Black Cohosh Interactions with Prescription Medications Associated with Serotonin Toxicity and Rhabdomyolysis: A Case Report.

BACKGROUND: Serotonin toxicity is a well-described phenomenon that is commonly attributed to a variety of drug-drug combinations. Some unregulated herbal supplements have been implicated in the onset of serotonin toxicity, however, there is currently minimal literature available on the potential for black cohosh to contribute to rhabdomyolysis and serotonin toxicity, in spite of its known serotonergic properties. CASE REPORT: A middle-aged woman presented to the emergency department with serotonin toxicity and rhabdomyolysis shortly after taking black cohosh supplements in the setting of long-term dual antidepressant use. The serotonin toxicity and rhabdomyolysis resolved with IV fluids, benzodiazepines, and discontinuation of the offending drugs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients are sometimes not aware of how over-the-counter supplements might interact with their prescription medications. Female patients taking black cohosh to manage hot flashes and menopausal symptoms could be at risk for developing rhabdomyolysis and serotonin toxicity if they are also taking other serotonergic agents.

Pre-Operative Rank of Expectations for Shoulder Surgery (PRESS): A Novel Survey.

BACKGROUND: Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction. Current surveys assessing patient expectations lack clinical applicability and allow patients to list multiple expectations at the highest level of importance. The purpose of this study was to develop and evaluate the use of a novel, rank-based survey assessing the relative importance of patient expectations for shoulder surgery. METHODS: The Preoperative Rank of Expectations for Shoulder Surgery (PRESS) survey was developed by polling 100 patients regarding their expectations for surgery. The PRESS survey consisted of eight common expectations for elective shoulder surgery by importance and a 0-100% scale of expected pain relief and range of motion improvement. After initial development of the PRESS survey, it was administered preoperatively to 316 patients undergoing surgery for shoulder arthritis, rotator cuff tear, subacromial pain syndrome, or glenohumeral instability between August 2020 and April 2021. Patients also completed preoperative outcome measures such as ASES, PROMIS PF, and PROMIS PI surveys. PROM surveys were administered six months postoperatively. RESULTS: Improvement in range of motion was the expectation most often ranked first for the entire study group (18%), arthritis subgroup (23%), and rotator cuff tear subgroup (19%). Subacromial pain syndrome patients most often ranked improving ability to complete ADL's and relieving daytime pain first (19%). Shoulder instability patients most often ranked improving ability to participate in sports first (31%). Patients that ranked improving range of motion or sports highly had better PROMs. Those who ranked relieving pain highly had worse PROMs. Patients with high (>90%) expectations of pain relief had better PROMIS PI scores. Patients with high pain relief expectations in the arthritis and subacromial pain syndrome groups had better PROMs, while patients with instability were less satisfied. CONCLUSION: The novel PRESS survey assesses patient expectations for shoulder surgery in a new, more clinically applicable rank-based format. The responses provided by patients provide actionable information to clinicians and are related to postoperative outcomes. Therefore the PRESS survey represents a useful tool for guiding discussions between patients and surgeons, as well as aiding in overall patient-centered clinical decision making.

No difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis.

INTRODUCTION: Cephalomedullary nail (CMN) cut-out is a severe complication of treatment of intertrochanteric femur fractures. This study aimed to identify modifiable risk factors predictive of implant cut-out including: CMN proximal fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, screw location, and surgeon fellowship training. METHODS: A systematic review of the published literature was conducted on Pubmed/MEDLINE and Cochrane Library databases for English language papers (January 1st, 1985-May 10th, 2020), with 21 studies meeting inclusion/exclusion criteria. Studies providing quantitative data comparing factors affecting CMN nail cut-out were included, including fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, and screw location. Twelve studies were included and graded by MINOR and Newcastle-Ottawa Scale to identify potential biases. Meta-analysis and pooled analysis were conducted when possible with forest plots to summarize odds ratios (OR) and associated 95% confidence interval (CI). RESULTS: There was no difference in implant cut-out rate between lag screws (n = 745) versus helical blade (n = 371) (OR: 1.03; 95% CI: 0.25-4.23). Pooled data analysis revealed TAD > 25 mm (n = 310) was associated with higher odds of increased cut-out rate relative to TAD < 25 mm (n = 730) (OR: 3.72; 95% CI: 2.06-6.72). CONCLUSION: Our review suggests that cephalomedullary implant type (lag screw vs. helical blade) is not a risk factor for implant cut-out. Consistent with the previous literature, increased tip-apex distance > 25 mm is a reliable predictor of implant cut-out risk. Suboptimal screw location and poor reduction quality are associated with increased risk of screw cut-out. LEVEL OF EVIDENCE: Level III.

