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Assessment practices for measuring adverse life events (ALEs) are often characterized by considerable variability, which is associated with inconsistency and reproducibility issues when conducting research on children with ALE exposure. One aspect of assessment variability for caregiver report of children's ALE history that has received minimal attention is assessment format. To address this issue, the current study evaluated concordance between two main ALE assessment formats: interviews and questionnaires. This involved examining overall endorsement of ALEs and concordance among multiple characteristics of ALE exposure, including type, polyvictimization, frequency, severity, and age of onset. Fifty-eight caregivers ( M age  = 33.72; 60% Black; 55% below the federal poverty line) of preschool and school-age children were administered an ALE assessment in both a questionnaire and interview format across two sessions. The sum scores and concordance rates between format responses were compared based on ALE type, polyvictimization, frequency, severity, and age of onset of exposure. Results indicated that most total or sum scores were similar between formats, with the exception of ALE severity scores. However, there was most often low-to-moderate concordance across the 50 types of ALEs examined in the current study, suggesting that a different constellation of events comprised each sum or total score. This was also the case across all characteristics of the ALEs and most notably for the severity of ALE. Based on these findings, the format of assessment may be associated with inconsistent reporting of children's ALE exposure across multiple characteristics of ALE. Researchers may need to utilize multiple types of ALE assessments when relying on caregiver report of a child's ALEs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Neal Duggal is a consultant for Medtronic.

NOD1 and NOD2 sense small bacterial peptidoglycan fragments, often called muropeptides, that access the cytosol. These muropeptides include iE-DAP and MDP, the minimal agonists for NOD1 and NOD2, respectively. Here, we synthesized and validated alkyne-modified muropeptides, iE-DAP-Alk and MDP-Alk, for use in click-chemistry reactions. While it has long been known that many cell types respond to extracellular exposure to muropeptides, it is unclear how these innate immune activators access their cytosolic innate immune receptors, NOD1 and NOD2. The subcellular trafficking and transport mechanisms by which muropeptides access these cytosolic innate immune receptors are a major gap in our understanding of these critical host responses. The click-chemistry-enabled agonists developed here will be particularly powerful to decipher the underlying cell biology and biochemistry of NOD1 and NOD2 innate immune sensing., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

American Samoa and the Federated States of Micronesia (FSM) are two small Pacific Island nations that have some of the highest noncommunicable disease (NCD) mortality rates in the world. Supported by church leaders to address obesity as an NCD risk factor, American Samoa, and Chuuk and Kosrae States of FSM selected the implementation of healthy beverages as a nutrition intervention through a water- and coconut water-only pledge in church events. The consumption of water and coconut water was tracked. Across 105 church events in the three jurisdictions, the count of water bottles before and after events decreased from 142.8 to 22.3, the number of coconuts before and after events decreased from 19.6 to 1.2, and cups of water before and after events decreased from 52.9 to 7.6. The promotion of healthy beverages in church settings holds promise in the Pacific as a feasible, accessible, and culturally responsive nutrition approach, given limited access to other nutritional alternatives, e.g., fresh fruits and vegetables. Supplemental health promotion messaging to maintain knowledge and attitudes about healthy is recommended for future scaling up.

School nurses have worked tirelessly during the COVID-19 pandemic. At times, the workload has been unsustainable and there were not enough hours in the day for school nurses to complete their duties. In one school district, the high school nurse and instructional technology specialist collaborated on improving the process of collecting COVID-19 information. This resulted in dramatically reducing the amount of time it took to process information and improved the way the data were collected and shared. This article describes the steps in pandemic-related data collection and communication used before and after implementation of the improved tools and processes. The authors also provide forms, email templates, and the resulting district COVID-19 metric figures helpful to school nurses desiring to replicate the process.

Objectives: Age-associated accelerated declines in physical health vary across individuals, and researchers have suggested that individual differences in decline may vary as a function of stressors. The relation of one such stressor, negative social exchanges, to accelerated declines in self-rated health is investigated., Method: Participants are from a 2-year, 5-wave, national, longitudinal study of social relationships among older adults. Growth curve analyses are used to examine the relation of negative and positive social exchanges to accelerated changes in self-rated health, controlling for age, sex, race/ethnicity, education, and depressive symptoms., Results: Individuals reporting more frequent negative social exchanges showed significantly accelerated declines in physical health. Positive social exchanges were not related to linear or accelerated declines in self-rated health over time., Discussion: The association between negative social exchanges and accelerated deterioration in self-rated health provides general support for hypotheses that interpersonal stressors play an important role age-related physical health decline.

The field of medicine, despite its prominent influence in society, has invested little to promote healthy lifestyle choices. The consequence of this is reflected in our ever-rising chronic disease statistics, most notably obesity and diabetes rates. This is especially regrettable considering overwhelming evidence confirms most non-communicable disease is preventable by modifying our diets. In light of this critical knowledge that optimizing our nutrition could save innumerable lives, one would naturally assume physicians would be readily practicing its promotion with their patients. Yet, that is far from true. By no fault of their own. Medical schools, entrusted with the responsibility of educating our future healthcare leaders, have managed to largely bypass the topic of nutrition, arguably the most powerful healthcare intervention known to mankind. In fact, on average, medical schools offer an anemic number of hours of nutrition education over 4 years. 1 What little is offered is focused on biochemistry and nutrient deficiencies, none of which prepares a physician in training for meaningful application in clinical care. This lapse in nutrition education continues throughout post-graduate training; in a recent survey of more than 600 cardiologists, 90% reported they had not received needed nutrition education during training. 2 Although we agree that not all physicians must be experts in nutrition, in the very least all should have knowledge of rudimentary and essential facts. We offer this commentary on six vital clinical topics, to increase awareness amongst physicians as to the importance of diet and its role in human health., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2022 The Author(s).)

