, will influence the wear resistance and the thermophysical properties, whereby the thermal conductivity will determine the temperatures at the tip of the chisel. Therefore, the thermal conductivity was investigated with the dynamic measurement method, where the specific heat capacity, density and thermal diffusivity of the extracted chisels and industrial reference chisels were measured separately. Moreover, the electrical resistivity was measured in order to calculate the electronic thermal conductivity according to the Wiedemann-Franz-Lorenz law. It was shown that all of these parameters exhibited different degrees of variability with rising temperature. In a detailed analysis, the thermal diffusivity could be identified as an essential parameter of thermal conductivity. By taking two conventional chisels with different chemical compositions and heat treatments into account, it can be seen that the microstructure determines the thermophysical properties. Considering the carbide direction, the chisels that were extracted parallel to the rolling direction showed differing thermophysical properties. Therefore, the carbide orientation is shown to play a significant role regarding the heat dissipation at the cutting edge, because differences, especially in the electronic thermal conductivity in the parallel and perpendicular extracted chisels, can be measured. In addition to the wear resistance factor, the thermal conductivity factor now also supports the removal of the repurposed chisels parallel to the rolling direction.

Association of Project ECHO Training With Buprenorphine Prescribing by Primary Care Clinicians in Minnesota for Treating Opioid Use Disorder.

Importance: Buprenorphine is an approved medication for opioid use disorder (MOUD); however, prescribing buprenorphine is limited by a requirement to obtain a waiver to prescribe it (hereinafter, "DATA [Drug Abuse Treatment Act]-waiver") and a lack of knowledge of the best practices among clinicians. Objective: To examine how Project ECHO (Extension for Community Healthcare Outcomes) telementoring is associated with changes in DATA-waiver attainment and buprenorphine prescribing among primary care clinicians in Minnesota. Design, Setting, and Participants: In this retrospective matched-cohort study of 918 clinicians, ECHO-trained clinicians were enrolled on the date they first attended ECHO (January 3, 2018, to June 11, 2020); comparison clinicians were assigned an enrollment date from the distribution of the first ECHO sessions. The baseline period was 12 months preceding enrollment, with follow-up for 18 months or until June 30, 2020. The ECHO-trained clinicians were a population-based sample of primary care clinicians who treated Medicaid patients in Minnesota 12 months prior to the initiation of ECHO training. This analysis used propensity score matching to select comparison clinicians who were similar across demographic and clinical practice characteristics at baseline in a 2:1 ratio. Follow-up was available for 167 ECHO-trained clinicians (54.6%) and 330 comparison clinicians (53.9%) at 18 months. Exposures: ECHO-trained clinicians attended at least 1 weekly, hour-long ECHO session. Comparison clinicians never participated in any ECHO sessions. Main Outcomes and Measures: DATA-waiver attainment, any buprenorphine prescribing, and the percentage of patients with opioid use disorder (OUD) who were prescribed buprenorphine. Results: The final sample included 918 clinicians (ECHO-trained [306]; comparison [612]), of whom 620 (67.5%) practiced outside the metropolitan Twin Cities (Minneapolis-St Paul) region. The mean (SD) age of the ECHO-trained clinicians was 46.0 (12.1) years and that of the comparison clinicians was 45.7 (12.3) years. Relative to the changes among the matched comparison clinicians, the ECHO-trained clinicians were more likely to obtain a DATA-waiver (difference-in-differences, 22.7 percentage points; 95% CI, 15.5-29.9 percentage points; P < .001) and prescribe any buprenorphine (16.5 percentage points; 95% CI, 10.4-22.5 percentage points; P < .001) after 6 quarters of follow-up. ECHO-trained clinicians prescribed buprenorphine to a greater share of patients with OUD (a difference of 7.6 percentage points per month; 95% CI, 4.6-10.6 percentage points per month; P < .001), relative to that prescribed by the comparison clinicians. Conclusions and Relevance: According to the findings of this matched-cohort study, ECHO telementoring may be associated with greater prescribing of buprenorphine by primary care clinicians. These findings suggest that Project ECHO training could be a useful tool for expanding access to MOUD.

