Retrograde Intramedullary Nailing Versus Locked Plating for Extreme Distal Periprosthetic Femur Fractures: A Multicenter Retrospective Cohort Study.

OBJECTIVES: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange. DESIGN: Retrospective review. SETTING: Eight academic level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP. OUTCOME MEASURES AND COMPARISONS: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP. RESULTS: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008). CONCLUSIONS: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cannabidiol Use Patterns and Efficacy for Children Who Have Cerebral Palsy.

Cannabidiol (CBD)-containing supplements are used by children with cerebral palsy (CP), but the prevalence and efficacy of their use have not been studied. We sought to describe CBD use patterns and perceived efficacy in the pediatric population with CP, evaluating any association between CBD use and health-related quality of life. Patients with CP were prospectively enrolled, and caregivers were offered the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) Questionnaire and a survey assessing CBD use. Of 119 participants, 20 (16.8%) endorsed CBD use (CBD+) and 99 (83.2%) denied it (CBD-). Participants in the CBD+ group had worse functional status (85% Gross Motor Function Classification System level IV-V for CBD+ vs 37.4% for CBD-, P<.001) and lower health-related quality of life (mean CPCHILD score of 49.3 for CBD+ vs 62.2 for CBD-, P=.001). Spasticity was the rationale most cited for CBD use (29%), followed by pain and anxiety (both 22.6%). CBD was perceived to be most effective for improving emotional health, spasticity, and pain. Fifty percent of the patients in the CBD+ group underwent surgery in the previous 2 years and most endorsed a general benefit in the postoperative setting. The most common side effects noted were fatigue and increased appetite (both 12%). Most participants endorsed no side effects (60%). CBD may serve as a useful adjunct for some children with CP, especially those with worse disease severity. Caregivers perceive CBD as offering some benefits, particularly in the domains of emotional health, spasticity, and pain. We found no evidence of severe adverse events in our small cohort. [Orthopedics. 2024;47(1):52-56.].

Incisional negative pressure wound therapy may not protect against post-operative surgical site complications in bicondylar tibial plateau fractures.

PURPOSE: To determine if incisional negative pressure wound therapy is protective against post-operative surgical site complications following definitive fixation of bicondylar tibial plateau fractures. METHODS: A retrospective analysis of patients diagnosed with an acute bicondylar tibial plateau fracture (AO/OTA 41-C) undergoing ORIF from 2010 to 2020 was performed. Patients received either a standard sterile dressing (SD) or incisional negative pressure wound therapy (iNPWT). Primary outcomes included surgical site infection, osteomyelitis, and wound dehiscence. Secondary outcomes included non-union and return to the operating room. Multivariate logistic regression analyses were performed. RESULTS: 180 patients were included and 22% received iNPWT (n = 40) and 78% received standard dressings (n = 140). iNPWT was more common in active smokers (24.7% vs. 19.3%, p = 0.002) and the SD group was more likely to be lost to follow up (3.6% vs. 0%, p = 0.025). iNPWT was not protective against infection or surgical site complications, and in fact, was associated with higher odds of post-operative infection (OR: 8.96, p = 0.005) and surgical site complications (OR:4.874, p = 0.009) overall. Alcohol abuse (OR: 19, p = 0.005), tobacco use (OR: 4.67, p = 0.009), and time to definitive surgery (OR = 1.21, p = 0.033) were all independent risk factors for post-operative infection. CONCLUSION: In this series of operatively treated bicondylar tibial plateau fractures, iNPWT did not protect against post-operative surgical site complications compared to conventional dressings. Tobacco use, alcohol abuse, and time to definitive surgery, were independent risk factors for post-operative infection. Further studies are needed to determine if iNPWT offers a protective benefit in exclusively high-risk patients with relevant medical and social history.

Validity of combined hydration self-assessment measurements to estimate a low vs. high urine concentration in a small sample of (tactical) athletes.