Background: Growing use of social media has led to the emergence of virtual controlled substance and illicit drug marketplaces, prompting calls for action by government and law enforcement. Previous studies have analyzed Instagram drug selling via posts. However, comments made by users involving potential drug selling have not been analyzed. In this study, we use unsupervised machine learning to detect and classify prescription and illicit drug-related buying and selling interactions on Instagram. Methods: We used over 1,000 drug-related hashtags on Instagram to collect a total of 43,607 Instagram comments between February 1st, 2019 and May 31st, 2019 using data mining approaches in the Python programming language. We then used an unsupervised machine learning approach, the Biterm Topic Model (BTM), to thematically summarize Instagram comments into distinct topic groupings, which were then extracted and manually annotated to detect buying and selling comments. Results: We detected 5,589 comments from sellers, prospective buyers, and online pharmacies from 531 unique posts. The vast majority (99.7%) of comments originated from drug sellers and online pharmacies. Key themes from comments included providing contact information through encrypted third-party messaging platforms, drug availability, and price inquiry. Commonly offered drugs for sale included scheduled controlled substances such as Adderall and Xanax, as well as illicit hallucinogens and stimulants. Comments from prospective buyers of drugs most commonly included inquiries about price and availability. Conclusions: We detected prescription controlled substances and other illicit drug selling interactions via Instagram comments to posts. We observed that comments were primarily used by sellers offering drugs, and typically not by prospective buyers interacting with sellers. Further research is needed to characterize these "social" drug marketplace interactions on this and other popular social media platforms.

Background: Total wrist arthroplasty (TWA) is a treatment option for many debilitating wrist conditions. With recent improvements in implant design, indications for TWA have broadened. However, despite these improvements, there are still complications associated with TWA, such as unplanned reoperation and eventual implant removal. The goal of this study was to identify risk factors for an unplanned reoperation or implant revision after a TWA at 2 academic medical centers between 2002 and 2015. Methods: In this retrospective study, 24 consecutive TWAs were identified using CPT codes. Medical records were manually reviewed to identify demographic, patient- or disease-related, and surgery-related risk factors for reoperation and implant removal after a primary TWA. Results: Forty-six percent of wrists (11 of 24 TWAs performed) had a reoperation after a median of 3.4 years, while 29% (7 of 24) underwent implant revision after a median of 5 years. Two patients had wrist surgery prior to their TWA, both eventually had their implant removed ( P = . 08). There were no risk factors associated with reoperation or implant removal. Conclusion: Unplanned reoperation and implant removal after a primary TWA are common. Approximately 1 in 3 wrists are likely to undergo revision surgery. We found no factors associated with reoperation or implant removal; however, prior wrist surgery showed a trend toward risk of implant removal after TWA.

Background: Antibiotics are commonly prescribed for uncomplicated urinary tract infection (UTI) and acute otitis media (AOM) and may be unnecessary at times. The aim of this study was to evaluate prescribing practices for UTIs and AOM in a rural ambulatory care setting and to identify areas for improvement., Methods: In a single-center, retrospective review conducted at a rural clinic, patients diagnosed with uncomplicated UTI and AOM were included. Patients were identified by International Classification of Diseases, Tenth (ICD-10) codes, and data were collected for visits between January 1, 2017, and December 31, 2017. The primary outcome was to assess adherence of antimicrobial prescribing to current treatment guidelines., Results: Of the 76 patients identified, 28 met inclusion criteria. Of the 28 patients, 75% received an agent recommended first line in the treatment guidelines, and 18 of the 21 received a recommended dose. Only 17% of patients were prescribed an appropriate duration of treatment., Conclusion: Opportunities exist for antimicrobial stewardship interventions for uncomplicated UTIs and AOM. Prescribers are not consistently adhering to guidelines in regard to antibiotic choice, dose, or duration. Additional education and stewardship interventions are crucial considering the increased prevalence of antimicrobial resistance.

Background: There is limited literature on risk stratification of patients with acute forearm compartment syndrome. The primary objective of this study was to identify factors associated with poor outcomes in patients with acute forearm compartment syndrome. Methods: We retrospectively identified 130 patients with acute compartment syndrome of 130 forearms treated with fasciotomies from January 2000 to June 2015 at 2 Level 1 trauma centers. Poor outcome was defined as a composite variable, including: (1) death; (2) limb amputation; (3) persistent neurological deficit; and (4) contracture. Patient- and treatment-related variables were collected. Bivariate analyses were used to screen for variables associated with poor outcome, and explanatory variables with a value of P < .05 were included in our multivariable logistic regression analyses. Results: Of the 130 patients, 43 (33%) with acute forearm compartment syndrome had poor outcomes, including 5 deaths, 5 limb amputations, 21 persistent neurological deficits, and 31 contractures. Multivariable logistic regression analyses showed that elevated serum creatine kinase at presentation ( P < .05) was associated with poor outcomes in patients with acute forearm compartment syndrome. Receiver operating characteristic curve analysis showed that a serum creatine kinase cutoff of 300 U/L yields 92% sensitivity and a serum creatine kinase cutoff of 10 000 U/L yields 95% specificity for poor outcomes in acute forearm compartment syndrome. Conclusions: Elevated creatine kinase levels above 300 U/L are a useful screening test for the highest risk patients with acute forearm compartment syndrome. Levels above 10 000 U/L may play a role in informed consent and counseling regarding expectations.