Pediatric hand ultrasound: common indications, injury, inflammation and masses.

Ultrasound is a uniquely valuable tool for evaluating musculoskeletal problems in the pediatric hand. Acute and chronic injuries involving tendons and ligaments of the hand can be quickly assessed and can guide surgical decision-making. Using ultrasound, palpable lesions and masses can be evaluated for cystic and solid components aiding in differential diagnosis. Additionally, ultrasound provides evaluation of acute versus chronic changes of inflammatory arthritis, assessing disease severity and subclinical synovitis and serving as an adjunct to medical management. This review will cover common indications and ultrasound findings of the pediatric hand, focusing on common injuries, inflammatory arthritis and masses. Important anatomical features of the hand will be discussed as well as imaging technique and evaluation in the pediatric patient.

Weekend night vs. school night sleep patterns, weight status, and weight-related behaviors among adolescents.

OBJECTIVE: In this study, we examine associations between objectively measured weekend night vs. school night sleep patterns, weight status, and weight-related behaviors among adolescents. DESIGN: Cross-sectional study. SETTING: Five Minnesota high schools that started early (7:30 or 7:45 AM) in Spring 2016. PARTICIPANTS: Ninth grade students, ages 14.5-16 years (n = 284). MEASUREMENTS: Students completed surveys, had body measurements taken, and wore sleep (wrist) actigraphs for 1 week (n = 284). We examined weekend night-school night differences in sleep duration and sleep timing. We then assessed whether these factors were related to weight status and weight-related behaviors (eating behaviors, food consumption, physical activity, beverage consumption) using generalized linear mixed models. RESULTS: On average, students slept 1.5 hours (95% confidence interval 1.3-1.7) more and had a sleep midpoint 1.9 hours (1.8-2.1) later on weekend nights compared to school nights. Female students had larger increases in sleep duration on weekend nights than males but similar timing differences. Sleep duration differences were uncorrelated with sleep timing differences (r = 0.01). Neither duration nor timing differences were associated with overweight, obesity, or any of the eating behaviors we examined. However, sleeping longer on weekend nights than on school nights was associated with lower probability of being active 6-7 days per week (p = .02). CONCLUSIONS: Adolescents have substantial sleep duration and sleep timing differences on weekend nights vs. school nights. While these differences may not be associated with weight status or weight-related behaviors, they reflect the reality that most adolescents have schedules that restrict their sleep.

Assessing Changes in Adolescents' Sleep Characteristics and Dietary Quality in the START Study, a Natural Experiment on Delayed School Start Time Policies.

BACKGROUND: Sleep duration, quality, and timing may influence dietary quality. In adults, poor dietary quality is a risk factor for numerous chronic diseases. It is unclear how these various sleep domains influence adolescents' diets because prior population-based studies have not effectively manipulated sleep, did not include objective sleep measures, and had short follow-up times. OBJECTIVES: The objectives of this study were to examine 1) how adolescent sleep characteristics relate to dietary quality; and 2) how delay in high school start times (which lengthened sleep duration) affects dietary quality over 2 y. METHODS: In the START study, adolescents (grades 9-11, n = 423) attending 5 high schools in the Minneapolis, Minnesota metropolitan area were annually assessed in 3 waves (2016-2018). At Baseline, all schools started "early" (07:30 or 07:45). From Follow-up 1 through Follow-up 2, 2 "policy change schools" shifted to later start times (to 08:20 and 08:50). Three "comparison schools" maintained their early start throughout. Sleep characteristics were measured with actigraphy. Mixed-effect regression models were used to examine cross-sectional and longitudinal associations of sleep characteristics with dietary quality, and school start time policy change with dietary quality change. RESULTS: Cross-sectionally, later sleep midpoint and onset were associated with dietary quality scores 1.6-1.7 lower (both P < 0.05). However, no prospective associations were observed between sleep characteristics and dietary quality in longitudinal models. Shifting to later school start time tended to be associated with a 2.4-point increase in dietary quality score (P = 0.09) at Follow-up 1, but was not associated with change in dietary quality scores at Follow-up 2 (P = 0.35). CONCLUSIONS: High school students attending delayed-start schools maintained better dietary quality than students in comparison schools; however, differences were not statistically significant. Overall study findings highlight the complexity of the relation between sleep behavior and diet in adolescence.

