Age Is Associated With Dampened Circadian Patterns of Rest and Activity: The Study of Muscle, Mobility, and Aging (SOMMA).

BACKGROUND: The effects of aging on circadian patterns of behavior are insufficiently described. To address this, we characterized age-specific features of rest-activity rhythms (RAR) in community-dwelling older adults both overall, and in relation, to sociodemographic characteristics. METHODS: We examined cross-sectional associations between RAR and age, sex, race, education, multimorbidity burden, financial, work, martial, health, and smoking status using assessments of older adults with wrist-worn free-living actigraphy data (N = 820, age = 76.4 years, 58.2% women) participating in the Study of Muscle, Mobility, and Aging (SOMMA). RAR parameters were determined by mapping an extension to the traditional cosine curve to activity data. Functional principal component analysis determined variables accounting for variance. RESULTS: Age was associated with several metrics of dampened RAR; women had stronger and more robust RAR versus men (all p < .05). Total activity (56%) and time of activity (20%) accounted for most of the RAR variance. Compared to the latest decile of acrophase, those in the earliest decile had higher average amplitude (p < .001). Compared to the latest decile of acrophase, those in the earliest and midrange categories had more total activity (p = .02). Being in a married-like relationship and a more stable financial situation were associated with stronger rhythms; higher education was associated with less rhythm strength (all p < .05). CONCLUSIONS: Older age was associated with dampened circadian behavior; behaviors were sexually dimorphic. Some sociodemographic characteristics were associated with circadian behavior. We identified a behavioral phenotype characterized by early time of day of peak activity, high rhythmic amplitude, and more total activity.

Effects of resveratrol on in vitro circadian clock gene expression in young and older human adipose-derived progenitor cells.

Observational studies in preclinical models demonstrate age-related declines in circadian functions. We hypothesized that age would be associated with declines in function of cell-autonomous circadian clocks in human tissue. Accordingly, we cultured adipose progenitor cells (APCs) from previously collected white-adipose tissue biopsies from abdominal subcutaneous depots of young (Age: 23.4 ± 2.1 yrs) vs. older female participants (Age: 70.6 ± 5.9 yrs). Using an in vitro model, we compared rhythmic gene expression profiles of core clock components, as an indicator of circadian oscillatory function. We observed consistent circadian rhythmicity of core clock components in young and older-APCs. Expression analysis showed increased levels of some components in older-APCs (CLOCK, CRY1, NR1D1) vs. young. We also investigated resveratrol (RSV), a well-known longevity-enhancing effector, for its effects on rhythmic clock gene expression profiles. We found that RSV resulted in gained rhythmicity of some components (CLOCK and CRY), loss of rhythmicity in others (PER2, CRY2), and altered some rhythmic parameters (NR1D1 and NR1D2), consistent in young and older-APCs. The observation of detectable circadian rhythmicity retained in vitro suggests that the oscillatory function of the cell-autonomous core clock in APCs is preserved at this stage of the aging process. RSV impacts core clock gene expression in APCs, implicating its potential as a therapeutic agent for longevity by targeting the core clock.

Prophylactic Muscle Flaps Decrease Wound Complication Rates in Patients with Oncologic Spine Disease.

BACKGROUND: Patients with oncologic spine disease face a high systemic illness burden and often require surgical intervention to alleviate pain and maintain spine stability. Wound healing complications are the most common reason for reoperation in this population and are known to impact quality of life and initiation of adjuvant therapy. Prophylactic muscle flap (MF) closure is known to reduce wound healing complications in high-risk patients; however, the efficacy in oncologic spine patients is not well established. METHODS: A collaboration at our institution presented an opportunity to study the outcomes of prophylactic MF closure. The authors performed a retrospective cohort study of patients who underwent MF closure versus a cohort who underwent non-MF closure in the preceding time. Demographic and baseline health data were collected, as were postoperative wound complication data. RESULTS: A total of 166 patients were enrolled, including 83 patients in the MF cohort and 83 control patients. Patients in the MF group were more likely to smoke ( P = 0.005) and had a higher incidence of prior spine irradiation ( P = 0.002). Postoperatively, five patients (6%) in the MF group developed wound complications, compared with 14 patients (17%) in the control group ( P = 0.028). The most common overall complication was wound dehiscence requiring conservative therapy, which occurred in six control patients (7%) and one MF patient (1%) ( P = 0.053). CONCLUSIONS: Prophylactic MF closure during oncologic spine surgery significantly reduces the wound complication rate. Future studies should examine the precise patient population that stands to benefit most from this intervention. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

C1-C2 Posterior Screw-Rod Fixation.