Background: Intracranial atherosclerotic disease (ICAD) is one of the most challenging stroke etiologies, with frequent recurrences despite optimized medical management. Encephaloduroarteriosynangiosis (EDAS) is an indirect revascularization method that produces extra-cranial collaterals to intracranial vessels. We present the results of a phase-II trial of EDAS in intracranial atherosclerotic disease patients., Aims: To evaluate the feasibility, safety, and preliminary efficacy of EDAS in intracranial atherosclerotic disease patients., Methods: ERSIAS was a prospective objective-performance-criterion trial of EDAS plus intensive medical management (IMM) in intracranial atherosclerotic disease (ICAD) patients failing medical treatment. Primary endpoint was any stroke/death within 30-days post-surgery or stroke in the territory of the qualifying artery beyond 30 days. The primary analysis compared event rates through one year with an objective-performance-criterion based on a 10% reduction from the 20% rate in the intensive medical management arm of the stenting versus aggressive medical management for preventing recurrent stroke in intracranial stenosis trial (SAMMPRIS) in patients with poor collaterals. Event rates through two years were compared with propensity-score-matched (PSM) medically treated patients from SAMMPRIS and the carotid occlusion surgery study (COSS)., Results: During a median follow-up of 24.5 months, 5 (9.6%) of 52 patients had a primary endpoint event. The primary endpoint rate at one year met the threshold for nonfutility and advancement to phase III (<10%). In the sensitivity analysis, primary endpoint event rate at two years was lower than in PSM controls, 9.6% versus 21.2% (p < 0.07). Overall, 86% of EDAS-plus-intensive medical management patients were functionally independent at last follow-up and 89% demonstrated neovascularization. There were two (3.8%) surgical complications and no intracranial hemorrhages., Conclusion: ERSIAS phase II provides evidence of safety and strong signals of efficacy of EDAS-plus-intensive medical management, supporting advancement to a seamless phase-IIb/III trial., Clinical Trial Registration: URL: https://www.clinicaltrials.gov.NCT01819597.

Background: Midfoot arthrodesis has long been successfully included in the treatment paradigm for a variety of pathologic foot conditions. A concern with midfoot arthrodesis is the rate of nonunion, which historically has been reported between 5% and 10%. Plantar plating has also been noted to be more biomechanically stable when compared to traditional dorsal plating in previous studies. Practical advantages of plantar plating include less dorsal skin irritation and the ability to correct flatfoot deformity from the same medial incision. The purpose of this study is to report the arthrodesis rate, the success of deformity correction, and the complications associated with plantar-based implant placement for arthrodesis of the medial column., Methods: A retrospective review was undertaken of all consecutive patients between 2012 and 2019 that underwent midfoot arthrodesis with plantar-positioned implants. Radiographic outcomes and complications are reported on 62 patients who underwent midfoot arthrodesis as part of a correction for hallux valgus deformity, flatfoot deformity, degenerative arthritis, Lisfranc injury, or Charcot neuroarthropathy correction., Results: Statistically significant improvement was seen in the lateral talus-first metatarsal angle (Meary angle) and medial arch sag angle for patients treated for flatfoot deformity correction. In patients treated for hallux valgus deformity, there was a reduction in the intermetatarsal angle from 15.4 to 6.8 degrees. The overall nonunion rate was 6.45% in all patients. The rate of nonunion was higher at the NC joint compared to the TMT joint and with compression claw plates. One symptomatic nonunion required revision surgery (1.7%). There were no nonunions when excluding neuroarthropathy patients and smokers. The odds ratio (OR) for nonunion in patients with neuroarthropathy was 6.05 ( P < .05), and in active smokers the OR was 2.33 ( P < .05)., Conclusion: Plates placed on the plantar bone surface for midfoot arthrodesis achieved and maintained deformity correction with rare instances of symptomatic hardware for a variety of orthopedic conditions. An overall clinical and radiographic union rate of 94% was achieved. The radiographic union rate improved to 100% when excluding both neuroarthropathy patients and smokers. The incidence of nonunion was higher in smokers, neuroarthropathy patients, naviculocuneiform joint fusions, use of compression claw plates, and when attempting to fuse multiple joints. Incisional healing complications were rarely seen other than in active smokers., Level of Evidence: Level IV, case series., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Jesse Doty, MD, reports personal fees from Arthrex Inc, personal fees from Globus Medical Inc, personal fees from Wright Medical Inc, outside the submitted work. ICMJE forms for all authors are available online., (© The Author(s) 2021.)

Aim: This project used historical hospital data to forecast demand for specialized bariatric beds. Models were evaluated that determined the relationship between the number of bariatric beds owned and service level for patients of size requiring these beds. A calculator was developed for minimizing the equipment costs of meeting demand., Background: Failing to provide enough bariatric beds may negatively affect outcomes for patients of size and healthcare workers, whereas owning more bariatric beds than required to meet demand means unnecessary cost. With rising rates of obesity increasing care costs, minimizing equipment costs is increasingly important., Method: One year of hospital admissions data were used to determine arrival rates and lengths of stay for patients of size. Two subsequent years verified the consistency of these rates. Simulations modeled the flow of patients of size through the hospital and the service level associated with the number of beds owned. A minimization function determined the optimal number of bariatric beds to be provided. A simplified, generalizable model was compared to the simulation., Results: The simplified model produced similar results to more complex simulation. The optimization was robust, or insensitive to small changes in inputs, and identified substantial opportunity for savings if demand for beds was substantially over- or underestimated., Conclusions: The simplified model and cost optimization could be used in many situations to prevent costly errors in equipment planning. However, hospitals should consider customized simulation to estimate demand for high-cost equipment or unique circumstances not fitting the assumptions of these models.

Purpose: The purpose of the study was to evaluate the effectiveness of diabetes self-management education and support (DSMES) among veterans with diabetes using the Healthy Teaching Kitchen (HTK) by means of telehealth communication., Methods: A retrospective chart review collected data from veterans with type 2 diabetes (T2DM) that participated in the DSMES-HTK program at 2 Veterans Affairs Northeast Ohio Healthcare System facilities between February 2013 and December 2018. A factorial design was used to compare A1C data and use of clinical video telehealth from main hub to satellite site. Statistical analyses were performed using SPSS (Version 25). Repeated measures analysis of variance (RMANOVA) were performed to compare mean A1C in veterans that attended HTK at the main site versus a telehealth site. RMANOVA was also used to compare mean A1C in veterans that attended at least 1 hands-on class versus those that attended at least 1 demonstration class., Results: A1C values of all groups improved over time and were sustained regardless of DSMES-HTK delivery method or location., Conclusions: Sustained improvement in A1C was observed in patients that participated in both DSMES-HTK in person and via clinical video telehealth classes conducted by hub site facilitator with RDN, CDCES credential. The use of a clinical video telehealth strategy for DSMES-HTK capitalizes on limited, highly skilled, credentialed instructional team members.

