Minimally invasive burn reconstruction with subcutaneous scar contracture release.

BACKGROUND: Scar contracture bands after burns are frequent problems that cause discomfort and physical limitation. This study investigates the efficacy of a minimally invasive contracture band release technique (MICBR) inspired by closed platysmotomy. METHODS: Patients with burn scars treated with MICBR in our center were included retrospectively. Our routine scar and contracture treatments (non-invasive and invasive) were utilized prior to undergoing MICBR. Range of motion (ROM) and Vancouver Scar Scale was measured before and after the procedure when feasible. RESULTS: Forty-five patients were included, with 97 total contracture sites treated all over the body. An average of 1.6 sites were treated per patient, with a maximum of six. Patients age was 6-68 years; total burn surface area ranged from 0.5% to 85%. 24% were performed under local anesthesia. 84% were in originally skin grafted areas. We found significant improvements in ROM and VSS. 84% of patients surveyed were "satisfied" or "very satisfied". 95% reported improved mobility. No significant adverse events occurred. CONCLUSION: This MICBR technique is a versatile, safe, and well-tolerated adjunct procedure that can help patients regain mobility after a burn injury.

Characteristics and Complication Rates of Mandibular Fractures Caused by Violent Mechanisms Versus Nonviolent Mechanisms.

Background: Mandibular fractures due to intentionally violent mechanisms represent a unique subset of facial fractures. The objective of our research is to identify how violence affects patterns of mandibular fractures and their outcomes. Methods: In this institutional review board-approved, retrospective study, we examined our institution's records for adult patients >18 years of age who presented with ≥ 1 mandibular fractures from January 2011 to January 2022. Violence was defined as trauma intended to hurt another or self. Demographics, fractures, mechanism, concomitant injuries, treatment, and complications were analyzed with Excel and SPSS statistical software. Results: A total of 692 patients were diagnosed with mandibular fractures, with 323 of these due to violence (47%). These patients of violence (POVs) had an average fracture per patient of 1.6 ± 0.7. The majority (88%) were male and African American (33%), and the average age was 34.3 ± 13.2 years. The most common violent mechanism was a punch (68%). The POVs presented with fewer concomitant injuries, were less likely to be admitted to the intensive care unit, and were more often surgically managed with open reduction than were patients of nonviolence (PONVs) (P < .01). POVs were more likely to have healing complications; though not statistically significant, this population was observed to be frequently lost to follow-up (P = .12). POVs notably had a much higher proportion of hardware exposure among complications than was seen in PONVs (23% vs 9%). Conclusions: Patients with violent fracture mechanisms may tend to be predisposed to more complications compared with patients who have nonviolent fracture mechanisms despite lesser severities due to social determinants of health. Characteristics of this patient subset may tend to cause difficulties in postoperative care and follow-up. Effective discharge instruction communication, patient outreach programs, and homelessness and drug abuse screening in this subset may help reduce healing complications.

The Fate of the Inconclusive Periprosthetic Joint Infection Workup and Reliability of Data Points.

In 2018, periprosthetic joint infection (PJI) criteria were revised to include a new category labeled "inconclusive." The purpose of this study was to characterize and describe the fate of the inconclusive PJI workup and to analyze preoperative factors associated with outcomes. We reviewed all PJI workups at our institution during a 3-year period (426 patients). Patients were labeled "infected," "not infected," or "inconclusive" according to 2018 PJI preoperative criteria. In addition to standard diagnostic variables, the presence or absence of clinical elements that increase the pretest probability of infection were collected. Patients with any missing preoperative diagnostic test results and those with clinical follow-up less than 30 days were excluded. Logistic regression was used to identify the factors associated with infection. Two hundred ninety-six workups remained after exclusion criteria were applied, consisting of 66 (22.2%) with a preoperative score of 6 or greater defined as infected, 52 (17.6%) inconclusive (score 2-5), and 178 (60.1%) not infected (score 0-1). Postoperative re-scoring of the inconclusive group based on intraoperative findings as per the 2018 criteria identified 6 of 52 (11.5%) as infected, 12 (23.1%) inconclusive, and 34 (65.4%) not infected. Among those preoperatively scored as inconclusive, variables statistically correlated with the presence of infection included history of PJI, factors that increase skin barrier penetration (eg, psoriasis and venous stasis), and presence of comorbidities predisposing to infection. For patients labeled inconclusive, clinical elements of the pretest probability for infection (eg, history of prior PJI) were as reliable as any diagnostic test, including alpha-defensin, in the diagnosis of PJI. [Orthopedics. 2023;46(5):e291-e297.].