Multiple approaches for instrumentation of the upper cervical spine have evolved to treat atlantoaxial instability which, until the 20th century, was largely considered to be inoperable and managed nonsurgically with immobilization. Surgeons set out to provide safe and effective approaches in a clearly dangerous and technically complex anatomic region. It is important to provide a historical analysis of the evolution of techniques that have shaped C1-C2 instrumentation, and how the diligent efforts of surgeons to improve the biomechanical stability and fusion rates of their constructs eventually led to the prevailing Harms technique. This technique is explored by describing its surgical steps, alternative techniques, and associated outcomes. For successful instrumentation of the atlantoaxial joint, a comprehensive understanding of spinal biomechanics, surgical techniques, and anatomic variations is imperative for surgeons to develop a tailored plan for each patient's individual pathology and anatomy.

The association between chrononutrition behaviors and muscle health among older adults: The study of muscle, mobility and aging.

Emerging studies highlight chrononutrition's impact on body composition through circadian clock entrainment, but its effect on older adults' muscle health remains largely overlooked. To determine the associations between chrononutrition behaviors and muscle health in older adults. Dietary data from 828 older adults (76 ± 5 years) recorded food/beverage amounts and their clock time over the past 24 h. Studied chrononutrition behaviors included: (1) The clock time of the first and last food/beverage intake; (2) Eating window (the time elapsed between the first and last intake); and (3) Eating frequency (Number of self-identified eating events logged with changed meal occasion and clock time). Muscle mass (D3 -creatine), leg muscle volume (MRI), grip strength (hand-held dynamometer), and leg power (Keiser) were used as outcomes. We used linear regression to assess the relationships between chrononutrition and muscle health, adjusting for age, sex, race, marital status, education, study site, self-reported health, energy, protein, fiber intake, weight, height, and moderate-to-vigorous physical activity. Average eating window was 11 ± 2 h/day; first and last intake times were at 8:22 and 19:22, respectively. After multivariable adjustment, a longer eating window and a later last intake time were associated with greater muscle mass (ß ± SE: 0.18 ± 0.09; 0.27 ± 0.11, respectively, p < 0.05). The longer eating window was also marginally associated with higher leg power (p = 0.058). An earlier intake time was associated with higher grip strength (-0.38 ± 0.15; p = 0.012). Chrononutrition behaviors, including longer eating window, later last intake time, and earlier first intake time were associated with better muscle mass and function in older adults.

Age is Associated with Dampened Circadian Patterns of Rest and Activity: The Study of Muscle, Mobility and Aging (SOMMA).

Background: Aging is associated with declines in circadian functions. The effects of aging on circadian patterns of behavior are insufficiently described. We characterized age-specific features of rest-activity rhythms (RAR) in community dwelling older adults, both overall, and in relation, to sociodemographic characteristics. Methods: We analyzed baseline assessments of older adults with wrist-worn free-living wrist-worn actigraphy data (N=820, Age=76.4 yrs, 58.2% women) participating in the Study of Muscle, Mobility and Aging (SOMMA). We applied an extension to the traditional cosine curve to map RAR to activity data, calculating the parameters: rhythmic strength (amplitude); robustness (pseudo-F statistic); and timing of peak activity (acrophase). We also used function principal component analysis to determine 4 components describing underlying patterns of activity accounting for RAR variance. Linear models were used to examine associations between RAR and sociodemographic variables. Results: Age was associated with several metrics of dampened RAR; women had stronger and more robust RAR metrics vs. men (all P < 0.05). Total activity (56%) and time of activity (20%) accounted for most the RAR variance. Compared to the latest decile of acrophase, those in the earliest decile had higher average amplitude (P <0.001). Compared to the latest decile of acrophase, those is the earliest and midrange categories had more total activity (P=0.02). RAR was associated with some sociodemographic variables. Conclusions: Older age was associated with dampened circadian behavior; and behaviors were sexually dimorphic. We identified a behavioral phenotype characterized by early time-of-day of peak activity, high rhythmic amplitude, and more total activity.

