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Objective: Determine the prevalence of lateral epicondylosis (LE) of the dominant elbow in manual wheelchair users based on ultrasound assessment and physical exam. Design: Prospective, cross-sectional. Setting: National Veteran Wheelchair Games 2018 and 2019 (event medical services). Participants: Manual wheelchair users who attended the National Veteran Wheelchair Games (n = 87). Interventions: Participants completed a questionnaire then underwent an ultrasound assessment and a physical exam of their dominant arm evaluating for common extensor tendinopathy (CET) or clinically LE. Main Outcome Measure: Prevalence of CET diagnosed by ultrasound criteria was compared with other diagnostic criteria with MaNemar test for paired binary data. Results: Forty-six percent (N = 40) of participants met diagnostic criteria for CET by ultrasound assessment and 17% (N = 15) of participants met criteria for LE based on physical exam. These values are dramatically higher than what has been reported in the able-bodied population where the prevalence is estimated to be

The goal of this study is to understand and mitigate the effects of wounds on acute radiation syndrome (ARS) and delayed effects of acute radiation exposure (DEARE), for preparedness against a radiological attack or accident. Combined injuries from concomitant trauma and radiation are likely in these scenarios. Either exacerbation or mitigation of radiation damage by wound trauma has been previously reported in preclinical studies. Female WAG/RijCmcr rats received 13 Gy X-rays, with partial-body shielding of one leg. Within 2 h, irradiated rats and non-irradiated controls were given full-thickness skin wounds with or without lisinopril, started orally 7 days after irradiation. Morbidity, skin wound area, breathing interval and blood urea nitrogen were measured up to 160 days post-irradiation to independently evaluate wound trauma and DEARE. Wounding exacerbated morbidity in irradiated rats between 5 and 14 days post-irradiation (during the ARS phase), and irradiation delayed wound healing. Wounding did not alter delayed morbidities from radiation pneumonitis or nephropathy after 30 days post-irradiation. Lisinopril did not mitigate wound healing, but markedly decreased morbidity during DEARE from 31 through 160 days. The results derived from this unique model of combined injuries suggest different molecular mechanisms of injury and healing of ARS and DEARE after radiation exposure.

Statisticians often face a dilemma, namely how to decide between choosing a parametric versus a nonparametric statistical model. Parametric statistical models can be asymptotically efficient if the model assumptions hold but biased under model misspecification. Nonparametric models, on the other hand, are often asymptotically unbiased but likely to be less efficient than parametric models if the parametric model is correctly specified. In this work, we propose a new estimator, which combines parametric and nonparametric estimators into a single estimating procedure. In contrast to previously suggested combined estimators, the new estimator ensures that it is asymptotically equivalent to the efficient parametric estimator if parametric assumptions hold. If the assumptions are violated, the combined estimator converges to the nonparametric estimator. The new combined estimator is illustrated with quantile regressions which estimate individualized prediction intervals. Through simulation studies, we explored the MSE of the proposed and competing estimators when data came from parametric distributions and, alternatively, when parametric assumptions were violated. The development of this approach was motivated by the real-data problem of predicting realistic hemoglobin A1C ranges in type 2 diabetes (T2DM) patients. A cross-validation confirmed that the proposed estimator shows better or similar prediction properties in comparison with several competing approaches.

Background: Cardiac rehabilitation (CR) is recommended in clinical practice guidelines, but dose prescribed varies highly by country. This study characterized the dose offered in supervised CR programs and alternative models worldwide and their potential correlates. Methods and Results: In this cross-sectional study, an online survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Countries were classified based on region and income categories. Dose was operationalized as program duration×sessions per week. Generalized linear mixed models were performed to assess correlates. Of 203 countries in the world, 111 (54.7%) offered CR; data were collected in 93 (83.8% country response rate; n=1082 surveys, 32.1% program response rate). Globally, supervised CR programs were a median of 24 sessions (n=619, 57.3% programs ≥12 sessions); home-based and community-based programs offered 6 and 20 sessions, respectively. There was significant variation in supervised CR dose by region ( P ≤0.001), with the Americas (median, 36 sessions) offering a significantly greater dose than several other regions; there was also a trend for variation by country income classification. There was no difference in home-based dose by region ( P =0.43) but there was for community-based programs ( P P =0.002 and P P =0.026), proximity to other programs ( P =0.002), and accepting patients with noncardiac indications ( P =0.037). Conclusions: CR programs in many countries may need to increase their dose, which could be supported through physician champions.

BACKGROUND Corpora amylacea (CAM), in benign prostatic acini, contain acute-phase proteins. Do CAM coincide with carcinoma? METHODS Within 270 biopsies, 83 prostatectomies, and 33 transurethral resections (TURs), CAM absence was designated CAM 0; corpora in less than 5% of benign acini: CAM 1; in 5% to 25%: CAM 2; in more than 25%: CAM 3. CAM were compared against carcinoma presence, clinicopathologic findings, and grade groups (GG) 1 to 2 vs 3 to 5. The frequency of CAM according to anatomic zone was counted. A pilot study was conducted using paired initial benign and repeat biopsies (33 benign, 24 carcinoma). RESULTS A total of 68.9% of biopsies, 96.4% of prostatectomies, and 66.7% of TURs disclosed CAM. CAM ≥1 was common at an older age (P = .019). In biopsies, 204 cases (75%) had carcinoma; and CAM of 2 to 3 (compared to 0-1) were recorded in 25.0% of carcinomas but only 7.4% of benign biopsies (P = .005; odds ratio [OR] = 5.1). CAM correlated with high percent Gleason pattern 3, low GG (P = .035), and chronic inflammation (CI). CI correlated inversely with carcinoma (P = .003). CAM disclosed no association with race, body mass index, serum prostate specific antigen (PSA), acute inflammation (in biopsies), atrophy, or carcinoma volume. With CAM 1, the odds of GG 3 to 5 carcinoma, by comparison to CAM 0, decreased more than 2× (OR = 0.48; P = .032), with CAM 2, more than 3× (OR = 0.33; P = .005), and with CAM 3, almost 3× (OR = 0.39, P = .086). For men aged less than 65, carcinoma predictive model was: Score = (2 × age) + (5 × PSA) - (20 × degree of CAM); using our data, area under the ROC curve was 78.17%. When the transition zone was involved by cancer, it showed more CAM than in cases where it was uninvolved (P = .012); otherwise zonal distributions were similar. In the pilot study, CAM ≥1 predicted carcinoma on repeat biopsy (P

Because of the complexity of hematopoietic cell transplant trial treatments, informed consent forms are often long and difficult to read. We evaluated a 2-column easy-to-read informed consent (ETRIC) form that incorporates elements of health literacy and readability in participants and centers participating in Blood and Marrow Transplant Clinical Trials Network (BMT CTN) clinical trials. In a randomized study 198 adult patients from 25 centers potentially eligible to participate in 4 BMT CTN interventional trials were randomized to the ETRIC form or a standard consent form for that trial. Both forms were written at no more than an eighth-grade reading level. The primary endpoint was objective comprehension score on the Quality of Informed Consent, part A (QuIC-A) instrument. In a parallel evaluation study, 2 moderators conducted semistructured interviews of 49 investigators, research staff, and institutional review board (IRB) members at 9 BMT CTN trial sites. The mean QuIC-A scores were comparable in 152 patients (77%) assessable for the primary endpoint (ETRIC form, 80.5; standard form, 81.8; P = .37). In regression analysis there was no significant association between the consent type and QuIC-A score. In the evaluation study dominant themes identified on qualitative analyses included general comfort and willingness to use the ETRIC template and that its formatting and layout enhancements would offer additional value to research participants, investigators, and IRBs. IRB language preferences and requirements, length, and prior experience with alternative consent formats were perceived as barriers. Among patients considering participation in BMT CTN clinical trials, the formatting enhancements of the ETRIC form did not alter comprehension of the trial. Despite local challenges to implementation, trial sites generally viewed the ETRIC form favorably and expressed willingness to use it over standard consent form.

