Animal naming test stratifies the risk of falls and fall-related fractures in patients with cirrhosis.

This study aimed to determine the relationship between animal naming test (ANT), falls, and fall-related fractures in patients with cirrhosis. Cognitive impairment and frailty were assessed using ANT and Karnofsky performance status (KPS), respectively. Factors stratifying the risk of previous falls and fall-related fractures within 1 year were assessed using a logistic regression model. Factors affecting patient performance in ANT were evaluated using multiple regression analysis. Of the 94 patients, 19% and 5% experienced falls and fall-related fractures, respectively. The performance in ANT was worse in patients who experienced falls (11 vs. 18; p < 0.001) and fall-related fractures (8 vs. 16; p < 0.001) than in those who did not. After adjustment, females, KPS, and ANT (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.65-0.93; p = 0.005) were associated with falls, while ANT was significantly associated with fall-related fractures (OR, 0.56; 95% CI 0.35-0.88; p = 0.012). Age and education affected the performance in ANT, whereas the use of Oriental zodiac did not. The ANT is useful for stratifying the risk of falls and fall-related fractures in patients with cirrhosis. The effects of age and education should be considered when applying ANT in the Japanese population.

Unhelpful thoughts and distress regarding symptoms are associated with recovery from upper extremity fracture.

BACKGROUND: There is evidence that thoughts and emotions regarding symptoms are strongly associated with levels of comfort and capability for a given injury or disease. Longitudinal data from a large cohort of people recovering from an upper extremity fracture provided an opportunity to study how these mindset factors evolve during recovery. METHODS: Seven hundred and four adults (66% women, mean age 59 ± 21 years) recovering from upper extremity fracture completed two measures of reaction to symptoms (the Pain Catastrophizing Scale and the Tampa Scale of Kinesiophobia), a visual analog scale of pain intensity, and two measures of magnitude of incapability 1 week, 3 to 4 weeks, and 6 to 9 months after fracture. RESULTS: Exploratory factor analysis identified distinct groupings of questions addressing unhelpful thoughts and feelings of distress regarding symptoms. The number of distinct question groupings of mindset factors diminished over time. Variations in those groupings of mindset factors were associated with a notable amount of the variation in comfort and capability at all time points. Questions pertaining to unhelpful thoughts about symptoms had stronger associations with comfort and capability than questions measuring distress about symptoms, more so as recovery progressed. CONCLUSIONS: The need to integrate mental health into musculoskeletal is bolstered by the observation that mindsets-interpretation of symptoms in particular-are key contributors to comfort and capability.

A head-to-head comparison of EQ-5D-5L and SF-6D in Dutch patients with fractures visiting a Fracture Liaison Service.

AIMS: This study compared the psychometric properties of EQ-5D-5L and SF-6D to assess the interchangeability of both instruments in patients with a recent fracture presenting at a Fracture Liaison Service (FLS). MATERIALS AND METHODS: Data from a prospective observational study in a Dutch FLS clinic were used. Over 3 years, subjects were interviewed at several time points using EQ-5D-5L and SF-36. Floor and ceiling effects were evaluated. Agreement was evaluated by intra-class correlation coefficients and visualized in Bland-Altman plots. Spearman's rank correlation coefficients were applied to assess convergent validity. Mann-Whitney U test or Kruskal-Wallis H test as well as effect size (ES) were used to explore known-groups validity. Responsiveness was explored using standardized response mean (SRM) and ES. For each measurement property, hypotheses on direction and magnitude of effects were formulated. RESULTS: A total of 499 patients were included. EQ-5D-5L had a considerable ceiling effect in comparison to SF-6D (21 vs. 1.2%). Moderate agreement between the (UK and Dutch) EQ-5D-5L and SF-6D was identified with intra-class correlation coefficients of 0.625 and 0.654, respectively. Bland-Altman plots revealed proportional bias as the differences in utilities between two instruments were highly dependent on the health states. High correlation between instruments was found (UK: rho = 0.758; Dutch: rho = 0.763). EQ-5D-5L and SF-6D utilities showed high correlation with physical component score but low correlation with mental component score of SF-36. Both instruments showed moderate discrimination (ES > 0.5) for subgroup by baseline fracture type, and moderate responsiveness (SRM > 0.5) in patients that sustained a subsequent fracture. CONCLUSION: Both EQ-5D-5L and SF-6D appeared to be valid utility instruments in patients with fractures attending the FLS. However, they cannot be used interchangeably given only moderate agreement was identified, and differences in utilities and ceiling effect were revealed. Comparable construct validity and responsiveness were indicated, and neither instrument was found to be clearly superior.

