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Accurate global mapping of soil moisture is the goal of the Soil Moisture Active Passive (SMAP) mission, which is expected to improve the estimation of water, energy, and carbon exchanges between the land and the atmosphere. Like other satellite products, the SMAP soil moisture retrievals need to be validated, with the validation relying heavily on in situ measurements. However, a one-to-one comparison is ill advised due to the spatial mismatch of the large SMAP footprint (∼40 km) and the point scale in situ measurements. This study uses a recently developed hyper-resolution land surface model—HydroBlocks—as a tool to upscale in situ soil moisture measurements for the SMAPVEX15 (SMAP Validation Experiment 2015) field campaign during 2–18 August 2015. Calibrated against in situ observation, HydroBlocks shows a satisfactory Kling-Gupta efficiency (KGE) of 0.817 and RMSE of 0.019 m3/m3 for the calibration period. These results indicate that HydroBlocks can be used to upscale in situ measurements for this site. Different from previous studies, here in situ measurements are upscaled using a land surface model without bias correction. The upscaled soil moisture is then used to evaluate SMAP (passive) soil moisture products. The comparison of the upscaled network to SMAP shows that the retrievals are generally able to capture the areal-averaged soil moisture temporal variations. However, SMAP appears to be oversensitive to summer precipitation. We expect these findings can be used to improve the SMAP soil moisture product and thus facilitate its usage in studying the water, energy, and carbon cycles.

Objective: To model the effect of excluding payment for eight hospital-acquired conditions (HACs) on hospital payments in Victoria, Australia.Design, Setting and Participants: Retrospective ecological study using the Victorian Admitted Episodes Dataset. The analysis involved all acute inpatient admissions to Victorian public and private hospitals between 1 July 2007 and 30 June 2008.Interventions: Each admission record includes up to 40 diagnosis and procedure codes from which payments are calculated. The model deleted diagnosis codes for eight HACs from all records, then recalculated payments to estimate the impact of a policy of non-payment for HACs.Main Outcome Measure: The effect on hospital payments of excluding diagnosis codes for eight HACs.Results: 2,047,133 cases with total estimated payments of $4902 million were identified; 994 cases (0.05%) had one or more diagnoses meeting the code definition for a definable HAC, representing total payments of $24.1 million. In-hospital falls and pressure ulcers were the most commonly coded HACs. Applying a model that excluded HAC diagnosis codes changed the diagnosis-related group for 134 cases (13.5%), thereby generating a $448,630 reduction in payments.Conclusions: Introducing a non-payment for HACs policy similar to that introduced by Medicare in the United States would have little direct financial impact in the Australian context, although additional savings would accrue if HAC rates were reduced. Such a policy could add further incentive to current initiatives aimed at reducing HACs. [ABSTRACT FROM AUTHOR]

Posterior spinal fusion has long been established as an effective treatment for the surgical management of spine deformity. However, interest in nonfusion options continues to grow. Vertebral body tethering is a nonfusion alternative that allows for the preservation of growth and flexibility of the spine. The purpose of this investigation is to provide a practical and relevant review of the literature on the current evidence-based indications for vertebral body tethering. Early results and short-term outcomes show promise for the first generation of this technology. At this time, patients should expect less predictable deformity correction and higher revision rates. Long-term studies are necessary to establish the durability of early results. In addition, further studies should aim to refine preoperative evaluation and patient selection as well as defining the benefits of motion preservation and its long-term effects on spine health to ensure optimal patient outcomes., Competing Interests: A.N.L. is a consultant in Orthopediatrics for Stryker, nView, Zimmer, Medtronic, and Globus with all funds directed to Pediatric Orthopedic Surgery Department at Mayo Clinic. T.A.M. is a consultant in Orthopediatrics for Depuy Synthes, Medtronic, and Zimmer with all funds directed to Pediatric Orthopedic Surgery at Mayo Clinic. Mayo Clinic has patent 10667845B2 issues with A.N.L. and T.A.M. as inventors. