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Abstract Background Instrumental activities of daily living (IADL) are typically self-reported ability to perform complex tasks vital for independent living. There is a need for a complementary objective, performance-based approach especially in tracking outcomes in visual rehabilitation for patients with irreversible vision impairment (“low vision”). Our goals are: (1) To describe the validity of timed performance of instrumental activities of daily living (timed IADL or TIADL) tasks in individuals with irreversible vision impairment, by examining its association with visual function (visual acuity, contrast sensitivity, visual field), (2) To explore the correlation between TIADL and self-reported IADL. Methods Twenty TIADL tasks were administered to 88 patients (median age 63.3 years, IQR 37.4–78.0) recruited from the UAB Department of Ophthalmology, Callahan Eye Hospital Clinics. An average Z-score incorporating time and accuracy of task completion was constructed. Minor accuracy errors were penalized 1 standard deviation from their calculated Z-score and major accuracy errors were assigned maximum allotted time. Linear regression was used to analyze the association between TIADL score and measured visual acuity (Early Treatment Diabetic Retinopathy Study, ETDRS chart), contrast sensitivity (Pelli-Robson), and binocular visual field (Esterman) with an unadjusted model and an adjusted model accounting for age, comorbidities, and depression scale (Center for Epidemiological Studies Depression, CES-D). Pearson correlation was used to estimate the correlation between TIADL and IADL. Results Increased time to task completion was associated with decreased visual function. Each decreased line of ETDRS read was associated with an increase of 0.002 (95% CI 0.001, 0.002) Z-score (P

Background: Periprosthetic joint infections (PJIs) are a major cause of morbidity after shoulder arthroplasty. Prior national database studies have estimated the trends of shoulder PJI up to 2012.21 Since 2012, the landscape of shoulder arthroplasty has changed drastically with the expanding popularity of reverse total shoulder arthroplasty. The dramatic growth in primary shoulder arthroplasties is likely paralleled with an increase of PJI case volume. The purpose of this study is to quantify the rise in shoulder PJIs and the economic stress they currently place on the American healthcare system as well as the toll they will incur over the coming decade. Methods: The Nationwide Inpatient Sample database was queried for primary and revision anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty from 2011-2018. Multivariate regression was used to predict cases and charges through the year 2030 adjusted to 2021 purchasing power parity. Results: From 2011 to 2018, PJI was found to be 1.1% shoulder arthroplasties, from 0.8% (2011) to 1.4% (2018). Anatomic total shoulder arthroplasty experienced the greatest proportion of infections at 2.0%, followed by hemiarthroplasty at 1.0% and reverse total shoulder arthroplasty at 0.3%. Total hospital charges grew 324%, from $44.8 million (2011) to $190.3 million (2018). Our regression model projects 176% growth in cases and 141% growth in annual charges by 2030. Conclusion: This study demonstrates the large economic burden that shoulder PJIs pose on the American healthcare system, which is predicted to reach nearly $500 million in charges annually by 2030. Understanding trends in procedure volume and hospital charges will be critical in evaluating strategies to reduce shoulder PJIs.

Abstract Objective The aim of the present study was to determine the influence of resident involvement on acute complication rates in revision total hip arthroplasty (THA). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 1,743 revision THAs were identified from 2008 to 2012; 949 of them involved a resident physician. Demographic information including gender and race, comorbidities including lung disease, heart disease and diabetes, operative time, length of stay, and acute postoperative complications within 30 days were analyzed. Results Resident involvement was not associated with a significant increase in the risk of acute complications. Total operative time demonstrated a statistically significant association with the involvement of a resident (161.35 minutes with resident present, 135.07 minutes without resident; p< 0.001). There was no evidence that resident involvement was associated with a longer hospital stay (5.61 days with resident present, 5.22 days without resident; p= 0.46). Conclusion Involvement of an orthopedic resident during revision THA does not appear to increase short-term postoperative complication rates, despite a significant increase in operative times.

Abstract Background Persons who experience paraquat poisoning rapidly develop damage to a variety of organ systems including acute kidney injury (AKI), the occurrence of which is associated with an increased risk of death. However, little is known about the effects of chronic paraquat exposure on renal function and the onset of chronic renal disease. The objective of the current study is to assess the association between paraquat exposure and the incidence of end stage renal disease (ESRD) in the United States. Methods Data on the incidence of ESRD for the period 2010 through 2017 and kilograms of paraquat use per square mile for each county in the conterminous United States was obtained from the United States Renal Data System (USRDS) and the National Water Quality Assessment (NAWQA) Program, respectively. Negative binomial regression was used to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for the association between quartiles of paraquat exposure and the incidence of ESRD. Results The incidence of ESRD increased with increasing paraquat density. Based on a 20-year exposure lag, those in the highest paraquat density quartile had a 21% higher rate of ESRD compared to the lowest quartile whereas for a 15-year lag the increase was 26%. Adjusted associations were attenuated though still followed an increasing linear trend across quintiles. Conclusions The results of this study are consistent with a large number of studies documenting a high incidence of AKI and a small number of studies chronic renal disease following acute and chronic paraquat exposure, respectively. While the pathophysiological mechanisms underlying kidney injury following paraquat poisoning are well understood, more research is necessary to understand the natural history of chronic kidney disease due to chronic paraquat exposure.

الملخص: أهداف البحث: نتيجة لازدياد عدد عمليات تقويم مفصل الركبة، فإن عدد عمليات مراجعة تقويم مفصل الركبة مستمر في الارتفاع. لكن عدد جراحي العظام المدربين على تقويم المفاصل لم يواكب هذه الازدياد، وسيقع العبء المتزايد في النهاية على عاتق جراحي العظام غير المتخصصين. أظهرت الأبحاث أن مشاركة الأطباء المقيمين في عمليات تقويم مفصل الركبة الأولية لا ترتبط بزيادة مضاعفات ما بعد الجراحة، ولكن عمليات مراجعة تقويم مفصل الركبة أكثر تعقيدا ولم يتم دراسة تأثير مشاركة المقيمين بشكل جيد. طرق البحث: باستخدام قاعدة بيانات البرنامج الوطني لتحسين جودة الجراحة بالكلية الأمريكية للجراحين، شملت هذه الدراسة 1834 عملية مراجعة تقويم مفصل الركبة أجريت بين عامي 2008 و 2012. من هذه العمليات، شارك الأطباء المقيمون في 863 عملية. تم تصنيف وتحليل المعلومات الديموغرافية، والأمراض المصاحبة، وأوقات الجراحة، ومدة الإقامة، ومضاعفات ما بعد الجراحة لمدة 30 يوما، حسب مشاركة الأطباء المقيمين. النتائج: لم ترتبط مشاركة الأطباء المقيمين مع زيادة مهمة في المضاعفات على المدى القصير. كانت أوقات العمليات أطول بشكل ملحوظ مع مشاركة المقيمين (147.5 دقيقة مع مشاركة المقيمين مقابل 124.55 دقيقة بدون مقيم). كما كانت مدة الإقامة بعد الإجراءات بمشاركة المقيمين أعلى بمقدار 0.34 يوما، لكن هذا لم يصل إلى الأهمية الإحصائية. الاستنتاجات: ارتبطت مشاركة المقيمين في مراجعة تقويم مفصل الركبة بزيادة كبيرة في وقت الجراحة. ومع ذلك، لم تكن هناك زيادة كبيرة في معدل المضاعفات بعد الجراحة في غضون 30 يوما. تدعم هذه النتائج استمرار مشاركة المقيمين في مراجعة حالات تقويم مفصل الركبة وإدارة ما بعد الجراحة. Abstract: Objectives: The number of revision total knee arthroplasty (TKA) procedures continues to rise, a direct consequence of the increase in primary TKA. The number of arthroplasty-trained orthopaedic surgeons has failed to increase at a corresponding rate, and the increased burden will ultimately fall on non-specialized orthopaedists. Resident involvement in primary TKA has not been found to increase postoperative complications, but revision TKA is more complex and the impact of resident involvement has not been well studied. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, this study identified 1834 revision TKA procedures between the years 2008 and 2012. Of these procedures, 863 included resident involvement. Demographic information, comorbidities, operative times, length of stay (LOS), and 30-day postoperative complications were stratified by resident and non-resident involvement and analyzed. Results: Resident involvement was not associated with a significant increase in short-term complications. Operative times were significantly longer with resident involvement (147.50 min with resident involvement vs. 124.55 min without a resident, p