The EQ-5D and SF-36 as generic multi-domain questionnaires are widely used to measure the health-related quality-of-life (HRQoL) in a sample of the persons who suffer from the diseases or the general population. Their responses could be converted to patients or societal Health State Utility Values (HSUVs) with the range of 0 ("death") to 1 ("full health"). A specific application of HSUV is to calculate quality-adjusted life years as the indicator of effectiveness to evaluate whether the cost of a new intervention is justified in terms of health gains through cost-utility analysis in health economics, the evidence can be further used to inform decision-making. However, different instruments differ in construct and valuation, potentially leading to different estimates for the person's same "health state", and healthcare decisions could be compromised when researchers or decision-makers are not aware of potential differences in HSUV. Therefore, it is important to gain insight into the specific psychometric properties of these instruments, and to understand whether instruments are interchangeable. Our study is based on data from a Dutch Fracture Liaison Service (FLS is a program for secondary fracture prevention), compared the psychometric properties and interchangeability of two instruments (EQ-5D-5L and SF-6D) in patients with a recent fracture presenting at the FLS, and suggested both instruments are valid in utility elicitation in our target population. However, they cannot be used interchangeably given only moderate agreement and differences in utilities. Neither instrument was found to be clearly superior given comparable construct and longitudinal validity, but different instruments values in different aspects of HRQoL assessment.

Early Pain Catastrophizing Exacerbates Impaired Limb Loading and 6-Minute Walk Test Distance 12 Months After Lower Extremity Fracture.

OBJECTIVE: Disability is common after lower extremity fracture (LEF). Although psychosocial factors have been associated with patient-reported outcomes after LEF, they have not been associated with objective measures of function. Aberrant gait patterns are important markers of function, but are poorly defined after LEF. The primary purpose of this study was to explore whether pain catastrophizing and fear of movement 6 weeks after surgery were associated with injured limb loading outcomes and 6-minute walk test (6MWT) distance 12 months after femur or tibia fracture. The secondary purpose was to determine if limb loading characteristics differed between injured and uninjured limbs. METHODS: At 6 weeks after LEF, patients completed validated measures of pain catastrophizing, fear of movement, and depression. At 12 months, patients completed a 6MWT while wearing instrumented insoles that recorded the limb loading outcomes of stance time, impulse, and loading rate. Bivariate correlations assessed how patient and psychosocial characteristics at 6 weeks were associated with injured limb loading outcomes and 6MWT distance. Multivariable regression analyses were performed to determine if psychosocial variables were associated with each outcome after controlling for depression and patient demographic and clinical characteristics. Finally, paired t tests compared limb loading outcomes between limbs. RESULTS: Forty-seven participants completed the 6MWT at 12 months (65%), and 38 completed the 6MWT with the instrumented insoles. Fear of movement carried a poor relationship (r = 0.11-0.32) and pain catastrophizing a moderate relationship (r = 0.46-0.54) with 12-month outcomes. The regression results indicated that pain catastrophizing continued to be associated with all outcomes. Finally, the injured limb had significantly lower limb loading outcomes than the uninjured limb at 12 months (Cohen d = 0.54-0.69). CONCLUSION: Pain catastrophizing early after LEF was associated with impaired limb loading and 6MWT distance at 12 months. IMPACT: Impaired limb loading persists 12 months after LEF. Further research is needed to determine whether rehabilitative efforts focused on pain catastrophizing can restore limb loading after LEF.

Reduced pain perception in patients with schizophrenia; A missed case of hand fracture.

