Risk Factors for Increased Hospital Costs for Primary Total Hip Arthroplasty.

BACKGROUND: Patient medical complexity increases the cost of primary total hip arthroplasty (THA). The goal of this study was to quantify the impact of specific medical comorbidities on the real hospital cost of primary THA. METHODS: This study consisted of a retrospective analysis of 1,222 patient encounters for Current Procedural Terminology code 27130 (primary THA) between January 2017 and March 2020 at a high-volume urban academic medical center. Patient demographics, comorbidities, and admission data were collected, and univariate and multivariate gamma regression analyses were performed to identify associations with increased costs incurred during THA admission. RESULTS: The median total cost for THA was $30,580. Univariate analysis showed increased cost for body mass index (BMI) > 35 versus BMI < 35 ($31,739 versus 30,071; P < .05), American Society of Anesthesiologists (ASA) score 3 to 4 versus ASA 1 to 2 ($32,268 versus 30,045; P < .05), prevalence of diabetes ($31,523 versus 30,379; P < .05), congestive heart failure ($34,814 versus 30,584; P < .05), peripheral vascular disease (PVD) ($35,369 versus 30,573; P < .05), chronic pulmonary disease (CPD) ($34,625 versus 30,405; P < .05), renal disease ($31,973 versus 30,352; P < .05), and increased length of stay (r = 0.424; P < .05). Multivariate gamma regression showed that BMI > 35 (relative risk [RR] = 1.05), ASA 3 to 4 (RR = 1.07), PVD (RR = 1.29), CPD (RR = 1.13), and renal disease (RR = 1.09) were independently associated with increased THA hospital cost (P < .01). Increased costs seen in BMI > 35 versus BMI < 35 patients were largely due to hospital room and board ($6,345 versus 5,766; P = .01) and operating room costs ($5,744 versus 5,185; P < .05). CONCLUSIONS: A BMI > 35, PVD, CPD, renal disease, and ASA 3 to 4 are associated with higher inpatient hospital costs for THA. LEVEL OF EVIDENCE: Level III; Retrospective cohort study.

Retrospective analysis of discordant results between histology and other clinical diagnostic tests on helicobacter pylori infection.

BACKGROUND: A reliable test is essential for diagnosing Helicobacter pylori (H. pylori) infection, and crucial for managing H. pylori-related diseases. Serving as an excellent method for detecting H. pylori infection, histologic examination is a test that clinicians heavily rely on, especially when complemented with immunohistochemistry (IHC). Additionally, other diagnostic tests for H. pylori, such as the rapid urease test (CLO test) and stool antigen test (SA), are also highly sensitive and specific. Typically, the results of histology and other tests align with each other. However, on rare occasions, discrepancy between histopathology and other H. pylori diagnostic tests occurs. AIM: To investigate the discordance between histology and other H. pylori tests, the underlying causes, and the impact on clinical management. METHODS: Pathology reports of gastric biopsies were retrieved spanning August 2013 and July 2018. Reports were included in the study only if there were other H. pylori tests within seven days of the biopsy. These additional tests include CLO test, SA, and H. pylori culture. Concordance between histopathology and other tests was determined based on the consistency of results. In instances where histology results were negative while other tests were positive, the slides were retrieved for re-assessment, and the clinical chart was reviewed. RESULTS: Of 1396 pathology reports were identified, each accompanied by one additional H. pylori test. The concordance rates in detecting H. pylori infection between biopsy and other tests did not exhibit significant differences based on the number of biopsy fragments. 117 discrepant cases were identified. Only 20 cases (9 with CLO test and 11 with SA) had negative biopsy but positive results in other tests. Four cases initially stained with Warthin-Starry turned out to be positive for H. pylori with subsequent IHC staining. Among the remaining 16 true discrepant cases, 10 patients were on proton pump inhibitors before the biopsy and/or other tests. Most patients underwent treatment, except for two who were untreated, and two patients who were lost to follow-up. CONCLUSION: There are rare discrepant cases with negative biopsy but positive in SA or CLO test. Various factors may contribute to this inconsistency. Most patients in such cases had undergone treatment.

Targeted inhibition of SCFSKP2 confers anti-tumor activities resulting in a survival benefit in osteosarcoma.