The association between chrononutrition behaviors and muscle health among older adults: The Study of Muscle, Mobility and Aging (SOMMA).

Background: Emerging studies highlight chrononutrition's impact on body composition through circadian clock entrainment, but its effect on older adults' muscle health remains largely overlooked. Objective: To determine the associations between chrononutrition behaviors and muscle health in older adults. Methods: Dietary data from 828 older adults (76±5y) recorded food/beverage amounts and their clock time over the past 24 hours. Studied chrononutrition behaviors included: 1) The clock time of the first and last food/beverage intake; 2) Eating window (the time elapsed between the first and last intake); and 3) Eating frequency (Number of self-identified eating events logged with changed meal occasion and clock time). Muscle mass (D 3 -creatine), leg muscle volume (MRI), grip strength (hand-held dynamometer), and leg power (Keiser) were used as outcomes. We used linear regression to assess the relationships between chrononutrition and muscle health, adjusting for age, sex, race, marital status, education, study site, self-reported health, energy, protein, fiber intake, weight, height, and moderate-to-vigorous physical activity. Results: Average eating window was 11±2 h/d; first and last intake times were at 8:22 and 19:22, respectively. After multivariable adjustment, a longer eating window and a later last intake time were associated with greater muscle mass (ß±SE: 0.18±0.09; 0.27±0.11, respectively, P <0.05). The longer eating window was also marginally associated with higher leg power ( P =0.058). An earlier intake time was associated with higher grip strength (-0.38±0.15; P =0.012). Conclusions: Chrononutrition behaviors, including longer eating window, later last intake time, and earlier first intake time were associated with better muscle mass and function in older adults. Key findings: Chrononutrition behaviors, including longer eating window, later last intake time, and earlier first intake time were associated with better muscle mass and function in older adults.

Nightshift imposes irregular lifestyle behaviors in police academy trainees.

Study Objective: Shiftwork increases risk for numerous chronic diseases, which is hypothesized to be linked to disruption of circadian timing of lifestyle behaviors. However, empirical data on timing of lifestyle behaviors in real-world shift workers are lacking. To address this, we characterized the regularity of timing of lifestyle behaviors in shift-working police trainees. Methods: Using a two-group observational study design (N = 18), we compared lifestyle behavior timing during 6 weeks of in-class training during dayshift, followed by 6 weeks of field-based training during either dayshift or nightshift. Lifestyle behavior timing, including sleep-wake patterns, physical activity, and meals, was captured using wearable activity trackers and mobile devices. The regularity of lifestyle behavior timing was quantified as an index score, which reflects day-to-day stability on a 24-hour time scale: Sleep Regularity Index, Physical Activity Regularity Index, and Mealtime Regularity Index. Logistic regression was applied to these indices to develop a composite score, termed the Behavior Regularity Index (BRI). Results: Transitioning from dayshift to nightshift significantly worsened the BRI, relative to maintaining a dayshift schedule. Specifically, nightshift led to more irregular sleep-wake timing and meal timing; physical activity timing was not impacted. In contrast, maintaining a dayshift schedule did not impact regularity indices. Conclusions: Nightshift imposed irregular timing of lifestyle behaviors, which is consistent with the hypothesis that circadian disruption contributes to chronic disease risk in shift workers. How to mitigate the negative impact of shiftwork on human health as mediated by irregular timing of sleep-wake patterns and meals deserves exploration.

Opportunities to Improve HPV Vaccination Among Pediatric, Adolescent, and Young Adult Cancer Survivors by Engaging both Oncology and Primary Care Teams.

The incidence of second primary cancers is rising particularly among pediatric, adolescent, and young adult (PAYA) cancer survivors. While human papillomavirus (HPV)-associated cancers can be prevented by vaccination, their uptake is lower and delayed in this group. Because a recommendation from a health care provider is the strongest predictor of HPV vaccination, there are great opportunities for PAYA cancer care providers to positively impact HPV vaccination rates. Prioritizing PAYA cancer care provider education as well as improving the education of and coordination with primary care providers are viewed as opportunities to encourage HPV vaccine uptake and prevent future cancers. See related article by Garcia et al., p. 581.