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The coronavirus disease 2019 (COVID-19) pandemic disrupted U.S. Military operations and potentially compounded the risk for adverse mental health outcomes by layering unique occupational stress on top of general restrictions, fears, and concerns. The objective of the current study was to characterize the prevalence of COVID-19 concerns and information needs, demographic disparities in these outcomes, and the degree to which COVID-19 concerns and information needs were associated with heightened risk for adverse mental health outcomes among U.S. Army soldiers., Materials and Methods: Command-directed anonymous surveys were administered electronically to U.S. soldiers assigned to one of three regional commands in the Northwest United States, Europe, and Asia-Pacific Region. Surveys were administered in May to June 2020 to complete (time 1: n = 21,294) and again in December 2020 to January 2021 (time 2: n = 10,861). Only active duty or active reservists/national guard were eligible to participate. Members from other branches of service were also not eligible., Results: Highly prevalent COVID-19 concerns included the inability to spend time with friends/family, social activities, and changing rules, regulations, and guidance related to COVID-19. Some information needs were endorsed by one quarter or more soldiers at both time points, including stress management/coping, travel, how to protect oneself, and maintaining mission readiness. COVID-19 concerns and information needs were most prevalent among non-White soldiers. Concerns and information needs did not decline overall between the assessments. Finally, COVID-19 concerns were associated with greater risk of multiple adverse mental health outcomes at both time points., Conclusions: COVID-19 concerns and information needs were prevalent and showed little evidence of decrement over the course of the first 6 months of the pandemic. COVID-19 concerns were consistently associated with adverse mental health outcomes. These data highlight two targets and potential demographic subgroups such that local leadership and Army medicine and public health enterprises can be better prepared to monitor and address to maintain force health and readiness in the face of possible future biomedical threats., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

The repair of neuronal tissue is a challenging process due to the limited proliferative capacity of neurons. Neural stem cells (NSCs) can aid in the regeneration process of neural tissue due to their high proliferation potential and capacity to differentiate into neurons. The therapeutic potential of these cells can only be achieved if sufficient cells are obtained without losing their differentiation potential. Toward this end, an astrocyte-derived coating (HAc) was evaluated as a promising substrate to promote the proliferation of NSCs. Mass spectroscopy and scanning electron microscopy were used to characterize the HAc. The proliferation rate and the expression of stemness and differentiation markers in NSCs cultured on the HAc were evaluated and compared to the responses of these cells to commonly used coating materials including Poly-L-Ornithine (PLO), and a Human Induced Pluripotent Stem Cell (HiPSC)-based coating. The use of the HAc promotes the in vitro cell growth of NSCs. The expression of the stemness markers Sox2 and Nestin, and the differentiation marker DCX in the HAc group was akin to the expression of these markers in the controls. In summary, HAc supported the proliferation of NSCs while maintaining their stemness and neural differentiation potential.

Sleep, activity, and nutrition (SAN) are key components in overall health, and an individual's knowledge about and self-confidence to engage in healthy SAN behaviors can have an impact on their actions. This evaluation examined SAN knowledge, self-confidence, and behaviors among U.S. Army Soldiers prior to participating in a health promotion program. Baseline surveys from participating Soldiers provide evidence in this evaluation. U.S. Army Soldiers ( N = 11,485) participating in a health promotion program completed surveys. Participants completed an online survey assessing SAN knowledge, self-confidence, and behaviors (among other constructs). We examined the common patterns of SAN behaviors, the associations between them, and the differences based on gender and rank. Knowledge, self-confidence, and behaviors were correlated within each of the three SAN domains. Men reported more aerobic exercise ( d = .48) and more resistance training ( d = .34) per week than women. Officers reported greater self-confidence in their ability to consume a post-exercise snack (i.e., refuel; d = .38), greater refueling behaviors ( d = .43), greater activity knowledge ( d = .33), and greater self-confidence in their ability to achieve activity goals ( d ranging from .33 to .39), compared to enlisted Soldiers. Finally, greater confidence in one's ability to achieve healthy sleep correlated with getting more sleep, both during workweek ( r = .56, p < .001) and weekend ( r = .25, p < .001). These baseline data support the need for health promotion of SAN behaviors among these Soldiers.