PURPOSE: Relationships between body weight, urine color (Uc), and thirst level (WUT) have been proposed as a simple and inexpensive self-assessment method to predict dehydration. This study aimed to determine if this method also allowed us to accurately identify a low vs. high urine concentration in (tactical) athletes. METHODS: A total of n = 19 Army Reserve Officer Training Corps cadets and club sports athletes (22.7 ± 3.8 years old, of which 13 male) were included in the analysis, providing morning body weight, thirst sensation, and Uc for five consecutive days. Each item received a score 0 or 1, resulting in a WUT score ranging from 0 (likely hydrated) to 3 (very likely dehydrated). WUT model and individual item outcomes were then compared with a ≥ 1.020 urine specific gravity (USG) cut-off indicating a high urine concentration, using descriptive comparisons, generalized linear mixed models, and logistic regression (to calculate the area under the curve (AUC)). RESULTS: WUT score was not significantly predictive of urine concentration, z = 1.59, p = 0.11. The AUC ranged from 0.54 to 0.77 for test days, suggesting a fair AUC on most days. Only Uc was significantly related to urine concentration, z = 2.49, p = 0.01. The accuracy of the WUT model for correctly classifying urine samples with a high concentration was 68% vs. 51% of samples with a low concentration, resulting in an average accuracy of 61%. CONCLUSION: This study shows that WUT scores were not predictive of urine concentration, and the method did not substantially outperform the accuracy of Uc scoring alone.

Virtual Post-Intervention Speech and Language Assessment of Toddler and Preschool Participants in Babble Boot Camp.

PURPOSE: Babble Boot Camp (BBC) is a parent-implemented telepractice intervention for infants at risk for speech and language disorders. BBC uses a teach-model-coach-review approach, delivered through weekly 15-min virtual meetings with a speech-language pathologist. We discuss accommodations needed for successful virtual follow-up test administration and preliminary assessment outcomes for children with classic galactosemia (CG) and controls at age 2.5 years. METHOD: This clinical trial included 54 participants, 16 children with CG receiving BBC speech-language intervention from infancy, age 2 years, five children receiving sensorimotor intervention from infancy and changing to speech-language intervention at 15 months until 2 years of age, seven controls with CG, and 26 typically developing controls. The participants' language and articulation were assessed via telehealth at age 2.5 years. RESULTS: The Preschool Language Scale-Fifth Edition (PLS-5) was successfully administered with specific parent instruction and manipulatives assembled from the child's home. The GFTA-3 was successfully administered to all but three children who did not complete this assessment due to limited expressive vocabularies. Referrals for continued speech therapy based on PLS-5 and GFTA-3 scores were made for 16% of children who received BBC intervention from infancy as compared to 40% and 57% of children who began BBC at 15 months of age or did not receive BBC intervention, respectively. CONCLUSIONS: With extended time and accommodations from the standardized administration guidelines, virtual assessment of speech and language was possible. However, given the inherent challenges of testing very young children virtually, in-person assessment is recommended, when possible, for outcome measurements.

Curiosity and intentions to use myblu e-cigarettes and an examination of the 'gateway' theory: Data from cross-sectional nationally representative surveys.

Encouraging adult smokers who are uninterested or unwilling to quit, and would otherwise continue to smoke, to transition to potentially less harmful nicotine products such as electronic nicotine delivery systems (ENDS) may positively impact population health. However, counterbalancing this benefit is the societal concern that ENDS may be used by never smokers and youth and serve as a 'gateway' into cigarette smoking. Data were analysed from two independent surveys of the prevalence and perceptions of myblu ENDS use in the United States. Total sample size was 22,232 young adults and 23,264 adults. Being curious to use myblu was 1.6-2.0 times more likely in young adult current smokers than young adult never smokers. This likelihood was 2.8 times greater for adult current smokers compared with adult never smokers in the perceptions survey, while in the prevalence survey, there was no difference between adult current and never smokers. Intentions to use myblu were significantly greater in young adult current smokers compared with young adult never smokers in both surveys and in adults in the prevalence survey. In all surveys and age cohorts, 124 of 45,496 participants (0.1% of the total survey population) reported first using myblu prior to smoking cigarettes and went on to become established smokers. Curiosity and intentions to use myblu were generally higher in current smokers compared with never smokers. There was minimal evidence to suggest the existence of a 'gateway' effect to established cigarette smoking among never-smoking myblu users.