Clinical and Radiographic Outcomes for Patients with Cervical Adjacent Segment Disease Treated with Anterior Cervical Discectomy and Fusion with Integrated Interbody Spacers.

INTRODUCTION: Anterior cervical discectomy and fusion (ACDF) is among the most common spine procedures. Adjacent segment disease (ASD), characterized by degenerative disease at an adjacent spinal level to a prior fusion, is a well-recognized and significant sequela following ACDF. Adjacent segment ACDF may be considered after the failure of non-surgical options for patients with symptomatic ASD. This study aimed to assess the incidence of dysphagia and other complications as well as radiographic outcomes in adult patients who have undergone ACDF with an integrated interbody spacer device for symptomatic ASD. METHODS: This was a retrospective review of patients who underwent ACDF for symptomatic ASD with commercially available integrated interbody spacers by three spine surgeons at an academic institution from March 2018 to April 2022. Demographic, radiographic, and postoperative data were collected, including dysphagia, device-related complications, and the need for revision surgery. RESULTS: There were 48 patients (26 male, 22 female) who met inclusion criteria (mean age 59.7 years, mean body mass index 19.5 kg/m2) who underwent ACDF for symptomatic ASD (1one-level, n = 44; 2-level, n = 4). Overall, 12 patients (25%) experienced dysphagia postoperatively before the first follow-up appointment. Nine of 44 (20.4%) of 1-level ACDF patients experienced dysphagia, and 3 of 4 (75%) of 2-level ACDF patients experienced dysphagia. Three patients had severe dysphagia which prompted an otolaryngology referral. Two of those patients remained symptomatic at 6 weeks postoperatively. Of 43 patients with prior plate cage systems, none required hardware removal at the time of surgery. Preoperative global and segmental lordosis were 9.07° ± 8.36° (P = 0.22) and 3.58° ± 4.57° (P = 0.14), respectively. At 6 weeks postoperatively, global and segmental lordosis were 11.44° ± 9.06° (P = 0.54) and 5.11° ± 4.44° (P = 0.44), respectively. This constitutes a change of +2.37° and +1.53° in global and segmental lordosis, respectively. The mean anterior disc height change between preoperative and immediate postoperative time points was 6.3 ± 3.1 mm. Between the immediate postoperative and 6-week postoperative time points, the mean anterior disc height change was -1.5 ± 2.7 mm. Between the immediate postoperative and 3-month postoperative time points, the mean anterior disc height change was -3.7 ± 5.0 mm. The posterior disc height changes at the same time points were 2.5 ± 1.7 mm, -0.4 ± 1.8. and -0.5 ± 1.4 mm, respectively. This fusion rate was 50% and 70% at 6 months and 1 year post-surgery, respectively. CONCLUSIONS: ACDF with integrated spacer is a viable alternative to traditional plate-cage systems for symptomatic ASD. An advantage over traditional plate-cage systems is that the removal of prior instrumentation is not needed in order to place implants. Based on a review of the literature, these standalone systems allowed for a shorter operative time and had less incidence of dysphagia than plate-cage systems for ASD after ACDF. The different standalone and plate-cage systems used in treating ASD after ACDF surgeries should be compared in prospective studies.

Nightshift Imposes Irregular Lifestyle Behaviors in Police Academy Trainees.