Background: Preoperative treatment recommendations and optimal time to perform total joint arthroplasty (TJA) in patients with hepatitis C virus after treatment completion for achieving best outcomes have not been elucidated. We aim to determine (1) if undetectable viral load (UVL) prior to TJA leads to decreased postoperative complication rates, specifically periprosthetic joint infection (PJI), and (2) if delaying TJA after treatment completion has benefit in decreasing PJI. Methods: A retrospective review of all hepatitis C virus patients undergoing TJA at 3 academic tertiary care centers was conducted. A total of 270 TJAs performed from 2005 to 2019 were included, 125 with positive viral load at the time of surgery. The duration from completion of treatment regimen to TJA was recorded for the UVL cohort. The primary study outcome was PJI at 1-year follow-up. Secondary outcomes included in-hospital complications, mechanical revision TJA rates, and optimal time to TJA upon completion of treatment. Results: Patients with positive viral load at the time of TJA had longer length of stay (3.9 vs 2.9 days, P

Background: Rotator cuff tear (RCT) chronicity is an important factor in considering treatment options and outcomes for surgical repair. Many factors may contribute to delayed treatment, including timely access to care due to insurance status. The purpose of this study was to evaluate the relationship between the magnitude of RCT on presentation and insurance status. We hypothesize that publicly insured patients will have a greater incidence of chronic RCTs and shoulder pathology on initial presentation. Methods: Retrospective chart review of patients undergoing RCT repair at an academic tertiary care institution from 2005 to 2019. Demographic data, including age, race, sex, and insurance carrier, were collected. Insurance carriers were categorized into public (Medicare and Medicaid) or private insurance coverage. Individual magnetic resonance imagings were then reviewed by a board-certified musculoskeletal radiologist for supraspinatus (SS), infraspinatus (IS), subscapularis, and biceps tendon tears, as well as acromioclavicular arthritis. In addition, rotator cuff atrophy was evaluated by the scapular ratio. Univariate analysis of variance and logistic regression analyses were used to compare demographics and rotator cuff pathology between those with Medicaid and Medicare, as well as between publicly and privately insured patients. Results: Of the 492 patients in this study, 192 had private insurance, and 300 had public insurance (Medicaid: 50 and Medicare: 250). Insurance status was not found to be associated with differences in RCTs between Medicare and Medicaid patients. Those with Medicaid or Medicare (public), presented more frequently with SS or IS atrophy (SS atrophy, P = .002; IS atrophy, P = .039) than those with private insurance. However, after adjusting for age, no significant differences in rotator cuff tendon tear or atrophy frequencies were found between insurance groups. Conclusions: Patients with private and public insurance tend to present with similar chronicity and magnitude of RCTs. Insurance status does not appear to influence timely access to surgical care for patients with RCTs at an academic medical center.

Purpose: Quantification of retinal xanthophyll carotenoids in eyes with and without age-related macular degeneration (AMD) via macular pigment optical volume (MPOV), a metric for xanthophyll abundance from dual wavelength autofluorescence, plus correlations to plasma levels, could clarify the role of lutein (L) and zeaxanthin (Z) in health, AMD progression, and supplementation strategies. Design: Cross-sectional observational study (NCT04112667). Participants: Adults ≥ 60 years from a comprehensive ophthalmology clinic, with healthy maculas or maculas meeting fundus criteria for early or intermediate AMD. Methods: Macular health and supplement use was assessed by the Age-related Eye Disease Study (AREDS) 9-step scale and self-report, respectively. Macular pigment optical volume was measured from dual wavelength autofluorescence emissions (Spectralis, Heidelberg Engineering). Non-fasting blood draws were assayed for L and Z using high-performance liquid chromatography. Associations among plasma xanthophylls and MPOV were assessed adjusting for age. Main Outcome Measures: Age-related macular degeneration presence and severity, MPOV in fovea-centered regions of radius 2.0° and 9.0°; plasma L and Z (μM/ml). Results: Of 809 eyes from 434 persons (89% aged 60–79, 61% female), 53.3% eyes were normal, 28.2% early AMD, and 18.5% intermediate AMD. Macular pigment optical volume 2° and 9° were similar in phakic and pseudophakic eyes, which were combined for analysis. Macular pigment optical volume 2° and 9° and plasma L and Z were higher in early AMD than normal and higher still in intermediate AMD (P

Purpose: We evaluate the impact of test target location in assessing rod-mediated dark adaptation (RMDA) along the transition from normal aging to intermediate age-related macular degeneration (AMD). We consider whether RMDA slows because the test locations are near mechanisms leading to or resulting from high-risk extracellular deposits. Soft drusen cluster under the fovea and extend to the inner ring of the ETDRS grid where rods are sparse. Subretinal drusenoid deposits (SDDs) appear first in the outer superior subfield of the ETDRS grid where rod photoreceptors are maximal and spread toward the fovea without covering it. Design: Cross-sectional. Participants: Adults ≥ 60 years with normal older maculas, early AMD, or intermediate AMD as defined by the Age-Related Eye Disease Study (AREDS) 9-step and Beckman grading systems. Methods: In 1 eye per participant, RMDA was assessed at 5° and at 12° in the superior retina. Subretinal drusenoid deposit presence was identified with multi-modal imaging. Main Outcome Measures: Rod intercept time (RIT) as a measure of RMDA rate at 5° and 12°. Results: In 438 eyes of 438 persons, RIT was significantly longer (i.e., RMDA is slower) at 5° than at 12° for each AMD severity group. Differences among groups were bigger at 5° than at 12°. At 5°, SDD presence was associated with longer RIT as compared to SDD absence at early and intermediate AMD but not in normal eyes. At 12°, SDD presence was associated with longer RIT in intermediate AMD only, and not in normal or early AMD eyes. Findings were similar in eyes stratified by AREDS 9-step and Beckman systems. Conclusions: We probed RMDA in relation to current models of deposit-driven AMD progression organized around photoreceptor topography. In eyes with SDD, slowed RMDA occurs at 5° where these deposits typically do not appear until later in AMD. Even in eyes lacking detectable SDD, RMDA at 5° is slower than at 12°. The effect at 5° may be attributed to mechanisms associated with the accumulation of soft drusen and precursors under the macula lutea throughout adulthood. These data will facilitate the design of efficient clinical trials for interventions that aim to delay AMD progression. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Background: Tendon-to-bone (TtB) healing is essential for successful rotator cuff repair (RCR). This study aimed to investigate if caffeine intake impaired TtB healing in a rat RCR model. Methods: Seventy-two rats were randomized into a caffeinated group or a noncaffeinated group. Specimens received one week of oral caffeine solution or normal saline before RCR. All rats then underwent bilateral RCR. Caffeination or saline gavages continued until rats were sacrificed at 2, 4, and 8 weeks postoperatively. Load-to-failure (primary outcomes measure), maximum stress, and stiffness of the TtB interface were measured for one shoulder of each specimen. Six random shoulders from each group underwent histological assessment of TtB healing. Results: Load-to-failure and maximum stress of RCR did not appear to differ between groups at any time point. No difference in RCR stiffness was found between groups at 2 and 4 weeks; however, stiffness in the caffeinated group did appear to lower at 8 weeks (P = .04). Conclusion: Perioperative caffeine intake did not appear to affect load-to-failure strength of RCR in an animal model. Although our secondary outcome measures of maximum stress and stiffness also did not appear to be influenced by perioperative caffeine intake, there did appear to be a trend toward decreased RCR stiffness at 8 weeks postoperatively in specimens that received caffeine.