Altered pain perception among patients with schizophrenia is often underrecognized in the medical community. The cause is not known, and medical professionals are not sure whether these patients experience less pain or are simply unable to express it. There are documented cases of patients with schizophrenia presenting to hospital settings with serious injuries without obvious (expected) pain. Research into the underlying cause(s) is underway; meanwhile, ensuring awareness of this issue among medical providers is of upmost importance. We report a case of a patient with schizophrenia who presented voluntarily to the emergency department (ED) with a hand fracture that went unrecognized in the ED and further discuss the implications of reduced pain perception. Additionally, we summarize existing hypotheses regarding the source of this reduced pain perception in this population.

Bone fractures during the time of coronavirus.

WHAT IS KNOWN AND OBJECTIVE: In response to rapid spread of coronavirus (SARS-CoV-2) and lack of vaccine or effective treatment for COVID-19 disease, governments imposed measures that resulted in a shift from work and school to isolation at home. Studies from three countries (China, Belgium and the United States) report the consequences on traumatic bone fractures. COMMENT: The coronavirus pandemic has resulted in a widespread change to a relative sedentary lifestyle and decreased exposure to light (vitamin D). A consequence of the stay-at-home policies is a negative change in bone-health and environmental surroundings that has led to age-related changes in the number of traumatic bone fractures. WHAT IS NEW AND CONCLUSION: A consequence of stay-at-home policies has been a decline in bone fractures for young and middle-aged adults; but an increase for the elderly. The trends are predicted to reverse, and present new problems, when isolation restrictions are removed.

Sexual dysfunction following traumatic pelvic fracture.

BACKGROUND: While sexual dysfunction (SD) in men following traumatic pelvic fracture is common, little is known of how men experience changes in their sexual health after injury. The aims of the present study were to explore the personal and interpersonal impacts of SD in men after pelvic injury and to understood how interactions with the health care system can be optimized to improve patient-centered trauma survivorship care. METHODS: Fifteen semistructured interviews were conducted with men who had a history of traumatic pelvic fracture and self-reported SD. Interviews were audio recorded, transcribed, and uploaded to a web-based qualitative analysis platform. A codebook was developed, and intercoder reliability was verified. Inductive thematic analysis was performed to identify notable themes related to patient postinjury sexual health experiences. RESULTS: Median age of interviewees was 46 years (interquartile range, 44-54 years), with a median time since injury of 41 months (interquartile range, 22-55 months). Five primary themes were identified from the analysis: (1) effects on self-image and romantic relationships, (2) unknown care pathways and lack of communication, (3) inconsistencies with health care provider priorities, (4) provision of sexual health information and resources, and (5) the importance of setting expectations. Interviewees suggested that improved communication, provision of information related to possible adverse effects of their injuries, and expectation setting would improve posttrauma experiences. CONCLUSION: Men's experiences with SD after pelvic trauma can be heavily influenced by their interactions with health care providers and the value that is placed on sexual health as a component of survivorship. Incorporating these findings into a patient-centered trauma survivorship program may improve patient experiences. LEVEL OF EVIDENCE: Therapeutic, level V.

Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery.