Study Objective: Shiftwork increases risk for numerous chronic diseases, which is hypothesized to be linked to disruption of circadian timing of lifestyle behaviors. However, empirical data on timing of lifestyle behaviors in real-world shift workers are lacking. To address this, we characterized the regularity of timing of lifestyle behaviors in shift-working police trainees. Methods: Using a two-group observational study design (N=18), we compared lifestyle behavior timing during 6 weeks of in-class training during dayshift, followed by 6 weeks of field-based training during either dayshift or nightshift. Lifestyle behavior timing, including sleep/wake patterns, physical activity, and meals, was captured using wearable activity trackers and mobile devices. The regularity of lifestyle behavior timing was quantified as an index score, which reflects day-to-day stability on a 24h time scale: Sleep Regularity Index (SRI), Physical Activity Regularity Index (PARI) and Mealtime Regularity Index (MRI). Logistic regression was applied to these indices to develop a composite score, termed the Behavior Regularity Index (BRI). Results: Transitioning from dayshift to nightshift significantly worsened the BRI, relative to maintaining a dayshift schedule. Specifically, nightshift led to more irregular sleep/wake timing and meal timing; physical activity timing was not impacted. In contrast, maintaining a dayshift schedule did not impact regularity indices. Conclusion: Nightshift imposed irregular timing of lifestyle behaviors, which is consistent with the hypothesis that circadian disruption contributes to chronic disease risk in shift workers. How to mitigate the negative impact of shiftwork on human health as mediated by irregular timing of sleep/wake patterns and meals deserves exploration.

Associations between urbanicity and spinal cord astrocytoma management and outcomes.

BACKGROUND: The management of spinal cord astrocytomas (SCAs) remains controversial and may include any combination of surgery, radiation, and chemotherapy. Factors such as urbanicity (metropolitan versus non-metropolitan residence) are shown to be associated with patterns of treatment and clinical outcomes in a variety of cancers, but the role urbanicity plays in SCA treatment remains unknown. METHODS: The Central Brain Tumor Registry of the United States (CBTRUS) analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results Programs, was used to identify individuals with SCAs between 2004 and 2019. Individuals' county of residence was classified as metropolitan or non-metropolitan. Multivariable logistic regression models were used to evaluate associations between urbanicity and SCA. Cox proportional hazard models were constructed to assess the effect of urbanicity on survival using the NPCR survival dataset (2004-2018). RESULTS: 1697 metropolitan and 268 non-metropolitan SCA cases were identified. The cohorts did not differ in age or gender composition. The populations had different racial/ethnic compositions, with a higher White non-Hispanic population in the non-metropolitan cohort (86 % vs 66 %, p < 0.001) and a greater Black non-Hispanic population in the metropolitan cohort (14 % vs 9.9 %, p < 0.001). There were no significant differences in likelihood of receiving comprehensive treatment (OR=0.99, 95 % CI [0.56, 1.65], p = >0.9), or survival (hazard ratio [HR]=0.92, p = 0.4) when non-metropolitan and metropolitan cases were compared. In the metropolitan cohort, there were statistically significant differences in SCA treatment patterns when stratified by race/ethnicity (p = 0.002). CONCLUSIONS: Urbanicity does not significantly impact SCA management or survival. Race/ethnicity may be associated with likelihood of receiving certain SCA treatments in metropolitan communities.

Sociodemographic Trends in Telemedicine Visit Completion in Spine Patients During the COVID-19 Pandemic.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study identifies potential disparities in telemedicine utilization in the wake of the COVID-19 pandemic and its aftermath in patients receiving spine surgery. SUMMARY OF BACKGROUND DATA: COVID-19 led to the rapid uptake of telemedicine in the spine surgery patient population. While previous studies in other medical subspecialties have identified sociodemographic disparities in telemedicine uptake, this is the first study to identify disparities in patients undergoing spine surgery. MATERIALS AND METHODS: This study included patients who underwent spine surgery between June 12, 2018 and July 19, 2021. Patients were required to have at least one scheduled patient visit, either virtual (video or telephone visit) or in-person. Binary socioeconomic variables used for modeling included: urbanicity, age at the time of the procedure, sex, race, ethnicity, language, primary insurer, and patient portal utilization. Analyses were conducted for the entire cohort and separately for cohorts of patients who had visits scheduled within specific timeframes: Pre-COVID-19 surge, initial COVID-19 surge, and post-COVID-19 surge. RESULTS: After adjusting for all variables in our multivariable analysis, patients who utilized the patient portal had higher odds of completing a video visit compared with those who did not (OR: 5.21; 95% CI: 1.28, 21.23). Hispanic patients (OR: 0.44; 95% CI: 0.2, 0.98) or those living in rural areas (OR: 0.58; 95% CI: 0.36, 0.93) had lower odds of completing a telephone visit. Patients with no insurance or on public insurance had higher odds of completing a virtual visit of either type (OR: 1.88; 95% CI: 1.10, 3.23). CONCLUSION: This study demonstrates the disparity in telemedicine utilization across different populations within the surgical spine patient population. Surgeons may use this information to guide interventions aimed at reducing existing disparities and work with certain patient populations to find a solution.