Graft choice or drilling technique does not influence outcomes of ACL reconstruction in patients over forty-five.

PURPOSE: To evaluate whether graft-type and tunnel location in ACL reconstruction impact patient-reported outcomes in individuals over the age of 45. METHODS: From 2015 to 2018, patients over 45 years old undergoing primary ACL reconstruction without multi-ligamentous injuries were enrolled in an institutional registry. Baseline International Knee Documentation Committee (IKDC) subjective scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Scale, and patient characteristics were collected. Follow-up occurred at a minimum of two years to obtain patient-reported outcomes. RESULTS: Of the 51 patients who qualified for the study, 44 (86.3%) patients were available at a minimum of two years after surgery date (range 24-60 months). Average age at time of surgery of the available patients was 51.6 ± 4.87 (range 45-66). Between femoral tunnel drilling methods, there were no differences in the proportion of patients achieving clinically significant improvement or post-operative outcome scores. While patients who received patellar tendon autografts were more likely to achieve clinically significant improvement in the KOOS sports subscale, there were no other differences in outcomes measures between graft types. Two patients had a retear of their graft, and an additional five patients complained of subjective instability. CONCLUSIONS: In patients over the age of 45, neither the method used to create the femoral tunnel nor the graft type used in ACL reconstruction caused a significant difference in post-operative PROMs with a minimum of two years of follow-up. LEVEL OF EVIDENCE: Therapeutic IV, Case Series.

Patient-Reported Outcomes Measurement Information System Scores Are Inconsistently Correlated With Legacy Patient-Reported Outcome Measures in Shoulder Pathology: A Systematic Review.

PURPOSE: To evaluate the current literature regarding Patient-Reported Outcomes Measurement Information System (PROMIS) and its correlation to legacy patient-reported outcomes measures (PROMs) in 5 domains: (1) rotator cuff disease, (2) shoulder instability, (3) shoulder arthroplasty, (4) proximal humerus fractures, and (5) glenohumeral arthritis. The secondary purpose is to evaluate the floor and ceiling effects, the number of questions, and time needed to complete PROMIS and legacy PROMs in shoulder care. METHODS: A systematic review of the available literature on PROMIS scores in shoulder care was performed. This review was accomplished per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS: A total of 11 studies that reported data on 1485 patients met inclusion criteria. There was a strong correlation between general function PROMs and the PROMIS PF for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and proximal humerus fractures. In addition, there was a strong correlation between PROMIS UE and legacy PROMs in patients with rotator cuff injury and shoulder instability. PROMIS instruments asked fewer questions than legacy PROMs (9.46 vs 12.99, respectively), took less time to complete (88.21 vs 96.53 seconds, respectively), had less floor effects in both PROMIS PF and UE (0.17% and 0.62% vs 2.89%, respectively), and had lower ceiling effects for PROMIS PF but not PROMIS UE assessments (0.17% and 6.37% vs 1.89%, respectively). CONCLUSIONS: This systematic review demonstrated PROMIS instruments have varying correlations with legacy PROMs measures for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and glenohumeral arthritis. PROMIS instruments do measure clinical outcomes faster and with fewer questions. Other than PROMIS UE v1.2 ceiling effects, PROMIS instruments have lower rates of floor and ceiling effects. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Does preoperative diagnosis impact patient outcomes following reverse total shoulder arthroplasty? A systematic review.