Preventing work-related musculoskeletal injuries among oral and maxillofacial surgeons.

BACKGROUND: Oral and maxillofacial surgeons (OMS) are continually required to adjust position and posture to access the limited surgical field in and around the head and neck, oral cavity, and oropharynx. Very limited data exists that quantifies the burden of musculoskeletal disorders (MSD) among OMS. OBJECTIVE: This exploratory study seeks to address these literature gaps by assessing the prevalence of MSD among OMS. METHOD: A 12-question survey was designed to investigate the prevalence of MSD for OMS, including residents in training, actively practicing surgeons, and retired surgeons. Seventy-six surveys were distributed and completed in person by surgeons attending professional conferences from September 2018-September 2019. Survey questions included the Baker-Wong Faces pain scale, years in practice, number of hours worked per week, job tenure, pain attributable to work, and age. The Nordic scale identified and delineated anatomic site of musculoskeletal complaints, duration and treatment sought. RESULTS: The most frequently cited sources and locations of pain attributable to occupation were shoulders, neck, and lower back. The risk of MSD symptoms was relatively two-fold [PR = 2.54, 95% CI = 0.90, 7.22] among OMS in practice for more than ten years compared to those in practice less than ten years. After adjusting for age and hours worked per week as potential confounders, the risk of MSD symptoms was higher among OMS in practice for more than ten years compared to those with less than ten years of experience, despite no statistically significant association. CONCLUSION: OMS are impacted by a high prevalence of MSD. The neck, shoulder, and lower back are the most frequently affected with discomfort and pain. This study found that practicing oral and maxillofacial surgery for more than 10 years is a potential risk factor for experiencing MSD.

What are the 2-year survivorship outcomes of custom hemipelvis reconstruction after hemipelvectomy and revision arthroplasty? The evolution of a custom ilium "monoflange".

BACKGROUND: Innovations in machined and three-dimensionally (3D) printed implant technology have allowed for customized complex pelvic reconstructions. We sought to determine the survivorship of custom hemipelvis reconstruction using ilium-only fixation at a minimum 2-year follow-up, their modes of failure, and the postoperative complications resulting from the procedure. METHODS: A retrospective review identified 12 consecutive patients treated with custom hemipelvis reconstruction. Indications for surgery were bone tumor requiring internal hemipelvectomy (four patients) or multiply revised, failed hip arthroplasty with massive bone loss (eight patients). All patients had a minimum of 2-year follow-up with a mean of 60.5 months. Kaplan-Meier survivorship analysis was determined for all patients. Postoperative complications and reoperations were categorized for all patients. RESULTS: At a mean of 60.5 months, 11 of 12 patients had retained their custom implant (92% survivorship). One implant was removed as a result of an acute periprosthetic joint infection (PJI). There were no cases of aseptic loosening. Seven of 12 patients required reoperation (three PJI; two dislocations; two superficial wound complications), with five patients going on to reoperation-free survival. CONCLUSIONS: Custom hemipelvis reconstruction utilizing an ilium monoflange provides durable short-term fixation at a minimum 2-year follow-up. Reoperation for infection and dislocation is common.

Epidermal-cell-based therapy as an adjunct to healing second degree burns-A randomized controlled pilot study.