Cryptococcosis is an invasive fungal infection found worldwide that causes significant morbidity and mortality among a broad range of hosts. There are approximately 223,000 new cases of cryptococcosis annually throughout the world, and at least 180,000 deaths are attributed to this infection each year. Most of these are due to complications of cryptococcal meningoencephalitis among HIV-infected patients in resource-limited environments. The majority of individuals diagnosed with cryptococcosis have underlying conditions associated with immune dysfunction such as HIV, solid organ transplant, hematologic malignancy, organ failure syndromes, and/or the use of immunosuppressive agents such as glucocorticosteroids and biologic agents. In most clinical series, there is a small proportion of patients with cryptococcosis who are phenotypically normal; that is, they have no clinically obvious predisposition to disease. Cryptococcal meningoencephalitis (CME) presentation and management differ substantially between these normal individuals and their immunocompromised counterparts. In this review, we will focus on CME in the phenotypically normal host and underscore differences in the clinical presentation, management, outcome, and potential risk factors for these patients compared to immunocompromised persons who develop this potential devastating invasive fungal infection.

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures are difficult injuries to manage as they are typically associated with extensive soft tissue damage. Although staged management of external fixation followed by open reduction and internal fixation is often used to prevent additional soft tissue damage and its associated complications, rates of nonunion remain high in this patient population. The purpose of this study is to evaluate and identify factors associated with increased rates of nonunion following operative fixation of pilon fractures. Methods: A retrospective review of all operatively managed pilon fractures at a single level 1 trauma center from 2014 to 2019 was performed. Minimum six-month follow-up was required for inclusion. Patients with skeletal immaturity or amputation prior to definitive fixation were excluded. Patients were grouped based on presence or absence of nonunion, which was defined as lack of bridging bone in at least 3 of 4 cortices and the presence of pain with ambulation at six-month follow-up. Demographics, injury and operative characteristics, and surgical outcomes were compared between the two groups. Results: Among the 279 patients meeting inclusion criteria, 48 developed nonunion at 6-month follow-up (17.2%). Average follow-up was 3.2 years. Patients with nonunion had significantly higher rates of open fractures (50.0% vs. 22.1%, p

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures are complex injuries that most commonly result from high-energy trauma. The extensive soft tissue damage and high rates of associated infection seen in these injuries remains a challenging concern for surgeons. The purpose of this study is to identify risk factors associated with surgical site infection (SSI) following operative management of pilon fractures. Methods: A retrospective review of all operatively managed pilon fractures at a single level 1 trauma center from 2014 to 2019 was performed. Minimum six-month follow-up and skeletal maturity was required for inclusion. Patients with amputation prior to definitive fixation were excluded. SSI consisted of superficial (defined as infection resolving with oral antibiotics) and/or deep infections (defined as return to the operating room for debridement with positive cultures). Patients were grouped based on presence or absence of SSI. Demographics, injury and operative characteristics, and surgical outcomes were compared between the two groups. Results: A total of 279 patients met inclusion criteria for the study, with 40 patients developing SSI (14.3%). Average follow-up was 3.2 years. Patients that developed SSI had a significantly higher proportion of open fractures (47.5% vs 23.4%, p=0.003); however, there were no significant differences in Gustilo-Anderson classification or open wound location compared to controls. The SSI group required significantly higher rates of skin grafts (25.0% vs 4.2%, p

Type 1 diabetes (T1D) is an autoimmune disease culminating in the destruction of insulin-producing pancreatic cells. There is a need for the development of novel antigen-specific strategies to delay cell destruction, including combinatorial strategies that do not elicit systemic immunosuppression. Gamma-aminobutyric acid (GABA) is expressed by immune cells, β-cells, and gut bacteria and is immunomodulatory. Glutamic-acid decarboxylase 65 (GAD65), which catalyzes GABA from glutamate, is a T1D autoantigen. To test the efficacy of combinatorial GABA treatment with or without GAD65-immunization to dampen autoimmune responses, we enrolled recent-onset children with T1D in a one-year clinical trial (ClinicalTrials.gov NCT02002130) and examined T cell responses. We isolated peripheral blood mononuclear cells and evaluated cytokine responses following polyclonal activation and GAD65 rechallenge. Both GABA alone and GABA/GAD65-alum treatment inhibited Th1 cytokine responses over the 12-month study with both polyclonal and GAD65 restimulation. We also investigated whether patients with HLA-DR3-DQ2 and HLA-DR4-DQ8, the two highest-risk human leukocyte antigen (HLA) haplotypes in T1D, exhibited differences in response to GABA alone and GABA/GAD65-alum. HLA-DR4-DQ8 patients possessed a Th1-skewed response compared to HLA-DR3-DQ2 patients. We show that GABA and GABA/GAD65-alum present an attractive immunomodulatory treatment for children with T1D and that HLA haplotypes should be considered.

Background: Percutaneous fixation of proximal humeral fractures places the axillary nerve and posterior humeral circumflex artery at risk for injury. Safe operative zones for the axillary nerve are described based on external measurements from anatomic landmarks, but no study to date has incorporated advanced imaging to help guide surgical procedures in the region of the axillary neurovascular bundle (ANVB). We sought to define the location and trajectory of the ANVB in relation to osseous landmarks using magnetic resonance imaging (MRI) measurements. Methods: Retrospective review of 750 consecutive MRI studies was performed with 55 imaging studies meeting inclusion criteria for patient positioning, image alignment, and quality. Five measurements were performed including the distance from mid-lateral acromion to lateral ANVB, mid-lateral acromion to medial ANVB, greater tuberosity to lateral ANVB, vertical distance between inferior anatomic neck and lateral ANVB, and angle the ANVB crosses the humerus. Height, gender, and age were recorded. Analysis was performed using ANOVA and Pearson correlation tests. Results: The lateral ANVB was below the inferior articular margin of the humeral head by an average of 12.9 ± 3.9 mm and within a 22 mm window. It was an average of 57.4 ± 5.1 mm from the lateral mid-acromion, and 34.7 ± 4.3 mm below the greater tuberosity. The angle formed by the ANVB crossing the humerus averaged 19.5 ± 3.9 degrees upward from medial to lateral. Height and gender directly impacted measurements. Conclusions: The use of the inferior humeral head articular margin provides a radiographic landmark to aid intraoperative lateral ANVB assessment which may be helpful during percutaneous fracture fixation.

Background:. To maintain the integrity of the match, postinterview communication (PIC) from programs to applicants is monitored and discouraged. The most recent report on the prevalence of PIC in orthopaedics found that 64% of surveyed applicants in 2014 and 2015 had received some form of PIC during their match cycle. In July 2019, the American Orthopaedic Association’s Council of Orthopaedic Residency Directors (AOA/CORD) released a guideline recommending the elimination of all PIC in any form. The goal of this follow-up study was to determine the current prevalence of PIC with orthopaedic surgery applicants and assess the perspectives of medical students who recently applied for orthopaedic surgery residency positions. Methods:. A 35-question survey was e-mailed to all orthopaedic surgery residency applicants of 4 geographically diverse residency programs in postmatch March 2020. The survey was open for 1 month, and the responses were reported using descriptive statistics. Results:. Of the 229 respondents (21% response rate), 91 (39.7%) received PIC during the 2019 to 2020 residency match cycle. The program director was most commonly identified (80.2%) as the person who communicated with the applicants. At the interview day, 198 respondents (86.5%) were told that programs would not be contacting the applicants with PIC. However, over a quarter of respondents (25.3%) who received PIC answered that those programs contacted applicants after announcing they would not. Nearly half of the respondents (48.5%) agreed or strongly agreed that PIC causes added stress on applicants, and over half (52.9%) agreed or strongly agreed that all programs should stop participating in any form of PIC. Conclusions:. Although the prevalence of PIC seems to have decreased since the 2014 and 2015 match, there is still room for improvement toward eliminating PIC. The AOA/CORD position statement from July 2019 should be disseminated to all members of the residency selection team to ensure consistency from all programs. The primary limitation of this study was the 21% response rate. Level of Evidence:. Level IV (survey study)