BACKGROUND: Value-based healthcare models aim to incentivize healthcare providers to offer interventions that address determinants of health. Understanding patient priorities for physical and socioeconomic recovery after injury can help determine which services and resources are most useful to patients. QUESTIONS/PURPOSES: (1) Do trauma patients consistently identify a specific aspect/domain of recovery as being most important at 6 weeks, 6 months, and 12 months after an injury? (2) Does the relative importance of those domains change within the first year after injury? (3) Are differences in priorities greater between patients than for a given patient over time? (4) Are different recovery priorities associated with identifiable biopsychosocial factors? METHODS: Between June 2018 and December 2018, 504 adult patients with fractures of the extremities or pelvis were surgically treated at the study site. For this prospective longitudinal study, we purposefully sampled patients from 6 of the 12 orthopaedic attendings' postoperative clinics. The participating surgeons surgically treated 243 adult patients with fractures of the extremities or pelvis. Five percent (11 of 243) of patients met inclusion criteria but missed their appointments during the 6-week recruitment window and could not be consented. We excluded 4% (9 of 243) of patients with a traumatic brain injury, 1% (2) of patients with a spinal cord injury, and 5% (12) of non-English-speaking patients (4% Spanish speaking [10]; 1% other languages [2]). Eighty-six percent of eligible patients (209 of 243) were approached for consent, and 5% (11 of 209) of those patients refused to participate. All remaining 198 patients consented and completed the baseline survey; 83% (164 of 198 patients) completed at least 6 months of follow-up, and 68% (134 of 198 patients) completed the 12-month assessment. The study participants' mean age was 44 ± 17 years, and 63% (125 of 198) were men. The primary outcome was the patient's recovery priorities, assessed at 6 weeks, 6 months, and 12 months after fracture using a discrete choice experiment. Discrete choice experiments are a well-established method for eliciting decisional preferences. In this technique, respondents are presented with a series of hypothetical scenarios, described by a set of plausible attributes or outcomes, and asked to select their preferred scenario. We used hierarchical Bayesian modeling to calculate individual-level estimates of the relative importance of physical recovery, work-related recovery, and disability benefits, based on the discrete choice experiment responses. The hierarchical Bayesian model improves upon more commonly used regression techniques by accounting for the observed response patterns of individual patients and the sequence of scenarios presented in the discrete choice experiment when calculating the model estimates. We computed the coefficient of variation for the three recovery domains and compared the between-patient versus within-patient differences using asymptotic tests. Separate prognostic models were fit for each of the study's three recovery domains to assess marginal changes in the importance of the recovery domain based on patient characteristics and factors that remained constant over the study (such as sex or preinjury work status) and patient characteristics and factors that varied over the study (including current work status or patient-reported health status). We previously published the 6-week results. This paper expands upon the prior publication to evaluate longitudinal changes in patient recovery priorities. RESULTS: Physical recovery was the respondents' main priority at all three timepoints, representing 60% ± 9% of their overall concern. Work-related recovery and access to disability benefits were of secondary importance and were associated with 27% ± 6% and 13% ± 7% of the patients' concern, respectively. The patients' concern for physical recovery was 6% (95% CrI 4% to 7%) higher at 12 months after fracture that at 6 weeks postfracture. The mean concern for work-related recovery increased by 7% (95% CrI 6% to 8%) from 6 weeks to 6 months after injury. The mean importance of disability benefits increased by 2% (95% CrI 1% to 4%) from 6 weeks to 6 months and remained 2% higher (95% CrI 0% to 3%) at 12 months after the injury. Differences in priorities were greater within a given patient over time than between patients as measured using the coefficient of variation (physical recovery [245% versus 7%; p < 0.001], work-related recovery [678% versus 12%; p < 0.001], and disability benefits [620% versus 33%; p < 0.001]. There was limited evidence that biopsychosocial factors were associated with variation in recovery priorities. Patients' concern for physical recovery was 2% higher for every 10-point increase in their Patient-reported Outcome Measure Information System (PROMIS) physical health status score (95% CrI 1% to 3%). A 10-point increase in the patient's PROMIS mental health status score was associated with a 1% increase in concern for work-related recovery (95% CrI 0% to 2%). CONCLUSION: Work-related recovery and accessing disability benefits were a secondary concern compared with physical recovery in the 12 months after injury for patients with fractures. However, the importance of work-related recovery was elevated after the subacute phase. Priorities were highly variable within a given patient in the year after injury compared with between-patient differences. Given this variation, orthopaedic surgeons should consider assessing and reassessing the socioeconomic well-being of their patients throughout their continuum of care. LEVEL OF EVIDENCE: Level II, therapeutic study.

Patient Satisfaction Is Improved With Exposure to Trauma Recovery Services.

INTRODUCTION: The purpose of this study is to assess the impact of Trauma Recovery Services (TRS), a program facilitating engagement and recovery on satisfaction after orthopaedic trauma. METHODS: Two hundred ninety-four patients with surgically managed extremity fractures were prospectively surveyed. Satisfaction was assessed after 12 months using a 13-question telephone survey, rated on a Likert scale from 1 to 5 (with five being excellent). TRS resource utilization during and after hospitalization was recorded. Eighty-eight patients (30%) used TRS. RESULTS: Overall satisfaction was high with a mean score of 4.32. Although no differences were observed between the control group and patients with TRS utilization in age, sex, race, insurance, smoking history, or employment status, TRS patients sustained more high-energy mechanisms (81% versus 56%) and had more associated psychiatric illness (33% versus 17%), both P < 0.01. Multivariable regression indicated general exposure to TRS to be an independent predictor of higher overall care ratings (B = 1.31; P = 0.03). DISCUSSION: Utilization of TRS was the greatest predictor of better overall care ratings. This study builds on existing evidence demonstrating the positive impact of Trauma Survivor Network programming. We conclude that a hospital-wide program supporting patient education and engagement can effectively increase patient satisfaction after traumatic injury. LEVEL OF EVIDENCE: Prognostic Level II.