Osteosarcoma(OS) is a highly aggressive bone cancer for which treatment has remained essentially unchanged for decades. Although OS is characterized by extensive genomic heterogeneity and instability, RB1 and TP53 have been shown to be the most commonly inactivated tumor suppressors in OS. We previously generated a mouse model with a double knockout (DKO) of Rb1 and Trp53 within cells of the osteoblastic lineage, which largely recapitulates human OS with nearly complete penetrance. SKP2 is a repression target of pRb and serves as a substrate recruiting subunit of the SCFSKP2 complex. In addition, SKP2 plays a central role in regulating the cell cycle by ubiquitinating and promoting the degradation of p27. We previously reported the DKOAA transgenic model, which harbored a knock-in mutation in p27 that impaired its binding to SKP2. Here, we generated a novel p53-Rb1-SKP2 triple-knockout model (TKO) to examine SKP2 function and its potential as a therapeutic target in OS. First, we observed that OS tumorigenesis was significantly delayed in TKO mice and their overall survival was markedly improved. In addition, the loss of SKP2 also promoted an apoptotic microenvironment and reduced the stemness of DKO tumors. Furthermore, we found that small-molecule inhibitors of SKP2 exhibited anti-tumor activities in vivo and in OS organoids as well as synergistic effects when combined with a standard chemotherapeutic agent. Taken together, our results suggest that SKP2 inhibitors may reduce the stemness plasticity of OS and should be leveraged as next-generation adjuvants in this cancer.

Missed Short-term Follow-up After Arthroscopic Rotator Cuff Surgery: Analysis of Surgical and Demographic Factors.

INTRODUCTION: Few current studies have examined loss to follow-up after rotator cuff-related shoulder arthroscopy. Understanding the demographic and surgical factors for missed follow-up would help identify patients most at risk and potentially mitigate the onset of complications while maximizing clinical outcomes. METHODS: A retrospective review of consecutive rotator cuff arthroscopic procedures with a minimum of 12-month follow-up done by a single, fellowship-trained surgeon was undertaken from February 2016 through January 2022. Demographic patient and surgical data, including age, sex, marital status, self-identified race, and body mass index, were collected. Follow-up at ≤3, 6 weeks, 3, 6, and 12 months was determined. Patient-related and surgical predictors for missed short-term follow-up, defined as nonattendance at the 6 and 12-month postoperative visits, were identified. RESULTS: There were 449 cases included, of which 248 (55%) were women. The median age was 57 years (interquartile range [IQR], 51 to 62). Patients with commercial insurance (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.23 to 0.64; P < 0.001) or workers' compensation (OR, 0.15; 95% CI, 0.05 to 0.43; P < 0.001) were less likely to miss the 6-month follow-up compared with patients with Medicare, whereas increased socioeconomic deprivation (OR, 0.86; 95% CI, 0.77 to 0.97, P = 0.015) was associated with decreased odds of missing that visit. Patients who missed the ≤3 weeks (OR, 1.77; 95% CI, 1.14 to 2.74, P = 0.010) and 3-month (OR, 8.55; 95% CI, 4.33 to 16.86; P < 0.001) follow-ups were more likely to miss the 6-month follow-up. Use of a patient contact system (OR, 0.55; 95% CI, 0.35 to 0.87, P = 0.01) and increased number of preoperative visits (OR, 0.91; 95% CI, 0.84 to 0.99, P = 0.033) were associated with decreased odds of missing the 12-month follow-up. Patients who missed the 6-month follow-up were more likely to miss the 12-month follow-up (OR, 5.38; 95% CI, 3.45 to 8.40; P < 0.001). CONCLUSION: Implementing an electronic patient contact system while increasing focus on patients with few preoperative visits and who miss the 6-month follow-up can reduce the risk of missed follow-up at 12 months after shoulder arthroscopy.

Identification of Glandular (Acinar)/Tubule Formation in Invasive Carcinoma of the Breast: A Study to Determine Concordance Using the World Health Organization Definition.