Optimizing Orthopaedic Trauma Implant Pricing Through a Data-Driven and Surgeon-Integrated Approach.

OBJECTIVE: To determine whether market-based pricing could be coupled with surgeon integration into negotiation strategies to achieve lower pricing levels for orthopaedic trauma implants. A secondary aim was to identify specific types of implants that may offer larger opportunities for cost savings. METHODS: Market pricing levels were reviewed from 2 industry implant databases. This information was used by surgeons and supply chain management at our institution to select appropriate target pricing levels (25th percentile) for commonly used orthopaedic trauma implants. Target price values were provided to the existing 12 vendors used by our institution with a clear expectation that vendors meet these thresholds. RESULTS: Benchmark modeling projected a potential savings of 20.0% over our prior annual spend on trauma implants. After 2 rounds of negotiation, savings amounted to 23.0% of prior annual spend. Total savings exceeded 1,000,000 USD with 11 of 12 vendors (91.7%) offering net savings. Total percent savings were highest for external fixators, drill bits, and K-wires. Plates and screws comprised the greatest proportion of our prior annual spend and achieved similar savings. CONCLUSION: A surgeon and supply chain coordinated effort led to major cost savings without a need for consolidation of vendors. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Examination of the impact of myblu electronic nicotine delivery system e-liquid nicotine strength on self-reported measures of dependence.

BACKGROUND: Greater nicotine delivery is associated with higher nicotine concentrations in electronic nicotine delivery system (ENDS) liquids. However, there is a current debate as to whether this leads to increased dependence and mitigates ENDS public health potential. METHODS: Self-reported dependence among users of myblu ENDS containing different nicotine concentrations was examined with data from a multiwave cross-sectional survey of US young adults and adults. Questions examined responses related to dependence measures and participants' most often used myblu ENDS nicotine concentration (low: 0%, 1% and 1.2%; medium: 2%, 2.4% and 2.5%; or high: 3.6% and 4%). RESULTS: A global general linear model using nicotine concentration, age and days myblu that was used in the past 30 revealed a significant difference in PROMIS scores among nicotine concentration groups (F = 4.07, p = 0.02). However, pairwise comparisons to examine which specific groups differed significantly from others showed no significant differences. Logistic regression demonstrated that strong past 30-day cravings to use myblu among participants using high or medium nicotine concentrations were not significantly different from those using a low concentration (ORs 0.66 [0.42, 1.03], p = 0.07 and 0.95 [0.49, 1.82], p = 0.98, respectively). Time to daily first use for high or medium nicotine concentration users was not significantly different from those using a low concentration (ORs 0.89 [0.70, 1.14], p = 0.35 and 0.84 [0.57, 1.25], p = 0.40, respectively). CONCLUSIONS: Use of myblu ENDS with different nicotine concentrations is not associated with differing levels of dependence. Our findings contradict the notion that high ENDS e-liquid nicotine levels generate increased dependence.

Market survey of disposable e-cigarette nicotine content and e-liquid volume.

Inaccurate labels on some e-cigarette products have prompted calls for routine testing to monitor product label integrity. The objective of this study was to compare label statements of commercial disposable/non-chargeable e-cigarette products for nicotine concentration and e-liquid volume with analytically verified levels. Commercial e-cigarette samples were analyzed for nicotine concentration (N = 51), e-liquid volume and total nicotine content (N = 39). Twenty-three of the 51 samples analyzed for nicotine deviated from their label statements by more than ± 10%. Deviations ranged from -50.1% to + 13.9%. Thirty of the 39 samples analyzed for e-liquid volume deviated from their label statements by more than ± 10%. Deviations ranged from -62.1% to + 13.3%. Only one brand listed total nicotine on the label. In thirty-one of the 39 samples, calculated total nicotine amount in e-liquid deviated from the amounts calculated from the label metrics by more than ± 10%. Deviations ranged from -66.8% to -1.43%. These findings underscore the need for regulatory enforcement of manufacturing quality control and product labeling practices to optimize the harm reduction potential and consumer experience associated with the use of e-cigarette products.