Prognostic factors and quality of life after pelvic fractures. The Brabant Injury Outcome Surveillance (BIOS) study.

INTRODUCTION: Pelvic fractures can have long-term consequences for health-related quality of life (HRQoL). The main purpose of this study is to provide insight into short-term HRQoL in the first year after pelvic injury and to identify short-term prognostic factors of decreased outcome. METHODS: This is a prospective, observational, multicenter, follow-up cohort study in which HRQoL and functional outcomes were assessed during 12-month follow-up of injured adult patients admitted to 1 of 10 hospitals in the county of Noord-Brabant, the Netherlands. The data were collected by self-reported questionnaires at 1 week (including preinjury assessment) and 1, 3, 6 and 12 months after injury. The EuroQoL-5D (EQ-5D), visual analog scale (VAS), Merle d'Aubigné Hip Score (MAHS) and Majeed Pelvic Score (MPS) were used. Multivariable mixed models were used to examine the course of the HRQoL and the prognostic factors for decreased HRQoL and functional outcomes over time. RESULTS: A total of 184 patients with pelvic fractures were identified between September 2015-September 2016; the fractures included 71 Tile A, 44 Tile B and 10 Tile C fractures and 59 acetabular fractures. At the pre-injury, 1 week, and 1, 3, 6 and 12 months after injury time points, the mean EQ-5D Index values were 0.90, 0.26, 0.45, 0.66, 0.77 and 0.80, respectively, and the mean EQ-VAS values were 83, 45, 57, 69, 75 and 75, respectively. At 6 and 12 months after injury, 22 and 25% of the MPS < 65 year group, 38 and 47% of the MPS ≥ 65 year group and 34 and 51% of the MAHS group, respectively, reached the maximum score. Pre-injury score, female gender and high Injury Severity Score (ISS) were important prognostic factors for a decreased HRQoL, and the EQ-5D VAS ß = 0.43 (95% CI: 0.31 - 0.57), -6.66 (95% CI: -10.90 - -0.43) and -7.09 (95% CI: -6.11 - -5.67), respectively. DISCUSSION: Patients with pelvic fractures experience a reduction in their HRQoL. Most patients do not achieve the HRQoL of their pre-injury state within 1 year after trauma. Prognostic factors for decreased HRQoL are a low pre-injury score, high ISS and female gender. We do not recommend using the MAHS and MPS in mid- or long-term follow-up of pelvic fractures because of ceiling effects. Trial registration number NCT02508675.

Exploring the burden of X-linked hypophosphatemia: a European multi-country qualitative study.

INTRODUCTION: X-linked hypophosphatemia (XLH) is a rare, lifelong, progressive disease characterised by renal phosphate wasting and abnormal bone mineralisation. Symptoms begin in early childhood, with the development of rickets and related skeletal deformities and reduced growth, progressing to long-term complications, including pseudofractures and fractures, as well as pain, stiffness and fatigue. The present study was designed to explore the patient experience of pain, stiffness and fatigue and the psychosocial impact of XLH in detail. METHODS: A cross-sectional qualitative study was conducted in the United Kingdom (18), Finland (6), France (4), Germany (1) and Luxembourg (1) with XLH patients aged 26 and over. Interview discussion guides were developed in consultation with clinical experts and patient associations. Data were analysed thematically. RESULTS: Participants (N = 30) described pain, stiffness and fatigue as frequently experienced symptoms with a significant impact on physical functioning and activities of daily living (ADLs). Some also described the symptoms as impacting their mood/mental health, relationships, social life and leisure activities. Participants described how common symptoms could interact or aggravate other symptoms. Symptoms had often worsened over time, and for many, were associated with concern about the future. Most participants were worried or felt guilty about having children with XLH. The findings confirmed and extended the existing model of the burden of XLH. CONCLUSION: The present study is the first to provide an in-depth analysis of pain, stiffness and fatigue, their impact and the interrelatedness of these symptoms among adults with XLH. The study also described the psychosocial impact of XLH as a hereditary, lifelong progressive disease.