Association Between Hospital Monopoly Status, Patient Socioeconomic Disadvantage, and Total Joint Arthroplasty Price Disclosure.

INTRODUCTION: In recent years, healthcare institutions and regulatory bodies have enacted cost transparency mandates for routine interventions such as total hip arthroplasty and total knee arthroplasty. However, disclosure rates remain low. This study examined the effect of financial characteristics of hospitals and the socioeconomic status of patients on price disclosure. METHODS: Hospitals conducting total hip arthroplasty/total knee arthroplasty, their quality ratings, and procedural volumes were identified using the Leapfrog Hospital Survey and linked to procedure-specific prices. Financial performance and the Area Deprivation Index (ADI) were used to correlate disclosure rates with hospital and patient characteristics. Hospital financial, operational, and patient summary statistics were compared by price-disclosure status using two-sample t -tests for continuous variables and Pearson chi-square test for categorical variables. The association between total joint arthroplasty price disclosure and hospital ADI was further evaluated using modified Poisson regression. RESULTS: A total of 1,425 hospitals certified by the Centers for Medicare & Medicaid Services were identified in the United States. 50.5% (n = 721) of hospitals had no published payer-specific price information. Hospitals in an area of higher socioeconomic disadvantage were more likely to disclose prices of total joint arthroplasty (incidence rate ratio = 0.966, 95% CI: 0.937 to 0.995, P = 0.024). Hospitals that were considered monopolies or were for-profit were less likely to disclose prices (IRR = 1.15, 95% CI: 1.030 to 1.280, P = 0.01; IRR = 1.256, 95% CI: 0.986 to 1.526, P = 0.038, respectively). When accounting for both ADI and monopoly status, hospitals with patients who had a higher ADI were more likely to disclose costs for a total joint arthroplasty, whereas for-profit hospitals or hospitals considered monopolies in their HSA were less likely to disclose prices. DISCUSSION: For nonmonopoly hospitals, a higher ADI correlated with a higher likelihood of price disclosure. However, for monopoly hospitals, there was no significant association between ADI and price disclosure. LEVEL OF EVIDENCE: II.

Association of Timing of Moderate-to-Vigorous Physical Activity With Changes in Glycemic Control Over 4 Years in Adults With Type 2 Diabetes From the Look AHEAD Trial.

OBJECTIVE: We aimed to determine the association of the time-of-day of bout-related moderate-to-vigorous physical activity (bMVPA) with changes in glycemic control across 4 years in adults with overweight/obesity and type 2 diabetes. RESEARCH DESIGN AND METHODS: Among 2,416 participants (57% women; mean age, 59 years) with 7-day waist-worn accelerometry recording at year 1 or 4, we assigned bMVPA timing groups based on the participants' temporal distribution of bMVPA at year 1 and recategorized them at year 4. The time-varying exposure of bMVPA (≥10-min bout) timing was defined as ≥50% of bMVPA occurring during the same time period (morning, midday, afternoon, or evening), <50% of bMVPA in any time period (mixed), and ≤1 day with bMVPA per week (inactive). RESULTS: HbA1c reduction at year 1 varied among bMVPA timing groups (P = 0.02), independent of weekly bMVPA volume and intensity. The afternoon group had the greatest HbA1c reduction versus inactive (-0.22% [95%CI -0.39%, -0.06%]), the magnitude of which was 30-50% larger than the other groups. The odds of discontinuation versus maintaining or initiating glucose-lowering medications at year 1 differed by bMVPA timing (P = 0.04). The afternoon group had the highest odds (odds ratio 2.13 [95% CI 1.29, 3.52]). For all the year-4 bMVPA timing groups, there were no significant changes in HbA1c between year 1 and 4. CONCLUSIONS: bMVPA performed in the afternoon is associated with improvements in glycemic control in adults with diabetes, especially within the initial 12 months of an intervention. Experimental studies are needed to examine causality.