A randomised, crossover, clinical study to assess nicotine pharmacokinetics and subjective effects of the BIDI® stick ENDS compared with combustible cigarettes and a comparator ENDS in adult smokers.

BACKGROUND: Nicotine pharmacokinetic assessments of electronic nicotine delivery systems (ENDS) are crucial to understand their ability to provide an alternative to cigarette smoking. Subjective effects data also strongly contribute to this understanding. The BIDI® Stick is a disposable ENDS product which contains 59 mg/ml nicotine benzoate salt and various flavours. METHODS: In this study, we assessed nicotine pharmacokinetics and subjective effects of 6 flavour variants of BIDI® Stick ENDS in adult smokers, compared to cigarettes and a comparator ENDS product. During each of eight study visits, 18 volunteer smoker subjects randomly used one of either their usual brand (UB) of cigarette, a BIDI® Stick ENDS, or a comparator ENDS (JUUL 59 mg/ml nicotine with Virginia Tobacco flavour), during both controlled (10 puffs, 30 s apart) and ad libitum (60 min) puffing sessions. Blood samples were collected at various time points and subjective effects questionnaires were administered. RESULTS: Mean [SD] plasma nicotine Cmax 0-120 was not significantly different between BIDI® Stick ENDS with any flavour (range 15.3 [9.90] ng/ml for BIDI® Stick Winter to 17.6 [9.00] ng/ml for BIDI® Stick Classic) and UB cigarettes (16.2 [9.17] ng/ml). Mean [SD] AUC0-120 (range 569.7 [327.29] to 628.6 [408.99]  min*ng/ml for BIDI® Stick ENDS and 747.1 [325.48]  min*ng/ml for UB cigarettes) and median Tmax 0-120 (range 5-7 min for all BIDI® Stick ENDS and UB cigarettes) values were also not significantly different between BIDI® Stick ENDS and UB cigarettes, while subjective effects measures were also similar between BIDI® Stick ENDS and UB cigarettes. Mean [SD] plasma nicotine Cmax 0-120, AUC0-120, and median Tmax 0-120 were 6.8 [4.13] ng/ml, 243.6 [179.04] min*ng/ml, and 5 min, respectively, for JUUL ENDS. These values were significantly different compared with those for all BIDI® Stick ENDS and UB cigarettes for both Cmax 0-120 and AUC0-120 but not for Tmax 0-120. CONCLUSIONS: BIDI® Stick ENDS delivered nicotine to users comparably to their UB combustible cigarette and higher than JUUL ENDS, and also elicited similar subjective effects such as satisfaction and relief. Thus, the BIDI® Stick ENDS may be a satisfying alternative to cigarettes among current smokers and may support their transitioning away from cigarette smoking. TRIAL REGISTRATION: ClinicalTrials.gov (identifier number NCT05072925).

ICD-10 codes do not accurately reflect ankle fracture injury patterns.