Fragility fractures in France: epidemiology, characteristics and quality of life (the EPIFRACT study).

Between 1 and 2% of people aged 50 years and over living at home in France are likely to experience a fragility fracture each year. Three-quarters of these individuals are not diagnosed with osteoporosis and lose the opportunity for appropriate care. PURPOSE: To estimate the incidence of fragility fractures in France and to describe the characteristics of individuals with such fractures and of their fractures. METHODS: In April-May 2018, a postal survey was performed in France targeting a representative panel of 15,000 individuals aged ≥ 50 years, who were invited to complete a questionnaire. If they reported experiencing a fracture in the previous 3 years, they were asked to provide information on demographics, fracture type, risk factors for fractures and osteoporosis diagnosis. Only fragility fractures were considered, and these were classified as major (associated with increased mortality) or minor, based on the fracture site. RESULTS: Around 13,914 panellists returned an exploitable questionnaire (92.8%). About 425 participants reported ≥ 1 fragility fracture (453 fractures), corresponding to a 12-month incidence rate of 1.4% [95%CI: 1.2, 1.6]. Incidence was higher in women (1.99% [1.87, 2.05]) than in men (0.69% [0.38, 0.86]) and increased with age. Around 157 fractures (34.6%) were classified as major. Participants reporting major fractures were older than those reporting minor fractures (mean age: 72.6 ± 11.3 vs 67.1 ± 10.6) and more likely to report previous corticosteroid use (odds ratio: 1.90 [95%CI: 1.13, 3.18]). No other patient characteristic was associated with fracture severity. About 117 participants with fractures (27.5%) had undergone bone densitometry, and 97 (22.8%) declared having received a diagnosis of osteoporosis. CONCLUSIONS: Around 340,000 people aged ≥ 50 years living at home in France are estimated to experience osteoporotic fractures each year. However, > 75% of panellists reporting fractures were never diagnosed with osteoporosis and thus did not have the opportunity to receive appropriate care.

Psychological morbidity and functional impairment following traumatic pelvic injury.

Pelvic injuries often result from high-energy trauma and lead to significant functional impairment. While the physical outcomes of these injuries have been widely studied, the psychological consequences remain largely unexplored. The purpose of this study was to examine psychosocial and functional outcomes of patients with pelvic trauma in the year after injury. The sample (N = 32) consisted of adult patients with traumatic pelvic injures, as defined by ICD-9 codes, who were admitted to a Level I Trauma Center for at least 24 h. Participants were primarily female (53%) with a mean age of 48.7 years (SD = 17.9). Demographic, injury-related, and psychosocial data (e.g., posttraumatic stress disorder (PTSD), depression, alcohol use, quality of life, pain, return to work) were gathered at the time of hospitalization as well as at 3-, 6-, and 12 month follow-ups. Mixed regression models were used to examine the outcome variables over time. There were significant decreases in pain and alcohol use at each follow-up compared to baseline. However, despite the decrease, the levels of pain and alcohol use remained high. Physical and mental health also decreased significantly, indicating worsened functioning and lowered quality of life. Neither PTSD nor depression changed significantly over time, indicating that participants' symptoms were not likely to improve. These data suggest that sustaining a traumatic pelvic injury increases the risk of diminished quality of life, both mentally and physically. Even one-year post-injury, participants experienced moderate physical pain and higher levels of PTSD, depression, and problematic alcohol use than would be expected in the general population. These findings highlight the need for an interdisciplinary approach to treating patients with pelvic injuries, including psychological screening and intervention in acute care and throughout recovery.

Keel bone fractures induce a depressive-like state in laying hens.