Study Design Prospective. Objectives The purpose of this study was to compare gait among patients with scoliosis undergoing posterior spinal fusion and instrumentation (PSFI) to typically developing subjects and determine if the location of the lowest instrumented vertebra impacted results. Summary of Background Data PSFI is the standard of care for correcting spine deformities, allowing the preservation of body equilibrium while maintaining as many mobile spinal segments as possible. The effect of surgery on joint motion distal to the spine must also be considered. Very few studies have addressed the effect of PSFI on activities such as walking and even fewer address how surgical choice of the lowest instrumented vertebra (LIV) influences possible motion reduction. Methods Individuals with scoliosis undergoing PSFI (n = 38) completed gait analysis preoperatively and at postoperative years 1 and 2 along with a control group (n = 24). Comparisons were made with the control group at each time point and between patients fused at L2 and above (L2+) versus L3 and below (L3–). Results The kinematic results of the AIS group showed some differences when compared to the Control Group, most notably decreased range of motion (ROM) in pelvic tilt and trunk lateral bending. When comparing the LIV groups, only minor differences were observed, and the results showed decreased coronal trunk and pelvis ROM at the one-year visit and decreased hip rotation ROM at the two-year visit in the L3– group. Conclusions Patients with AIS showed decreased ROM preoperatively with further decreases postoperatively. These changes remained relatively consistent following the two-year visit, indicating that most kinematic changes occurred in the first year following surgery. Limited functional differences between the two LIV groups may be due to the lack of full ROM used during normal gait, and future work could address tasks that use greater ROM. Level of Evidence Level II.

Context: Patellofemoral pain (PFP) is a common injury that interferes with quality of life and physical activity. Clinical subgroups of patients may exist, one of which is caused by proximal muscle dysfunction. Objectives: To develop clinical prediction rules that predict a positive outcome after either a hip and core- or knee-focused strengthening program for individuals with PFP. Design: Secondary analysis of data from a randomized control trial. Setting: Four university laboratories. Patients or Other Participants: A total of 199 participants with PFP. Intervention(s): Participants were randomly allocated to either a hip and core-focused (n = 111) or knee-focused (n = 88) rehabilitation group for a 6-week program. Main Outcome Measure(s): Demographics, self-reported knee pain (visual analog scale) and function (Anterior Knee Pain Scale), hip strength, abdominal muscle endurance, and hip range of motion were evaluated at baseline. Treatment success was defined as a decrease in visual analog scale score by ≥2 cm or an increase in the Anterior Knee Pain Scale score by ≥8 points or both. Bivariate relationships between the outcome (treatment success) and the predictor variables were explored, followed by a forward stepwise logistic regression to predict a successful outcome. Results: Patients with more pain, better function, greater lateral core endurance, and less anterior core endurance were more likely to have a successful outcome after hip and core strengthening (88% sensitivity and 54% specificity). Patients with lower weight, weaker hip internal rotation, stronger hip extension, and greater trunk-extension endurance were more likely to have success after knee strengthening (82% sensitivity and 58% specificity). Conclusion: The patients with PFP who have more baseline pain and yet maintain a high level of function may experience additional benefit from hip and core strengthening. The clinical prediction rules from this study remain in the developmental phase and should be applied with caution until externally validated.

BACKGROUND Gallbladder cancer (GBC) is a lethal disease with high incidence among Hispanics. Overall survival (OS) among races/ethnicities has not been described using the most recent National Cancer Database. This study hypothesized that prognosis is worse for Hispanics compared to similar non-Hispanic populations. METHODS Patients with GBC were identified from the National Cancer Database and categorized as White, Black, Hispanic, and Other. Descriptive statistics, OS, and Cox regression were examined. RESULTS The study identified 12 952 patients. Median age was 71 years and 68.8% were female. The study characterized 69.8% White, 13.9% Black, 11.0% Hispanic, and 5.4% other patients. A 5-year OS curves differed, with survival highest in Hispanic patients (27% vs 23% Other, 18% White, and 17% Black, P