BACKGROUND: Healing of partial-thickness (2a and 2b) burns is notoriously unpredictable as far as healing time, scarring and (hypo)pigmentation is concerned. Epidermal blister grafting is an autologous grafting technique involving transfer of epidermal islands without dermal elements. Cellutome™ is an FDA-acknowledged epidermal harvesting device. This proof-of-concept study evaluates whether blister grafting of partial-thickness burns results in improved healing compared to standard acellular treatment. METHODS: This is a randomized controlled trial with 8 patients in which each patient received both treatments randomized to different burn sites. Healing was assessed at regular intervals. Twelve months after treatment, outcomes were measured with the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), photography, spectrometry, Semmes-Weinstein Filaments, cutometry and high-resolution ultrasound. RESULTS: Areas treated with epidermal blister grafting healed slightly faster than acellular treatment. Epidermal treatment yielded healing with less erythema, closer to that of surrounding normal skin (p = 0.0404). Donor sites were not visible and not measurably different than normal skin. CONCLUSIONS: Results favor cellular over acellular technique for the treatment of partial-thickness (2a and 2b) burns. Significant improvement in erythema implies a higher quality healing process. Further studies should look primarily at larger areas of treatment, and larger sample size.

Abnormal Spinopelvic Motion and Spine Deformity are Associated With Native Femoral Retroversion in the Setting of Total Hip Arthroplasty.

Background: The effect of spinopelvic pathology on femoral version is unclear. This study investigated variability in native femoral anteversion in patients undergoing total hip arthroplasty (THA) and its relationship to the patient's underlying spinopelvic pattern. Methods: A retrospective chart review was performed to include in the study all patients undergoing robot-assisted THA over a 3-year period. Native femoral version was measured for each patient using a preoperative computed tomography scan and categorized as excessive, normal, or retroverted. Additionally, a subset analysis was performed for all patients with sit-to-stand dynamic pelvic radiographs available, and cases were classified by spinopelvic pattern. Results: A total of 119 patients were included in the study with a mean age of 68.6 years; 61 (51%) were female. The median femoral anteversion for the entire study group was 6.0° (-32° to 40°, interquartile range 13.5°). Eleven patients (9.2%) had excessive femoral anteversion, 54 of the 119 (45.4%) had normal femoral version, and 54 of the 119 (45.4%) had native retroversion. Forty-two patients (35.3%) had sit-to-stand radiographs available and were subclassified by femoral version type and spinopelvic parameters. Welch's analysis of variance demonstrated a significant difference in femoral version among spinopelvic patterns (F = 7.826, P = .003), with Games-Howell post hoc analysis showing increased retroversion in deformity-stiff patients compared to deformity-normal mobility patients (P = .003). Conclusions: This study demonstrates that native femoral retroversion is present in a significant number of patients undergoing THA and is more common in patients with stiff spine deformities. Based on this observation, currently available spinopelvic classification systems should be modified to account for native femoral version.

Robotic-Assisted Total Knee Arthroplasty Allows for Trainee Involvement and Teaching Without Lengthening Operative Time.

BACKGROUND: Robot-assisted total knee arthroplasty (RA-TKA) is more accurate than mechanical total knee arthroplasty (M-TKA) and can provide real-time feedback about alignment and soft-tissue balancing that may be helpful in trainee education. However, both robotic-assist and trainee involvement potentially increase the surgical time. This study sought to evaluate whether RA-TKA procedures were longer than M-TKA procedures and whether trainee participation added additional surgical time. METHODS: This retrospective cohort study reviewed 220 consecutive primary TKAs (110 M-TKA and 110 RA-TKA) performed by an orthopedic trainee under supervision or performed by the consultant surgeon with an assistant present. For M-TKAs, a measured resection technique was used. For all RA-TKAs, the MAKO robotic system (Stryker, USA) was used. Tourniquet time was measured from inflation immediately prior to skin incision to deflation after placement of the final polyethylene insert. Procedures performed by a consulting surgeon with a surgical assist were used as controls for procedures performed by the trainee. In trainee-conducted procedures, the trainee is responsible for performing all critical aspects of the procedure while the consulting surgeon provides supervision and acts as first assist. RESULTS: 103 M-TKA and 96 RA-TKA were included. Tourniquet time was significantly longer for RA-TKAs vs M-TKAs (100 vs 89 minutes, P < .0001). However, there were no significant differences in tourniquet times between surgery performed by a trainee vs the consulting surgeon with surgical assist for either M-TKA (P = .3452) or RA-TKA (P = .6724). CONCLUSIONS: While RA-TKA takes longer, orthopedic trainees do not add additional time. Trainees at all stages of postgraduate learning can be educated in the use of robotic technology and potentially benefit from real-time feedback without further compromising surgical efficiency or increasing patient risk.