BACKGROUND: The indications for reverse total shoulder arthroplasty (rTSA) have expanded to include the treatment of a wide variety of shoulder pathologies, and there may be significant differences in patient outcomes based on preoperative diagnosis. METHODS: A systematic review of the orthopedic literature contained in the PubMed, Cochrane, and Embase databases was performed on November 14, 2019. Studies investigating rTSA indicated for 7 distinct preoperative diagnoses (massive rotator cuff tear [MCT] without glenohumeral osteoarthritis [GHOA], MCT with GHOA or cuff tear arthropathy, primary GHOA, inflammatory arthritis with MCT, failed shoulder arthroplasty, proximal humeral fracture [PHF], and sequelae following PHF) were included. The main outcomes of interest included functional outcomes (abduction, external rotation, and forward flexion) and patient-reported outcome measures (American Shoulder and Elbow Surgeons shoulder score and Constant-Murley score). Because of significant variation in measurement and reporting, data on internal rotation were not extracted. In addition, radiographic outcomes and complication rates were extracted and recorded for each of the included studies. RESULTS: In total, 47 studies, comprising 2280 patients, met the inclusion criteria. Significant improvements in functional outcomes and patient-reported outcome measures were found across the preoperative diagnostic groups. There were no significant differences between the diagnostic groups regarding improvement between preoperative and postoperative values for the outcomes of interest, with the exception that the inflammatory arthropathy group had significantly less improvement in the Constant-Murley score than the primary GHOA and revision arthroplasty groups. Although there were few differences in improvement between groups, there were significant differences regarding the level of postoperative functional performance, which was not as consistent in the context of trauma or revision operations (ie, complex PHF, fracture sequela, and revision arthroplasty groups). CONCLUSION: Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. The groups with primary GHOA and MCTs with or without GHOA demonstrated the most reliable postoperative functional outcomes of the examined diagnostic groups. Postoperative outcomes were not as consistent in the context of trauma or revision operations, and these groups may benefit from a variety of modern advancements in rTSA, although further research into these modalities for these groups is needed. Finally, rTSA remains an important treatment option in the context of rheumatoid arthritis, with similar outcomes and complication rates compared with the 6 other operative indications.

Factors that influence inpatient satisfaction after shoulder arthroplasty.

BACKGROUND: It is important to distinguish satisfaction regarding the outcome of care and satisfaction with the delivery of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are modern assessments of hospitals and providers of delivery of care. The purpose of this study was to report inpatient satisfaction according to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) scores after shoulder arthroplasty and to determine factors that influence them, as well as their correlation with surgical expectations, pain perception, quality of life, surgical setting, and functional outcomes. METHODS: All patients scheduled for a shoulder arthroplasty were prospectively asked to complete a demographic and initial shoulder assessment form, a shoulder surgery expectations survey, a pain catastrophizing scale, the SF-12 (12-item Short Form) survey, and a resiliency form (Resilience Scale 11). Patient satisfaction was measured with the CG-CAHPS and HCAHPS surveys. Legacy forms, patient-specific factors, type of surgery performed, location of surgery, length of hospital stay, and discharge disposition were evaluated on their ability to predict these survey scores. Linear regression was used to calculate correlations and predictions of continuous variables, and logistic regression was used to compared the satisfied vs. unsatisfied cohorts. RESULTS: The average HCAHPS and CG-CAHPS satisfaction scores for the population were 74.7 ± 20.7 and 82.1 ± 19.4, respectively. Nonsmokers had a mean HCAHPS score of 77.7 ± 22.0, whereas current smokers reported a mean of 59.6 ± 5.2 (P = .03). Patients who were discharged home had a mean HCAHPS score of 77.3 ± 21.9, whereas those discharged to a skilled nursing facility reported a mean of 59.3 ± 6.6 (P = .05). These same groups also had significantly higher odds of being satisfied with the hospital. No significant differences or higher odds were seen for comparisons between overall CG-CAHPS satisfaction and any of the patient-specific factors tested. There was no significant correlation between age, length of stay, pain (pain catastrophizing scale), resiliency (Resilience Scale 11), expectations (shoulder surgery expectations survey), or function (SF-12) and both the HCAHPS and CG-CAHPS satisfaction scores. CONCLUSION: Overall, 37 patients (74%) had CG-CAHPS scores that indicated satisfaction and 34 patients (68%) had HCAHPS scores that indicated satisfaction. Nonsmokers and patients discharged home after surgery report higher levels of inpatient hospital (HCAHPS) satisfaction after shoulder arthroplasty. Patients with high preoperative surgical expectations, pain perception, and resiliency are not generally more satisfied with the hospital or clinician. Preoperative diagnosis, location of surgery, and length of stay do not reliably impact satisfaction with the hospital or clinician. Inpatient HCAHPS and CG-CAHPS satisfaction does not correlate with legacy functional outcome measures and, therefore, may not be predictive of long-term functional outcomes.