Acute myeloid leukemia (AML) is an aggressive malignancy of the blood and bone marrow resulting from the accumulation of multiple serially acquired mutations. The mutational complexity of the disease makes AML difficult to treat, contributing to a low 5-year survival rate. A better understanding of how different mutations interact with one another to influence disease characteristics is critical and may result in the development of targeted therapies to improve patient outcome. The most common recurrent somatic mutation in AML affects the gene NPM1 and occurs in 25-30% of patients. This mutation results in the aberrant cytoplasmic localization of the protein and is termed NPM1cA (Falini et al. 2005, Cancer Genome Atlas Research Network 2013). NPM1cA is considered to be a driver of AML, however Npm1 cA/+ mice only develop disease after a long latency (median 18 months), suggesting that other cooperating mutations are required for AML development (Vassiliou et al. 2011). Approximately 50% of patients with an NPM1cA mutation also harbor a mutation in one of four members of the cohesin complex (STAG2, SMC3, SMC1A, and RAD21). Mutations in cohesin genes are mutually exclusive and result in haploinsufficiency of the complex. As cohesin is known to regulate gene expression by facilitating promoter-enhancer interactions and three-dimensional genome organization, we wished to determine how cohesin mutation influences AML biology and gene expression in the presence of NPM1cA. We utilized the inducible Npm1 cAflox/+ and Smc3 flox/+ mouse models to examine this genetic interaction. We and others have shown that cohesin mutations result in enhanced hematopoietic stem and progenitor cell (HSPC) self-renewal (Mazumdar et al. 2015, Viny et al. 2015, Mullenders et al. 2015, Galeev et al. 2016, Fisher et al. 2017). Consistent with this, Npm1 cA/+;Smc3 Δ/+ HSPCs show enhanced self-renewal in vitro over HSPCs harboring either single mutation. Despite a shared role in self-renewal, Npm1 cA/+;Smc3 Δ/+mice developed AML with similar latency as Npm1 cA/+ mice. Interestingly, however, Npm1 cA/+;Smc3 Δ/+ HSPCs exhibited dysregulation of a unique set of genes compared to cells from either single mutant, suggesting that the Npm1 cA;cohesin mutational combination uniquely alters the transcriptional environment. Further, Npm1 cA/+;Smc3 Δ/+ leukemias had a completely unique spectrum of acquired mutations compared to Npm1 cA/+ leukemias, suggesting that the addition of Smc3 haploinsufficiency to Npm1 cA/+alters AML evolution and that different driver mutations result in the accumulation of very different somatic mutations. Among the uniquely upregulated genes in Npm1 cA/+;Smc3 Δ/+ HSPCs is Dock1, a guanine nucleotide exchange factor (GEF) for Rac1/2. As high Dock1 expression has been associated with low overall and disease-free survival in multiple cohorts of AML patients (Lee et al. 2017, Zhang et al. 2019), we hypothesized that Dock1 would be a novel target for the treatment of Npm1cA; cohesin mut leukemias. Consistent with this hypothesis, We found that knockdown of Dock1 resulted in decreased growth and adhesion and increased apoptosis in an Npm1 cA/+;Smc3 Δ/+leukemic line, but not in an Npm1 cAsingle mutant line. Higher Rac activity was also observed in Npm1 cA/+;Smc3 Δ/+ vs. Npm1 cA/+ leukemic lines. We found that DN Rac2 specifically impacted both the growth and apoptosis of an Npm1 cA/+;Smc3 Δ/+line, suggesting that Dock1 functions primarily through Rac2 to regulate survival. Importantly, the Dock1/Rac pathway is specifically targetable in Npm1 cA/+;Smc3 Δ/+ AMLs in vitro and in vivo, as knockdown of Dock1 resulted in prolonged latency in a Npm1 cA/+;Smc3 Δ/+ transplant model and slowed the growth and enhanced apoptosis of an Npm1 cA/+;Smc3 Δ/+, but not an Npm1 cA/+, leukemic line. Further, small molecule inhibitors of Dock and Rac had similar effects. Our results suggest that Dock1/Rac2 represent unique targets for the treatment of patients harboring the NPM1cA;cohesin mutational combination and provide validity to the concept that combinatorial genetics can uncover novel precision oncology targets. Disclosures Vassiliou: Kymab Ltd: Divested equity in a private or publicly-traded company in the past 24 months; STRM.BIO: Consultancy; Astrazeneca: Consultancy.

Degenerative joint disease (DJD) of the ankle is a debilitating chronic disease associated with severe pain and dysfunction resulting in antalgic gait alteration. Little information is available about segmental foot and ankle motion distribution during gait in ankle osteoarthritis. The aim of the current study was to dynamically characterize segmental foot and ankle kinematics of patients with severe ankle arthrosis requiring total ankle replacement. This was a prospective study involving 36 (19 M, 17 F) adult patients with a clinical diagnosis of ankle arthrosis ("DJD" group) and 36 (23 M, 13 F) healthy subjects ("Control" group). Motion data were collected at 120 Hz using a 3-D motion camera system at self-selected speed along a 6-m walkway and processed using the Milwaukee Foot Model (MFM). The SF-36 Health Survey and Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale were administered to evaluate functional levels. Findings include decreases in walking speed, cadence, stride length and swing phase, and reduced outcomes scores (SF-36 and AOFAS). Multisegemental motion in patients with ankle DJD demonstrates significant changes in foot mechanics characterized by altered segment kinematics and significant reduction in dynamic ROM at the tibia, hindfoot, forefoot, and hallux when compared to controls. The results demonstrate decreased temporal-spatial parameters and low outcomes scores indicative of functional limitations. Statement of clinical significance: Altered segment kinematics and reduced overall range of motion demonstrate how a single joint pathology affects kinematic distribution in the other segments of the foot and ankle and alters patients' overall gait. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1739-1746, 2018.

Children with severe osteogenesis imperfecta (OI) typically experience numerous fractures and progressive skeletal deformities over their lifetime. Recent studies proposed finite element models to assess fracture risk and guide clinicians in determining appropriate intervention in children with OI, but lack of appropriate material property inputs remains a challenge. This study aimed to characterize macroscopic anisotropic cortical bone material properties and investigate relationships with bone density measures in children with severe OI. Specimens were obtained from tibial or femoral shafts of nine children with severe OI and five controls. The specimens were cut into beams, characterized in bending, and imaged by synchrotron radiation X-ray micro-computed tomography. Longitudinal modulus of elasticity, yield strength, and bending strength were 32-65% lower in the OI group (p

Background Orthoses commonly are prescribed to children with cerebral palsy (CP) to provide foot correction and to improve ambulatory function. Immediate effects of ankle foot orthosis (AFOs) have been investigated, but long-term kinematic effects are lacking clinical evidence. Objective To determine changes in 3-dimensional ankle and foot segment motion in pediatric patients with CP between initial and follow-up visits (18-month average time differences) in both barefoot gait and gait with their AFO. We also investigated intravisit changes between barefoot and AFO gait. Design A prospective cohort study. Setting Children's Hospital of Wisconsin, Department of Orthopaedic Surgery, Medical College of Wisconsin. Patients A total of 23 children with CP, mean age 10.5 years (6.2-18.1 years) were clinically prescribed either a solid ankle foot orthotic (SAFO), hinged ankle foot orthotic (HAFO), or supramalleolar orthotic. Methods Holes were cut in the study orthoses so that electromagnetic markers could be directly placed on the skin. A 6-foot segment model was used. Outcome Measurements Kinematic and kinetic data were recorded for each patient's initial and follow-up visit (18-month follow-up average, 15-20 months range). Results For the SAFO group (gait with AFO), a significant decrease in dorsiflexion was found between the initial and third visit ( P = .008). Furthermore, the SAFO group (barefoot gait) had an increased eversion at the midfoot for most of the gait cycle ( P Conclusion The use of AFOs long term either maintained or improved foot deformities or dysfunction. Level of Evidence Level II.

Background Despite significant advances in the prevention and treatment of pediatric trauma, preventable injuries continue to burden the lives of millions of children. To target prevention strategies, it is critical to identify areas with high burdens of pediatric trauma. Therefore, this study analyzed statewide data from the Ohio Trauma Registry from 2007 to 2012 to identify geographical patterns in pediatric injury. Methods Data from the first hospital of care for 16,330 pediatric trauma patients younger than 16 years were analyzed using the disease mapping method adaptive spatial filtering to estimate a series of maps that display age- and sex-adjusted rates of pediatric trauma, severe trauma, and standardized mortality ratios while controlling for population size to create stable estimates throughout the study area. The locations of all trauma centers were mapped to highlight access to trauma care. Results Areas with significantly higher than expected rates of severe injury were identified in nonurban areas, where children lacked timely access to a pediatric trauma center or Level I adult trauma center. Although highest standardized mortality ratios were in urban areas, nonurban areas experienced elevated mortality with rates over four times higher than expected. Conclusion Areas with higher than expected age- and sex-adjusted rates of severe injury and mortality should be further explored to identify opportunities for injury prevention and appropriate access to timely care. Level of evidence Epidemiologic study, level III.