Abstract Background Age-related macular degeneration (AMD), a leading cause of irreversible vision impairment in the United States and globally, is a disease of the photoreceptor support system involving the retinal pigment epithelium (RPE), Bruch’s membrane, and the choriocapillaris in the setting of characteristic extracellular deposits between outer retinal cells and their blood supply. Research has clearly documented the selective vulnerability of rod photoreceptors and rod-mediated (scotopic) vision in early AMD, including delayed rod-mediated dark adaptation (RMDA) and impaired rod-mediated light and pattern sensitivity. The unifying hypothesis of the Alabama Study on Early Macular Degeneration (ALSTAR2) is that early AMD is a disease of micronutrient deficiency and vascular insufficiency, due to detectable structural changes in the retinoid re-supply route from the choriocapillaris to the photoreceptors. Functionally this is manifest as delayed rod-mediated dark adaptation and eventually as rod-mediated visual dysfunction in general. Methods A cohort of 480 older adults either in normal macular health or with early AMD will be enrolled and followed for 3 years to examine cross-sectional and longitudinal associations between structural and functional characteristics of AMD. Using spectral domain optical coherence tomography, the association between (1) subretinal drusenoid deposits and drusen, (2) RPE cell bodies, and (3) the choriocapillaris’ vascular density and rod- and cone-mediated vision will be examined. An accurate map and timeline of structure-function relationships in aging and early AMD gained from ALSTAR2, especially the critical transition from aging to disease, will identify major characteristics relevant to future treatments and preventative measures. Discussion A major barrier to developing treatments and prevention strategies for early AMD is a limited understanding of the temporal interrelationships among structural and functional characteristics while transitioning from aging to early AMD. ALSTAR2 will enable the development of functionally valid, structural biomarkers for early AMD, suitable for use in forthcoming clinical trials as endpoint/outcome measures. The comprehensive dataset will also allow hypothesis-testing for mechanisms that underlie the transition from aging to AMD, one of which is a newly developed Center-Surround model of cone resilience and rod vulnerability. Trial registration ClinicalTrials.gov Identifier NCT04112667 , October 7, 2019.

Abstract Background Older drivers have a crash rate nearly equal to that of young drivers whose crash rate is the highest among all age groups. Contrast sensitivity impairment is common in older adults. The purpose of this study is to examine whether parameters from the photopic and mesopic contrast sensitivity functions (CSF) are associated with incident motor vehicle crash involvement by older drivers. Methods This study utilized data from older drivers (ages ≥60 years) who participated in the Strategic Highway Research Program Naturalistic Driving Study, a prospective, population-based study. At baseline participants underwent photopic and mesopic contrast sensitivity testing for targets from 1.5–18 cycles per degree. Model fitting generated area under the log CSF (AULCSF) and peak log sensitivity. Participant vehicles were instrumented with sensors that captured continuous driving data when the vehicle was operating (accelerometers, global positioning system, forward radar, 4-channel video). They participated for 1–2 years. Crashes were coded from the video and other data streams by trained analysts. Results The photopic analysis was based on 844 drivers, and the mesopic on 854 drivers. Photopic AULCSF and peak log contrast sensitivity were not associated with crash rate, whether defined as all crashes or at-fault crashes only (all p > 0.05). Mesopic AULCSF and peak log sensitivity were associated with an increased crash rate when considered for all crashes (rate ratio (RR): 1.36, 95% CI: 1.06–1.72; RR: 1.28, 95% CI: 1.01–1.63, respectively) and at-fault crashes only (RR: 1.50, 95% CI: 1.16–1.93; RR: 1.38, 95% CI: 1.07–1.78, respectively). Conclusions Results suggest that photopic contrast sensitivity testing may not help us understand future crash risk at the older-driver population level. Results highlight a previously unappreciated association between older adults’ mesopic contrast sensitivity deficits and crash involvement regardless of the time of day. Given the wide variability of light levels encountered in both day and night driving, mesopic vision tests, with their reliance on both cone and rod vision, may be a more comprehensive assessment of the visual system’s ability to process the roadway environment.

Category: Ankle Introduction/Purpose: Advances in surgical technique and technology have allowed orthopedic surgeons to attempt early operative fixation of closed ankle fractures. Little is known about the modifiable factors impacting the recovery of these patients and how early operative intervention affects patient reported outcomes. This study aims to determine if early surgical treatment can be performed safely without increasing a patient’s risk for postoperative wound complications and how time to surgery affects both clinical and patient reported outcomes. Methods: A review of 311 patients records who underwent open reduction and internal fixation (ORIF) for an ankle fracture between July 1st, 2011 and July 1st, 2018 at a single academic center was conducted. Medical records were reviewed. Patients were contacted for collection of PROMIS Physical function, PROMIS Pain Interference, and the Foot Function Index. Patients with open fractures, high energy fractures with ipsilateral lower extremity injuries, pilon fractures, revision cases, non-respondents to the patient reported outcomes survey, and those lost to follow-up prior to radiographic evidence of union or non-union were excluded. After exclusions, 86 patients were then stratified by time to surgery after injury and injury classification. A linear regression model was constructed for each outcome instrument with the covariates of age, BMI, diabetes, smoking status, union, wound complication, time from surgery, and severe injuries by the Lauge-Hansen classification. Results: The delayed union, nonunion, and wound complication rate was similar regardless of timing of operative intervention (p=.470, p=.149, & p=.578, respectively). At a median of 4.5 (2.0 IQR) years postoperatively, outcomes scores were as follows (median (IQR)): PROMIS Physical Function 47.9 (11.2), PROMIS Pain Interference 50.1 (17.4), FFI Pain 26.0 (52.0), FFI Disability 17.0 (49), FFI Activity Limitation 3.0 (22.0), and FFI Total 20.0 (41.5). Time to intervention was not found to have an independent effect on any outcome score. Severe injuries by the Lauge-Hasen classification were found to be independent predictors of PROMIS physical function -6.3 (Unstandardized beta, 95% CI -11.5 to -1.1). Diabetes had a significant independent effect on PROMIS pain interference 52.4 (Unstandardized beta, 95% CI 24.3 to 80.5). Conclusion: Early surgical intervention did not significantly delayed union rate, nonunion rate, wound complications, or patient reported outcomes instruments. Severity of injury classification has a significant independent effect on patient’s physical function. Notably, this effect is above the minimal clinically important difference for PROMIS physical function. Overall, the intermediate term outcomes of ankle fracture fixation indicate patients are within one standard deviation of the population mean in terms of pain and physical function. Surgeons should be aware timing of intervention did not have an effect on outcomes scores at intermediate term follow-up.

Background:. The prosperous financial relationship between physicians and industry remains a highly scrutinized topic. Recently, a publicly available website was developed in conjunction with the U.S. Affordable Care Act to shed light on payments from industry to physicians with the goal of increasing transparency. The purpose of this study was to assess possible relationships between industry payments and orthopaedic surgeon gender, subspecialty training, and practice settings. Methods:. A retrospective analysis was performed using publicly available information from the Centers for Medicare & Medicaid Services (CMS) to identify the 25 orthopaedic surgeons with the highest compensation from each of the 10 largest orthopaedic companies from 2013 to 2017. Statistical analyses were conducted to investigate the factors that contributed to payment differences. Results:. Among the 347 highest-compensated orthopaedic surgeons, only 1 woman (0.29%) was identified. Orthopaedic surgeons in the subspecialties of spine (32.9%), adult reconstruction (27.9%), and sports medicine (14.5%) made up a majority of the 25 highest earners. A larger proportion of the physicians in this study worked in private practice (57.6%) compared with an academic setting (42.4%). Orthopaedic surgeons who subspecialize in sports medicine had significantly higher total mean payment amounts when compared with all other specialties. The primary method of compensation was found to be through licensing or royalty payments. Conclusions:. The large majority of orthopaedic surgeons who are highly compensated from industry are men. Among these, the greatest number specialize in the spine, while sports medicine surgeons receive significantly higher total mean payment amounts. Additional studies are warranted to evaluate the disparities between men and women and encourage policies to promote gender equality.

Background Trauma is a major public health issue. In 2015, the White House launched the “Stop the Bleed” (STB) campaign, which aims to equip would-be bystanders with the ability and equipment to assist in bleeding emergencies. This study sought to estimate the number of patients who might benefit from STB intervention, in an everyday setting, and their spatial injury profile.Methods This is a retrospective analysis of trauma registry and medical examiners’ data, collected between 2013 and 2017. The majority of patients were male. The median age was 32 years. Incidents were geocoded by ZIP code, and mapped using Quantum Geographic Information System (QGIS).Results We identified 139 patients from medical examiner records and UAB’s trauma registry who might have benefitted from STB intervention. The number of incidents per year ranged from 22 to 35, averaging 2.3 incidents per month. There was no evidence of geographical clustering, although the small number of incidents precluded a formal geostatistical analysis.Conclusion The number of patients who might benefit from STB interventions on a daily basis is small, and incident locations are difficult to predict. Educating the public in how to stop bleeding is appealing, but providing easy and widespread access to STB kits may be difficult. Although there are parallels to the provision of cardiopulmonary resuscitation and defibrillation for cardiac arrest, there are also differences, which should not be overlooked.