CONTEXT.­: The Nottingham Grading System (NGS) developed by Elston and Ellis is used to grade invasive breast cancer (IBC). Glandular (acinar)/tubule formation is a component of NGS. OBJECTIVE.­: To investigate the ability of pathologists to identify individual structures that should be classified as glandular (acinar)/tubule formation. DESIGN.­: A total of 58 hematoxylin-eosin photographic images of IBC with 1 structure circled were classified as tubules (41 cases) or nontubules (17 cases) by Professor Ellis. Images were sent as a PowerPoint (Microsoft) file to breast pathologists, who were provided with the World Health Organization definition of a tubule and asked to determine if a circled structure represented a tubule. RESULTS.­: Among 35 pathologists, the κ statistic for assessing agreement in evaluating the 58 images was 0.324 (95% CI, 0.314-0.335). The median concordance rate between a participating pathologist and Professor Ellis was 94.1% for evaluating 17 nontubule cases and 53.7% for 41 tubule cases. A total of 41% of the tubule cases were classified correctly by less than 50% of pathologists. Structures classified as tubules by Professor Ellis but often not recognized as tubules by pathologists included glands with complex architecture, mucinous carcinoma, and the "inverted tubule" pattern of micropapillary carcinoma. A total of 80% of participants reported that they did not have clarity on what represented a tubule. CONCLUSIONS.­: We identified structures that should be included as tubules but that were not readily identified by pathologists. Greater concordance for identification of tubules might be obtained by providing more detailed images and descriptions of the types of structures included as tubules.

The Effect of Guided Growth Surgery on Langenskiold Stage and Mechanical Axis in Early-Onset Blount Disease: A Retrospective Case Series.

INTRODUCTION: Our understanding of the efficacy of guided growth surgery with tension-band plating (TBP) in early-onset Blount disease is evolving. Preliminary work has demonstrated that TBP can normalize the mechanical axis, yet its effect on Langenskiöld stage (LS) has not previously been reported. The primary outcome of this study was improvement in LS after TBP. Secondary outcomes were improvement in LS at most recent follow-up and improvement in mechanical axis deviation (MAD), mechanical medial proximal tibial angle, and mechanical lateral distal femoral angle at treatment completion and most recent follow-up. METHODS: A retrospective review was done of patients with early-onset Blount disease treated with TBP between January 1, 2010, and December 31, 2019, across two institutions. Inclusion criteria were a radiographic diagnosis of early-onset Blount disease (LS changes present), surgery with TBP, and follow-up beyond implant removal. Radiographs before surgery, at removal of hardware (ROH), and at most recent follow-up were evaluated. RESULTS: Twenty-five limbs in 16 children who underwent TBP at a mean age of 5.8 ± 2.3 years were included. Implants were in situ a mean of 1.9 ± 0.7 years. The mean follow-up after ROH was 3.6 ± 1.4 years. LS ranged from 1 to 5 preoperatively with 14 of 25 limbs (56%) staged ≥3. LS improved in 15 of 25 limbs (60%) at ROH and in 21 of 25 limbs (84%) at most recent follow-up. Langenskiöld changes resolved in 7 of 25 limbs (28%) at most recent follow-up. Preoperatively, the MAD was varus in all limbs, but at ROH, the MAD had improved in 22 of 23 limbs with neutral or valgus alignment in 20 of 23 limbs (87%). At most recent follow-up, 16 of 23 limbs (70%) maintained improved alignment. DISCUSSION: There was improvement/resolution of LS and varus deformity in early-onset Blount disease in most patients who underwent TBP. Based on these results, TBP for early-onset Blount disease should be the first-line surgical treatment. LEVEL OF EVIDENCE: IV.

A pragmatic methodology to extract anesthetic and physiological data from the electronic health record.

BACKGROUND/AIMS: Traditional manual methods of extracting anesthetic and physiological data from the electronic health record rely upon visual transcription by a human analyst that can be labor-intensive and prone to error. Technical complexity, relative inexperience in computer coding, and decreased access to data warehouses can deter investigators from obtaining valuable electronic health record data for research studies, especially in under-resourced settings. We therefore aimed to develop, pilot, and demonstrate the effectiveness and utility of a pragmatic data extraction methodology. METHODS: Expired sevoflurane concentration data from the electronic health record transcribed by eye was compared to an intermediate preprocessing method in which the entire anesthetic flowsheet narrative report was selected, copy-pasted, and processed using only Microsoft Word and Excel software to generate a comma-delimited (.csv) file. A step-by-step presentation of this method is presented. Concordance rates, Pearson correlation coefficients, and scatterplots with lines of best fit were used to compare the two methods of data extraction. RESULTS: A total of 1132 datapoints across eight subjects were analyzed, accounting for 18.9 h of anesthesia time. There was a high concordance rate of data extracted using the two methods (median concordance rate 100% range [96%, 100%]). The median time required to complete manual data extraction was significantly longer compared to the time required using the intermediate method (240 IQR [199, 482.5] seconds vs 92.5 IQR [69, 99] seconds, p = .01) and was linearly associated with the number of datapoints (rmanual = .97, p < .0001), whereas time required to complete data extraction using the intermediate approach was independent of the number of datapoints (rintermediate = -.02, p = .99). CONCLUSIONS: We describe a pragmatic data extraction methodology that does not require additional software or coding skills intended to enhance the ease, speed, and accuracy of data collection that could assist in clinician investigator-initiated research and quality/process improvement projects.