This study examined the association between Latino acculturation indicators (language and citizenship/nativity status) and periodontitis using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012. Descriptive statistics and logistic regression analyses were performed and all analyses were adjusted for the complex survey design. Results showed that 63.2% of participants had periodontitis: 9.4% mild, 37.9% moderate, and 16% severe. Language was significantly associated with periodontitis after adjusting for age, educational level, gender, usual source of care, flossing, smoking, and glycohemoglobin level (P = .02). Dental public and private health efforts should implement culturally tailored oral health promotion education efforts for this population.

The estimation problem of a parameter of interest when some model assumptions may be incorrect is considered. The parameter of interest is defined in a model-independent manner and the estimating procedure selects a model with the smallest mean square error (MSE) as estimated by a proposed MSE estimator. This proposed MSE estimator combines both a nonparametric bootstrap and plug-in estimation in its structure. It requires at least one consistent estimator with a quickly disappearing systematic bias ( $$\sqrt n $$ mean convergence). This estimator is not tied up to a single set of model assumptions (e.g., a class of parametric models), and thus it works across various sets of possibly nonnested classes of statistical models. The derived large sample properties constitute theoretical justification of its use and allow the estimation of the probability of how likely this estimator will have the smallest MSE in a pool of candidate estimators. Multiple simulation studies illustrate the performance of the proposed procedure under various scenarios. A real data example highlights its practical use when a single model is selected from several conceptually different statistical modeling techniques (parametric regression, Cox regression, stratified Cox regression, regression on pseudo-values) and other model selection approaches are not applicable.

Introduction: ES after autoHCT encompasses a continuum of peri-engraftment complications characterized by non-infectious fever, rash, diarrhea, and capillary leak features. ES is an increasingly recognized complication after autoHCT in MM, with the varying incidence reported, based on the diagnostic criteria used. ES is typically mild and self-limited in most patients, while a subset can develop severe complications. In this study, we explored whether the use of budesonide prophylaxis reduces ES rates in MM patients undergoing autoHCT. Methods: All patients who underwent autoHCT for MM from 12/2017 to 11/2019 were included after IRB approval at our institution. Beginning on 12/15/2018, as a quality improvement institutional initiative to reduce ES, budesonide 3 mg orally three times a day was initiated at day +5 post autoHCT and continued until the time of discharge. In patients developing ES, systemic steroids were started, and budesonide was discontinued. The efficacy of the intervention was compared with patients who did not receive prophylaxis prior to the study period. ES was defined according to the previously published criteria [T R Spitzer BMT 50, 469-475(2015)]. Patient demographics, disease, and treatment outcomes between the 2 groups were compared using Mann-Whitney and Chi-squared tests when appropriate. The primary outcome was the ES rates between the 2 groups. Multiple logistic regression was used to model ES rates with other predictors, including budesonide prophylaxis as the main effect. Length of stay (LOS) and 30-day readmission were the secondary endpoints. Results: Table 1 shows the patient-, disease- and treatment characteristics between no prophylaxis (N=148) and prophylaxis (N=109) groups. The two groups were well matched overall except for induction therapy and Karnofsky performance status (KPS). The rates of ES were significantly higher in the no prophylaxis group vs. prophylaxis group [69 (75%) vs. 23 (25%); p On adjusted analysis, budesonide prophylaxis was associated with a significantly lower risk of developing ES compared to no prophylaxis groups [Odds ratio, OR 0.30 (95%CI: 0.17-0.53); p Conclusion: Our study concludes that the use of budesonide prophylaxis significantly reduces the risk of ES in MM patients undergoing autoHCT. Future large-scale randomized studies are needed to confirm these findings in patients undergoing autoHCT for MM and other diseases. Disclosures Dhakal: Celgene: Consultancy, Honoraria; Takeda: Consultancy, Other: Advisory Board; Sanofi: Research Funding; Amgen: Consultancy, Other: AdvIsory Board, Research Funding; Janssen: Consultancy, Other: Advisory Board, Research Funding; GSK: Consultancy, Research Funding, Speakers Bureau.

Consider an experiment in which the primary objective is to determine the significance of a treatment effect at a predetermined type I error and statistical power. Assume that the sample size required to maintain these type I error and power will be re-estimated at an interim analysis. A secondary objective is to estimate the treatment effect. Our main finding is that the asymptotic distributions of standardized statistics are random mixtures of distributions, which are non-normal except under certain model choices for sample size re-estimation (SSR). Monte-Carlo simulation studies and an illustrative example highlight the fact that asymptotic distributions of estimators with SSR may differ from the asymptotic distribution of the same estimators without SSR.

OBJECTIVEThis study aimed to assess the safety and efficacy of MR-guided stereotactic laser ablation (SLA) therapy in the treatment of pediatric brain tumors.METHODSData from 17 North American centers were retrospectively reviewed. Clinical, technical, and radiographic data for pediatric patients treated with SLA for a diagnosis of brain tumor from 2008 to 2016 were collected and analyzed.RESULTSA total of 86 patients (mean age 12.2 ± 4.5 years) with 76 low-grade (I or II) and 10 high-grade (III or IV) tumors were included. Tumor location included lobar (38.4%), deep (45.3%), and cerebellar (16.3%) compartments. The mean follow-up time was 24 months (median 18 months, range 3–72 months). At the last follow-up, the volume of SLA-treated tumors had decreased in 80.6% of patients with follow-up data. Patients with high-grade tumors were more likely to have an unchanged or larger tumor size after SLA treatment than those with low-grade tumors (OR 7.49, p = 0.0364). Subsequent surgery and adjuvant treatment were not required after SLA treatment in 90.4% and 86.7% of patients, respectively. Patients with high-grade tumors were more likely to receive subsequent surgery (OR 2.25, p = 0.4957) and adjuvant treatment (OR 3.77, p = 0.1711) after SLA therapy, without reaching significance. A total of 29 acute complications in 23 patients were reported and included malpositioned catheters (n = 3), intracranial hemorrhages (n = 2), transient neurological deficits (n = 11), permanent neurological deficits (n = 5), symptomatic perilesional edema (n = 2), hydrocephalus (n = 4), and death (n = 2). On long-term follow-up, 3 patients were reported to have worsened neuropsychological test results. Pre-SLA tumor volume, tumor location, number of laser trajectories, and number of lesions created did not result in a significantly increased risk of complications; however, the odds of complications increased by 14% (OR 1.14, p = 0.0159) with every 1-cm3 increase in the volume of the lesion created.CONCLUSIONSSLA is an effective, minimally invasive treatment option for pediatric brain tumors, although it is not without risks. Limiting the volume of the generated thermal lesion may help decrease the incidence of complications.