Cost-effectiveness of Single vs Double Debridement and Implant Retention for Acute Periprosthetic Joint Infections in Total Knee Arthroplasty: A Markov Model.

BACKGROUND: Periprosthetic joint infection (PJI) is a common cause of revision total knee surgery. Although debridement and implant retention (DAIR) has lower success rates in the chronic setting, it is an accepted treatment of acute PJI, whether postoperatively or with late hematogenous seeding. There are two broad DAIR strategies: single debridement and planned double debridement. The purpose of this study is to evaluate the cost-effectiveness of single vs double DAIR for acute PJI in total knee arthroplasty. METHODS: A decision tree using single or double DAIR as the treatment strategy for acute PJI was constructed. Quality-adjusted life years and costs associated with the two treatment arms were calculated. Treatment success rates, failure rates, and mortality rates were derived from the literature. Medical costs were derived from both the literature and Medicare data. A cost-effectiveness plane was constructed from multiple Monte Carlo trials. A sensitivity analysis identified parameters most influencing the optimal strategy decision. RESULTS: Double DAIR was the optimal treatment strategy both in terms of the health utility state (82% of trials) and medical cost (97% of trials). Strategy tables demonstrated that as long as the success rate of double debridement is 10% or greater than the success rate of a single debridement, the two-stage protocol is cost-effective. CONCLUSIONS: A double DAIR protocol is more cost-effective than single DAIR from a societal perspective.

Rationale and design of the Prone Position and Respiratory Outcomes in Non-intubated COVID-19 PatiEnts: The "PRONE" Study.

While benefits of prone position in mechanically-ventilated patients have been well-described, a randomized-control trial to determine the effects of prone positioning in awake, spontaneously-breathing patients with an acute pneumonia has not been previously conducted. Prone Position and Respiratory Outcomes in Non-Intubated COVID-19 PatiEnts: the "PRONE" Study (PRONE) was conducted in non-intubated hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia as defined by respiratory rate ≥ 20/min or an oxyhemoglobin saturation (SpO2) ≤ 93% without supplemental oxygen [1]. The PRONE trial was designed to investigate the effects of prone positioning on need for escalation in respiratory support, as defined by need for transition to a higher acuity level of care, increased fraction of inspired oxygen (FiO2), or the initiation of invasive mechanical ventilation. Secondary objectives were to assess the duration of effect of prone positioning on respiratory parameters such as respiratory rate and SpO2, as well as other outcomes such as time to discharge or transition in level of care.

A Contemporary Classification System of Femoral Bone Loss in Revision Total Hip Arthroplasty.

BACKGROUND: Current femoral bone loss classification systems in revision total hip arthroplasty were created at a time when the predominant reconstructive methods used cylindrical porous-coated cobalt-chrome stems. As these stems have largely been replaced by fluted-tapered titanium stems, the ability of these classification systems to help guide implant selection is limited. The purpose of this study was to describe a novel classification system based on contemporary reconstructive techniques. METHODS: We reviewed the charts of all patients who underwent femoral component revision at our institution from 2007 through 2019. Preoperative images were reviewed, and FBL was rated according to the Paprosky classification and compared to ratings using our institution's NCS. Rates of reoperation at the time of most recent follow-up were determined and compared. RESULTS: Four-hundred and forty-two femoral revisions in 330 patients with a mean follow-up duration of 2.7 years were identified. Femoral type according to Paprosky and NCS were Paprosky I (36, 8.1%), II (61, 13.8%), IIIA (180, 40.7%), IIIB (116, 26.2%), and IV (49 11.1%) and NCS 1 (35, 7.9%), 2 (364, 82.4%), 3 (8, 1.8%), 4 (27, 6.1%), and 5 (8, 1.8%). Of the 353 nonstaged rTHAs, there were 42 cases requiring unplanned reoperation (11.9%), including infection (18, 5.1%), instability (10, 2.8%), femoral loosening (5, 1.4%), and various other causes (9, 2.5%). The NCS was more predictive of reoperation than the Paprosky classification (Fisher's exact test, P = .008 vs P = ns, respectively). CONCLUSION: We present a novel femoral classification system that can help guide contemporary implant selection.