In commercial flocks of laying hens, keel bone fractures (KBFs) are prevalent and associated with behavioural indicators of pain. However, whether their impact is severe enough to induce a depressive-like state of chronic stress is unknown. As chronic stress downregulates adult hippocampal neurogenesis (AHN) in mammals and birds, we employ this measure as a neural biomarker of subjective welfare state. Radiographs obtained longitudinally from Lohmann Brown laying hens housed in a commercial multi-tier aviary were used to score the severity of naturally-occurring KBFs between the ages of 21-62 weeks. Individual birds' transitions between aviary zones were also recorded. Focal hens with severe KBFs at 3-4 weeks prior to sampling (n = 15) had lower densities of immature doublecortin-positive (DCX+) multipolar and bipolar neurons in the hippocampal formation than focal hens with minimal fractures (n = 9). KBF severity scores at this time also negatively predicted DCX+ cell numbers on an individual level, while hens that acquired fractures earlier in their lives had fewer DCX+ neurons in the caudal hippocampal formation. Activity levels 3-4 weeks prior to sampling were not associated with AHN. KBFs thus lead to a negative affective state lasting at least 3-4 weeks, and management steps to reduce their occurrence are likely to have significant welfare benefits.

Valuing the Recovery Priorities of Orthopaedic Trauma Patients After Injury: Evidence From a Discrete Choice Experiment Within 6 Weeks of Injury.

OBJECTIVES: To determine the recovery priorities of extremity fracture patients during the subacute phase and the patient factors associated with variation in recovery priorities. DESIGN: Discrete choice experiment. SETTING: Academic trauma center. PATIENTS: One hundred ninety-eight patients with a fracture to the appendicular skeleton. Patients with severe traumatic brain injuries, spinal cord injuries, and non-English-speaking patients were excluded. MAIN OUTCOME MEASUREMENT: The relative importance of clinical recovery, work-related recovery, and obtaining disability benefits after injury. RESULTS: In the subacute period, clinical recovery was the main priority for fracture patients (mean: 62%, SD: 5.3). Work-related recovery (mean: 27%, SD: 3.9) and the receipt of other disability benefits (mean: 11%, SD: 6.4) were each of significantly less importance. Heterogeneity was observed across these estimates based on the physical demands of preinjury employment, preinjury physical health, preinjury work status, health insurance type, and the severity of the fracture. CONCLUSION: Clinical recovery was of paramount importance for fracture patients during the subacute recovery phase. However, patients also valued resuming work and access to disability benefits. Understanding a patient's recovery priorities early in the clinical care pathway will enable the development of multidisciplinary care plans that are responsive to these priorities and, hence, deliver value-based health care. LEVEL OF EVIDENCE: Level V. See Instructions for Authors for a complete description of levels of evidence.

Creating Value by Prioritizing Mental and Social Health After Injury.

Given the strong influence of mental and social health on symptom intensity and magnitude of limitations, attempts to increase value in orthopedic trauma must attend to emotional and social recovery. Low value and potentially harmful interventions after trauma such as excessive reliance on medication, low value surgeries for "delayed healing" or "symptomatic implants," repeated visits with a physical therapist, and other biomedical interventions often reflect misdiagnosis and mismanagement of social and mental health. A better approach is to anticipate emotional and social recovery; to get social and mental health specialists involved immediately after injury; and to develop strategies that set firm limits on biomedical tests and treatments that are unlikely to contribute to health and risk reinforcing stress, distress, and less effective coping strategies.

Construct Validity and Precision of Different Patient-reported Outcome Measures During Recovery After Upper Extremity Fractures.