Competing Interests: A.N.L. is a consultant in Orthopediatrics for Stryker, nView, Zimmer, Medtronic, and Globus with all finds directed to Pediatric Orthopedic Surgery Department at Mayo Clinic. T.A.M. is a consultant in Orthopediatrics for Depuy Synthes, Medtronic, and Zimmer with all funds directed to Pediatric Orthopedic Surgery at Mayo Clinic. Mayo Clinic has patent 10667845B2 issues with A.N.L. and T.A.M. as inventors. The remaining authors declare no conflict of interest.

We previously reported that creatine supplementation improved intermittent isometric exercise performance by augmenting the total impulse performed above end-test torque (total IET'). However, our previous analyses did not enable mechanistic assessments. The objective of this study was to determine if creatine supplementation affected the IET' speed of recovery. To achieve this objective, we retrospectively analyzed our data using the IET' balance model to determine the time constant for the recovery of IET' ( τ IET'). Sixteen men were randomly allocated into creatine ( N  = 8) or placebo ( N  = 8) groups. Prior to supplementation, participants performed quadriceps all-out exercise to determine end-test torque (ET) and IET'. Participants then performed quadriceps exercise at ET + 10% until task-failure before supplementation (Baseline), until task-failure after supplementation (Creatine or Placebo), and until the Baseline time after supplementation (Creatine- or Placebo-Isotime). τ IET' was faster than Baseline for Creatine (669 ± 98 vs 470 ± 66 s), but not Placebo (792 ± 166 vs 786 ± 161 s). The creatine-induced change in τ IET' was inversely correlated with the creatine-induced changes in both the rate of peripheral fatigue development and time to task-failure. τ IET' was inversely correlated with total IET' and ET in all conditions, but creatine supplementation shifted this relationship such that τ IET' was faster for a given ET. Creatine supplementation, therefore, sped the recovery of IET' during intermittent isometric exercise, which was inversely related to the improvement in exercise performance. These findings support that the improvement in exercise performance after creatine supplementation was, at least in part, specific to effects on the physiological mechanisms that determine the IET' speed of recovery. HIGHLIGHTS Sixteen healthy participants were randomly allocated to creatine supplementation or placebo groups.Creatine supplementation accelerated the time constant for the recovery of IET' ( τ IET').The time constant for the recovery of IET' ( τ IET') was inversely related to both the rate of peripheral fatigue development and the time to task failure.

Background: Assessment of cortical bone porosity and geometry by imaging in vivo can provide useful information about bone quality that is independent of bone mineral density (BMD). Ultrashort echo time (UTE) MRI techniques of measuring cortical bone porosity and geometry have been extensively validated in preclinical studies and have recently been shown to detect impaired bone quality in vivo in patients with osteoporosis. However, these techniques rely on laborious image segmentation, which is clinically impractical. Additionally, UTE MRI porosity techniques typically require long scan times or external calibration samples and elaborate physics processing, which limit their translatability. To this end, the UTE MRI-derived Suppression Ratio has been proposed as a simple-to-calculate, reference-free biomarker of porosity which can be acquired in clinically feasible acquisition times., Purpose: To explore whether a deep learning method can automate cortical bone segmentation and the corresponding analysis of cortical bone imaging biomarkers, and to investigate the Suppression Ratio as a fast, simple, and reference-free biomarker of cortical bone porosity., Methods: In this retrospective study, a deep learning 2D U-Net was trained to segment the tibial cortex from 48 individual image sets comprised of 46 slices each, corresponding to 2208 training slices. Network performance was validated through an external test dataset comprised of 28 scans from 3 groups: (1) 10 healthy, young participants, (2) 9 postmenopausal, non-osteoporotic women, and (3) 9 postmenopausal, osteoporotic women. The accuracy of automated porosity and geometry quantifications were assessed with the coefficient of determination and the intraclass correlation coefficient (ICC). Furthermore, automated MRI biomarkers were compared between groups and to dual energy X-ray absorptiometry (DXA)- and peripheral quantitative CT (pQCT)-derived BMD. Additionally, the Suppression Ratio was compared to UTE porosity techniques based on calibration samples., Results: The deep learning model provided accurate labeling (Dice score 0.93, intersection-over-union 0.88) and similar results to manual segmentation in quantifying cortical porosity (R 2  ≥ 0.97, ICC ≥ 0.98) and geometry (R 2  ≥ 0.82, ICC ≥ 0.75) parameters in vivo. Furthermore, the Suppression Ratio was validated compared to established porosity protocols (R 2  ≥ 0.78). Automated parameters detected age- and osteoporosis-related impairments in cortical bone porosity (P ≤ .002) and geometry (P values ranging from <0.001 to 0.08). Finally, automated porosity markers showed strong, inverse Pearson's correlations with BMD measured by pQCT (|R| ≥ 0.88) and DXA (|R| ≥ 0.76) in postmenopausal women, confirming that lower mineral density corresponds to greater porosity., Conclusion: This study demonstrated feasibility of a simple, automated, and ionizing-radiation-free protocol for quantifying cortical bone porosity and geometry in vivo from UTE MRI and deep learning., Competing Interests: Declaration of competing interest B.C.J. No relevant relationships. F.W.W. No relevant relationships. N.K. No relevant relationships. R.D. No relevant relationships. B.D.V. No relevant relationships. H.K.S. No relevant relationships. H.L. No relevant relationships. R.G. No relevant relationships. T.J.C. No relevant relationships. W.R.W. No relevant relationships. N.J.J. No relevant relationships. S.K.I. No relevant relationships. M.a.M. Funding from Ipsen/Clementia, Incyte; funding from Regeneron; honoraria from Excel, Catalyst; support for meetings from Cooley Anemia Foundation, International Clinical. Counsel on Fibrodysplasia Ossificans Progressiva (FOP), International Fibrodysplasia. Ossificans Progressiva Association (IFOPA); advisory board member for Biocryst and IFOPA; member of the International Clinical Council on FOP. P.J.S. No relevant relationships. C.S.R. No relevant relationships., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Understanding the genome of Cannabis sativa holds significant scientific value due to the multi-faceted therapeutic nature of the plant. Links from cannabis gene to therapeutic property are important to establish gene targets for the optimization of specific therapeutic properties through selective breeding of cannabis strains. Our work establishes a resource for quickly obtaining a complete set of therapeutic properties and genes associated with any known cannabis chemical constituent, as well as relevant literature., Methods: State-of-the-art natural language processing (NLP) was used to automatically extract information from many cannabis-related publications, thus producing an undirected multipartite weighted-edge paragraph co-occurrence relationship network composed of two relationship types, gene-chemical and chemical property. We also developed an interactive application to visualize sub-graphs of manageable size., Results: Two hundred thirty-four cannabis constituent chemicals, 352 therapeutic properties, and 124 genes from the Cannabis sativa genome form a multipartite network graph which transforms 29,817 cannabis-related research documents from PubMed Central into an easy to visualize and explore network format., Conclusion: Use of our network replaces time-consuming and labor intensive manual extraction of information from the large amount of available cannabis literature. This streamlined information retrieval process will enhance the activities of cannabis breeders, cannabis researchers, organic biochemists, pharmaceutical researchers and scientists in many other disciplines., (© 2023. The Author(s).)