OBJECTIVE: To determine the accuracy of International Classification of Disease Version 10 (ICD-10) coding for ankle fracture injury patterns. DESIGN: Retrospective cohort study PATIENTS: 97 adult patients with fractures about the ankle (rotational ankle fracture or distal tibia fracture) from 2016 to 2020, selected by stratified random sampling. INTERVENTION: Assignment of an ICD-10 code representative of a rotational ankle fracture, pilon fracture, or unspecified fracture of the lower leg. OUTCOME MEASUREMENTS: Injury radiographs were reviewed by three authors to determine the correct code. Agreement between the correct code and the electronic medical record (EMR) assigned code was determined using kappa's statistic in the aggregate as well as percent agreement, sensitivity, specificity, and positive predictive value (PPV) between individual codes. RESULTS: 59 of 97 cases (60.8%) demonstrated discordance between the existing EMR and surgeon-assigned codes. Aggregate agreement between all codes was fair (K = 0.26). Lateral malleolus fracture codes demonstrated the highest PPV (0.91, 95% CI 0.72-0.99), while the lowest PPV was found for "other fractures of the lower leg" (0.05, 95% CI 0.0-0.24) and "other fracture of the fibula" (0.0, 95% CI 0.0-0.15). Generalized "other fracture" codes comprised 45% of EMR codes compared to only 6% of assigned codes (p < 0.001). EMR codes were specific but not sensitive. CONCLUSION: There is substantial discordance between existing EMR and surgeon-assigned ICD-10 codes for ankle fractures. Database research that relies on ICD-10 coding as a surrogate for primary clinical data should be interpreted with caution and institutions should make efforts to increase the accuracy of their coding.

Changes in Pediatric Sports Injury Presentation During the COVID-19 Pandemic: A Multicenter Analysis.

BACKGROUND: The current coronavirus 2019 (COVID-19) pandemic has prompted a multitude of public health response measures including social distancing, school cancellations, and cessation of organized sports. PURPOSE: To examine the impact of COVID-19 and corresponding public health measures on the characteristics of common pediatric musculoskeletal injuries associated with sports. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a multicenter retrospective cohort study comparing patients with sports injuries presenting to 3 geographically diverse level I pediatric trauma hospitals and outpatient orthopaedic surgery clinics in the United States during the COVID-19 pandemic and a prepandemic period at the same institutions. Patients were included if they presented for care between February 15 and July 15 in 2020 (pandemic cohort) or between March 15 and April 15 in 2018 and 2019 (prepandemic cohort). RESULTS: Included were 1455 patients with an average age of 12.1 ± 4.5 years. When comparing patients presenting in 2018 and 2019 with those presenting in 2020, we observed a decrease in mean age during the pandemic (12.6 ± 4.0 vs 11.0 ± 5.2 years; P = .048). Additionally, a decrease in the proportion of injuries attributed to sports (48.8% vs 33.3%; P < .001) and those occurring at school (11.9% vs 4.0%; P = .001) was observed. The proportion of injuries attributable to clavicle fractures increased during the early stages of the pandemic (13.2% vs 34.7%; P < .001). There was no statistically significant delay to care in injuries presenting during the pandemic (41.5 ± 141.2 vs 19.23 ± 79.1 days; P = .175). CONCLUSION: Across 3 tertiary care institutions, patients were seen without significant delay during the pandemic. We observed a significant decline in pediatric musculoskeletal injuries associated with sports during the COVID-19 pandemic. This decrease has been accompanied by a shift in both injury type and mechanism.

Automated Generation of Personalized Shock Wave Lithotripsy Protocols: Treatment Planning Using Deep Learning.

BACKGROUND: Though shock wave lithotripsy (SWL) has developed to be one of the most common treatment approaches for nephrolithiasis in recent decades, its treatment planning is often a trial-and-error process based on physicians' subjective judgement. Physicians' inexperience with this modality can lead to low-quality treatment and unnecessary risks to patients. OBJECTIVE: To improve the quality and consistency of shock wave lithotripsy treatment, we aimed to develop a deep learning model for generating the next treatment step by previous steps and preoperative patient characteristics and to produce personalized SWL treatment plans in a step-by-step protocol based on the deep learning model. METHODS: We developed a deep learning model to generate the optimal power level, shock rate, and number of shocks in the next step, given previous treatment steps encoded by long short-term memory neural networks and preoperative patient characteristics. We constructed a next-step data set (N=8583) from top practices of renal SWL treatments recorded in the International Stone Registry. Then, we trained the deep learning model and baseline models (linear regression, logistic regression, random forest, and support vector machine) with 90% of the samples and validated them with the remaining samples. RESULTS: The deep learning models for generating the next treatment steps outperformed the baseline models (accuracy = 98.8%, F1 = 98.0% for power levels; accuracy = 98.1%, F1 = 96.0% for shock rates; root mean squared error = 207, mean absolute error = 121 for numbers of shocks). The hypothesis testing showed no significant difference between steps generated by our model and the top practices (P=.480 for power levels; P=.782 for shock rates; P=.727 for numbers of shocks). CONCLUSIONS: The high performance of our deep learning approach shows its treatment planning capability on par with top physicians. To the best of our knowledge, our framework is the first effort to implement automated planning of SWL treatment via deep learning. It is a promising technique in assisting treatment planning and physician training at low cost.