Does preoperative disease severity influence outcomes in reverse shoulder arthroplasty for cuff tear arthropathy?

BACKGROUND: The degree of symptomatic disease and functional burden has been demonstrated to influence patient results and satisfaction in total hip and knee arthroplasty. Although the relationship between preoperative diagnosis and patient outcomes has been an area of study for reverse total shoulder arthroplasty (RTSA), the influence of the progression of cuff tear arthropathy (CTA) has not yet been examined. The purpose of this study was to evaluate whether preoperative radiographic disease burden and scapular geometry impact patient outcomes and satisfaction in a cohort of patients with CTA treated with RTSA. METHODS: Eighty-six patients were treated for CTA with RTSA performed by the senior author (B.G.) between September 2016 and September 2018 and were enrolled in an institutional registry. At the time of initial evaluation, the baseline American Shoulder and Elbow Surgeons (ASES) score, patient demographic characteristics, history of shoulder surgery, and presence of pseudoparalysis were collected. Radiographs were obtained to evaluate the critical shoulder angle, acromial index, and progression of CTA as assessed by Hamada grading and the Seebauer classification. Patients were contacted to reassess the ASES score and their satisfaction with the improvement in their shoulder function. RESULTS: A total of 79 patients (91.6%) were available for evaluation at a minimum of 24 months of follow-up. Multivariate logistic regression modeling revealed that scapular geometry measurements (critical shoulder angle and acromial index) and the degree of CTA (Seebauer and Hamada classifications) were not associated with worse outcomes as assessed by the ASES score. However, degenerative changes as assessed by the Hamada grade (odds ratio, 0.13 [95% confidence interval, 0.02-0.86]; P = .03) and preoperative ASES score (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .008) were independently associated with higher satisfaction at 24 months of follow-up. CONCLUSION: The results indicate that patients with greater CTA disease progression did not show differing outcomes after RTSA compared with patients with milder disease. In contrast, both poorer preoperative function and degenerative changes as assessed by the Hamada classification were associated with greater satisfaction after RTSA for CTA. Given the broad spectrum of disease in CTA, there is likely a corresponding range in patient expectations that requires further study to maximize patient satisfaction.

Outcome Reporting in Total Ankle Arthroplasty: A Systematic Review.

Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.

Thirty-Day Readmissions After Upper and Lower Gastrointestinal Hemorrhage: A National Perspective in the United States.