Single Long-Incision Minimally Invasive Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study is to determine differences in outcomes in patients with adolescent idiopathic scoliosis undergoing spinal deformity correction surgery using a posterior spinal fusion (PSF) approach versus single and triple-incision minimally invasive surgery (MIS). SUMMARY OF BACKGROUND DATA: MIS increased in popularity as surgeons' focus moved towards soft tissue preservation, but it carries technical demands and increased surgical time compared with PSF. PATIENTS AND METHODS: Surgeries performed from 2016 to 2020 were included. Cohorts were formed based on surgical approach: PSF versus single long-incision MIS (SLIM) versus traditional MIS [3-incision MIS (3MIS)]. There were a total of 7 subanalyses. Demographic, radiographic, and perioperative data were collected for the 3 groups. Kruskal-Wallis and χ 2 tests were used for continuous and categorical variables, respectively. RESULTS: Five hundred thirty-two patients met our inclusion criteria, 294 PSF, 179 3MIS, and 59 SLIM.Estimated blood loss (mL) ( P < 0.00001) and length of stay (LOS) ( P < 0.00001) was significantly higher in PSF than in SLIM and 3MIS. Surgical time was significantly higher in 3MIS than in PSF and SLIM ( P = 0.0012).Patients who underwent PSF had significantly lower postoperative T5 to T12 kyphosis ( P < 0.00001) and percentage kyphosis change ( P < 0.00001). Morphine equivalence was significantly higher in the PSF group during total hospital stay ( P = 0.0042).Patients who underwent SLIM and 3MIS were more likely to return to noncontact ( P = 0.0096) and contact sports ( P = 0.0095) within 6 months and reported lower pain scores ( P < 0.001) at 6 months postoperation. CONCLUSION: SLIM has a similar operative time to PSF and is technically similar to PSF while maintaining the surgical and postoperative outcome advantages of 3MIS.

Interferon ɛ restricts Zika virus infection in the female reproductive tract.

Interferon ɛ (IFNɛ) is a unique type I IFN that has been implicated in host defense against sexually transmitted infections. Zika virus (ZIKV), an emerging pathogen, can infect the female reproductive tract (FRT) and cause devastating diseases, particularly in pregnant women. How IFNɛ contributes to protection against ZIKV infection in vivo is unknown. In this study, we show that IFNɛ plays a critical role in host protection against vaginal ZIKV infection in mice. We found that IFNɛ was expressed not only by epithelial cells in the FRT but also by immune and stromal cells at baseline or after exposure to viruses or specific Toll-like receptor (TLR) agonists. IFNɛ-deficient mice exhibited abnormalities in the epithelial border and underlying tissue in the cervicovaginal tract, and these defects were associated with increased susceptibility to vaginal but not subcutaneous ZIKV infection. IFNɛ deficiency resulted in an increase in magnitude, duration, and depth of ZIKV infection in the FRT. Critically, intravaginal administration of recombinant IFNɛ protected Ifnɛ-/- mice and highly susceptible Ifnar1-/- mice against vaginal ZIKV infection, indicating that IFNɛ was sufficient to provide protection even in the absence of signals from other type I IFNs and in an IFNAR1-independent manner. Our findings reveal a potentially critical role for IFNɛ in mediating protection against the transmission of ZIKV in the context of sexual contact.

Prevalence and Risk Factors for Missed Short-term Follow-up After Primary Total Shoulder Arthroplasty.