The Double DAIR: A 2-Stage Debridement with Prosthesis-Retention Protocol for Acute Periprosthetic Joint Infections.

BACKGROUND: Debridement and implant retention (DAIR) has variable success as a treatment for acute periprosthetic joint infection (PJI), with generally poor outcomes reported in the literature1. Because of the unacceptably high failure rate of DAIR, we implemented a 2-stage debridement protocol that includes the use of high-dose antibiotic beads between stages for the treatment of acute PJI. In 2 previous studies, with an average follow-up of 3.5 years in each study, we reported overall infection-control rates of 87% and 90%2,3. DESCRIPTION: Following exposure of the joint, cultures are obtained, and all modular components are removed, scrubbed, and soaked in an antiseptic solution. A thorough irrigation and debridement with complete synovectomy is performed, followed by temporary reinsertion of the original modular parts. High-dose antibiotic cement beads are inserted into the joint, and the joint is closed. Approximately 5 to 6 days later, a second debridement is performed, the beads are removed, and the new modular, sterile components are implanted. The patient is placed on a course of intravenous and, later, oral antibiotics, in addition to a standard postoperative rehabilitation protocol. ALTERNATIVES: Long-term suppressive antibiotic therapy.One-stage DAIR.One-stage exchange arthroplasty.Two-stage exchange arthroplasty.Resection arthroplasty.Amputation. RATIONALE: The treatment of acute PJI has historically consisted of a single irrigation and debridement, with exchange of modular parts and retention of the components, followed by intravenous antibiotic therapy. Despite having lower rates of patient morbidity compared with a 2-stage exchange arthroplasty, this more traditional procedure also has a higher rate of failure, with reported rates as high as 60% to 84%4-12. The utility of component retention continues to be a topic of debate13. Alternatives to component retention include both 1- and 2-stage exchange procedures. Although these modalities offer potentially higher rates of infection control, they are associated with substantial patient morbidity, particularly in patients with well-fixed implants14-16. Furthermore, exchange procedures may result in substantial iatrogenic bone loss, which can be problematic in revision total joint arthroplasty procedures, in which bone stock may already be limited. The double-DAIR protocol offers infection-control rates that are comparable with those of component-exchange procedures, but with the lower patient morbidity associated with component-retention procedures. Furthermore, the double-DAIR procedure provides the added benefit of retaining important bone stock. EXPECTED OUTCOMES: The success rate for the double-DAIR procedure has been reproducible, with infection-control rates of 87% and 90% reported in 2 studies from a single cohort at our institution2,3. These rates represent a substantial improvement compared with a single irrigation and debridement1, and are on par with those reported for 2-stage exchange arthroplasty procedures17-21. The infection-control rates of the double-DAIR procedure did not significantly vary depending on whether infection occurred following a total knee or total hip arthroplasty. However, not surprisingly, patients who underwent debridement following a revision procedure had a lower rate of success (77.1% successful infection control) compared with patients debrided following a primary procedure (93.8% successful infection control). We could not demonstrate an association with organism and success or failure of treatment.Although not significant, there was a trend toward an association between the time from symptom onset to initial treatment and infection control (p = 0.07)2. Patients with successful infection control underwent the initial debridement an average of 6.2 days after symptom onset, compared with 10.7 days in patients in whom treatment had failed. Several other studies have demonstrated that successful infection control is associated with earlier initial irrigation and debridement22-27. We strongly support that, in the setting of confirmed acute PJI, prompt initiation of treatment optimizes the chances for successful infection control. IMPORTANT TIPS: Thorough debridement is key to successful infection control of infection.Antibiotic-loaded bone cement has repeatedly been demonstrated to be safe, and we recommend its use28-31.Extended oral antibiotics following debridement with component retention can increase infection-free survivorship32.