Introduction: The objective of this study is to characterize the associations between demographic, attitudinal, and leadership factors with COVID-19 vaccination rates, vaccination intentions among those not vaccinated, and attitudes about vaccination safety, effectiveness, and importance., Methods: A serial cross-sectional anonymous online survey was administered to soldiers at two large U.S. Army Divisions located in the Southwestern region of the U.S. at two different time points (April-May 2021 [Time 1; T1] N = 24,629; July-August 2021 [Time 2; T2] N = 21,116). Binary logistic regressions were used to assess demographic and attitudinal predictors of vaccination receipt and vaccination intent. Multinomial logistic regressions were used to assess demographic and leadership predictors of endorsement of three vaccination attitudes concerning effectiveness, safety, and importance., Results: Approximately 43% of soldiers reported that they received a COVID-19 vaccine at T1, increasing to 67% at T2. Soldiers who agreed with three separate statements on vaccination effectiveness, safety, or importance were more likely to indicate that they intended to get the vaccination at both time points. Soldiers who reported that their immediate supervisor encouraged soldiers to get a COVID-19 vaccine were more likely to indicate that the vaccination was effective, safe, or important at both time points., Discussion: Negative attitudes about COVID-19 vaccines were prevalent and correlated with less intention to get a vaccination. However, prioritizing leadership engagement around the importance of vaccinations may be a simple but widely effective intervention point to increase future vaccine uptake following the development of novel vaccines to future COVID-19 variants., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To evaluate a new protocol of risk stratification and early discharge for children with febrile neutropenia (FN)., Design: Prospective service evaluation from 17 April 2020 to 16 April 2021., Setting: 13 specialist centres in the UK., Patients: 405 children presenting with FN., Intervention: All children received intravenous antibiotics at presentation. Risk stratification was determined using the Australian-UK-Swiss (AUS) rule and eligibility for homecare assessed using criteria including disease, chemotherapy, presenting features and social factors. Those eligible for homecare could be discharged on oral antibiotics after a period of observation proportional to their risk group., Main Outcome Measures: Median duration of admission and of intravenous antibiotics, and percentage of patients with positive blood cultures, significant infection, readmission within 7 days of initial presentation, intensive care unit (ICU) admission, death from infection and death from other causes., Results: 13 centres contributed 729 initial presentations of 405 patients. AUS rule scores were positively correlated with positive blood cultures, significant infection, ICU admission and death. 20% of children were eligible for homecare with oral antibiotics, of which 55% were low risk (AUS 0-1). 46% low-risk homecare eligible patients were discharged by 24 hours vs 2% homecare ineligible. Homecare readmission rates were 14% overall and 16% for low-risk cases (similar to a meta-analysis of previous studies). No child eligible for homecare was admitted to ICU or died., Conclusions: Use of the AUS rule and homecare criteria allow for safe early outpatient management of children with FN., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The International Society of Paediatric Oncology Renal Tumour Study Group (SIOP-RTSG) advocate treating children with Wilms tumour (WT) with preoperative chemotherapy, whereas the Renal Tumor Committee of the Children's Oncology Group (COG) advocates primary nephrectomy (without biopsy) when feasible. Successive SIOP-RTSG trial protocols recommended pretreatment biopsy of children with unilateral tumours only where there were features to suggest an increased probability of a non-WT requiring a change in management. The UK experience in the SIOP WT 2001 trial showed that an alternate approach of performing biopsies on all children with renal tumour masses to determine histology at diagnosis rarely changes management, and can result in misdiagnosis (particularly patients in the age range typical for WT). Although a more selective approach to biopsy has been routine practice in all other countries participating in SIOP-RTSG trials, there was variation between national groups. To address this variation and provide evidence-based recommendations for the indications and recommended approach to renal tumour biopsy within the SIOP paradigm, an international, multidisciplinary working group of SIOP-RTSG members was convened. We describe the resulting recommendations of this group, which are to be incorporated in the ongoing SIOP-RTSG UMBRELLA study., (© 2022 The Authors. Pediatric Blood & Cancer published by Wiley Periodicals LLC.)