INTRODUCTION: The importance of consistent postoperative follow-up has been established for collecting patient-reported outcomes and surveilling for potential complications. Despite this, the prevalence of and risk factors for missed short-term follow-up after elective shoulder arthroplasty remain limited. METHODS: A retrospective review of consecutive primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty cases with a minimum of 12-month follow-up performed by a single, fellowship-trained shoulder surgeon was undertaken from January 2015 to December 2021. Demographic patient and surgical data, including age, sex, marital status, self-identified race, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder surgery and/or contralateral arthroplasty, distance from home to clinic, smoking status, and hospital length of stay, were collected. The follow-up at 1 week, 6 weeks, 6 months, 12 months, and 24 months and beyond was determined. Patient-related and surgical predictors for missing the 12-month and 24-month follow-up were identified. RESULTS: There were 295 cases included (168 aTSA and 127 reverse total shoulder arthroplasty), of whom 199 (67%) were women. Of the total cases, 261 (86%) were eligible for 24-month follow-up. Patients undergoing aTSA, those of younger age, those of male sex, and those who missed their 6-week and 6-month follow-up were significantly more likely to miss the 12-month follow-up visit. Following multivariable analysis, a missed 6-month follow-up (OR 10.10, 95% CI 5.32 to 19.16, P < 0.001) was associated with 12-month visit nonattendance, and increasing age (per year) (OR 0.96, 95% CI 0.93 to 0.99, P = 0.011) was associated with improved 12-month follow-up. Not having a surgical complication within 6 months postoperatively, not undergoing ipsilateral revision arthroplasty, and missing the 1-week and 12-month follow-up were significantly associated with missing the 24-month follow-up. After multivariable analysis, missing the 1-week (OR 3.07, 95% CI 1.12 to 8.41, P = 0.029) and 12-month (OR 3.84, 95% CI 2.11 to 6.99, P < 0.001) follow-ups was associated with missing the 24-month visit, whereas having a postoperative complication was associated with increased attendance at 24 months (OR 0.38, 95% CI 0.14 to 0.99, P = 0.047). DISCUSSION: Strategies for preventing missed short-term follow-up should be focused on ensuring that patients undergoing TSA attend the 6-month and 12-month visit, particularly among younger patients and those with an uneventful postoperative course.

Does a dedicated "Scoliosis Team" and surgical standardization improve outcomes in adolescent idiopathic scoliosis surgery and is it reproducible?

PURPOSE: The objective of this study was to determine if standardization improves adolescent idiopathic scoliosis (AIS) surgery outcomes and whether it is transferrable between institutions. METHODS: A retrospective review was conducted of AIS patients operated between 2009 and 2021 at two institutions (IA and IB). Each institution consisted of a non-standardized (NST) and standardized group (ST). In 2015, surgeons changed institutions (IA- > IB). Reproducibility was determined between institutions. Median and interquartile ranges (IQR), Kruskal-Wallis, and χ2 tests were used. RESULTS: 500 consecutive AIS patients were included. Age (p = 0.06), body mass index (p = 0.74), preoperative Cobb angle (p = 0.53), and levels fused (p = 0.94) were similar between institutions. IA-ST and IB-ST had lower blood loss (p < 0.001) and shorter surgical time (p < 0.001). IB-ST had significantly shorter hospital stay (p < 0.001) and transfusion rate (p = 0.007) than IB-NST. Standardized protocols in IB-ST reduced costs by 18.7%, significantly lowering hospital costs from $74,794.05 in IB-NST to $60,778.60 for IB-ST (p < 0.001). Annual analysis of surgical time revealed while implementation of standardized protocols decreased operative time within IA, when surgeons transitioned to IB, and upon standardization, IB operative time values decreased once again, and continued to decrease annually. Additions to standardized protocol in IB temporarily affected the operative time, before stabilizing. CONCLUSION: Surgeon-led standardized AIS approach and streamlined surgical steps improve outcomes and efficiency, is transferrable between institutions, and adjusts to additional protocol changes.

Does Morbid Obesity (BMI ≥40 kg/m2) Impact Operative Time, Blood Loss, Length of Stay, or Complications Following Anatomic Total Shoulder Arthroplasty?