There is an increasing focus on reducing inequalities in health outcomes in developing countries. Subnational variation is of particular interest, with geographically-indexed data being used to understand the spatial risk of detrimental outcomes and to identify who is at greatest risk. While some health surveys provide observations with associated geographic coordinates (point data), many others provide data that have their locations masked and instead only report the strata (polygon information) within which the data resides (masked data). How to harmonize these data sources for spatial analysis has been previously considered although only ad hoc methods and comparison of methods is lacking. In this paper, we present a new method for analyzing masked survey data, using a method that is consistent with the data-generating process. In addition, we critique two previously proposed approaches to analyzing masked data and illustrate that they are fundamentally flawed methodologically. To validate our method, we compare our approach with previously formulated solutions in several realistic simulation environments in which the underlying structure of the risk field is known. We simulate samples from spatiotemporal fields in a way that mimics the sampling frame implemented in the most common health surveys in low- and middle-income countries, the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. In simulations, the newly proposed approach outperforms previously proposed approaches in terms of minimizing error while increasing the precision of estimates. The approaches are subsequently compared using child mortality data from the Dominican Republic where our findings are reinforced. The ability to accurately increase precision of child mortality estimates, and health outcomes in general, by leveraging various types of data, improves our ability to implement precision public health initiatives and better understand the landscape of geographic health inequalities.

With the introduction of the anterior locking plate in the early part of this century, there was a large change in how distal radial fractures were treated. Early articles about the techniques reported tendon ruptures occurring in as many as 10%, although studies from our unit reported rates closer to 2%. Subsequent refinements in surgical technique and improvements in plate design have been made with the aim of reducing the number of ruptures. Despite this, the original articles and their rates continue to be quoted. In this retrospective study of 798 cases treated with anterior locking plates, tendon ruptures have been significantly reduced and are now as low as 0.5%. Contributing factors leading to this improvement are identified and discussed. Level of evidence: III.

Background: Intensive care unit (ICU) patients are at high risk of anemia, which is associated with adverse clinical outcomes and death. Blood sampling for diagnostic testing is a potentially modifiable contributor to anemia., Methods: We conducted a systematic review by searching MEDLINE and EMBASE from inception to October 5, 2017, for studies reporting the volume of blood taken for laboratory testing using blood sampling conservation devices compared to standard care or another intervention in adult ICU patients., Results: We identified 8 eligible studies (n = 1204 patients) that used 2 types of devices: arterial access devices (n = 5) and reduced-volume blood collection tubes (n = 3). All studies reported a reduction in the volume of blood taken for laboratory testing with devices compared to standard practice (range 19%-80%). The studies were judged to have serious risk of bias, and due to heterogeneity, pooling for meta-analysis was not considered appropriate., Conclusions: Devices used to reduce the volume of blood taken for laboratory testing in ICU patients appear to be effective, although study heterogeneity limited our ability to calculate pooled estimates of efficacy for each device. Further assessment of clinical outcomes may establish clinical benefit with minimal negative consequences for hospitals and laboratories to facilitate the use of small-volume tubes.

Background: The goal of this study is to biomechanically compare Fowler central slip tenotomy with spiral oblique retinacular ligament (SORL) reconstruction in correcting a chronic mallet deformity as part of a swan-neck deformity. Methods: We used 24 human cadaver fingers from 6 hands. Mallet finger and swan-neck deformities were created; then, Fowler tenotomy was done on one group including 3 hands with 12 fingers, and SORL reconstruction was done on the others. Results: During simulated finger extension, there was no significant difference between the 2 techniques in correcting the distal interphalangeal joint droop; however, Fowler tenotomy resulted in hyperflexion of the proximal interphalangeal (PIP) joint, whereas it remained straight after SORL reconstruction. Conclusions: This study supports the SORL reconstruction in correcting a chronic mallet deformity, especially when there is a concomitant PIP hyperextension deformity, which lowers the risk of reversing the deformity after a Fowler procedure.

Previous research suggests that people who feel forgiven by God may experience lower levels of death anxiety. The purpose of the current study is to contribute to this work by assessing whether the relationship between forgiveness by God and death anxiety varies according to how people view God. Three images of God are assessed: a pantheistic view of God, a theistic view of God, and a deistic view of God. Data from nationwide survey that was conducted in 2014 ( N  = 2,650) suggest that the relationship between forgiveness by God and death anxiety is strongest among people with a theistic view of God, significantly weaker among people with a pantheistic view of God, and not significant among individuals with a deistic view of God. The findings point to the importance of taking views of God into account when assessing the relationship between forgiveness by God and death anxiety.

Previous studies indicated that the assumption of logistic form of parametric item response functions (IRFs) is violated often enough to be worth checking. Using nonparametric item response theory (IRT) estimation methods with the posterior predictive model checking method can obtain significance probabilities of fit statistics in a Bayesian framework by accounting for the uncertainty of the parameter estimation and can indicate the location and magnitude of misfit for an item. The purpose of this study is to check the performance of the Bayesian nonparametric method to assess the IRF fit of parametric IRT models for mixed-format tests and compare it with the existing bootstrapping nonparametric method under various conditions. The simulation study results show that the Bayesian nonparametric method can detect misfit items with higher power and lower type I error rates when the sample size is large and with lower type I error rates compared with the bootstrapping method for the conditions with nonmonotonic items. In the real-data study, several dichotomous and polytomous misfit items were identified and the location and magnitude of misfit were indicated., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

The total and indirect effect of hostility on systolic and diastolic blood pressure was compared as a function of religious and spirituality identity in a nationally representative sample of 2971 adults aged 46.44 years. Structural equation modeling uncovered an indirect path from hostility to diastolic blood pressure via unhealthy behaviors and hostility to unhealthy behaviors via social isolation. Compared to a non-religious/non-spiritual reference group, the effect for unhealthy behaviors on diastolic blood pressure was greater for those endorsing some form of religious identity. However, the direction of the effect for hostility on social isolation and social isolation on unhealthy behaviors was reversed in those endorsing spiritual and religious identity.