The Perilous Use of Proxy Variables.

It is often not stated or quantified how well measured proxy variables account for the variance in latent constructs they are intended to represent. A sensitivity analysis was run using data from the Survey of Health, Ageing and Retirement in Europe to estimate models varying in the degree to which proxy variables represent intended constructs. Results showed that parameter estimates differ substantially across different levels of variable representation. When variables are used with poor construct validity, an insufficient amount of variance is removed from the observed spurious relationship between design variable and outcome. The findings from this methodological demonstration underscore the importance of selecting proxy variables that accurately represent the underlying construct for which control is intended.

Prospective study of short-term quality-of-life after traumatic rib fractures.

BACKGROUND: Postdischarge convalescence after traumatic rib fractures remains unclear. We hypothesized that patients with rib fractures, even as an isolated injury, have associated poor quality of life (QoL) after discharge. METHODS: We prospectively enrolled adult patients at our level I trauma center with rib fractures between July 2019 and January 2020. We assessed QoL at 1 and 3 months after discharge using the Trauma-specific Quality-of-Life (T-QoL; 43-question survey evaluating five QoL domains on a 4-point Likert scale, where 4 indicates optimal and 1, worst QoL) and supplementary questionnaires. We used generalized estimating equations to assess T-QoL score trends over time and effect of age, sex, injury pattern, self-perceived injury severity, and Injury Severity Score. RESULTS: We enrolled 139 patients (108 completed the first and 93 completed both surveys). Three months after discharge, 33% of patients were not working at preinjury capacity, and 7% were still using opioid analgesia. Suffering rib fractures mostly impacted recovery and resilience (T-QoL score, mean [robust standard error] at 1 month, 2.7 [0.1]; 3 months, 3.0[0.1]) and physical well-being domains (1 month, 2.5 [0.1]; 3 months, 2.9[0.1]). Quality of life improved over time across all domains. Compared with patients who perceived their injuries as mild/moderate, patients who perceived their injuries as severe/very severe reported worse T-QoL scores across all domains. In contrast, Injury Severity Score did not affect QoL. Patients 65 years or older (-0.6 [0.1]) and women (-0.6 [0.2]) reported worse functional engagement compared with those 65 years or older and men, respectively. CONCLUSION: We found that patients with traumatic rib fractures experience suboptimal QoL after discharge. Quality of life improved over time, but even 3 months after discharge, patients reported challenges performing activities of daily living, slower-than-expected recovery, and not returning to work at preinjury capacity. Perception of injury severity had a large effect on QoL. Patients with rib fractures may benefit from close short-term follow-up. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record. METHODS: Our institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine-a machine learning algorithm attuned for small sample sizes-was used to compare the associations between the two classification systems and decision to operate and incidence of complications. RESULTS: 67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%). CONCLUSIONS: This study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.

A Multidomain Approach to Assessing the Convergent and Concurrent Validity of a Mobile Application When Compared to Conventional Methods of Determining Body Composition.