Objectives: There have been conflicting reports regarding the effects of obesity on both surgical time and blood loss following anatomic shoulder arthroplasty. Varying categories of obesity has made comparison amongst existing studies difficult. Methods: A retrospective review of consecutive anatomic shoulder arthroplasty cases (aTSA) was undertaken. Demographic data, including age, gender, body mass index (BMI), age-adjusted Charleson Comorbidity Index (ACCI), operative time, hospital length of stay (LOS), and both POD#1 and discharge visual analogue score (VAS) was collected. Intra-operative total blood volume loss (ITBVL) and need for transfusion was calculated. BMI was categorized as non-obese (<30 kg/m2), obese (30-40 kg/m2) and morbidly obese (≥40 kg/m2). Unadjusted associations of BMI with operative time, ITBVL and LOS were examined using Spearman correlation coefficients. Regression analysis was used to identify factors associated with hospital LOS. Results: There were 130 aTSA cases performed, including 45 short stem and 85 stemless implants, of which 23 (17.7%) were morbidly obese, 60 (46.2%) were obese and 47 (36.1%) were non-obese. Median operative time for the morbidly obese cohort was 119.5 minutes (IQR 93.0, 142.0) versus 116.5 minutes (IQR 99.5, 134.5) for the obese cohort versus 125.0 minutes (IQR, 99.0, 146.0) for the non-obese cohort. (P=0.61) The median ITBVL for the morbidly obese cohort was 235.8 ml (IQR 144.3, 329.7) versus 220.1 ml (IQR 147.7, 262.7) for the obese cohort versus 216.3 ml (IQR 139.7, 315.5) for the non-obese cohort. (P=0.72). BMI ≥40kg/m2 (IRR 1.32, P=0.038), age (IRR 1.01, P=0.026), and female gender (IRR 1.54, P<0.001) were predictive of increased LOS. There was no difference with regards to in-hospital medical complications (P=0.13), surgical complications (P=1.0), need for re-operation (P=0.66) and 30-day return to the ER (P=0.06). Conclusion: Morbid obesity was not associated with increased surgical time, ITBVL and perioperative medical or surgical complications following aTSA, though it was predictive of increased hospital LOS.

Pediatric Fractures: Does Vitamin D Play a Role?

BACKGROUND: Vitamin D (25-OHD) deficiency and insufficiency are reported in about half of all children. The literature on low 25-OHD and pediatric fracture risk presents inconsistent results. This study evaluates the association between pediatric fractures and 25-OHD, parathyroid hormone (PTH), and calcium. METHODS: This is a prospective case-control study in 2 urban pediatric emergency departments (2014-2017). Patients aged 1 to 17 requiring intravenous access were enrolled. Demographics, nutrition, and activity information were recorded and levels of 25-OHD, calcium, and PTH were measured. RESULTS: Two hundred forty-five subjects were enrolled: 123 fractures and 122 controls. Overall, the mean 25-OHD level was 23 ng/mL±8.5: 52 (21%) of patients were 25-OHD sufficient; 193 (79%) were not. Ninety-six percent of patients with lower extremity fractures had low 25-OHD versus 77% of patients with upper extremity fractures ( P =0.024). The fracture cohort was younger ( P =0.002), included more males ( P =0.020), and spent more time playing outdoor sports ( P =0.011) than the control cohort. The 25-OHD level (fracture 22.8 ng/mL±7.6 vs. nonfracture 23.5 ng/mL±9.3, P =0.494) and median calcium level (fracture 9.8 mg/dL vs. nonfracture 10.0 mg/dL, P =0.054) were similar between cohorts. The median PTH level was higher in the fracture than the control cohort (33 vs. 24.5 pg/mL; P <0.0005); PTH was elevated to hyperparathyroidism (>65 pg/mL) in 13% of fractures and 2% of controls ( P =0.006). Matched subgroup analysis of 81 fracture patients and 81 controls by age, gender, and race showed that PTH was the only variable independently associated with increased odds of fracture (odds ratio=1.10, 95% CI, 1.01-1.19, P =0.021) in a model adjusted for vitamin D sufficiency and time spent playing outdoor sports. CONCLUSIONS: Low 25-OHD is common in children with fractures but we found no difference in 25-OHD levels between fracture and nonfracture cohorts. This research can impact evidence-based guidelines on vitamin D level screening and/or supplementation after fracture. LEVEL OF EVIDENCE: Diagnostic level IV-case-control study.

Effect of Pedicle Screw Size on Surgical Outcomes Following Surgery for 412 Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Retrospective Review. OBJECTIVE: The objective of this study was to determine differences in surgical and post-operative outcomes in AIS patients undergoing spinal deformity correction surgery using standard or large pedicle screw size. SUMMARY OF BACKGROUND: Use of pedicle screw fixation in spinal deformity correction surgery is considered safe and effective. Still, the small size of the pedicle and the complex 3D anatomy of the thoracic spine makes screw placement challenging, with improper pedicle screw fixation leading to catastrophic complications including injuries to nerve roots, spinal cord, and major vessels. Thus, insertion of larger diameter screw sizes has raised concerns amongst surgeons, especially in the pediatric population. MATERIALS AND METHODS: AIS patients undergoing PSF between 2013 and 2019 were included. Demographic, radiographic, and operative outcomes collected. Patients in the large screw size group (GpI) received 6.5 mm diameter screw sizes at all levels while standard screw size group (GpII) received 5.0 to 5.5 mm diameter screw sizes at all levels. Kruskall-Wallis and Fisher's exact test performed for continuous and categorical variables respectively.Subanalyses included (1) screw accuracy in patients with available CT scans, (2) stratified analysis of large- and standard-screw patients with ≥60% flexibility rate, (3) stratified analysis of large- and standard-screw patients with <60% flexibility rate, and (4) matched analysis of large- and standard-screw patients by surgeon and year of surgery. RESULTS: GpI patients experienced significantly higher overall curve correction ( P <0.001), with 87.6% experiencing at least one grade reduction of apical vertebral rotation from preoperative to postoperative visit( P =0.008).Patients with larger screws displayed higher postoperative kyphosis. No patient experienced medial breaching. CONCLUSION: Large screw sizes have similar safety profiles to standard screws without negatively impacting surgical and perioperative outcomes in AIS patients undergoing PSF. Additionally, coronal, sagittal, and rotational correction is superior for larger-diameter screws in AIS patients.