Advances in minimally invasive tissue resection techniques now allow for the majority of early colorectal neoplasia to be managed endoscopically. To optimize their respective risk-benefit profiles, and, therefore, appropriately select between endoscopic mucosal resection, endoscopic submucosal dissection, and surgery, the endoscopist must accurately predict the risk of submucosal invasive cancer and estimate depth of invasion. Herein, we discuss the evidence and our approach for optical evaluation of large (⩾ 20 mm) colorectal laterally spreading lesions., Competing Interests: Conflict of interest statement: Michael J. Bourke: Research Support: Olympus Medical, Cook Medical, Boston Scientific. The remaining authors have no conflicts of interest to disclose., (© The Author(s), 2020.)

The 2018 Bipartisan Budget Act in the United States extended telehealth access to Medicare beneficiaries who receive home dialysis in which two of three monthly visits in a quarter may be performed by telehealth after three initial face-to-face monthly visits. The originating site (where the patient is located) can be a dialysis unit or the patient's home and without geographic restriction. Patient awareness and interest in this new telehealth benefit in urban patients has not been well characterized. Patients receiving peritoneal dialysis (PD) treatment located in an urban facility completed a survey to ascertain knowledge of telehealth and readiness and willingness to participate in telehealth for their monthly visit. A total of 30 patients participated: 37% who completed the survey had heard of telehealth and 40% were able to define telehealth in words and correctly identify an example of telehealth. None of the patients were aware of the 2018 US Bipartisan Budget Act which extended telehealth assess to Medicare beneficiaries. Almost everyone had a mobile phone (83%), owned a computer (50%), and had access to Internet services (90%). The majority of patients (73%) were willing to use telehealth services for their monthly visit with the physician. PD patients living in an urban setting appear to be ready and interested in using telehealth to perform their monthly visit with the physician.

Matching on an estimated propensity score is frequently used to estimate the effects of treatments from observational data. Since the 1970s, different authors have proposed methods to combine matching at the design stage with regression adjustment at the analysis stage when estimating treatment effects for continuous outcomes. Previous work has consistently shown that the combination has generally superior statistical properties than either method by itself. In biomedical and epidemiological research, survival or time-to-event outcomes are common. We propose a method to combine regression adjustment and propensity score matching to estimate survival curves and hazard ratios based on estimating an imputed potential outcome under control for each successfully matched treated subject, which is accomplished using either an accelerated failure time parametric survival model or a Cox proportional hazard model that is fit to the matched control subjects. That is, a fitted model is then applied to the matched treated subjects to allow simulation of the missing potential outcome under control for each treated subject. Conventional survival analyses (e.g., estimation of survival curves and hazard ratios) can then be conducted using the observed outcome under treatment and the imputed outcome under control. We evaluated the repeated-sampling bias of the proposed methods using simulations. When using nearest neighbor matching, the proposed method resulted in decreased bias compared to crude analyses in the matched sample. We illustrate the method in an example prescribing beta-blockers at hospital discharge to patients hospitalized with heart failure.

Background . Getting a sufficient amount of sleep is an important component of living a healthy lifestyle. Consequently, it is important for researchers to identify the factors that influence sleep duration. Aims. The current study has a twofold objective. The first is to see if two types of social support are associated with sleep duration. The second objective is to see if meaning in life and depressive symptoms serve as indirect pathways in the relationship between social support and sleep. Method. The data come from an internet survey of a random probability sample of adults who reside in the United States ( N = 2,287). Questions were administered on received support, satisfaction with support, meaning in life, depressive symptoms, and sleep. Results. The findings indicate that the amount of support that is received is associated with satisfaction with support, greater satisfaction with support is associated with a stronger sense of meaning in life, a stronger sense of meaning is related to fewer depressive symptoms, and fewer depressive symptoms is significantly associated with the likelihood of getting the recommended number of hours of sleep. Discussion and Conclusions. Instead of merely showing that social support is associated with sleep, our findings take a modest step toward explaining how this relationship arises (i.e., through an increased sense of meaning in life and, in turn, reduced depressive symptoms). This theoretical specificity is helpful for devising interventions to improve sleep habits.

Background: Although many techniques have been described, there is no clear optimal surgical treatment for chronic scapholunate interosseous ligament (SLIL) disruption. Methods: We identified 255 articles reporting outcomes of SLIL reconstruction. Of these, 40 studies (978 wrists) met eligibility requirements and reported sufficient data on radiographic outcomes to be included in the study. The mean and standard deviation of preoperative and follow-up assessments including scapholunate gap (SLG) and scapholunate angle (SLA) were used to calculate pooled standardized mean differences (SMD) with 95% confidence intervals (CIs). For other radiographic or clinical outcomes, there were not enough reported data to calculate a pooled effect size, and pooled nonstandardized comparisons were made. Results: The SMD between preoperative and postoperative SLA in tenodesis reconstruction was 0.7 (CI, 0.29 to 1.11, P = .001) and 0.04 (CI, -0.27 to 0.38, P = .8) for capsulodesis reconstruction. For SLG, tenodesis demonstrated an SMD of 1.1 (CI, 0.6 to 1.55, P < .001) compared with 0.1 (CI, -0.36 to 0.59, P = .6) for capsulodesis reconstruction. Tenodesis had a significant improvement compared with capsulodesis in SLA ( P = .01) and SLG ( P = .005). Tenodesis also showed improvement in grip strength and Disabilities of the Arm, Shoulder and Hand scores. Conclusions: Comparing preoperative and postoperative radiographic measurements, tenodesis reconstruction demonstrated significantly improved SLG and SLA relative to capsulodesis. Interpreted in the context of the limitations, existing data demonstrates some benefit of tenodesis reconstruction.