OBJECTIVE Create and validate an objective structured assessment of technical skills (OSATS) for otolaryngology residents learning how to perform a tonsillectomy. STUDY DESIGN Multicenter prospective longitudinal validation study. METHODS A multi-institutional study at six tertiary academic otolaryngology residency programs from July 2009 to May 2012. Using the modified Delphi technique, a panel of pediatric otolaryngologists created a tonsillectomy task-based checklist (TBC) for a tonsil OSATS using a 5-point Likert-type scale. Residents were assessed by pediatric otolaryngology staff at the time of surgery with the TBC and a global rating scale. Procedure time, patient age, number of previously performed tonsillectomies, and surgical technique were also collected. RESULTS One hundred sixty-seven tonsil OSATS were completed for 38 residents, and competency was recorded for 99 (59.2%). Residents scored as competent had performed significantly more previous tonsillectomies than those deemed noncompetent, 44.4 ± 35.6 and 13.5 ± 11.6, respectively (P

INTRODUCTION AND OBJECTIVES:Urinary retention is a significant adverse event after surgery which predisposes patients to increased hospital stay and avoidable returns to the Emergency Department. T...

Objective: The retina is an extension of the central nervous system (CNS), and ocular symptoms can precede manifestations of CNS disorders. Given that several neurodegenerative conditions that affect the brain exhibit ocular symptoms, the retina may be an accessible biomarker to monitor disease progression. Dopamine, the key neurotransmitter related to Parkinson’s disease (PD), is contained in amacrine and interplexiform cells, which reside in specific retinal layers. Understanding how loss of dopaminergic cells affects retinal anatomy could be relevant for monitoring disease progression. Here, our objective is to evaluate retinal structure (foveal pit morphology and thickness) in patients with PD. Methods: Thirty-three Caucasian subjects diagnosed with PD and 40 age-matched Caucasian control subjects underwent retinal imaging with spectral-domain optical coherence tomography (SD-OCT). Axial length measurements were used to correct the lateral scale of each macular volume scan. From these corrected volumes, foveal morphology was quantified with previously described algorithms, and Early Treatment Diabetic Retinopathy Study (ETDRS) grids of retinal thickness were generated and incorporated into a logistic regression model to predict PD. Results: Interocular foveal morphology measurements were highly symmetrical in PD patients and control subjects. There were no significant differences in foveal pit morphology between PD patients and control subjects. Using a model incorporating gender and axial-length corrected ETDRS regions; we generated a receiver operating characteristic curve with a c-statistic of 0.80. Conclusion: Our study, which to our knowledge is the first to properly scale OCT measurements when quantifying retinal thickness, demonstrates that PD patients retain foveal symmetry between eyes. When constructing a model to predict PD, gender, along with the center 1mm and temporal outer ETDRS regions, were significant predictors of PD. In addition to proper scaling of OCT measures, gender and racial differences in retinal anatomy should be considered in building future predictive PD models when using OCT.

Purpose To evaluate how metrics used to describe the cone mosaic change in response to simulated photoreceptor undersampling (i.e., cell loss or misidentification). Methods Using an adaptive optics ophthalmoscope, we acquired images of the cone mosaic from the center of fixation to 10° along the temporal, superior, inferior, and nasal meridians in 20 healthy subjects. Regions of interest (n = 1780) were extracted at regular intervals along each meridian. Cone mosaic geometry was assessed using a variety of metrics - density, density recovery profile distance (DRPD), nearest neighbor distance (NND), intercell distance (ICD), farthest neighbor distance (FND), percentage of six-sided Voronoi cells, nearest neighbor regularity (NNR), number of neighbors regularity (NoNR), and Voronoi cell area regularity (VCAR). The "performance" of each metric was evaluated by determining the level of simulated loss necessary to obtain 80% statistical power. Results Of the metrics assessed, NND and DRPD were the least sensitive to undersampling, classifying mosaics that lost 50% of their coordinates as indistinguishable from normal. The NoNR was the most sensitive, detecting a significant deviation from normal with only a 10% cell loss. Conclusions The robustness of cone spacing metrics makes them unsuitable for reliably detecting small deviations from normal or for tracking small changes in the mosaic over time. In contrast, regularity metrics are more sensitive to diffuse loss and, therefore, better suited for detecting such changes, provided the fraction of misidentified cells is minimal. Combining metrics with a variety of sensitivities may provide a more complete picture of the integrity of the photoreceptor mosaic.

Elucidating quantitative associations between antibiotic exposure and antibiotic resistance development is important. In the absence of randomized trials, observational studies are the next best alternative to derive such estimates. Yet, as antibiotics are prescribed for varying time periods, antibiotics constitute time-dependent exposures. Cox regression models are suited for determining such associations. After explaining the concepts of hazard, hazard ratio, and proportional hazards, the effects of treating antibiotic exposure as fixed or time-dependent variables are illustrated and discussed. Wider acceptance of these techniques will improve quantification of the effects of antibiotics on antibiotic resistance development and provide better evidence for guideline recommendations.

Directional optical coherence tomography (D-OCT) allows the visualization of the Henle fiber layer (HFL) in vivo. Here, we used D-OCT to characterize the HFL and outer nuclear layer (ONL) in albinism and examine the relationship between true foveal ONL and peak cone density.Horizontal D-OCT B-scans were acquired, registered, and averaged for 12 subjects with oculocutaneous albinism and 26 control subjects. Averaged images were manually segmented to extract HFL and ONL thickness. Adaptive optics scanning light ophthalmoscopy was used to acquire images of the foveal cone mosaic in 10 subjects with albinism, from which peak cone density was assessed.Across the foveal region, the HFL topography was different between subjects with albinism and normal controls. In particular, foveal HFL thickness was thicker in albinism than in normal controls (P0.0001), whereas foveal ONL thickness was thinner in albinism than in normal controls (P0.0001). The total HFL and ONL thickness was not significantly different between albinism and controls (P = 0.3169). Foveal ONL thickness was positively correlated with peak cone density in subjects with albinism (r = 0.8061, P = 0.0072).Foveal HFL and ONL topography are significantly altered in albinism relative to normal controls. Our data suggest that increased foveal cone packing drives the formation of Henle fibers, more so than the lateral displacement of inner retinal neurons (which is reduced in albinism). The ability to quantify foveal ONL and HFL may help further stratify grading schemes used to assess foveal hypoplasia.

This article examines the effects of a multi-level, community-based HIV prevention intervention for crack users residing in low-income neighborhoods in San Salvador, El Salvador conducted between August 2011 and June 2016. The intervention consisted of three components introduced sequentially: 1) rapid HIV testing in community settings; 2) a Social Network HIV testing intervention; and 3) Small Group interventions with crack users who were members of the same social network. The intervention was evaluated with an interrupted time series design in which we used respondent-driven sampling to conduct 7 cross-sectional surveys with crack users along a 3–4 month period for each assessment (total n=1597). Results revealed a significant increase in exposure to the intervention over time with 50% of the participants reporting exposure to one or more of the three components. Getting an HIV test at the community site was associated with reductions in total times each individual had sex without a condom (p

Assault is the most common form of intentional injury resulting in pediatric death. This large retrospective study analyzed statewide data from the Ohio Trauma Registry (87% of the state's hospitals) to describe risk factors of assault for pediatric trauma patients.Of 16,938 pediatric trauma patients younger than 16 years in the state trauma registry, assault was identified in 758 patients. Patients with assault injuries and nonassault injuries were compared using χ2 tests. Multiple logistic regression evaluated associations between assault and mortality, adjusting for potential confounders. Results of the regression analyses are reported as odds ratios (OR) with 95% confidence intervals.Children younger than 1 year were 5 times more likely to be assaulted (OR, 5.34; 95% CI, 4.14-6.88) compared to children 14 to 15 years old, and black children had 3 times the risk compared to white children (OR, 3.36; 95% CI, 2.79-4.04). Children with government insurance were 3 times more likely to be assaulted compared to children with commercial insurance (OR, 3.00; 95% CI, 2.23-4.04). Assault victims were twice as likely arrive at the first hospital of care over 24 hours after injury (OR, 1.95; 95% CI, 1.44-2.66). Assault victims were more likely to die after adjusting for injury severity.Assault victims experience delays in care and had twice the mortality rate after adjusting for injury severity. The worse outcomes for pediatric assault victims highlight the importance of accurately diagnosing and intervening.