Interferon ε restricts Zika virus infection in the female reproductive tract.

Interferon ε (IFNε) is a unique type I IFN that has been implicated in host defense against sexually transmitted infections (STIs). Zika virus (ZIKV), an emerging pathogen, can infect the female reproductive tract (FRT) and cause devastating diseases, particularly in pregnant women. How IFNε contributes to protection against ZIKV infection in vivo is unknown. Here, we show that IFNε plays a critical role in host protection against vaginal ZIKV infection in mice. We found that IFNε was expressed not only by epithelial cells in the FRT, but also by certain immune and other cells at baseline or after exposure to viruses or specific TLR agonists. IFNε-deficient mice exhibited abnormalities in the epithelial border and underlying tissue in the cervicovaginal tract, and these defects were associated with increased susceptibility to vaginal, but not subcutaneous ZIKV infection. IFNε-deficiency resulted in an increase in magnitude, duration, and depth of ZIKV infection in the FRT. Critically, intravaginal administration of recombinant IFNε protected Ifnε-/- mice and highly susceptible Ifnar1-/- mice against vaginal ZIKV infection, indicating that IFNε was sufficient to provide protection even in the absence of signals from other type I IFNs and in an IFNAR1-independent manner. Our findings reveal a potentially critical role for IFNε in mediating protection against transmission of ZIKV in the context of sexual contact.

EZH2 Protein Expression in Estrogen Receptor Positive Invasive Breast Cancer Treated With Neoadjuvant Endocrine Therapy: An Exploratory Study of Association With Tumor Response.

INTRODUCTION: Neoadjuvant endocrine therapy (NET) can be used to treat estrogen receptor positive (ER+) invasive breast cancer (IBC). Tumors with Ki67>10% after 2 to 4 weeks of NET are considered resistant to endocrine therapy. Enhancer of Zeste Homolog 2 (EZH2) is a targetable oncoprotein and overexpression in ER+ IBC has been linked to resistance to endocrine therapy. We examined whether EZH2 expression levels in ER+ IBC could be used to predict response to NET. MATERIALS AND METHODS: We retrospectively identified 46 patients with localized ER+ HER2/neu negative IBC treated with a minimum of 4 weeks of NET. We quantified EZH2 nuclear expression in pretherapy core biopsies using a score that included intensity and percent of cells staining. Ki67 was evaluated in both pretherapy core biopsies and posttherapy tumor resections and scored according to the guidelines of the International Ki67 Working Groups, with a global weighted score. Ki67≤10% after NET was considered endocrine responsive. Logistic regression analysis was performed to determine the association between EZH2 expression and response to NET. RESULTS: We found significant associations of tumor grade ( P =0.011), pretherapy Ki67 ( P =0.003), and EZH2 ( P <0.001), with response to NET. On logistic regression adjusted for tumor grade and pretherapy Ki67, increased EZH2 scores were associated with decreased odds of endocrine responsiveness, defined as posttreatment Ki67≤10% (odds ratio=0.976, 95% CI, 0.956 to 0.997; P =0.026). In addition, with EZH2 score in the model, associations of tumor grade and pretreatment Ki67 with posttreatment Ki67≤10% response to NET became not significant. CONCLUSIONS: Our results suggest that EZH2 might be a useful biomarker to predict response to NET.

A Newer Way of Determining LIV in AIS Patients: Rotation of the Touched Vertebrae.