Category: Ankle; Hindfoot Introduction/Purpose: Flexor Hallucis Longus (FHL) tendon transfer to the calcaneus is a common adjuvant procedure in the treatment of Achilles pathology. The FHL tendon can be harvested using a posterior incision where the tendon is dissected along its course into the fibroosseous tunnel. Alternatively, the FHL may be harvested through a separate plantar medial incision as it crosses the flexor digitorium longus at the Knot of Henry. This study aims to quantify FHL tendon lengths achieved through the two common approaches utilizing pair matched cadavers. Methods: Seven pair matched fresh-frozen cadaver legs without signs of musculoskeletal abnormalities were used for this assessment. One leg in each pairing underwent a single incision harvest while the contralateral leg underwent an accessory medial plantar harvest. After dissecting the tendon, a calcaneus tunnel was prepared from dorsal to plantar in both calcanei in standard fashion. Two measurements were obtained. The first measurement was taken from the distal aspect of the muscle belly to the distal end of the tendon. The tendon was then pulled through the calcaneus, and the foot was held in tension at 20 degrees of plantar flexion. The second measurement was taken from site where tendon entered the calcaneous to the distal end of the tendon graft. The measurements were analyzed using Wilcoxon Signed Ranks Test and Fischer Exact Test. Results: Using a posterior incision, the mean tendon measurement from calcaneous tunnel to the distal end of the tendon was 4.0 cm. Using an accessory plantar medial incision, the mean tendon measurement from the calcaneous tunnel to the distal end of the tendon was 7.2 cm. The average tunnel length obtained using an accessory medial incision was significantly greater than the length obtained using the single incision approach (p= 0.0003, p=0.0022, and p=0.0016). The accessory plantar medial incision obtained an FHL tendon tunnel length that was an average of 2.9 cm greater than the posterior incision. Conclusion: The single incision approach provided sufficient length to safely anchor the FHL into the calcaneus which suggests that the accessory plantar medial approach is not necessary for routine FHL transfers to the calcaneus with interference screw fixation. However, if additional length is needed for other applications such as posterior tibialis tendon dysfunction or peritoneal tendon tears, the accessory incision does provide an average of 2.9 cm of additional length.

Category: Hindfoot; Trauma Introduction/Purpose: The lateral extensile approach (LEA) to the calcaneus has long been a popular surgical approach to treat calcaneal fractures. However, high rates of wound complications have led surgeons to investigate alternative approaches. As a result, the sinus tarsi approach has grown in popularity. The lateral extensile approach affords substantial visualization of the calcaneus. However, this visualization has never been compared in a quantitative manner to the sinus tarsi approach (STA). The objective of this cadaveric study is to compare calcaneal visualization afforded by a sinus tarsi approach and a lateral extensile approach. Methods: Seven pair-matched, fresh-frozen, below-knee cadaver specimens were obtained. For each pair, one side received an LEA and the other side received a STA. To identify areas of the calcaneus accessible by instrument, a curette was used to mark the visualized calcaneal surfaces. The calcaneus was then disarticulated and cleared of all soft tissue. The curette markings were then identified and marked with blue surgical marker. Photos were taken of each calcaneus, and visualized surface areas were calculated using Image J software. Results: There were no statistically significant differences in the articular surfaces accessible between the two approaches (831.99 mm2 for LEA vs. 903.41 mm2 for STA, p=0.53) including the anterior, middle, and posterior facets. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA (p=0.02). The LEA allowed better exposure to the lateral wall (p

Category: Ankle; Trauma Introduction/Purpose: With the U.S. healthcare system focused on value of care, providers and hospitals are increasingly measured by factors that increase patient care and decrease healthcare cost. Early postoperative adverse events not only increase healthcare cost, but also illuminate areas of potential improvement in patient care. This study aims to delineate factors that may influence emergency department visits, admissions, and reoperations within 30 days of ankle fracture surgery. Methods: This retrospective review of patients at a Level 1 trauma center evaluated 30-day outcomes after ankle fracture surgery over a 4-year period (2015-2018). The outcome measures assessed were emergency department visits within 30 days, unplanned readmissions within 30 days and unplanned return to the operating room (OR) within 30 days. Patient and injury characteristics were investigated as potential factors related to these 30-day outcomes. Multiple linear regression was used for outcomes. P-values less than 0.05 were considered significant. Results: A total of 619 patients were identified. After exclusion of concurrent pilon fractures, 596 patients were eligible for final analysis. Forty-three (7.2%) patients visited the emergency department within thirty days, 30 (5.0%) patients were readmitted within thirty days, and 10 (1.7%) patients requiring unplanned return to the OR within thirty days. Sex, insurance status, comorbidities such as pulmonary disease, diabetes mellitus, psychiatric disease, and chronic kidney disease, smoking status, and fracture type/location were not found to be significantly related to 30-day events. Age less than 45 was a significant risk factor for returning to the ED within 30 days (RR 2.1, p=0.02). Open fractures were more likely to require unplanned reoperation than closed fractures (RR 5.7, p

Category: Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. The purpose of this study is to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery. Methods: Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. All patients prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin. Results: Among patients not taking opioids or gabapentin preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed postoperative gabapentin (177.3 OME) in comparison to those prescribed only opioids (442.2 OME) (p=0.0018) in the 3-6 week postoperative interval. When all patients were analyzed, including those taking preoperative opioids or gabapentin, patients who received postoperative gabapentin were also prescribed significantly fewer OME at weeks 1-2 (p= 0.0270), weeks 3-6 (p = 0.0006), and weeks 7 - 12 (p = 0.0149). Conclusion: Gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Prospective clinical trials are warranted to further validate these results.

ABSTRACT Objective: To identify independent risk factors, complications and early hospital readmission following total knee arthroplasty. Methods: Using the ACS-NSQIP database, we identified patients who underwent primary TKA from 2012-2015. The primary outcome was early hospital readmission. Patient demographics, preoperative comorbidities, laboratory data, operative characteristics, and postoperative complications were compared between readmitted and non-readmitted patients. Logistic regression identified independent risk factors for 30-day readmission. Results: 137,209 patients underwent TKA; 3.4% were readmitted within 30 days. Advanced age, male sex, black ethnicity, morbid obesity, presence of preoperative comorbidities, high ASA classification, and increased operative time were independently related risk factors. Asian and no reported race were negative risk factors. Postoperative complications: acute myocardial infarction, acute renal failure, stroke, pneumonia, pulmonary embolism, and deep vein thrombosis show positive associations. Conclusions: Advanced age, male sex, black ethnicity, morbid obesity, presence of comorbidities, high ASA classification and long operative time are independent risk factors for postoperative complications and early hospital readmission following total knee arthroplasty. Level of Evidence III, Case control study.

Abstract Background Older drivers aged ≥70 years old have among the highest rates of motor vehicle collisions (MVC) compared to other age groups. Driving is a highly visual task, and older adults have a high prevalence of vision impairment compared to other ages. Most studies addressing visual risk factors for MVCs by older drivers utilize vehicle accident reports as the primary outcome, an approach with several methodological limitations. Naturalistic driving research methods overcome these challenges and involve installing a high-tech, unobtrusive data acquisition system (DAS) in an older driver’s own vehicle. The DAS continuously records multi-channel video of driver and roadway, sensor-based kinematics, GPS location, and presence of nearby objects in front of the vehicle, providing an objective measure of driving exposure. In this naturalistic driving study, the purpose is to examine the relationship between vision and crashes and near-crashes, lane-keeping, turning at intersections, driving performance during secondary tasks demands, and the role of front-seat passengers. An additional aim is to compare results of the on-road driving evaluation by a certified driving rehabilitation specialist to objective indicators of driving performance derived from the naturalistic data. Methods Drivers ≥70 years old are recruited from ophthalmology clinics and a previous population-based study of older drivers, with the goal of recruiting persons with wide ranging visual function. Target samples size is 195 drivers. At a baseline visit, the DAS is installed in the participant’s vehicle and a battery of health and functional assessments are administered to the driver including visual-sensory and visual-cognitive tests. The DAS remains installed in the vehicle for six months while the participant goes about his/her normal driving with no imposed study restrictions. After six months, the driver returns for DAS de-installation, repeat vision testing, and an on-road driving evaluation by a certified driving rehabilitation specialist (CDRS). The data streams recorded by the DAS are uploaded to the data coordinating center for analysis. Discussion The Alabama VIP Older Driver Study is the first naturalistic older driver study specifically focused on the enrollment of drivers with vision impairment in order to study the relationship between visual dysfunction and driver safety and performance.