Changes in Emergency Department Patient Volume and Acuity Associated with Early Stages of the COVID-19 Pandemic in a Unique Environment.

INTRODUCTION: Hospitals and emergency departments (EDs) faced profound uncertainty during the COVID-19 pandemic. Early concerns regarding demand far exceeding capacity were balanced by anecdotal reports of decreased patient visits, including those for specific high-acuity conditions. This study sought to identify changes in ED volume and acuity, within a specific managed care environment, associated with the onset of the pandemic. METHODS: Data from patient visits to 2 San Diego, California, EDs-within an integrated health-care system-were extracted from the electronic health record. Daily patient visits, hospital admissions from the ED, Emergency Severity Index scores, and mode of arrival were compared between two 28-day periods, with the 28 days following a "stay at home" order issued by the governor of California and a control period of the same dates in 2019. RESULTS: These EDs observed a significant decrease in daily visits (42% compared to the previous year) associated with the pandemic. An increased rate of hospital admissions (16.6%-21.6%) was suggestive of an overall increase in acuity; however, changes in the distribution of Emergency Severity Index scores were less pronounced. The overall number of admissions declined significantly. Although overall ambulance traffic decreased, the proportion of patients arriving by ambulance was unchanged. CONCLUSION: Patient volume in 2 EDs dropped significantly in association with a statewide response to the COVID-19 pandemic. There was also a shift in acuity as measured by the proportion of patients admitted to the hospital, but overall admissions declined, suggesting sicker patients also did not seek care.

Patterns and Factors Associated With Adherence to Lung Cancer Screening in Diverse Practice Settings.

Importance: For lung cancer screening to confer mortality benefit, adherence to annual screening with low-dose computed tomography scans is essential. Although the National Lung Screening Trial had an adherence rate of 95%, current data are limited on screening adherence across diverse practice settings in the United States. Objective: To evaluate patterns and factors associated with adherence to annual screening for lung cancer after negative results of a baseline examination, particularly in centralized vs decentralized screening programs. Design, Setting, and Participants: This observational cohort study was conducted at 5 academic and community-based sites in North Carolina and California among 2283 individuals screened for lung cancer between July 1, 2014, and March 31, 2018, who met US Preventive Services Task Force eligibility criteria, had negative results of a baseline screening examination (American College of Radiology Lung Imaging Reporting and Data System category 1 or 2), and were eligible to return for a screening examination in 12 months. Exposures: To identify factors associated with adherence, the association of adherence with selected baseline demographic and clinical characteristics, including type of screening program, was estimated using multivariable logistic regression. Screening program type was classified as centralized if individuals were referred through a lung cancer screening clinic or program and as decentralized if individuals had a direct clinician referral for the baseline low-dose computed tomography scan. Main Outcomes and Measures: Adherence to annual lung cancer screening, defined as a second low-dose computed tomography scan within 11 to 15 months after baseline screening. Results: Among the 2283 eligible individuals (1294 men [56.7%]; mean [SD] age, 64.9 [5.8] years; 1160 [50.8%] aged ≥65 years) who had negative screening results at baseline, overall adherence was 40.2% (n = 917), with higher adherence among those who underwent screening through centralized (46.0% [478 of 1039]) vs decentralized (35.3% [439 of 1244]) programs. The independent factor most strongly associated with adherence was type of screening program, with a 2.8-fold increased likelihood of adherence associated with centralized screening (adjusted odds ratio [aOR], 2.78; 95% CI, 1.99-3.88). Another associated factor was age (65-69 vs 55-59 years: aOR, 1.38; 95% CI, 1.07-1.77; 70-74 vs 55-59 years: aOR, 1.47; 95% CI, 1.10-1.96). Conclusions and Relevance: After negative results of a baseline examination, adherence to annual lung cancer screening was suboptimal, although adherence was higher among individuals who were screened through a centralized program. These results support the value of centralized screening programs and the need to further implement strategies that improve adherence to annual screening for lung cancer.