BACKGROUND: Upper gastrointestinal hemorrhage (UGIH) and lower gastrointestinal hemorrhage (LGIH) are 2 of the most common reasons for hospital admissions across the United States. The 30-day readmission after index admission poses a major burden on the health care infrastructure, and thus, it is important to assess the causes of 30-day readmission for patients with UGIH and LGIH. METHODS: The study cohort was derived from the 2013 National Readmission Database. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Volume 3 diagnosis codes were utilized to identify UGIH and LGIH patients from this data set. Patients who were readmitted to the hospital within 30 days within the same calendar year were further analyzed. Categorical variables and continuous variables were assessed by the χ test and the student t test, respectively. The independent predictors of unplanned 30-day readmissions were recognized by multivariate logistic regression, adjusting for stratified cluster design of National Readmission Database. SAS 9.4 (SAS Institute Inc., Cary, NC) was used for data analysis. RESULTS: The number of index admissions identified from the National Readmission Data 2013 were 82,290 for UGIH and 133,114 for LGIH. All-cause 30-day readmission rate for UGIH versus LGIH was 14.6% (readmitted N=12,046; 56.64% age 65 y and above) versus 14.4% (readmitted N=19,128; 70.21% age 65 y and above and 49.61% men). Gastrointestinal causes were most common (33.9% vs. 39.6%), followed by cardiac (13.3% vs. 15.3%), infectious (10.4% vs. 9.1%), and respiratory causes (7.8% vs. 7.1%) for 30-day readmission for UGIH and LGIH. Significant predictors of increased 30-day readmission (odds ratio, 95% confidence interval, P-value) included metastatic disease (2.15, 1.75-2.64, P<0.001), discharge against medical advice (1.85, 1.55-2.22, P<0.001), and length of stay >3 days (1.50, 1.38-1.63, P<0.001). Predictors for 30-day readmission for LGIH included metastatic disease (1.75, 1.48-2.06, P<0.001), liver disease (1.59, 1.49-1.71, P<0.001), and drug abuse (1.38, 1.21-1.58, P<0.001). CONCLUSIONS: Most common reason for UGIH and LGIH readmission was related to gastrointestinal disease, followed by cardiac, infectious, and respiratory etiologies. By addressing these etiologies for readmission, it may be possible to reduce adverse outcomes.

Inhibition of Pseudomonas aeruginosa biofilm formation on wound dressings.

Chronic nonhealing skin wounds often contain bacterial biofilms that prevent normal wound healing and closure and present challenges to the use of conventional wound dressings. We investigated inhibition of Pseudomonas aeruginosa biofilm formation, a common pathogen of chronic skin wounds, on a commercially available biological wound dressing. Building on prior reports, we examined whether the amino acid tryptophan would inhibit P. aeruginosa biofilm formation on the three-dimensional surface of the biological dressing. Bacterial biomass and biofilm polysaccharides were quantified using crystal violet staining or an enzyme linked lectin, respectively. Bacterial cells and biofilm matrix adherent to the wound dressing were visualized through scanning electron microscopy. D-/L-tryptophan inhibited P. aeruginosa biofilm formation on the wound dressing in a dose dependent manner and was not directly cytotoxic to immortalized human keratinocytes although there was some reduction in cellular metabolism or enzymatic activity. More importantly, D-/L-tryptophan did not impair wound healing in a splinted skin wound murine model. Furthermore, wound closure was improved when D-/L-tryptophan treated wound dressing with P. aeruginosa biofilms were compared with untreated dressings. These findings indicate that tryptophan may prove useful for integration into wound dressings to inhibit biofilm formation and promote wound healing.

Synthetic oral mucin mimic from polymer micelle networks.

Mucin networks are formed in the oral cavity by complexation of glycoproteins with other salivary proteins, yielding a hydrated lubricating barrier. The function of these networks is linked to their structural, chemical, and mechanical properties. Yet, as these properties are interdependent, it is difficult to tease out their relative importance. Here, we demonstrate the ability to recreate the fibrous like network through a series of complementary rinses of polymeric worm-like micelles, resulting in a 3-dimensional (3D) porous network that can be deposited layer-by-layer onto any surface. In this work, stability, structure, and microbial capture capabilities were evaluated as a function of network properties. It was found that network structure alone was sufficient for bacterial capture, even with networks composed of the adhesion-resistant polymer, poly(ethylene glycol). The synthetic networks provide an excellent, yet simple, means of independently characterizing mucin network properties (e.g., surface chemistry, stiffness, and pore size).