Objective: The objective of this study is to evaluate the the reliability of magnetic resonance imaging (MRI) in diagnosing alar ligament disruption in patients with potential atlanto-occipital dissociation (AOD). Materials and Methods: Three-blinded readers performed retrospective review on 6 patients with intra-operative confirmed atlanto-occipital dissocation in addition to a comparison cohort of patients with other cervical injuries that did not involve the atlanto-occipital articulation. Ligament integrity was graded from 1 to 3 as described by Krakenes et al. The right and left ligaments were assessed separately. Inter-observer agreement by patient, by group (AOD vs. non-AOD), and intra-observer agreement was calculated using weighted Cohen's kappa. Results: Interobserver agreement of alar ligament grade for individual patients ranged from slight to fair (κ = 0.05–0.30). Interobserver agreement of alar ligament grade for each group (AOD vs. non-AOD) ranged from fair to substantial (κ = 0.37–0.66). No statistically significant difference in categorical analysis of groups (AOD vs. non-AOD) and grade (0–1 vs. 2–3) was observed. Intraobserver agreement of individual patient's alar ligament grade ranged from moderate to substantial (κ = 0.50–0.62). Conclusion: The use of MRI to detect upper cervical ligament injuries in AOD is imperfect. Our results show inconsistent and unsatisfactory interobserver and intraobserver reliability in evaluation of alar ligament injuries. While MRI has immense potential for detection of ligamentous injury at the craniovertebral junction, standardized algorithms for its use and interpretation need to be developed.

Abstract Background Muscle mass and strength are strong determinants of a person’s quality of life and functional independence with advancing age. While resistance training is the most effective intervention to combat age-associated muscle atrophy (sarcopenia), the ability of older adults to increase muscle mass and strength in response to training is blunted and highly variable. Thus, finding novel ways to complement resistance training to improve muscle response and ultimately quality of life among older individuals is critical. The purpose of this study is to determine whether a commonly prescribed medication called metformin can be repurposed to improve the response to resistance exercise training by altering the muscle tissue inflammatory environment. Methods/design Individuals aged 65 and older are participating in a two-site, randomized, double-blind, placebo-controlled trial testing the effects of metformin or placebo on muscle size, strength, and physical function when combined with a progressive resistance training program. Participants consume 1700 mg of metformin per day or placebo for 2 weeks before engaging in a 14-week progressive resistance training regimen, with continued metformin or placebo. Participants are then monitored post-training to determine if the group taking metformin derived greater overall benefit from training in terms of muscle mass and strength gains than those on placebo. Muscle biopsies are taken from the vastus lateralis at three time points to assess individual cellular and molecular adaptations to resistance training and also changes in response to metformin. Discussion The response of aged muscles to a resistance training program does not always result in a positive outcome; some individuals even experience a loss in muscle mass following resistance training. Thus, adjuvant therapies, including pharmacological ones, are required to optimize response to training in those who do not respond and may be at increased risk of frailty. This is the first known metformin repurposing trial in non-diseased individuals, aimed specifically at the resistance exercise “non-responder” phenotype present in the aging population. The overall goal of this trial is to determine if combined exercise-metformin intervention therapy will benefit older individuals by promoting muscle hypertrophy and strength gains, thereby maintaining functional independence. Trial registration ClinicalTrials.gov, NCT02308228 . Registered on 25 November 2014.

Background The use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for patients with severe acute respiratory distress syndrome is gaining greater acceptance among trauma intensivists. The objective of this study was to review ECMO usage in trauma patients in the USA.Methods The National Inpatient Sample (NIS) from years 2002 to 2012 was queried for patients aged 15 and older treated with ECMO who had one or more acute traumatic injuries as defined by the International Diagnostic Codes, Ninth Edition (ICD-9). The primary outcomes of interest were incidence of ECMO and overall inpatient mortality.Results A total of 1347 patients were identified in the NIS database who had both ECMO performed and ICD-9 codes consistent with trauma. Patients were predominantly aged 15 to 29 years (31.4%) and were male (65.5%). The incidence of ECMO for patients after traumatic injuries has increased 66-fold during the 10-year period. In-hospital mortality was 48.0% overall, with a decreasing trend during the study period that approached statistical significance (p=0.06).Discussion Although ECMO use in patients in the post-trauma setting remains controversial, there is an increasing trend to use ECMO nationwide, suggesting an increasing acceptance and/or increased availability at trauma centers. Given the decrease in mortality during the study period, ECMO as a salvage method in trauma patients remains a potentially viable option. Evaluation in a prospective manner may clarify risks and benefits.Level of evidence Level IV, epidemiological.

Category: Foot & Ankle Surgery Introduction/Purpose: Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. This study aims to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery. Methods: Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. Those prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin. Results: Among patients prescribed gabapentin plus opioids, total opioids prescribed (in morphine equivalents, OME) was 68.33, 221.25, 87.50, and 400.83 at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. Although not statistically significantly different, patients prescribed only opioids had greater average amounts of opioids prescribed at all time intervals, equaling 98.34 OME, 553.52 OME, 540.53 OME, and 766.25 OME at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. When excluding patients taking opioids preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed gabapentin (196.94 OME) in comparison to those prescribed only opioids (457.41 OME) (p=0.0255). Conclusion: The findings of this study suggest that gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Gabapentin may be particularly beneficial within the three to six week postoperative period. Prospective clinical trials are warranted to further validate these results.

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are commonly-seen orthopaedic injuries across all age groups, and often warrant operative management. Postoperative complications are particularly common among elderly patients, and can lead to a progressive culmination of negative outcomes. Although several studies have focused on the risk factors for and prevention of such complications in elderly patients, a paucity of literature exists addressing risk of postoperative complications in younger patient populations. The purpose of this study was to compare the incidence of and risk factors for various postoperative complications between younger and older patient populations. Methods: Patients who underwent open reduction and internal fixation for an ankle fracture at a single institution between the years 2008 and 2018 were retrospectively identified based on seven different Current Procedural Terminology (CPT) codes: 27829, 27784, 27822, 27814, 27769, 27792, and 27766. Patient charts were reviewed for demographic data and comorbid conditions. Patients with open fractures, pilon fractures, and polytraumatic injuries were excluded. The sample was stratified into two cohorts based on age in years: 18-49 (group 1), and 50 and older (group 2). Incidence of various postoperative complications—including infection, wound dehiscence, sepsis, DVT, implant failure, revision surgery, and non-union— was compared between groups. Secondary analysis was conducted to compare risk factors for these complications between ages 18- 49 and older than 50. Results: 881 patients were included. A significantly greater number of patients in group 2 experienced wound dehiscence (p = 0.033) and nonunion (p

Category: Ankle, Trauma Introduction/Purpose: There is hesitancy to administer nonsteroidal anti-inflammatories (NSAIDs) within the postoperative period following fracture care due to concern for delayed union or nonunion. However, aspirin (ASA) is routinely used for chemoprophylaxis of deep vein thrombosis (DVT) and is gaining popularity for use after treatment of ankle fractures. We examine the incidence of nonunion of operative ankle fractures and risk of DVT in patients who did and did not receive postoperative ASA. We hypothesize that time to clinical and radiographic union and the risk of DVT are no different. Methods: A retrospective chart review was performed on all patients treated between 2008 and 2018 for ankle fractures requiring operative fixation by three Foot and Ankle fellowship trained orthopaedic surgeons at a single institution with a minimum of 3 months follow up. Demographics, preoperative comorbidities, and postoperative medical and surgical complications were compared between patients who did and did not receive ASA postoperatively. For both groups, union was evaluated by clinical exam as well as by radiograph. Results: 506 patients met inclusion criteria: 152 received ASA and 354 did not. Radiographic healing at 6 weeks was demonstrated in 95.9% (94/98) and 98.6% (207/210) respectively (p-value .2134). There was no significant difference in time to radiographic union between groups. The risk of postoperative DVTs in those with and without ASA was not significantly different (0.7% (1/137) vs 1.2% (4/323), respectively; p-value .6305). Conclusion: Postoperative use of ASA does not delay radiographic union of operative ankle fractures or affect the rate of postoperative DVT. This is the first and largest study to examine the effect of ASA on time to union of ankle fractures.