Determining body composition via mobile application may circumvent limitations of conventional methods. However, the accuracy of many technologies remains unknown. This investigation assessed the convergent and concurrent validity of a mobile application (LS) that employs 2-dimensional digital photography (LS2D) and 3-dimensional photonic scanning (LS3D). Measures of body composition including circumferences, waist-to-hip ratio (WHR), and body fat percentage (BF%) were obtained from 240 healthy adults using LS and a diverse set of conventional methods-Gulick tape, bioelectrical impedance analysis (BIA), and skinfolds. Convergent validity was consistently high-indicating these methods vary proportionally and can thus reliably detect changes despite individual measurement differences. The span of the Limits of Agreement (LoA) using LS were comparable to the LoA between conventional methods. LS3D exhibited high agreement relative to Gulick tape in the measurement of WHR, despite poor agreement with individual waist and hip circumferences. In BF%, LS2D exhibited high agreement with BIA and skinfold methods, whereas LS3D demonstrated low agreement. Interestingly, the low inferred bias between LS3D and DXA using existing data suggests that LS3D may have high agreement with dual-energy x-ray absorptiometry. Overall, the suitability of LS2D and LS3D to replace conventional methods must be based on an individual user's criteria.

Combining Stress Exposure and Stress Generation: Does Neuroticism Alter the Dynamic Interplay of Stress, Depression, and Anxiety Following Job Loss?

OBJECTIVE: Emerging models of stress point to a dynamic formulation where stressors and internalizing symptoms reciprocally influence each other. This study tested whether this dynamic interplay is the result of a general internalizing process underlying both depression and anxiety, and whether it varies with neuroticism. METHOD: A total of 426 adults (51% female; 47% White, 42% African American) were assessed five times over 6 months following loss of employment, using repeated measurements of stressors, depression, anxiety, and neuroticism. RESULTS: Latent growth across 6 months and multilevel cross-lagged regressions across 6 weeks supported the hypothesis that stressors and internalizing symptoms have reciprocal effects after job loss. Findings for unique variation in depression paralleled those for general internalizing, whereas few findings emerged for general or social anxiety after controlling for internalizing. Neuroticism strengthened the association of change in stressors with change in symptoms across 6 months. Those with high neuroticism showed less reduction in internalizing following reemployment and were less likely to be reemployed when starting with higher internalizing. CONCLUSIONS: The moderated reciprocal effects model helps account for onset, maintenance, and resolution of symptoms following job loss. We speculate that these findings may be due in part to differential emotion regulation and reductions in motivation.

Relationship between smokers' modes of entry into quitlines and treatment outcomes.

OBJECTIVES: To assess the relationship between the mode of entry into a quitline service and subsequent tobacco use treatment outcomes. METHODS: A retrospective study using logistic regression analysis of 11,040 Arizona Smokers' Helpline (ASHLine) clients was conducted to determine whether self- or medical referrals were related to 7- and 30-day point prevalence tobacco treatment outcomes at 7 months postquit. RESULTS: Smokers referred to the ASHLine by a health care provider were more likely to quit smoking than were those who self-referred. CONCLUSIONS: Mode of entry into a quitline service for smoking cessation is related to treatment outcomes. Reasons for this outcome are uncertain and require additional research.

Performance measure of urinary antigen in patients with Streptococcus pneumoniae bacteremia.

The Streptococcus pneumoniae (SP) urinary antigen (UAg) test is a commonly used assay. The purpose of this study was to evaluate the test's actual performance in the clinical setting and determine the effects of renal function, grade of bacteremia, and severity-of-illness scores on its outcome. Patients with pneumococcal bacteremia were retrospectively identified and stratified on the basis of glomerular filtration rates, number of positive blood cultures, and CURB-65 scores. Logistic regression was used to determine the effect that these 3 variables had on test outcomes. SP UAg testing was performed in 65 of 129 patients with pneumococcal bacteremia and was positive in 42 of 65 (64.5%). Impaired renal function was the only variable to have a significant effect on test outcome (P = 0.03). Test performance was less sensitive than prospective studies indicate. Patients with impaired renal function were significantly more likely to have positive UAg tests.