Rationale: Despite guidelines advising passive rewarming for mild accidental hypothermia (AH), patients are frequently admitted to intensive care unit (ICU) for active rewarming using a forced-air warming device. We implemented a new policy at our institution aimed at safely reducing ICU admissions for AH. We analyzed our practice pre- and post-policy intervention and compared our experiences with acute care hospitals in Connecticut., Methods: A retrospective chart review was performed on 203 participants with AH identified by primary and secondary discharge codes. Our new policy recommended passive rewarming on the medical floors for mild hypothermia (>32°C) and ICU admission for moderate hypothermia (<32°C). Practices of other Connecticut hospitals were obtained by surveying ICU nurse managers and medical directors., Results: Over a 3-year period, prior to rewarming policy change, 64% (n = 92) of patients with AH were admitted to ICU, with a mean ICU length of stay (LOS [SD]) of 2.75 (2.2) days. After the policy change, over a 3-year period, 15% (n = 9) were admitted to ICU ( P < .001), with an ICU LOS of 2.11 (0.9) days ( P = 0.005). In both groups with AH, altered mental status, infection, and acute alcohol intoxication were the most common diagnoses at presentation. Alcohol intoxication was more prevalent in the post-policy intervention group, pre 17% versus post 46% ( P < .001). No complications such as dermal burns or cardiac arrhythmias were noted with forced-air warming device use during either time period. Among the 29 hospitals surveyed, 20 used active rewarming in ICU or intermediate care units and 9 cared for patients on telemetry units. Most hospitals used active external rewarming for core body temperature of <35°C; however, 37% of hospitals performed active rewarming at temperatures >35°Cor lacked a policy., Conclusions: Reserving forced-air warming devices for the treatment of moderate-to-severe hypothermia (<32°C) significantly reduced ICU admissions for AH.

Bacterial infection is a leading cause of morbidity and mortality (from infants to the elderly) and accounts for more than $20 billion in healthcare costs in the United States each year. The pathogens responsible for many of the common infectious diseases, such as urinary tract infection (UTI) and ventilator-associated infections (VAIs), have proven to be highly adept in acquiring mechanisms of antimicrobial resistance. The use of broad-spectrum antibiotics by healthcare providers and the infiltration of antibiotics in the environment have accelerated the selection and growth of resistant pathogens. To further exacerbate the problem, the need for new antibiotics has far outpaced the development of new classes of antibiotics by the pharmaceutical industry (only two new classes of antibiotics have reached the market in the last 20 years), in large part due to prohibitive cost and historically poor return on investment to develop new antibiotics. Consequently, clinicians have limited treatment options, particularly in the neediest patients. To tackle this major global health issue, we are developing novel technological approaches for rapid definitive clinical microbiological analysis. These technologies will improve the clinical management of bacterial infections and reduce the improper use of antibiotics in current practice, hopefully limiting the spread of drug-resistant organisms.

Background: The purpose of this study was to identify factors associated with unplanned reoperation after surgery for scapholunate interosseous ligament (SLIL) insufficiency. Methods: Using Current Procedural Terminology (CPT) codes from 3 hand surgery centers across 2 metropolitan areas, we identified 316 patients undergoing surgery for SLIL insufficiency from 2000 to 2014. Medical records were manually reviewed to collect data on factors that might be associated with unplanned reoperation, including age, sex, tobacco use, occupation, acuity of treatment, and reconstruction method. Results: Thirty-eight patients (12%) had an unplanned reoperation; most of them (65%) were a secondary reconstruction or salvage procedure (eg, 6 proximal row carpectomies, 9 revision reconstruction, and 10 partial carpal arthrodeses), while 5 (13%) were for unplanned screw removal. The median time between the index and second surgery was 16 months (range, 2-97 months). The type of index procedure was not associated with reoperation. The only factor associated with reoperation was cigarette smoking, and this association persisted when looking specifically at reoperations for revision or salvage. Conclusions: Patients should be counseled that smoking is associated with reoperation after SLIL surgery. Smoking cessation or decreasing nicotine usage may be beneficial prior to surgery. With the numbers available, there was no association between surgical technique and reoperation.

Background: Both cruciate retaining (CR) and posterior stabilized (PS) implants are commonly used for primary total knee arthroplasty. There is evidence to support improved range of motion in PS knee replacements, but there is no evidence showing functional superiority. The aim of this study was to compare functional outcomes between CR and PS knee replacements., Patient and Methods: Prospectively collected regional joint registry data were used to compare preoperative and postoperative one, 5- and 10-year Oxford and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in 1287 primary total knee replacements. Differences in functional scores between CR and PS knees were calculated., Results: The PS group had better functional scores than the CR group at baseline (mean Oxford score 15.59 vs. 14.52 ( p = 0.026) and mean WOMAC score 59.51 vs. 62.35 ( p = 0.012)), at 1 year postoperatively (mean Oxford score 37.94 vs. 36.63 ( p = 0.015) and mean WOMAC score 16.20 vs. 19.73 ( p = 0.001)) with a similar trend at 5 years postoperatively (mean Oxford score 39.66 vs. 38.50 ( p = 0.054) and mean WOMAC score 16.89 vs. 18.83 ( p = 0.131)). There was no difference in the overall functional improvement between the PS and CR groups at 1, 5, or 10 years. WOMAC subcomponent scores showed greater improvement in stiffness; 3.76 versus 3.36 ( p = 0.012) in PS knees at 1 year postoperatively. No significant differences were observed at 5 or 10 years., Conclusions: PS knee replacements showed greater improvement in stiffness at 1 year postoperatively. There was no difference observed at 5 or 10 years postoperatively. PS knees had better functional outcomes at 1 year with a similar trend at 5 years postoperatively., Level of Evidence: III.