BACKGROUND: Patient perceptions of their limitations after illness and injury can be quantified using patient-reported outcome measures (PROMs). Few studies have assessed construct validity (using correlations and factor analysis) and precision (floor and ceiling effects) of a range of frequently used PROMs longitudinally in a population of patients recovering from common upper extremity fractures according to area (general health, region-specific, or joint-specific measures) and mode of administration (fixed-scale or computer adaptive test). QUESTIONS/PURPOSES: (1) What is the strength of the correlation between different PROMs within 1 week, 2 to 4 weeks and 6 to 9 months after shoulder, elbow, and wrist fractures? (2) Using a factor analysis, what underlying constructs are being measured by these PROMs? (3) Are there strong floor and ceiling effects with these instruments? METHODS: Between January 2016 and August 2016, 734 patients recovering from an isolated shoulder, elbow, or wrist fracture completed physical-limitation PROMs at baseline (the initial office visit after diagnosis in the emergency department), 2 to 4 weeks after injury, and at the final assessment 6 to 9 months after injury. In all, 775 patients were originally approached; 31 patients (4%) declined to participate due to time constraints, four patients died of unrelated illness, and six patients were lost to follow-up. The PROMs included the PROMIS Physical Function (PF, a computer adaptive, general measure of physical function), the PROMIS Upper Extremity (UE, a computer adaptive measure of upper extremity physical function), the QuickDASH (a fixed-scale, region-specific measure), the Oxford Shoulder Score (OSS), the Oxford Elbow Score (OES) and the Patient-rated Wrist Evaluation (PRWE) (a fixed-scale, joint-specific measure), and the EQ-5D-3L (a fixed-scale measure of general health). PROMs were evaluated during recovery for construct validity (using correlations and factor analysis) and precision (using floor and ceiling effects). RESULTS: Physical-limitation PROMs were intercorrelated at all time points, and the correlation strengthened over time (for example, PROMIS UE and QuickDASH at 1 week, r = -0.4665; at 2 to 4 weeks, r = -0.7763; at 6 to 9 months, r = -0.8326; p < 0.001). Factor analysis generated two factors or groupings of PROMs that could be described as capability (perceived ability to perform or engage in activities), and quality of life (an overall sense of health and wellbeing) that varied by time point and fracture type, Joint-specific and general-health PROMs demonstrated high ceiling effects 6 to 9 months after injury and PROMIS PF, PROMIS UE and QuickDASH had no floor or ceiling effects at any time points. CONCLUSIONS: There is a substantial correlation between PROMs that assess physical limitations (based on anatomic region) and general health after upper extremity fractures, and these relationships strengthen during recovery. Regardless of the delivery mode or area of focus, PROMs largely appear to represent two underlying constructs: capability and quality of life. Computer adaptive tests may be favored over fixed-scale measures for their efficiency and limited censoring. LEVEL OF EVIDENCE: Level II, therapeutic study.

Treatment and management of seven children with fractured femurs experiencing night terrors in hospital: a case study.

This article reports on seven cases of night terror disorder in children with no previous history of parasomnias, or night time disturbance. All children were admitted to a metropolitan children's hospital with a traumatic fracture of the femur and treated with Thomas' traction splint, a phenomenon not previously reported in the literature. The characteristic presentation of a night terror is described and a strategy for immediate nursing management of a night terror is suggested. Various forms of projective play therapy as a safe short-term treatment are described to assist children with night terror disorder.

Psychosocial factors affecting variation in patient-reported outcomes after elbow fractures.

BACKGROUND: The purpose of this study was to identify factors associated with limitations in function measured by patient-reported outcome measures (PROMs) 6-9 months after elbow fractures in adults from a range of demographic, injury, psychological, and social variables measured within a week and 2-4 weeks after injury. METHODS: We enrolled 191 adult patients sustaining an isolated elbow fracture and invited them to complete PROMs at their initial visit to the orthopedic outpatient clinic (within a maximum of 1 week after fracture), between 2 and 4 weeks, and between 6 and 9 months after injury; 183 patients completed the final assessment. Bivariate analysis was performed, followed by multivariable regression analysis accounting for multicollinearity. This was evaluated using partial R2, correlation matrices, and variable inflation factor assessment. RESULTS: There was a correlation between multiple variables within a week of injury and 2-4 weeks after injury with PROMs 6-9 months after injury in bivariate analysis. Kinesiophobia measured within a week of injury and self-efficacy measured at 2-4 weeks were the strongest predictors of limitations 6-9 months after injury in multivariable regression. Regression models accounted for substantial variance in all PROMs at both time points. CONCLUSIONS: Developing effective coping strategies to overcome fears related to movement and reinjury and finding ways of persevering with activity despite pain within a month of injury may enhance recovery after elbow fractures. Heightened fears around movement and suboptimal coping ability are modifiable using evidence-based behavioral treatments.