Background: Interest in vertebral body tethering (VBT) as an alternative to posterior spinal fusion for adolescent idiopathic scoliosis (AIS) continues to grow. The purpose of this study was to prospectively assess intervertebral disk health on magnetic resonance imaging (MRI) at 1 year following VBT in AIS patients., Methods: AIS patients were enrolled in a prospective surgeon-sponsored Food and Drug Administration (FDA) Investigational Device Exemption (IDE) Study and underwent MRI at 1-year following VBT. All spanned disks and the untethered disks immediately adjacent to the upper instrumented vertebra and lowest instrumented vertebra levels were evaluated according to Pfirrmann grading criteria. Associations between patient factors and preoperative and postoperative disk health and patient-reported outcomes were evaluated., Results: Twenty-two patients were enrolled with a postoperative MRI (25 curves, 188 disks), and 7 patients (7 curves) had both preoperative and postoperative MRIs (67 disks). The mean age was 12.7 years. Most were Risser 0 (65%) and either Sanders Skeletal Maturity Score 3 (35%) or 4 (53%). In the 7 patients with preoperative and postoperative MRI, the mean Pfirrmann grade of the disks spanned by the tether was 1.88 preoperatively and 2.31 postoperatively ( P =0.0075). No statistically significant differences in preoperative versus postoperative Pfirrmann grade were identified in the disks adjacent to the upper or lower instrumented vertebrae. No association was found between patient-reported outcomes and Pfirrmann grade., Conclusion: At 1 year postoperatively, increased degenerative changes in disks spanned by the tether was identifiable on MRI without evidence of adjacent segment disk disease. These changes were not associated with patient-reported outcomes., Level of Evidence: Level III., Competing Interests: Outside of the study, T.A.M. reports consulting activities with Orthopediatrics, Medtronic, Zimmer and stock ownership in Viking Scientific. A.N.L. reports consulting activities with Orthopediatrics, Medtronic, Zimmer, and Globus. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To improve success rates of children requiring sedation for MRI., Methods: Audits of sedation success for children attending planned MRI using three different approaches: (1) National Institute for Health and Care Excellence (NICE) guidance (chloral hydrate if <15 kg and oral midazolam if ≥15 kg), (2) Chloral hydrate for all patients, (3) Chloral hydrate±intranasal dexmedetomidine if <15 kg and intranasal dexmedetomidine alone if ≥15 kg., Results: 74 patients had 85 MRI scan attempts. Overall success rates were significantly higher when using intranasal dexmedetomidine compared with following NICE guidance (81% vs 52% p=0.017). Dexmedetomidine performed better than oral midazolam for the same indication (76% vs 33% p=0.026). The side effect profile for dexmedetomidine was as reported in larger studies., Conclusions: Intranasal dexmedetomidine is an effective alternative to oral midazolam for sedation for MRI and as a rescue medication where chloral hydrate has been ineffective., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Service Members and military beneficiaries face complex and ill-structured challenges, including suicide, sexual violence, increasing health care costs, and the evolving coronavirus pandemic. Military and other government practitioners must identify effective programs, policies, and initiatives to preserve the health and ensure the readiness of our Force. Both research and program evaluation are critical to identify interventions best positioned to prevent disease, protect the public's health, and promote health and well-being within our ranks to retain a medically ready force and reduce the global burden of disease. While military and medical leaders are typically well versed in research and understand the role of research in evidence-informed decisions, they may be less aware of program evaluation. Program evaluation is the systematic application of scientific methods to assess the design, implementation, improvement, or outcomes of a program, policy, or initiative. Although program evaluators commonly utilize scientific or research methods to answer evaluation questions, evaluation ultimately differs from research in its intent. Several recently published federal and Department of Defense policies specifically reference program evaluation, emphasizing its importance to the military and government as a whole. The Army is uniquely positioned to conduct medical and public health evaluation activities and there are several Army organizations and entities that routinely perform this work. For example, the United States Army Public Health Center (APHC) is among recognized military experts in public health assessment and program evaluation. Given the breadth of our work, the APHC understands the challenges to conducting evaluation studies in the Army and we have thoughtfully examined the conditions common to successful evaluation studies. In this commentary, we share our lessons learned to assist military colleagues, potential partners, and others in successfully evaluating the programs, policies, and initiatives necessary to keep our Service