The Association Between Sociodemographic Factors, Social Determinants of Health, and Spine Surgical Patient Portal Utilization.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To examine patient portal use among the surgical spine patient population across different sociodemographic groups and assess the impact of patient portal use on clinical outcomes. SUMMARY OF BACKGROUND DATA: Patient portals (PP) have been shown to improve outcomes and quality of care. Engaging them requires internet access, technological literacy, and dexterity, which may serve as access barriers. METHODS: After exclusion criteria were applied, the study included data for 9211 encounters from 7955 patients. PP utilization was defined as having activated and used the Duke University Medical Center patient portal system, MyChart, at least once. Sociodemographic characteristics included urbanicity, age, race, ethnicity, language, employment, and primary insurer. Clinical outcomes included the length of hospital stay during the procedure, 30-day return to the emergency department, 30-day readmission, and being discharged somewhere other than home. RESULTS: Being older than 65, non-White, unemployed, non-English-speaking, male, not-partnered, uninsured or publicly insured (Medicaid, Medicare and under 65 years of age, or other government insurance), and living in a rural environment were all risk factors for decreased PP utilization among surgical spine patients. A one-risk factor decrease in the number of social risk factors was associated with a 78% increase in the odds of PP utilization [odds ratio (OR): 1.78; 95% Confidence interval (CI): 1.69-1.87; P <0.001]. Patients not utilizing the portal at the time of their procedure had higher odds of 30-day readmission (OR: 1.59; 95% CI: 1.26-2.00), discharge somewhere other than home (OR: 2.41, 95% CI: 1.95-2.99), and an increased length of hospital stay (geometric mean ratio: 1.21; 95% CI: 1.12-1.30) compared with those who utilized it. CONCLUSIONS: In patients undergoing spine procedures, PPs are not equally utilized among different sociodemographic groups. PP utilization is also associated with better outcomes. Interventions aimed at increasing PP uptake may improve care for certain patients.

Representation of Female Speakers at the American Academy of Orthopaedic Surgeons Annual Meetings Over Time.

BACKGROUND: In the United States, women comprise 16% of orthopaedic surgery residents, 4% of fellows, and 6% of practicing orthopaedic surgeons. The underrepresentation of women in surgical subspecialties may be because of lack of early exposure to female mentors. Conference speaker roles are important for visibility. This study aims to evaluate the representation of women in speaker roles and responsibilities at the American Academy of Orthopaedic Surgeons (AAOS) meetings over time. METHODS: The names of speakers and session titles at the annual AAOS meetings were obtained from conference programs for the years 2009, 2014, and 2019. Each speaker was classified based on sex and role. Sessions discussing scientific or surgical topics were classified as technical and those that did not were classified as nontechnical. Descriptive statistics are provided, as well as individual-year odds ratios (ORs) and confidence intervals (CIs) examining sex versus technical session status and sex versus speaker role; combined results controlling for year are calculated using the Cochran-Mantel-Haenszel method. RESULTS: Overall, 3,980 speaking sessions were analyzed; 6.8% of speaking sessions were assigned to women. Women were more likely than men to participate in nontechnical speaking roles (OR 3.85; 95% CI, 2.79 to 4.78). Among talks given by women, the percentage that were nontechnical increased (25.5% in 2009, 24.3% in 2014, and 44.1% in 2019). Among moderator roles, the percentage assigned to women increased (4.5% in 2009, 6.0% in 2014, 14.5% in 2019). DISCUSSION: Our findings demonstrate an increase in female speakers at AAOS meetings from 2009 to 2019. The percentage of female moderators and nontechnical sessions given by women increased since 2009. A need for a shift in the distribution of speaker role exists, which promotes inclusivity and prevents professional marginalization. Representation of women as role models increases visibility and may address the leaky pipeline phenomenon and paucity of women in orthopaedics.

Instrument Tracking for Prone Lateral Surgery.