STUDY DESIGN: A retrospective review. OBJECTIVE: The objective of this study was to determine whether fusing to touched vertebra (TV) on prone x-rays (XRs) with minimal rotation (Gd 0/1) allow for shorter fusion with optimal correction. SUMMARY OF BACKGROUND: Previous studies have shown risk of "adding on" when TV is not selected as lowest instrumented vertebra (LIV). Fusion proximal to TV leads to suboptimal results but fusing to TV on standing XRs can result in longer fusions. On lying down XRs, TV moves proximally, and its rotation decreases by a grade. METHODS: TV patients with minimal rotation were selected on prone (TVP) or standing XRs (TVS). Patients fused to rotated (Gd 2+) TV on standing or prone XRs were considered touched vertebra rotated (TVR). In the non-TV (NTV) group, LIV was fused proximal to TV. Disk wedging ≥5° determined risk of "adding-on." To compare patients fused to minimally rotated TV, to those that were not, patients in group A (TVP + TVS) were compared with group B (TVR + NTV).In part II: TVP, TVS, TVR, and NTV patients were compared. Subanalysis compared levels saved as the difference between predicted and real LIV in TVP and TVS patients. Another subanalysis was carried out for Lenke 1+2 and Lenke 3, 4, 5.In part III: XRs of nonoperative adolescents idiopathic scoliosis patients with Cobb <30 and Risser 4/5 were analyzed to determine "acceptable" end vertebra tilt and disc wedging and served as controls. RESULTS: There were a significantly greater number of patients in group B patients(TVR + NTV) with final disk wedging ≥5°, final LIV translation ≥1 and ≥2 cm ( P <0.001).Utilizing prone XRs in TVP saved average 1 level, and 1.2 levels in TVS patients. TVP patients also had similar LIV tilt, disk wedging and coronal balance( P >0.05) to controls. CONCLUSION: Choosing minimally rotated (Gd 0/1) TV on prone XR saves levels without sacrificing radiographic outcomes.

A Comparison of Operative Time and Intraoperative Blood Volume Loss Between Stemless and Short-stem Anatomic Total Shoulder Arthroplasty: A Single Institution's Experience.

INTRODUCTION: There has been increasing interest in the use of stemless humeral implants for total shoulder arthroplasty when compared with both short-stem (SS) and standard-length implants. Although evidence for decreased surgical time and blood loss exists for stemless versus standard-length stems, far less literature exists comparing these clinical parameters for stemless versus SS implants. METHODS: A retrospective review of consecutive anatomic total shoulder arthroplasty (aTSA) cases conducted by a single, fellowship-trained shoulder surgeon was undertaken from January 2016 through January 2022 with the exception of March 2020 through January 2021 secondary to the COVID-19 pandemic. Demographic patient and surgical data, including age, sex, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder arthroscopy, surgical time, use of a Hemovac drain and/or tranexamic acid, hospital length of stay (LOS), and both postoperative day #1 (POD 1) and discharge visual analog scores. The use of a stemless or SS implant was recorded. Intraoperative total blood volume loss (TBVL) was calculated, in addition to the need for either intraoperative or postoperative transfusions. Nonparametric analysis of covariance was used to examine effects of stemless versus SS aTSA on surgical time and intraoperative TBVL adjusted for demographic, clinical, and surgical variables. RESULTS: There were 47 SS and 83 stemless anatomic implants included, of which 74 patients (57%) overall were women. The median surgical time for the stemless cohort was 111 minutes (IQR 96-130) versus 137 minutes (IQR 113-169) for the SS cohort (P < 0.00001). The median intraoperative TBVL for the stemless cohort was 298.3 mL (IQR 212.6-402.8) versus 359.7 mL (IQR 253.9-415.0) for the SS cohort (P = 0.05). After multivariable regression analysis, use of stemless humeral implants was independently associated with both decreased surgical time and intraoperative blood loss (P < 0.001 and P = 0.005, respectively). There was a shorter median hospital LOS in the stemless group (2 days [IQR 1-2] versus 2 days [IQR 2-3], P = 0.03). The visual analog score pain score at discharge was lower among the stemless cohort (0 [IQR 0-3] versus 4 [IQR 2-6], P < 0.00001). Increased surgical time was associated with intraoperative TBVL (r = 0.340, P < 0.0001). DISCUSSION: Stemless aTSA is associated with a markedly decreased surgical time and intraoperative TBVL when compared with a SS aTSA. Furthermore, the use of a stemless implant results in a shorter hospital LOS and lower discharge pain scores.