Association of Delaying School Start Time With Sleep-Wake Behaviors Among Adolescents.

PURPOSE: Few adolescents spend enough time asleep on school nights. This problem could be addressed by delaying high school start times, but does this translate to reduced prevalence of sleep-wake problems like awakening too early or feeling sleepy during the day? METHODS: The START study (n = 2,414) followed a cohort of students from five Minnesota high schools to evaluate impacts of school start time delays. Participants were enrolled in ninth grade (Baseline) when all schools started early (7:30 or 7:45 a.m.). At Follow-Up 1 (10th grade) and Follow-Up 2 (11th grade), two schools had delayed their start times by 50 and 65 minutes while three comparison schools started at 7:30 a.m. Six sleep-wake behaviors were assessed at all three time points via survey. Generalized estimating equation models were used to investigate changes in sleep-wake problems between policy change and comparison schools. RESULTS: The prevalence of sleep-wake problems at Baseline ranged from 11% for being late to class due to oversleeping to 48% for needing to be told to wake multiple times in the morning. Compared to students from comparison schools, students at policy change schools reported smaller increases in the prevalence of feeling sleepy daily and oversleeping and being late to class between 9th and 11th grade. After implementation of the delayed start, awakening too early was more common among students at policy change schools compared to the comparison schools. CONCLUSIONS: This longitudinal study provides evidence that delaying high school start times reduces daytime sleepiness and school tardiness.

Direct Repair of the Lower Trunk to Residual Nerve Roots for Restoration of Finger Flexion After Total Brachial Plexus Injury.

PURPOSE: Residual nerve root stumps have been used to neurotize the median nerve in an attempt to restore finger flexion function in patients suffering from total brachial plexus injury. However, the results have been unsatisfactory mainly because of the need to use a long nerve graft. The authors have tried to improve the quality of restored finger flexion by direct approximation of available (ruptured) ipsilateral root stumps to the lower trunk (LT). We sought to validate these results using objective outcome measures. METHODS: This is a study of 27 cases of total posttraumatic brachial plexus palsies. In each case, the neck was explored and ruptured root stumps identified. The LT was mobilized by separating it from the posterior division and the medial cutaneous nerve of the forearm distally. The mobilized LT was then approximated directly to an ipsilateral root stump. The arm was immobilized against the trunk for 2 months. The patients were observed for return of function in the paralyzed upper limb. The presence and strength of finger flexion was measured using the British Medical Council grading. RESULTS: The follow-up period was 36 to 74 months (average, 56.9 ± 13.7 months). Recovery of active finger flexion was M4 in 10 patients, M3 in 8 patients, and M2 to M0 in 9 patients. Meaningful recovery (M3 or greater) of finger flexion was achieved in 18 of 27 patients. CONCLUSIONS: The results of active finger flexion can be improved by direct approximation of the LT to an ipsilateral root stump. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Role of International Traveling Fellowships in Training the Contemporary US Hand Surgeon.

Hand trauma has always been a common etiology treated by the hand surgeon. However, the amount of severe hand trauma in the United States has decreased as the safety of working environments have improved and the amount of heavy industry jobs has decreased. Largely because of this, the typical hand surgery trainee is now exposed relatively infrequently to pathologies such as brachial plexus injuries, replantation surgery, and upper-extremity reconstructive microsurgery. Our hand surgery colleagues in countries such as India and China have a different experience, though. This difference provides an opportunity for educational exchange through the form of well-structured international fellowships. The American Society for Surgery of the Hand International Traveling Fellowship is specifically designed to supplement the training of young US hand surgeons in brachial plexus surgery, replantation surgery, and reconstructive microsurgery by spending short but intensive periods at some of the premier institutions in China and India.