What Is The Value Of A Star When Choosing A Provider For Total Joint Replacement? A Discrete Choice Experiment.

The past decade witnessed a rapid rise in the public reporting of surgeon- and hospital-specific quality-of-care measures. However, patients' interpretations of star ratings and their importance relative to other considerations (for example, cost, distance traveled) are poorly understood. We conducted a discrete choice experiment in an outpatient setting (an academic joint arthroplasty practice) to study trade-offs that patients are willing to make in choosing a provider for a hypothetical total joint arthroplasty. Two hundred consecutive new patients presenting for hip or knee pain in 2018 were included. The average patient was willing to pay $2,607 and $3,152 extra for an additional hospital or physician star, respectively, and an extra $11.45 to not travel an extra mile for arthroplasty care. History of prior surgery and prior experience with rating systems reduced the relative value of an incremental star by $539.25 and $934.50, respectively. Patients appear willing to accept significantly higher copayments for higher quality of care, and surgeon quality seems relatively more important than hospital quality. Further study is needed to understand the value and trust patients place in publicly reported hospital and surgeon quality ratings.

Toddler dysregulated fear predicts continued risk for social anxiety symptoms in early adolescence.

Identifying early risk factors for the development of social anxiety symptoms has important translational implications. Accurately identifying which children are at the highest risk is of critical importance, especially if we can identify risk early in development. We examined continued risk for social anxiety symptoms at the transition to adolescence in a community sample of children (n = 112) that had been observed for high fearfulness at age 2 and tracked for social anxiety symptoms from preschool through age 6. In our previous studies, we found that a pattern of dysregulated fear (DF), characterized by high fear in low threat contexts, predicted social anxiety symptoms at ages 3, 4, 5, and 6 years across two samples. In the current study, we re-evaluated these children at 11-13 years of age by using parent and child reports of social anxiety symptoms, parental monitoring, and peer relationship quality. The scores for DF uniquely predicted adolescents' social anxiety symptoms beyond the prediction that was made by more proximal measures of behavioral (e.g., kindergarten social withdrawal) and concurrent environmental risk factors (e.g., parental monitoring, peer relationships). Implications for early detection, prevention, and intervention are discussed.

The July Effect for Total Joint Arthroplasty Procedures.

The "July effect" refers to the assumed increased risk of complications during the months when medical school graduates transition to residency programs. The actual existence of a July effect is controversial. With this study, the authors sought to determine whether evidence exists for the presence of a July effect among total joint arthroplasty (TJA) procedures. The 2013 and 2014 Nationwide Readmission Databases were combined and all index primary and revision arthroplasty procedures were identified, and then patients from December were excluded. Thirty-day readmission rates, time to readmission, and readmission costs were analyzed by index procedure month and index procedure type. A total of 1,193,034 procedures (index primary: n=1,107,657; revision arthroplasty: n=85,377) were identified. Among all procedure types, 46,674 (3.9%) 30-day readmissions were observed. Among all procedures, an index procedure with a discharge in July resulted in the highest monthly readmission rate of the year (4.2%), which was significantly higher than the mean annual readmission rate (P<.0001). This effect was most pronounced for primary total knee arthroplasty (3.9% vs 3.6%, P<.0001). When stratifying results into teaching vs nonteaching hospitals, the highest readmission rate occurred if the index procedure occurred at a nonteaching hospital in July (4.5%, P<.0001). These data provide evidence that a July effect appears to exist for TJA procedures and is most pronounced at nonteaching institutions. Based on published mean readmission costs, the total annualized cost variation attributable to the higher readmission rate for primary TJA procedures in July is approximately $18.6 million. [Orthopedics. 2020;43(6):e543-e548.].