Objective Our study identified risk factors for the development of clinically identifiable catheter-associated thrombosis (CT). Study Design We performed a retrospective cohort study of neonates in whom a central catheter was present. A total of 1,475 catheters were identified in 766 patients during a 36-month study period. The odds ratio (OR) of thrombi formation in catheterized neonates was modeled using simple (single predictor) and multiple (multiple predictors) logistic regressions as well as simple and multiple Cox's proportional hazard models. Result The incidence of CT was 1.17 per 100 neonates. Unadjusted factors including age at insertion, history of surgery before or during line placement, cholestasis, femoral location, and line size significantly increased the OR or hazards ratio (HR) of developing thrombi formation. In multiple logistic and Cox's regression analyses, three factors continued to be significantly associated with OR or HR of thrombi formation: line size, femoral location, and cholestasis. Conclusion We conclude that clinically identifiable CT is rare in the neonatal population. Furthermore, catheter-specific characteristics are predictive for CT and require further investigation.

The contents of this article were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90AR5022-01-00 Formerly H133P140023-14). NIDILRR is a Center within the Administration for Community Living (ACL), Department of

Background While wearing shoes is common in daily activities, most foot kinematic models report results on barefoot conditions. It is difficult to describe foot position inside shoes. This study used fluoroscopic images to determine talocrural and subtalar motion. Research Question What are the differences in sagittal talocrual and subtalar kinematics between walking barefoot and while wearing athletic walking shoes? Methods Thirteen male subjects (mean age 22.9 ± 2.9 years, mean weight 77.2 ± 6.9 kg, mean height 178.2 ± 3.7 cm) screened for normal gait were tested. A fluoroscopy unit was used to collect images during stance. Sagittal motion of the talocrural and subtalar joints of the right foot were analyzed barefoot and in an athletic walking shoe. Results Shod talocrural position at heel strike was 6.0° of dorsiflexion and shod peak talocrural plantarflexion was 4.2°. Barefoot talocrural plantarflexion at heel strike was 4.2° and barefoot peak talocrural plantarflexion was 10.9°. Shod subtalar position at heel strike was 2.6° of plantarflexion and peak subtalar dorsiflexion was 1.5°. The barefoot subtalar joint at heel strike was in 0.4° dorsiflexion and barefoot peak subtalar dorsiflexion was 3.5°. As the result of wearing shoes, average walking speed and stride length increased and average cadence decreased. Comparing barefoot to shod walking there was a statistical significance in talocrural dorsiflexion and at heel strike and peak talocrural dorsiflexion, subtalar plantarflexion at heel strike and peak subtalar dorsiflexion, walking speed, stride length, and cadence. Significance This work demonstrates the ability to directly measure talocrural and subtalar kinematics of shod walking using fluoroscopy. Future work using this methodology can be used to increase understanding of hindfoot kinematics during a variety of non-barefoot activities.

Purpose To examine repeatability and reproducibility of ellipsoid zone (EZ) width measurements in patients with retinitis pigmentosa (RP) using a longitudinal reflectivity profile (LRP) analysis. Methods We examined Bioptigen optical coherence tomography (OCT) scans from 48 subjects with RP or Usher syndrome. Nominal scan lengths were 6, 7, or 10 mm, and the lateral scale of each scan was calculated using axial length measurements. LRPs were generated from OCT line scans, and the peak corresponding to EZ was manually identified using ImageJ. The locations at which the EZ peak disappeared were used to calculate EZ width. Each scan was analyzed twice by each of two observers, who were masked to their previous measurements and those of the other observer. Results On average, horizontal width (HW) was significantly greater than vertical width (VW), and there was high interocular symmetry for both HW and VW. We observed excellent intraobserver repeatability with intraclass correlation coefficients (ICCs) ranging from 0.996 to 0.998 for HW and VW measurements. Interobserver reproducibility was also excellent for both HW (ICC = 0.989; 95% confidence interval [CI] = 0.983-0.995) and VW (ICC = 0.991; 95% CI = 0.985-0.996), with no significant bias observed between observers. Conclusions EZ width can be measured using LRPs with excellent repeatability and reproducibility. Our observation of greater HW than VW is consistent with previous observations in RP, though the reason for this anisotropy remains unclear. Translational Relevance We describe repeatability and reproducibility of a method for measuring EZ width in patients with RP or Usher syndrome. This approach could facilitate measurement of retinal band thickness and/or intensity.

Background Implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) in the U.S. on October 1, 2015 was a significant policy change with the potential to affect established injury morbidity trends. This study used data from a single state to demonstrate 1) the use of a statistical method to estimate the effect of this coding transition on injury hospitalization trends, and 2) interpretation of significant changes in injury trends in the context of the structural and conceptual differences between ICD-9-CM and ICD-10-CM, the new ICD-10-CM-specific coding guidelines, and proposed ICD-10-CM-based framework for reporting of injuries by intent and mechanism. Segmented regression analysis was used for statistical modeling of interrupted time series monthly data to evaluate the effect of the transition to ICD-10-CM on Kentucky hospitalizations’ external-cause-of-injury completeness (percentage of records with principal injury diagnoses supplemented with external-cause-of-injury codes), as well as injury hospitalization trends by intent or mechanism, January 2012–December 2017. Results The segmented regression analysis showed an immediate significant drop in external-cause-of-injury completeness during the transition month, but returned to its pre-transition levels in November 2015. There was a significant immediate change in the percentage of injury hospitalizations coded for unintentional (3.34%) and undetermined intent (− 3.39%). There were immediate significant changes in the level of injury hospitalization rates due to poisoning, suffocation, struck by/against, other transportation, unspecified mechanism, and other specified not elsewhere classifiable mechanism. Significant change in slope after the transition (without immediate level change) was identified for assault, firearm, cut/pierce, and motor vehicle traffic injury rates. The observed trend changes reflected structural and conceptual features of ICD-10-CM coding (e.g., poisoning and suffocations are now captured via diagnosis codes only), new coding guidelines (e.g., requiring coding of injury intent as “accidental” if it is unknown or unspecified), and CDC proposed external-cause-of-injury code groupings by injury intent and mechanism. Researchers can replicate this methodology assessing trends in injuries or other ICD-10-CM-coded conditions using administrative billing data sets. Conclusions The CDC ‘s Proposed Framework for Presenting Injury Data Using ICD-10-CM External Cause of Injury Codes provided a logical transition from the ICD-9-CM-based matrix on injury hospitalization trends by intent and mechanism. Our findings are intended to raise awareness that changes in the ICD-10-CM coding system must be understood to assure accurate interpretation of injury trends. Electronic supplementary material The online version of this article (10.1186/s40621-018-0165-8) contains supplementary material, which is available to authorized users.