Subjective and objective results 1 year after robotic sacrocolpopexy using a lightweight Y-mesh.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to assess outcomes following robotic sacrocolpopexy using a lightweight polypropylene Y-mesh. METHODS: During our study period, all patients who underwent robotic sacrocolpopexy were enrolled in this single-arm prospective trial. Endpoints included Pelvic Organ Prolapse Quantification (POP-Q) values; Pelvic Floor Distress Inventory, short form 20 (PFDI-20); Pelvic Floor Impact Questionnaire, short form 7 (PFIQ-7); Surgical Satisfaction scores; and the Sandvik Incontinence Severity Index. All surgeries were performed with a pre-configured monofilament type 1 polypropylene Y-mesh (Alyte©, C.R. Bard, Covington, GA, USA). Cure rates at 12 months were calculated using two separate definitions: (1) "clinical cure": no POP-Q points > 0, point C ≤ -5, no prolapse symptoms on the PFDI-20, and no reoperations for prolapse and (2) "objective anatomic cure": POP-Q stage 0 or 1, point C of ≤ -5, and no reoperations for prolapse. RESULTS: A total of 150 patients underwent robotic sacrocolpopexy and 143 (95 %) were available for 12-month follow-up. Mean age was 58.6 ± 9.8 and mean body mass index was 26.3 ± 4.5. Mean operative time and blood loss were 148 ± 27.6 min (range 75-250 min) and 51.2 ± 32, respectively. There were no mesh erosions or exposures, and mesh edges were not palpable in any patient. At 12 months the clinical cure rate was 95 %, and the objective anatomic cure rate was 84 %. The PFDI-20 mean score improved from 98 at baseline to 17 at 12 months (p < 0.0001); PFIQ-7 scores improved from 59 to 6.5 (p < 0.0001). CONCLUSIONS: Robotic sacrocolpopexy using this lightweight polypropylene Y-mesh offers excellent subjective and objective results at 1 year.

Postoperative Negative Pain Thoughts and Their Correlation With Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair: An Observational Cohort Study.

BACKGROUND: Pain and pain perception are influenced by patients' thoughts. The short form Negative Pain Thoughts Questionnaire (NPTQ-SF) can be used to quantify unhelpful negative cognitive biases about pain, but the relationship between NPTQ-SF scores and orthopaedic surgery outcomes is not known. PURPOSE/HYPOTHESIS: The purpose was to assess the relationship between negative pain thoughts, as measured by the NPTQ-SF, and patient-reported outcomes in patients undergoing arthroscopic rotator cuff repair, as well as to compare NPTQ-SF scores and outcomes between patients with and without a history of chronic pain and psychiatric history. It was hypothesized that patients with worse negative pain thoughts would have worse patient-reported outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In total, 109 patients undergoing arthroscopic rotator cuff repair were administered the 4-item NPTQ-SF, 12-item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Evaluation Form, and visual analog scale pain survey preoperatively between July 2021 and August 2022. The same surveys were completed ≥6 months postoperatively by 74 patients confirmed to have undergone arthroscopic rotator cuff repair. RESULTS: Preoperative NPTQ-SF scores did not show any correlation with the postoperative patient-reported outcomes measured in this study. Postoperative NPTQ-SF scores were statistically significantly negatively correlated with postoperative SF-12 Physical Health Score, SF-12 Mental Health Score, ASES, and satisfaction scores (P < .05). Postoperative NPTQ-SF scores were statistically significantly positively correlated with postoperative visual analog scale scores (P < .001). Moreover, postoperative NPTQ-SF scores were statistically significantly negatively correlated with achieving a Patient Acceptable Symptom State and the minimal clinically important difference on the postoperative ASES form (P < .001 and P = .009, respectively). CONCLUSION: Postoperative patient thought patterns and their perception of pain are correlated with postoperative outcomes after rotator cuff repair. This correlation suggests a role for counseling and expectation management in the postoperative setting. Conversely, preoperative thought patterns regarding pain, as measured by the NPTQ-SF, do not correlate with postoperative patient-reported outcome measures. Therefore, the NPTQ-SF should not be used as a preoperative tool to aid the prediction of outcomes after rotator cuff repair.

Unplanned reoperation is common following intramedullary nailing of open femoral shaft fractures: A retrospective review.