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are among the most common orthopedic injuries. While open reduction and internal fixation (ORIF) is the standard treatment for displaced ankle fractures in younger patients, there is controversy regarding the optimal management of these injuries among geriatric patients due to the high prevalence of comorbidities. Closed manipulation leads to poor long-term functional outcomes, with high rates of malunion and non-union in all populations as well as higher mortality in patients over 65 years of age. However, surgical management in the elderly carries rates of complications as high as 20-40%. The purpose of this study was to investigate risk factors for healing complications following ORIF of ankle fractures in patients greater than 75 years of age. Methods: All patients 75 years of age and older undergoing open reduction and internal fixation of ankle fractures at a single institution from 2008 to 2018 were identified. Patients with polytrauma and/or pilon fractures were excluded. Patient medical records were reviewed to obtain information regarding details about the injury, surgery, and follow-up as well as patient demographics and comorbidities. Radiographs from post-operative clinic visits were examined by a foot and ankle certified orthopedic fellow for each patient and the time for complete union was recorded as well as any delayed union or malunion. Fisher’s exact tests were used to compare post-operative complications (wound infection, wound dehiscence, sepsis, deep vein thrombosis, revision surgery, and malunion/nonunion) among those with and without specific comorbidities. Results: Patients with other comorbidities had a statistically significant increased risk of revision surgery (p

Objective To report results of a national survey of provider attitudes, observations, and opinions regarding the use of extracorporeal membranous oxygenation (ECMO) to manage severe acute respiratory distress syndrome (ARDS) in trauma patients.Design A survey was created to query providers on the use of ECMO in trauma, as well as general management principals related to care of the patient with refractory hypoxic respiratory failure. The survey was sent to all members of Eastern Association for the Surgery of Trauma (EAST). Once completed, the survey was returned to the University of Alabama at Birmingham and results were analyzed.Setting/patients Trauma patients with refractory ARDS.Interventions None.Measurements and main results Respondents were from 37 states, the District of Columbia, and Puerto Rico. 56.9% reported institutional ECMO capabilities, but only 45.2% reported using ECMO for trauma patients. Most respondents (90.2%) reported ECMO use in less than or equal to five trauma patients per year. 20.9% think there is not enough data to support its use in trauma but only 4.7% would absolutely not consider ECMO use for trauma patients. Ranking the preferred modality of treatments for refractory ARDS from most to least preferable is as follows: airway pressure release ventilation, bilevel ventilation, paralysis, prone positioning, inhaled nitric oxide, epoprostenol, high-frequency oscillatory ventilation, corticosteroids, surfactant.Conclusions ARDS has a high mortality among trauma patients. Despite its utility in treating severe ARDS and other pulmonary disease processes, ECMO has not been universally embraced by the trauma community. There are an increasing number of studies that suggest that ECMO is a safe and viable treatment option for trauma patients with ARDS. Based on the results of this survey, ECMO use remains limited by trauma providers that care for patients with refractory hypoxic respiratory failure and ARDS, likely due to a combination of knowledge gaps and lack of access to ECMO.Level of evidence Level V.

Aims To determine whether the proportion of time systemic lupus erythematosus patients achieve remission/low disease activity state (LDAS) is associated with a better quality of life (QoL).Patients and methods Patients from a well-established multiethnic, multicentre US cohort were included: remission: Systemic Lupus Activity Measure (SLAM) score=0, prednisone≤5 mg/day and no immunosuppressants); LDAS not in remission, SLAM score≤3, prednisone≤7.5 mg/day, no immunosuppressants; the combined proportion of time patients were in these states was the independent variable. The endpoints were the Physical and Mental Components Summary measures (PCS and MCS, respectively) and the individual subscales of the Short Form (SF)-36 at the last visit. Linear regression was used to estimate the association between the proportion of follow-up time in remission/LDAS and the SF-36 measures with and without adjustment for possible confounders.Results Four hundred and eighty-three patients were included. The per cent of time on remission/LDAS was associated with better QoL after adjusting for potential confounders; for the PCS the parameter estimate was 9.47 (p

Background and study aims Colonoscopy can be technically challenging and cause discomfort in patients. The integrated Scope Guide assist is built in to show that with its use outcomes are improved during colonoscopy. We aimed to test the usefulness of the Magnetic Scope Guide Assist (ScopeGuide) with respect to cecal intubation time, and other procedural quality outcomes. Patients and methods We conducted a prospective study of outpatients undergoing elective colonoscopy at the endoscopic units of the University of Alabama at Birmingham (UAB) from March 2016 to July 2016. Patients were randomly assigned in a 1:1 block design to groups that either had standard colonoscopy or Scope-guided colonoscopy. The primary outcome measure was cecal intubation time (CIT). Secondary outcome measures included use of manual pressure, position changes for cecal intubation and sedation requirements. Results Three hundred patients were randomized to either group; standard (n = 150) vs. Scope-guided (n = 150). The mean CIT was not statistically different for the standard and the Scope-guided groups (4.6 vs. 4.3 minutes; P = 0.46). There were also no statistical differences in frequency of manual pressure applied (16.7 % for Scope-guided vs. 19.1 % for standard; P = 0.65) or position changes (11.4 % for scope guided vs. 8.8 % standard; P = 0.56). Sedation requirements showed lesser use of midazolam (3.9 mg vs. 4.7 mg, P = 0.003) in the Scope-guide group, while there was no significant difference in use of fentanyl (fentanyl – 62.1 mg vs. 68.9 mg, P = 0.09 similar between groups, for Scope-guided vs. standard groups, respectively). Adverse events were similar in both groups. Conclusions In patients undergoing routine elective colonoscopy, use of ScopeGuide by experienced colonoscopists did not improve CIT or affect the frequency of ancillary maneuvers. The benefit of this device during training of endoscopists could be considered for further studies.

Introduction. Spinopelvic dissociation injuries are historically treated with open reduction with or without decompressive laminectomy. Recent technological advances have allowed for percutaneous fixation with indirect reduction. Herein, we evaluate outcomes and complications between patients treated with open reduction versus percutaneous spinopelvic fixation. Methods. Retrospective review of patients undergoing spinopelvic fixation from a single, level one trauma center from 2012 to 2017. Patient information regarding demographics, associated injuries, and treatment outcome measures was recorded and analyzed. All fractures were classified via the AO Spine classification system. Results. Thirty-one spinopelvic dissociations were identified: 15 treated with open and 16 with percutaneous techniques. The two treatment groups had similar preoperative characteristics including spinopelvic parameters (pelvic incidence and lumbar lordosis). Compared to open reduction internal fixation, percutaneous fixation of spinopelvic dissociation resulted in statistically significantly lower blood loss (171 cc versus 538 cc; p=0.0013). There were no significant differences in surgical site infections (p=0.48) or operating room time (p=0.66). Conclusion. Percutaneous fixation of spinopelvic dissociation is associated with significantly less blood loss. Treatment outcomes in terms of infection, length of stay, operative cost, and final alignment between the open and percutaneous group were similar.