Over 1 million HIV infections have been diagnosed in Russia, and HIV care uptake and viral suppression are very low. 241 HIV-positive individuals in St. Petersburg were enrolled through social networks, provided blood for viral load testing, and completed measures of medication-taking adherence, readiness, and self-efficacy; psychosocial well-being; and substance use. Outcomes included attending an HIV care appointment in the past 6 months, >90% ART adherence, and undetectable viral load. 26% of participants had no recent care appointment, 18% had suboptimal adherence, and 56% had detectable viral load. Alcohol use consistently predicted all adverse health outcomes. Having no recent care visit was additionally associated with being single and greater past-month drug injection frequency. Poor adherence was additionally predicted by lower medication-taking self-efficacy and lower anxiety. Detectable viral load was additionally related to younger age. Comprehensive interventions to improve HIV care in Russia must address substance abuse, anxiety, and medication-taking self-efficacy.

OBJECTIVES Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease. METHODS We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations. RESULTS Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44). CONCLUSIONS Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.

Carefully conducted randomized trials have established that sexual behavior change interventions can significantly reduce intervention participants' risk of acquiring HIV. Establishing the effectiveness of these evidence-based interventions when implemented by frontline HIV prevention service providers is increasingly important in order to achieve maximum public health impact. This study sought to assess the effectiveness of an evidence-based intervention when implemented by frontline HIV prevention service providers. We evaluated Sisters Informing Sisters on Topics about AIDS (SISTA), an HIV prevention intervention for heterosexual African American women, as implemented by four AIDS service organizations. Women enrolled in HIV counseling, testing, and referral (CTR) at each agency served as contemporaneous controls. Measures included self-reported number of occasions of unprotected vaginal intercourse and number of vaginal sex partners in the previous 90 days. 1,262 participants completed baseline and follow-up assessments across both conditions (SISTA = 537 [57%]; CTR = 725 [62%]). In the full sample of HIV-negative women, CTR participants' odds of having had unprotected sex decreased over time by 38% while SISTA participants' odds of having had unprotected sex did not change. Similar results were found among only those participants who had sex at baseline. Hypothesized interaction effects indicating positive changes in sexual risks over time for SISTA participants were not observed.

We introduce a family of tests for regression coefficients based on signs of quantile regression residuals. In our approach, we first fit a quantile regression for the model where an independent variable of interest is not included in the set of model predictors (the null model). Then signs of residuals of this null model are tested for association with the predictor of interest. This conditionally exact testing procedure is applicable for randomized studies. Further, we extend this testing procedure to observational data when co-linearity between the variable of interest and other model predictors is possible. In the presence of possible co-linearity, tests for conditional association controlling for other model predictors are used. Monte Carlo simulation studies show superior performance of the introduced tests over several other widely available testing procedures. These simulations explore situations when normality of regression coefficients is not met. An illustrative example shows the use of the proposed tests for investigating associations of hypertension with quantiles of hemoglobin A1C change.

In El Salvador, crack users are at high risk for HIV but they are not targeted by efforts to promote early HIV diagnosis. We evaluated the promise of peer-referral chains with incentives to increase HIV testing and identify undiagnosed HIV infections among networks of crack users in San Salvador. For 14 months, we offered HIV testing in communities with a high prevalence of crack use. For the following 14 months, we promoted chains in which crack users from these communities referred their peers to HIV testing and received a small monetary incentive. We recorded the monthly numbers of HIV testers, and their crack use, sexual risk behaviors and test results. After launching the referral chains, the monthly numbers of HIV testers increased significantly (Z = 6.90, p < .001) and decayed more slowly (Z = 5.93, p < .001), and the total number of crack-using testers increased nearly fourfold. Testers in the peer-referral period reported fewer HIV risk behaviors, but a similar percentage (~5 %) tested HIV positive in both periods. More women than men received an HIV-positive diagnosis throughout the study (χ2(1, N = 799) = 4.23, p = .040). Peer-referral chains with incentives can potentially increase HIV testing among networks of crack users while retaining a focus on high-risk individuals.

Prior to withdrawing the EUS-FNA needle from the lesion, the stopcock of the suction syringe is closed to reduce contamination. Residual negative pressure (RNP) may persist in the needle despite closing the stopcock. To determine whether neutralizing RNP before withdrawing the needle will improve the cytology yield. Bench-top testing was done to confirm the presence of RNP followed by a prospective, randomized, cross-over study on patients with pancreas mass. Ten milliliters of suction was applied to the FNA needle. Before withdrawing the needle from the lesion, the stopcock was closed. Based on randomization, the first pass was done with the stopcock either attached to the needle (S+) or disconnected (S−) to allow air to enter and neutralize RNP and accordingly the second pass was crossed over to S+ or S−. On-site cytopathologist was blinded to S+/S−. Bench tests confirmed the presence of RNP which was successfully neutralized by disconnecting the syringe (S−) from the needle. Sixty patients were enrolled, 120 samples analyzed. S+ samples showed significantly greater GI tract contamination compared to S− samples (16.7 vs. 6.7 %, p = 0.03). Of the 53 patients confirmed to have pancreas adenocarcinoma, FNA using S− approach was positive in 49 (93 %) compared to 40 using the S+ approach (76 %, p = 0.02). Despite closing the stopcock of the suction syringe, RNP is present in the FNA needle. Neutralizing RNP prior to withdrawing the needle from the target lesion significantly decreased GI tract contamination of the sample thereby improving the FNA cytology yield. NCT01995474.

Timely access to the appropriate level of care, both in the prehospital and in the hospital setting, is necessary to optimize outcomes in severely injured pediatric trauma patients. However, a substantial portion of the pediatric population does not have adequate timely access to a verified Level 1 trauma center. This study aimed to identify significant predictors of in-hospital mortality and transfer to a higher level of care. This is the first statewide analysis that includes pediatric patients who are first seen at nontrauma centers (NTCs).Mortality interhospital transfers to a higher level of care were analyzed for the first hospital of care. Clustering was accounted for by generalized estimating equations. p0.01 was considered significant.Younger age was significantly associated with mortality for all patients and with transfer for less severely injured children (Injury Severity Score [ISS]15). The odds of mortality in NTCs were lower than in Level 1 trauma centers; however, the majority of NTC patients were transferred, artificially decreasing NTC mortality. The type of trauma (blunt or penetrating) was significantly associated with both mortality and transfer for more severe cases. Although insurance was not significantly associated with transfer, self-pay patients had significantly higher mortality odds.The NTCs are transferring 98% of their patients, even those with very low ISS and high Glasgow Coma Scale (GCS). Further evaluation of the outcomes and characteristics of patients transferred from NTCs will provide important information to inform the triage guidelines to potentially safely avoid transfer of less severely injured patients from NTCs in their community.Therapeutic study, level IV; epidemiologic/prognostic study, level III.