Members and beneficiaries healthy and ready. There are several challenges to executing evaluation studies in the Army that may be relevant across all Services. These include but are not limited to frequent Army leadership transitions, urgency to report study results, lack of program documentation and adequate planning for evaluation, expectation management to ensure stakeholders are well-informed about the evaluation process, and a disorganized data landscape. These challenges may hinder the successful execution of evaluation studies, or prevent them from being attempted in the first place, depriving Army leaders of quality, actionable information to make evidence-informed decisions. Despite the aforementioned challenges, we have identified a number of best practices to overcome these challenges and conduct successful evaluation studies. These facilitators of successful evaluations can be summarized as: collaboration with engaged stakeholders who understand the value of evaluation, evaluation studies aligned with larger strategic priorities, agile methodology, thoughtful evaluation planning, and effective communication with stakeholders. We wholeheartedly recommend and encourage program evaluation at every opportunity, and we anticipate the call for evaluation and evidence-informed decisions to continually increase. Our hope is that others - to include partners and stakeholders within and external to the military - will be able to leverage and apply this information, especially the identified best practices, in their evaluation efforts to ensure success., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Study Design: Retrospective Study., Objective: To compare methods of assessing pre-operative bone density to predict risk for osteoporosis related complications (ORC), defined as proximal junctional kyphosis, pseudarthrosis, accelerated adjacent segment disease, reoperation, compression fracture, and instrument failure following spine fusions., Methods: Chart review of primary posterior thoracolumbar or lumbar fusion patients during a 7 year period. Inclusion criteria: preoperative dual-energy x-ray absorptiometry (DXA) test within 1 year and lumbar CT scan within 6 months prior to surgery with minimum of 1 year follow-up. Exclusion criteria: <18 years at time of index procedure, infection, trauma, malignancy, skeletal dysplasia, neuromuscular disorders, or anterior-posterior procedures., Results: 140 patients were included. The average age was 67.9 years, 83 (59.3%) were female, and 45 (32%) had an ORC. There were no significant differences in patient characteristics between those with and without an ORC. Multilevel fusions were associated with ORCs (46.7% vs 26.3%, p = 0.02). Patients with ORCs had lower DXA t-scores (-1.62 vs -1.10, p = 0.003) and average Hounsfield units (HU) (112.1 vs 148.1, p ≤ 0.001). Multivariable binary logistic regression analysis showed lower average HU (Adj. OR 0.00 595% CI 0.0001-0.1713, p = 0.001) was an independent predictor of an ORC. The odds of an ORC increased by 1.7-fold for every 25 point decrease in average HU., Conclusions: The gold standard for assessing bone mineral density has been DXA t-scores, but the best predictor of ORC remains unclear. While both lower t-scores and average HU were associated with ORC, only HU was an independent predictor of ORC.

Background: Previous studies have documented the impact of domain-specific leadership behaviors on targeted health outcomes in employees. The goal of the present study was to determine the association between specific leadership behaviors addressing COVID-19 and US soldiers' mental health and adherence to COVID-19 public health guidelines., Methods: An electronic, anonymous survey was administered to US Army soldiers across three major commands (N = 7,829) from December 2020 to January 2021. The primary predictor of interest was soldiers' ratings of their immediate supervisors' behaviors related to COVID-19. The outcomes were soldiers' mental health (i.e., depression and generalized anxiety) and adherence to COVID-19 public health guidelines. Covariates were rank, gender, ratings of immediate supervisors' general leadership, level of COVID-19 concerns, and COVID-19 status (e.g., tested positive, became seriously ill). Logistic regressions were used to model the unique association of COVID-19 leadership behaviors with outcomes after adjusting for covariates., Results: High levels of COVID-19 leadership behaviors were associated with lesser likelihood of soldiers' screening positive for depression (AOR = 0.46; 95% CI [0.39, 0.54]) and anxiety (AOR = 0.54; 95% CI [0.45, 0.64]), and greater likelihood of frequent adherence to preventive health guidelines (AORs = 1.58; 95% CI [1.39, 1.80] to 2.50; 95% CI [2.01, 3.11])., Conclusion: Higher levels of COVID-19 leadership behaviors may support soldiers' mental health and encourage their adherence to COVID-19 public health guidelines. Given the link between these leader behaviors and soldier adaptation to the pandemic over and above general leadership, training for supervisors should focus on targeting specific health-promoting behaviors. Results can inform leader training for the military and other high-risk occupations., (© 2022. The Author(s).)