The prone lateral transpsoas approach for lumbar interbody fusion and posterior instrumentation enables a large surface area implant without disruption of the posterior spine musculature from a single position.1,2 The addition of virtual live fluoroscopy instrument tracking navigation to surgery provides multiple benefits, including a reduction in patient and surgeon radiation exposure, highly accurate and dynamic spatial tool localization, and flexible equipment and patient positioning.3,4 Here, we highlight the use of virtual live fluoroscopy in prone lateral spine surgery. A 75-year-old man presented with prior L3-L5 fusion and progressive lower extremity pain and weakness. Using the described techniques, the patient underwent a lateral retroperitoneal interbody fusion and posterior instrumentation at L2-L3. The operation proceeded without complication, and the patient reported improved ambulation at 6-week follow-up. The prone lateral transpsoas approach and minimally invasive posterior instrumentation for lumbar interbody fusion permits effective fusion without significant posterior muscle disruption from a single position. The integration of virtual live fluoroscopy enables real-time instrument tracking throughout the minimally invasive case, with reductions in patient and surgeon radiation exposure. Video 1 depicts the use and benefits of this technology in lateral spine surgery. Compared with computed tomography-guided navigation, virtual live fluoroscopy technology enables rapid remapping to iatrogenic anatomic changes for more fluid progression through the operation.5 Virtual live fluoroscopy instrument tracking is a valuable tool that increases the safety and efficiency of single-position lateral spine surgery.

Understanding heterogeneity of responses to, and optimizing clinical efficacy of, exercise training in older adults: NIH NIA Workshop summary.

Exercise is a cornerstone of preventive medicine and a promising strategy to intervene on the biology of aging. Variation in the response to exercise is a widely accepted concept that dates back to the 1980s with classic genetic studies identifying sequence variations as modifiers of the VO2max response to training. Since that time, the literature of exercise response variance has been populated with retrospective analyses of existing datasets that are limited by a lack of statistical power from technical error of the measurements and small sample sizes, as well as diffuse outcomes, very few of which have included older adults. Prospective studies that are appropriately designed to interrogate exercise response variation in key outcomes identified a priori and inclusive of individuals over the age of 70 are long overdue. Understanding the underlying intrinsic (e.g., genetics and epigenetics) and extrinsic (e.g., medication use, diet, chronic disease) factors that determine robust versus poor responses to various exercise factors will be used to improve exercise prescription to target the pillars of aging and optimize the clinical efficacy of exercise training in older adults. This review summarizes the proceedings of the NIA-sponsored workshop entitled, "Understanding Heterogeneity of Responses to, and Optimizing Clinical Efficacy of, Exercise Training in Older Adults" and highlights the importance and current state of exercise response variation research, particularly in older adults, prevailing challenges, and future directions.

In Vitro Circadian Clock Gene Expression Assessments in Mesenchymal Stem Cells from Human Infants: A Pilot Study.

BACKGROUND: Exposure to intrauterine obesity can disrupt clock gene rhythmicity in animal models. The aim of this pilot study was to determine if maternal obesity alters rhythmic expression of core clock in mesenchymal stem cells (MSCs) from umbilical cords of human infants born to mothers with obesity (Ob-MSC) vs. normal weight (NW-MSC). METHODS: We compared in vitro rhythmic expression patterns of core clock (BMAL1, CLOCK, PER2) and clock-output (NR1D1), components in undifferentiated Ob-MSCs (n = 3) vs. NW-MSCs (n = 3). MSCs were harvested every 2 h, following a dexamethasone shock, for 30 h. Adipogenesis or myogenesis was induced in vitro and markers of adipogenesis and fat storage were assessed, respectively. RESULTS: We detected significant rhythmicity in expression patterns of BMAL1, PER2, and NR1D1 at the group level in Ob- and NW-MSCs (p < 0.05). PER2 oscillatory amplitude was 3-fold higher in Ob-MSCs vs. NW-MSCs (p < 0.006). During adipogenesis, Ob-MSCs had higher PPARγ protein content (p = 0.04) vs. NW-MSC. During myogenesis, Ob-MSCs had higher saturated triacylglycerols (p = 0.04) vs. NW-MSC. CONCLUSION: Rhythmic expressions of BMAL1, PER2, and NR1D1 are detectable in undifferentiated MSCs. Higher PER2 oscillatory amplitude was paralleled by higher markers of fat storage during differentiation in Ob-MSCs vs. NW-MSCs, and supports that the core clock and cellular metabolism may be linked in infant MSCs.