Prior work suggests blood pressure in African Americans is more sensitive to the effects of aldosterone than in Caucasians. This mechanism may relate to a negative response of the vascular endothelium to aldosterone, including reduced glucose-6-phosphate dehydrogenase (G6PD) activity. Thirty-three African Americans (11 hypertensives, 22 controls) without evidence of diabetes or metabolic syndrome completed the protocol. The protocol included measurement of in vivo microvascular endothelial function by digital pulse arterial tonometry and ex vivo measurement of endothelial function by videomicroscopy of arterioles obtained from these same subjects with and without exposure to aldosterone or spironolactone. Systemic and arteriolar G6PD activities were also measured. In vivo and ex vivo microvascular endothelial function were impaired in African Americans with hypertension. One-hour exposure with aldosterone impaired endothelium-dependent vasodilation in arterioles from normotensive subjects, while 1 hour of spironolactone exposure reversed endothelial dysfunction in arterioles from hypertensive subjects. G6PD activity was impaired in hypertensive arterioles. Aldosterone-related endothelial dysfunction may be responsible for at least a portion of the greater blood pressure sensitivity to aldosterone in African Americans. This may be in part related to vascular suppression of G6PD activity.

This study examines the association between periodontitis, diabetes (DM), and glycemic control.National Health and Nutrition Examination Survey data for 2009 to 2012 were analyzed. Periodontitis status of each participant was assessed using the full-mouth periodontal examination protocol, classified using the Centers for Disease Control and Prevention and the American Academy of Periodontology surveillance case definition for total periodontitis. Self-reported DM status was defined as yes or no. Glycemic control was assessed using glycohemoglobin data at cutoff points of 7.0%, 7.5%, 8.0%, 8.5%, and 9.0%. Descriptive statistics and logistic regression analyses were performed, and all analyses were adjusted for the survey design.Overall, 7,042 adults ≥30 years old with complete data were included in the study. The mean glycohemoglobin levels for individuals with and without periodontitis were 5.9% and 5.6%, respectively, and increased to 7.4% and 7.0% for participants with DM. The majority of participants with and without periodontitis were aged 50 to 64 and 35 to 49 years (37.4% versus 44.5%), respectively. In the bivariate analysis, several demographic factors were significantly associated with having periodontitis, including self-reported DM status and glycemic control. In the multivariate analysis, demographic factors, glycohemoglobin cutoff values of 8.0%, 8.5%, and 9.0%, and mean glycohemoglobin level remained significant, but self-reported DM status was not.This study demonstrates that glycohemoglobin and demographic factors are significantly associated with periodontitis, but not self-reported status.

The aim of this study was to examine the dose-response relationship between walking activity and physical function (PF) in community-dwelling older adults. Physical activity (PA, pedometry) and PF (self-report [SF-36] and 6-minute walk test [6MWT]) were assessed in 836 individuals. Accumulated PA was categorized into four groups (1 = ≤ 2,500; 2 = 2,501–5,000; 3 = 5,001–7,500; and 4 = ≥ 7,501 steps/day). Across individual groups 1–4, SF-36 scores increased from 66.9 ± 25.0% to 73.5 ± 23.2% to 78.8 ± 19.7% to 81.3 ± 20.6%, and 6MWT increased from 941.7 ± 265.4 ft to 1,154.1 ± 248.2 ft to 1,260.1 ± 226.3 ft to 1,294.0 ± 257.9 ft. Both SF-36 and 6MWT scores were statistically different across all groups, apart from groups 3 and 4. PA and ranks of groups were highly significant predictors (p < .0001) for both SF-36 and 6MWT. There was a positive dose-response relationship evident for both SF-36 and 6MWT with increasing levels of PA. Low levels of PA appear to be an important indicator of poor functionality in older adults.

There is a subset of patients with mild traumatic brain injury (mTBI) who report persistent symptoms that impair their functioning and quality of life. Being able to predict which patients will experience prolonged symptom recovery would help clinicians target resources for clinical follow-up to those most in need, and would facilitate research to develop precision medicine treatments for mTBI. The purpose of this study was to investigate the predictors of symptom recovery in a prospective sample of emergency department trauma patients with either mTBI or non-mTBI injuries. Subjects were examined at several time points from within 72 h to 45 days post-injury. We quantified and compared the value of a variety of demographic, injury, and clinical assessment (symptom, neurocognitive) variables for predicting self-reported symptom duration in both mTBI (n = 89) and trauma control (n = 73) patients. Several injury-related and neuropsychological variables assessed acutely (< 72 h) post-injury predicted symptom duration, particularly loss of consciousness (mTBI group), acute somatic symptom burden (both groups), and acute reaction time (both groups), with reasonably good model fit when including all of these variables (area under the receiver operating characteristic curve [AUC] = 0.76). Incorporating self-reported litigation involvement modestly increased prediction further (AUC = 0.80). The results highlight the multifactorial nature of mTBI recovery, and injury recovery more generally, and the need to incorporate a variety of variables to achieve adequate prediction. Further research to improve this model and validate it in new and more diverse trauma samples will be useful to build a neurobiopsychosocial model of recovery that informs treatment development.

Three-dimensional (3D) spinal models of children with idiopathic scoliosis (IS) were created using the EOS imaging system (EOS) and sterEOS software. To determine the inter- or intraobserver reproducibility of the 3D spinal models in children with IS of different apex locations. 3D spinal model measurements include the Cobb angle, kyphosis, lordosis, and axial vertebral rotation (AVR). Variation of these measurements between two investigators and two different trials by the same investigator were analyzed by inter- and intraclass correlation coefficients (ICCs). Biplanar radiographic images of 15 patients (age: 6–15 years) with IS were uploaded into the sterEOS software. Spinal and pelvic markers were manually identified to construct a 3D spinal model and measure spinal parameters. Two trained examiners independently performed modeling and performed modeling in spaced out trials. The ICC between inter- and intraobservers were calculated. ICCs between inter- and intraobservers were significant for all parameters (p < .05). Both the inter- and intraobservers showed excellent agreement for the Cobb angles in the thoracic segment, kyphosis and lordosis. Substantial interobserver agreement and excellent intraobserver agreement were determined for the Cobb angle in the thoracolumbar or lumbar (TL/L) segment, with less than 6° difference between two raters and less than 2° difference between two trials. Substantial interobserver agreement for the AVR in the TL/L region and substantial interobserver agreement for the AVR in the thoracic region were found, with less than 4° difference between raters. One rater had substantial intraobserver agreement for the AVR in the TL/L region whereas another rater reported moderate to substantial intraobserver agreement in both the thoracic and TL/L regions, with less than 3° difference between trials. The EOS system shows reliable and repeatable results in 3D spinal modeling of children with IS. Level III.