Background: The objective of this study is to investigate the incidence of unplanned reoperation, nonunion and infection following open femoral shaft fractures treated with an intramedullary nail and correlate these occurrences with patient variables and injury characteristics. Methods: A retrospective review of open femur fractures from a level 1 trauma center between 2012 and 2020 was performed. Ninety-five patients who sustained an open femur fracture, were treated definitively with an intramedullary nail, and had at least 3 months of follow-up were included in the analysis for surgical site infection. Seventy-three of these patients had at least one year of follow-up. After excluding planned bone grafting for segmental defects, 67 patients were included in the analysis of unplanned reoperation. Results: The rate of unplanned reoperation was 31.3 %, with 57 % of these operations occurring to address nonunion. The overall nonunion rate was 18 %. In patients who did not require reoperation to obtain union, the median time to union for the cohort was 6 months, with an interquartile range of 3-7.5 months. Post-operative surgical site infection occurred in 11.6 % of patients. Conclusions: In conclusion, unplanned reoperation following intramedullary nailing of open femur fractures occurs in nearly 1/3rd of patients and the rates of nonunion and surgical site infection may be higher than previously reported in the literature. Reoperation most closely correlates with the OTA Open Fracture Classification System. Patients with open femur fractures should be counseled that reoperation is often required to obtain fracture union, with soft tissue and fracture injury severity predicting complications.

Early Treatment of Acetabular Fractures Using an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion.

OBJECTIVE: The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss. DESIGN: Retrospective review. SETTING: Three level 1 trauma centers at 2 academic institutions. PATIENT SELECTION CRITERIA: Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures). OUTCOME MEASURES AND COMPARISONS: Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery. RESULTS: 195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross method, P = 0.003; -0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (-1.69 mL per hour by Gross method, P = 0.013; -0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 [IQR 277-733] mL early versus 364 [IQR 160-661] delayed by Gross method, P = 0.017; 165 [IQR 99-249] g of Hgb early versus 143 [IQR 55-238] g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative ( P > 0.05). CONCLUSION: There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tranexamic Acid and Holding Venous Thromboembolism Prophylaxis Morning of Surgery Do Not Decrease Transfusion Requirements in Patients Undergoing Anterior Intrapelvic Approach for Acetabular Open Reduction and Internal Fixation.

INTRODUCTION: The objective of this study was to determine factors that may affect transfusion rates for patients requiring an anterior intrapelvic (AIP) approach for an acetabulum fracture. METHODS: This was a multicenter retrospective comparison study (3 trauma centers at two urban academic centers). Patients who had an AIP approach for an acetabulum fracture without other notable same-day procedures (irrigation and débridement and/or external fixation were only other allowed procedures) were included. One hundred ninety-five adult (18 and older) patients had adequate records to complete analysis with no preexisting coagulopathy. The main outcome evaluated was the number of units transfused at the time of surgery and up to 7 days after surgery. RESULTS: Factors that were found to affect intraoperative transfusion rates were older age, lower preoperative hematocrit, longer surgery duration, and requiring increased intraoperative intravenous fluids. Factors that did not affect transfusion rate included sex, body mass index, hip dislocation at the time of injury, fracture pattern, AIP approach alone or with lateral window ± distal extension, Injury Severity Score, preoperative platelet count, use of tranexamic acid, and venous thromboembolism prophylaxis received morning of surgery. When followed out through the remainder of a week after surgery, the results for any factor did not change. DISCUSSION: In this large multicenter retrospective study of patients requiring an AIP approach, tranexamic acid and use of venous thromboembolism prophylaxis (or holding it the morning of surgery) did not affect transfusion rates either during surgery or up to a week after surgery. Older age, lower preoperative hematocrit level, longer surgery time, and increased intraoperative intravenous fluids were associated with higher transfusion rates. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: Data are available on request. LEVEL OF EVIDENCE: Level 3, retrospective case-control study.

How do authors' perceptions of their papers compare with co-authors' perceptions and peer-review decisions?