Background: Return to play and player satisfaction have been quite high after ulnar collateral ligament reconstruction (UCLR); however, there has been little reported on how outcomes are affected by surgical technique, graft type, and tear characteristics., Purpose: To evaluate surgical techniques, graft type, and tear characteristics on Major League Baseball (MLB) performance after UCLR., Study Design: Cohort study; Level of evidence, 2., Methods: MLB pitchers who underwent primary UCLR at a single institution were included. Tear characteristics included tear location, tear grade, and acuity. Surgical technique and graft type were also collected. Pitching performance statistics, including earned run average (ERA), walks and hits per innings pitched (WHIP), innings pitched, and fastball velocity were evaluated 3 years before and after UCLR., Results: Forty-six MLB pitchers were identified as having primary UCLR. Return to play was 96%, with 82% returning to MLB play. Technique performed showed no difference in performance. As compared with pitchers with gracilis grafts, pitchers with palmaris grafts were younger ( P = .043), played longer after surgery ( P = .012), and returned to play at 100% (35 of 35) versus 82% (9 of 11, P = .010). When compared with pitchers with proximal tears, pitchers with distal tears pitched at higher velocity (93.0 vs 90.6 mph, P = .023) and had better performance before surgery (ERA, P = .003; WHIP, P = .021); however, those with proximal tears improved to match this performance and velocity after reconstruction. As compared with those having partial tears, pitchers with complete tears played longer after surgery (5.9 vs 4.0 years, P = .033), had a better ERA before injury ( P = .041), and had better WHIP ( P = .037) and strikeouts per 9 innings ( P = .025) after reconstruction. Pitchers with chronic tears had a significant improvement in postoperative ERA, from 4.49 to 3.80 ( P = .040)., Conclusion: Technique performed and graft type used did not affect performance; however, pitchers with palmaris grafts returned at a higher rate than those with gracilis grafts. Distal tears occurred in pitchers with greater velocity and better performance before injury, yet pitchers with proximal tears matched this performance after reconstruction. Pitchers with complete tears played longer after reconstruction. Pitchers who had partial tears had worse performance before injury and after reconstruction, and those with chronic tears saw a significant improvement in ERA with reconstruction.

Background: In-center hemodialysis (HD) has been the standard treatment for older dialysis patients, but reports suggest an associated decline in physical and cognitive function. Cross-sectional data suggest that assisted peritoneal dialysis (aPD), an alternative treatment, is associated with quality of life (QoL) outcomes that are comparable to in-center HD. We compared longitudinal changes in QoL between modalities., Methods: We enrolled 106 aPD patients, matched with 100 HD patients from 20 renal centers in England and Northern Ireland. Patients were assessed quarterly for 2 years using the Hospital Anxiety and Depression Scale (HADS), SF-12 physical and mental scores, symptom score, Illness Intrusiveness Rating Scale (IIRS), Barthel's score, and the Renal Treatment Satisfaction Questionnaire (RTSQ). Mixed model analysis was used to assess the impact of dialysis modality on these outcomes during follow-up. P values were adjusted for multiple significance testing., Results: Multivariate analysis showed no difference in any of the outcome measures between aPD and HD. Longitudinal trends in outcomes were also not significantly different. Higher age at baseline was associated with lower IIRS and RTSQ scores during follow-up. One-hundred and twenty-five (60.6%) patients dropped out of the study: 59 (28.6%) died, 61 (29.6%) withdrew during follow-up, and 5 (2.5%) were transplanted., Conclusions: Quality of life outcomes in frail older aPD patients were equivalent to those receiving in-center HD. Assisted PD is thus a valid alternative to HD for older people with end-stage kidney disease (ESKD) wishing to dialyze at home., (Copyright © 2019 International Society for Peritoneal Dialysis.)

Background: Amplifying endogenous neuroprotective mechanisms is a promising avenue for stroke therapy. One target is mammalian target of rapamycin (mTOR), a serine/threonine kinase regulating cell proliferation, cell survival, protein synthesis, and autophagy. Animal studies investigating the effect of rapamycin on mTOR inhibition following cerebral ischemia have shown conflicting results., Aim: To conduct a systematic review and meta-analysis evaluating the effectiveness of rapamycin in reducing infarct volume in animal models of ischemic stroke., Summary of Review: Our search identified 328 publications. Seventeen publications met inclusion criteria (52 comparisons: 30 reported infarct size and 22 reported neurobehavioral score). Study quality was modest (median 4 of 9) with no evidence of publication bias. The point estimate for the effect of rapamycin was a 21.6% (95% CI, 7.6%-35.7% p < 0.01) improvement in infarct volume and 30.5% (95% CI 17.2%-43.8%, p < 0.0001) improvement in neuroscores. Effect sizes were greatest in studies using lower doses of rapamycin., Conclusion: Low-dose rapamycin treatment may be an effective therapeutic option for stroke. Modest study quality means there is a potential risk of bias. We recommend further high-quality preclinical studies on rapamycin in stroke before progressing to clinical trials.

Male lower urinary tract symptoms (LUTS) is an increasingly important problem for the majority of late middle aged and elderly men. Fexapotide triflutate (FT) is a first in-class compound given by local injection via the transrectal intraprostatic route under ultrasound guidance. Data from >1700 FT and control injections in prospective randomized blinded controlled multicenter trials are reviewed and discussed in relation to current developments in the field of treatments for LUTS associated with benign prostatic hyperplasia (BPH). Long-term studies of FT in the United States have shown statistically significant improvement in BPH symptoms and objective outcomes including significant reduction in both spontaneous acute urinary retention as well as the subsequent incidence of BPH surgery. FT has been shown to be well tolerated with an excellent safety profile, and is an efficacious clinic-based treatment for BPH involving an intraprostatic injection that requires only a few minutes to administer, with no catheter nor anesthesia requirements., Competing Interests: Conflict of interest statement: Authors Shore and Tutrone are consultants/speakers for NeoTract. Author Shore is a consultant for NxThera. Authors Shore, Tutrone and Roehrborn are consultants for Nymox. Author Tutrone owns stock in Nymox. Author Roehrborn has a financial interest or other relationship with NxThera, NeoTract, Procept, ZenFlow and Meditate.