Changes in association between school foods and child and adolescent dietary quality during implementation of the Healthy, Hunger-Free Kids Act of 2010.

PURPOSE: The purposes of the study were to estimate the effect of Healthy, Hunger-Free Kids Act of 2010 (HHFKA) implementation on dietary quality of all U.S. school-aged children and adolescents and examine whether those effects differed by the demographic group. METHODS: We used survey regression on 2007-2016 National Health and Nutrition Examination Survey data to estimate the proportion of energy intake from school foods and the association between school food intake and dietary quality, before and after HHFKA passage/implementation. To account for demographic changes in the U.S. population over time, inverse probability weighting was used. The product of the proportion of energy from school foods and the association between school food intake and dietary quality estimated the effect of HHFKA implementation on dietary quality. RESULTS: School food intake quantity remained stable during the study period. HHFKA implementation improved students' dietary quality by 4.3 Healthy Eating Index-2010 points (95% confidence interval: 2.5, 6.1) on days when school foods were eaten and by 1.3 Healthy Eating Index-2010 points (95% confidence interval: 0.73, 1.8) averaged over all days annually. CONCLUSIONS: HHFKA implementation improved the total dietary quality of U.S. school students. U.S. students would benefit from eating school meals in the post-HHFKA era, and HHFKA regulations should not be relaxed.

Association of Delaying School Start Time With Sleep Duration, Timing, and Quality Among Adolescents.

Importance: Sleep is a resource that has been associated with health and well-being; however, sleep insufficiency is common among adolescents. Objective: To examine how delaying school start time is associated with objectively assessed sleep duration, timing, and quality in a cohort of adolescents. Design, Setting, and Participants: This observational cohort study took advantage of district-initiated modifications in the starting times of 5 public high schools in the metropolitan area of Minneapolis and St Paul, Minnesota. A total of 455 students were followed up from grade 9 (May 3 to June 3, 2016) through grade 11 (March 15 to May 21, 2018). Data were analyzed from February 1 to July 24, 2019. Exposures: All 5 participating schools started early (7:30 am or 7:45 am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), 2 schools delayed their start times by 50 and 65 minutes, whereas 3 comparison schools started at 7:30 am throughout the observation period. Main Outcomes and Measures: Wrist actigraphy was used to derive indices of sleep duration, timing, and quality. With a difference-in-difference design, linear mixed-effects models were used to estimate differences in changes in sleep time between delayed-start and comparison schools. Results: A total of 455 students were included in the analysis (among those identifying sex, 225 girls [49.5%] and 219 boys [48.1%]; mean [SD] age at baseline, 15.2 [0.3] years). Relative to the change observed in the comparison schools, students who attended delayed-start schools had an additional mean 41 (95% CI, 25-57) objectively measured minutes of night sleep at follow-up 1 and 43 (95% CI, 25-61) at follow-up 2. Delayed start times were not associated with falling asleep later on school nights at follow-ups, and students attending these schools had a mean difference-in-differences change in weekend night sleep of -24 (95% CI, -51 to 2) minutes from baseline to follow-up 1 and -34 (95% CI, -65 to -3) minutes from baseline to follow-up 2, relative to comparison school participants. Differences in differences for school night sleep onset, weekend sleep onset latency, sleep midpoints, sleep efficiency, and the sleep fragmentation index between the 2 conditions were minimal. Conclusions and Relevance: This study found that delaying high school start times could extend adolescent school night sleep duration and lessen their need for catch-up sleep on weekends. These findings suggest that later start times could be a durable strategy for addressing population-wide adolescent sleep deficits.