How do author perceptions match up to the outcomes of the peer-review process and perceptions of others? In a top-tier computer science conference (NeurIPS 2021) with more than 23,000 submitting authors and 9,000 submitted papers, we surveyed the authors on three questions: (i) their predicted probability of acceptance for each of their papers, (ii) their perceived ranking of their own papers based on scientific contribution, and (iii) the change in their perception about their own papers after seeing the reviews. The salient results are: (1) Authors had roughly a three-fold overestimate of the acceptance probability of their papers: The median prediction was 70% for an approximately 25% acceptance rate. (2) Female authors exhibited a marginally higher (statistically significant) miscalibration than male authors; predictions of authors invited to serve as meta-reviewers or reviewers were similarly calibrated, but better than authors who were not invited to review. (3) Authors' relative ranking of scientific contribution of two submissions they made generally agreed with their predicted acceptance probabilities (93% agreement), but there was a notable 7% responses where authors predicted a worse outcome for their better paper. (4) The author-provided rankings disagreed with the peer-review decisions about a third of the time; when co-authors ranked their jointly authored papers, co-authors disagreed at a similar rate-about a third of the time. (5) At least 30% of respondents of both accepted and rejected papers said that their perception of their own paper improved after the review process. The stakeholders in peer review should take these findings into account in setting their expectations from peer review.

The role of author identities in peer review.

There is widespread debate on whether to anonymize author identities in peer review. The key argument for anonymization is to mitigate bias, whereas arguments against anonymization posit various uses of author identities in the review process. The Innovations in Theoretical Computer Science (ITCS) 2023 conference adopted a middle ground by initially anonymizing the author identities from reviewers, revealing them after the reviewer had submitted their initial reviews, and allowing the reviewer to change their review subsequently. We present an analysis of the reviews pertaining to the identification and use of author identities. Our key findings are: (I) A majority of reviewers self-report not knowing and being unable to guess the authors' identities for the papers they were reviewing. (II) After the initial submission of reviews, 7.1% of reviews changed their overall merit score and 3.8% changed their self-reported reviewer expertise. (III) There is a very weak and statistically insignificant correlation of the rank of authors' affiliations with the change in overall merit; there is a weak but statistically significant correlation with respect to change in reviewer expertise. We also conducted an anonymous survey to obtain opinions from reviewers and authors. The main findings from the 200 survey responses are: (i) A vast majority of participants favor anonymizing author identities in some form. (ii) The "middle-ground" initiative of ITCS 2023 was appreciated. (iii) Detecting conflicts of interest is a challenge that needs to be addressed if author identities are anonymized. Overall, these findings support anonymization of author identities in some form (e.g., as was done in ITCS 2023), as long as there is a robust and efficient way to check conflicts of interest.

A large scale randomized controlled trial on herding in peer-review discussions.

Peer review is the backbone of academia and humans constitute a cornerstone of this process, being responsible for reviewing submissions and making the final acceptance/rejection decisions. Given that human decision-making is known to be susceptible to various cognitive biases, it is important to understand which (if any) biases are present in the peer-review process, and design the pipeline such that the impact of these biases is minimized. In this work, we focus on the dynamics of discussions between reviewers and investigate the presence of herding behaviour therein. Specifically, we aim to understand whether reviewers and discussion chairs get disproportionately influenced by the first argument presented in the discussion when (in case of reviewers) they form an independent opinion about the paper before discussing it with others. In conjunction with the review process of a large, top tier machine learning conference, we design and execute a randomized controlled trial that involves 1,544 papers and 2,797 reviewers with the goal of testing for the conditional causal effect of the discussion initiator's opinion on the outcome of a paper. Our experiment reveals no evidence of herding in peer-review discussions. This observation is in contrast with past work that has documented an undue influence of the first piece of information on the final decision (e.g., anchoring effect) and analyzed herding behaviour in other applications (e.g., financial markets). Regarding policy implications, the absence of the herding effect suggests that the current status quo of the absence of a unified policy towards discussion initiation does not result in an increased arbitrariness of the resulting decisions.