Purpose. To identify treatment preferences of patients with diabetic macular edema (DME) having undergone laser and intravitreal injections. Methods. Patients with DME who received lasers and injections were surveyed, measuring preferences toward specific treatments. 66/210 diabetic patients met the criteria for our survey assessing preference for lasers and/or injections, incorporating demographics and treatment preference questions. Outcome measures included treatment preference (laser or injections), how often patients are willing to be treated, and how much vision they will sacrifice to avoid being treated every month. Results. 66 patients completed the survey. The mean diabetes duration was 20.7 years, the mean retina follow-up was 4.4 years, and patients received a mean of 4.82 lasers and 4.86 injections. 56% preferred injections, 33% preferred laser, and 11% had no preference. Regarding treatment effectiveness, 38% found no difference, 36% chose laser, and 25% chose injections. Regarding anxiety, 56% reported injection anxiety. While 50% versus 38% reported that laser was easier than injections. 91% would give up zero lines on the eye chart, and 76% would come in 12 times yearly for treatment to maintain vision. Conclusion. Patients with DME have no profound preference regarding laser versus intravitreal injections but prefer aggressive treatment and are unwilling to sacrifice vision for less visits.

This study examined whether cognitive impairment and decline as assessed by a brief mental status screening test is associated with future crash risk in a cohort of older drivers. A three-year prospective study was conducted in a population-based sample of 2000 licensed drivers, aged 70 years and older. At the baseline visit, cognitive impairment was defined as

Previous studies have suggested that the pattern of cognitive impairment in crash-involved older drivers is different from non-crash-involved older drivers. This study assessed the relationship between seven areas of cognitive functioning (orientation to time, orientation to place, registration, attention and calculation, recall, language, and visual construction) on the Mini-Mental State Examination (MMSE) collected at baseline and rates of future crash involvement in a prospective population-based sample of older drivers. Motor vehicle collision (MVC) involvement was obtained from the Alabama Department of Public Safety. Poisson regression was used to calculate crude and adjusted rate ratios (RR). Older drivers having difficulties in place orientation were more than 6 times (95% CI 1.90–19.86) more likely to be involved in a future crash (adjusted RR = 6.14, 95% confidence interval (CI) 1.90–19.86) and at-fault crash (adjusted RR = 6.39, 95% CI 1.51–27.10). Impairment in the other cognitive areas was not associated with higher rates of crash or at-fault crash involvement. The findings were validated in an independent sample of high-risk older drivers and a similar pattern of results was observed. Spatial orientation impairment can help identify older drivers who are more likely to crash in the future.

Purpose: The purpose of this study was to evaluate the association between the federally mandated Minimum Data Set (MDS) Vision Patterns assessment for nursing home residents in the United States and an assessment of their vision-targeted quality of life as assessed by certified nursing assistants (CNAs). Methods: Participants were 371 residents over the age of 55 from 17 nursing homes in the Birmingham, Alabama metropolitan area and the CNAs directly assigned to their care. CNAs assessed the vision-targeted quality of life of residents in their charge using the Nursing Home Vision-Targeted Health-Related Quality of Life (NHVQoL) questionnaire. MDS assessment categories assigned to each resident by the MDS nurse coordinator (“adequate”, “impaired”, “moderately impaired”, “highly impaired”, “severely impaired”) were obtained from the medical record. Visual acuity was measured using logMAR charts by trained research staff. Results: CNA-rated NHVQoL subscale scores decreased as the MDS rating indicated more vision impairment (all P's for trend

Background: The diagnostic yield of capsule endoscopy is vulnerable to inadequate visualization related to residual bile or chyme remaining in the lumen despite intestinal lavage. It has been challenging to determine the optimal lavage preparation of the bowel and patient diet before capsule endoscopy, as well as the timing of the procedure, because no well-accepted, validated grading system for assessing the quality of intestinal lavage before capsule endoscopy is available. There remains no consensus on the reliability of qualitative, quantitative, or computer-derived assessments of the quality of preparation for capsule endoscopy. This study evaluates intra-observer and interobserver agreement for a previously validated scale. Materials and methods: The digital images of 34 patients who underwent capsule endoscopy were independently reviewed by two blinded physicians according to a previously validated grading scale. One of the physicians reviewed and graded the patients a second time. The quality of the bowel luminal preparation was assessed with a qualitative parameter (fluid transparency) and a more quantitative parameter (mucosal invisibility) for each of three small-intestinal segments, and an overall small-bowel score for each parameter was assigned as well. A weighted kappa coefficient was used to calculate intra-observer (observer 1A and 1B) and interobserver (observer 1A and observer 2) agreement. A kappa value of 0.60 or more suggests strong agreement, 0.40 to 0.60 moderate agreement, and less than 0.40 poor agreement. Results: The intra-observer weighted kappa index for both fluid transparency and mucosal visibility was 0.52, which is consistent with moderate agreement. The interobserver weighted kappa indices for fluid transparency and mucosal invisibility were 0.29 and 0.42, respectively, demonstrating suboptimal interobserver agreement. The individual segment interobserver kappa indices were better for mucosal visibility (0.52, 0.39, and 0.47 for small-bowel segments 1, 2, and 3, respectively) than for fluid transparency (0.18, 0.38, and 0.31). Conclusions: The proposed grading scale for assessing the quality of preparation for capsule endoscopy has inadequate interobserver and intra-observer agreement. Capsule endoscopy preparation grading scales that focus more on quantitative than on qualitative assessment may demonstrate more reliable performance characteristics. Optimizing the quality of preparation and diagnostic yield of capsule endoscopy will first require the development of a well-validated grading scale.

Background. This study aimed to determine whether it is possible to predict driving safety of individuals with homonymous hemianopia or quadrantanopia based upon a clinical review of neuroimages that are routinely available in clinical practice. Methods. Two experienced neuroophthalmologists viewed a summary report of the CT/MRI scans of 16 participants with homonymous hemianopic or quadrantanopic field defects which indicated the site and extent of the lesion and they made predictions regarding whether participants would be safe/unsafe to drive. Driving safety was independently defined at the time of the study using state-recorded motor vehicle crashes (all crashes and at-fault) for the previous 5 years and ratings of driving safety determined through a standardized on-road driving assessment by a certified driving rehabilitation specialist. Results. The ability to predict driving safety was highly variable regardless of the driving safety measure, ranging from 31% to 63% (kappa levels ranged from −0.29 to 0.04). The level of agreement between the neuroophthalmologists was only fair (kappa = 0.28). Conclusions. Clinical evaluation of summary reports of currently available neuroimages by neuroophthalmologists is not predictive of driving safety. Future research should be directed at identifying and/or developing alternative tests or strategies to better enable clinicians to make these predictions.

Renal involvement is a serious manifestation of systemic lupus erythematosus (SLE); it may portend a poor prognosis as it may lead to end-stage renal disease (ESRD). The purpose of this study was to determine the factors predicting the development of renal involvement and its progression to ESRD in a multi-ethnic SLE cohort (PROFILE).PROFILE includes SLE patients from five different United States institutions. We examined at baseline the socioeconomic-demographic, clinical, and genetic variables associated with the development of renal involvement and its progression to ESRD by univariable and multivariable Cox proportional hazards regression analyses. Analyses of onset of renal involvement included only patients with renal involvement after SLE diagnosis (n = 229). Analyses of ESRD included all patients, regardless of whether renal involvement occurred before, at, or after SLE diagnosis (34 of 438 patients). In addition, we performed a multivariable logistic regression analysis of the variables associated with the development of renal involvement at any time during the course of SLE. In the time-dependent multivariable analysis, patients developing renal involvement were more likely to have more American College of Rheumatology criteria for SLE, and to be younger, hypertensive, and of African-American or Hispanic (from Texas) ethnicity. Alternative regression models were consistent with these results. In addition to greater accrued disease damage (renal damage excluded), younger age, and Hispanic ethnicity (from Texas), homozygosity for the valine allele of FcgammaRIIIa (FCGR3A*GG) was a significant predictor of ESRD. Results from the multivariable logistic regression model that included all cases of renal involvement were consistent with those from the Cox model.Fcgamma receptor genotype is a risk factor for progression of renal disease to ESRD. Since the frequency distribution of FCGR3A alleles does not vary significantly among the ethnic groups studied, the additional factors underlying the ethnic disparities in renal disease progression remain to be elucidated.

ABSTRACT Objective To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients. Methods The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years). Results The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments. Conclusion Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.