The hierarchical item response theory (H-IRT) model is very flexible and allows a general factor and subfactors within an overall structure of two or more levels. When an H-IRT model with a large number of dimensions is used for an adaptive test, the computational burden associated with interim scoring and selection of subsequent items is heavy. An alternative approach for any high-dimension adaptive test is to reduce dimensionality for interim scoring and item selection and then revert to full dimensionality for final score reporting, thereby significantly reducing the computational burden. This study compared the accuracy and efficiency of final scoring for multidimensional, local multidimensional, and unidimensional item selection and interim scoring methods, using both simulated and real item pools. The simulation study was conducted under 10 conditions (i.e., five test lengths and two H-IRT models) with a simulated sample of 10,000 students. The study with the real item pool was conducted using item parameters from an actual 45-item adaptive test with a simulated sample of 10,000 students. Results indicate that the theta estimations provided by the local multidimensional and unidimensional item selection and interim scoring methods were relatively as accurate as the theta estimation provided by the multidimensional item selection and interim scoring method, especially during the real item pool study. In addition, the multidimensional method required the longest computation time and the unidimensional method required the shortest computation time., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Social and economic factors have been shown to affect health outcomes. In particular, social determinants of health (SDH) are linked to poor health outcomes in children. Research and some professional academies support routine social needs screening during primary care visits. Translating this recommendation into practice remains challenging due to the resources required and dearth of evidence-based research to guide health center level implementation. We describe our experience implementing a novel social needs screening program at an academic pediatric clinic. Methods: The Community Linkage to Care (CLC) pilot program integrates social needs screening and referral support using community health workers (CHWs) as part of routine primary care visits. Our multidisciplinary team performed process mapping, developed workflows, and led ongoing performance improvement activities. We established key elements of the CLC program through an iterative process We conducted social needs screens at 65% of eligible well-child visits from May 2017 to April 2018; 19.7% of screens had one or more positive responses. Childcare (48.8%), housing quality and/or availability (39.9%), and food insecurity (22.8%) were the most frequently reported needs. On average, 76% of providers had their patients screened on more than half of eligible well-child visits. Discussion: Our experience suggests that screening for social needs at well-child visits is feasible as part of routine primary care. We attribute progress to leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.

Objectives: To assemble an algorithm that will describe a "Signature" predictive of an individual's vulnerability to persistent traumatic brain injury (TBI)., Subjects and Methods: Studies of athletes and warriors who are subjected to repeated head impacts with rapid acceleration/deceleration forces are used to assist in the diagnosis and management of TBI-affected individuals. Data from multiple areas, including clinical, anatomical, magnetic resonance imaging, cognitive function, and biochemical analyses, are integrated to provide a Signature of persistent TBI., Results: Studies to date indicate that susceptibility to TBI results from an interaction between host genetic and structural vulnerability factors and force and torque of impact on the head and torso. The host factors include molecular markers affecting immune and inflammatory responses to stress/insult as well as anatomical features such as the degree of transcortical fiber projections and vascular malformations. The host response to forceful impact includes the release of intracellular neural proteins and nucleic acids into the cerebrospinal fluid and vascular compartment as well as mobilization of cytokines and macrophages into the central nervous system with subsequent activation of microglia and inflammatory responses including autoimmune processes. Maximum impact to the base of the sulci via a "water hammer effect" is consistent with the localization of microvascular and inflammatory responses in the affected brain region., Conclusions: An assessment of an individuals' predisposition to persistent TBI with delayed cognitive deficits and behavioral changes requires an understanding of host vulnerability (genetic factors and brain structure) and external stressors (force and torque of impact as well as repetitive head injury and time interval between impacts). An algorithm that has utility in predicting vulnerability to TBI will include qualitative and quantitative measures of the host factors weighted against post impact markers of neural injury. Implementation of the resulting "Signature" of vulnerability at early stages of injury will help inform athletes and warriors, along with commanders and management, of the risk/benefit approaches that will markedly diminish health care costs to the nation and suffering to this population. This report attempts to define a strategy to create such an algorithm., Competing Interests: Declaration of Conflicting Interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: It remains unclear how many patients undergo secondary surgery after initial arthroscopy for trapeziometacarpal (TMC) arthrosis. We studied the factors related to secondary TMC arthroplasty after TMC arthroscopy. We also examined secondary questions of: (1) what percentage of patients underwent secondary TMC arthroplasty; and (2) how much time elapsed from initial arthroscopy to arthroplasty., Methods: In this retrospective study, we included all adult patients who were treated with arthroscopy of the TMC joint at 2 level I hospitals and affiliates. Factors were assessed for their independent association with secondary TMC arthroplasty using bivariate and multivariable analyses., Results: Fourteen of 84 (17%) thumbs underwent secondary TMC arthroplasty an average of 11 months after the initial arthroscopy. Synovectomy alone and smoking tobacco were independently associated with secondary TMC arthroplasty when compared with arthroscopic (partial) trapeziectomy with additional tendon interposition or allograft., Conclusions: This study demonstrated that 1 in 6 thumbs underwent secondary TMC arthroplasty, an average of 11 months after the initial arthroscopy. Coupling arthroscopy with partial trapeziectomy, interposition, or extension osteotomy may be a preferable strategy to isolated synovectomy. In addition, smoking tobacco is associated with inferior outcomes regardless of surgical procedure.