Objectives: To identify risk factors for poor outcome one year post-mild traumatic brain injury (mTBI)., Design: This study was a prospective observational study using consecutive adult hospital admissions with mTBI., Subjects: A total of 869 consecutive mTBI patients were enrolled in this study., Methods: All patients were reviewed by the specialist TBI rehabilitation team at six weeks and one year following mTBI. Demographic and injury data collected included: age, gender, TBI severity and Glasgow Coma Scale (GCS). At twelve months, global outcome was assessed by the Extended Glasgow Outcome Score (GOSE) and participation restriction by the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) via semi-structured interview. An ordinal regression (OR) was used to identify associated factors for poor GOSE outcome and a linear regression for a poor RHFUQ outcome., Results: In the GOSE analysis, lower GCS (p < 0.001), medical comorbidity (p = 0.027), depression (p < 0.001) and male gender (p = 0.008) were identified as risk factors for poor outcome. The RHFUQ analysis identified: lower GCS (p = 0.002), female gender (p = 0.001) and injuries from assault (p = 0.003) were variables associated with worse social functioning at one year., Conclusion: mTBI is associated with a significant impact upon the physical health and psychosocial function of affected individuals. The results of this study demonstrate that differences in mTBI outcome can be identified at twelve months post-mTBI and that certain features, particularly GCS, are associated with poorer outcomes., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Introduction: Klippel-Feil Syndrome is the congenital fusion of at least two cervical vertebrae. Often asymptomatic, though in rare cases it may lead to severe cervical spine deformity and neurologic injury., Case Presentation: We report a case of a 48-year-old woman with a history of Klippel-Feil Syndrome and congenital scoliosis who developed progressive cervical myelopathy. She was surgically treated with anterior C5 corpectomy and arthrodesis. Pre-operative evaluation was facilitated by 3D printed models. The surgical decompression and spinal reconstruction was completed with the use of a patient-specific, custom-made cervical spine locking plate., Discussion: Pre-operative evaluation with 3D printing technology was useful in understanding the patient's complex curve pattern and in designing a patient specific implant. Custom designed implant is a reasonable option to treat cervical myelopathy associated with complex cervical deformity., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: Factor Xa inhibitors (Xai) are an increasingly common consideration in perioperative anticoagulation management. However, there no existing guidelines established for use in Spine Surgery. This survey study aims to capture current practice trends regarding the perioperative management of Xai among spine surgeons., Methods: An 11-question survey was sent to all surgeon members of 3 spinal surgery societies. Responses were remitted anonymously. Questions characterized the background and experience of the respondent and inquired into their current perioperative Xai and other anticoagulant management. Questions were all single-best option, multiple-choice., Results: A total of 116 surveys were received. Twenty-six (22.4%) were from neurosurgeons and 90 (77.6%) were from orthopedic surgeons. Practiced preoperative Xai hold length tended to be longer than recommended by the respondent's medical colleagues. Only 65.2% (P≤0.0001) of respondents practiced in agreement with the recommendations of their medical colleagues. Postoperative Xai holds trended toward longer holds than that of other anticoagulants with 37.9% (P=0.0125) of respondents showed differences within their own practice between length of Xai hold and length of other anticoagulant holds. One out of four respondents reported noticing a change in the rate of perioperative bleeding complications among Xai patients. Despite reported increased bleeding issues, only 39% of those who noted this increase in bleeding complications reported they would hold a Xai longer than other anticoagulants., Conclusions: There exists a wide range of recommended and practiced chronic anticoagulant hold lengths. This inconsistency likely highlights conflicting risk aversion among surgeons, between complications which are viewed as medical (i.e., thromboembolism and stroke) vs. surgical (i.e., compressive hematoma). Yet, survey responses suggest the length of Xai hold times did not necessarily reflect the surgeon's experience with postoperative bleeding complications in Xai patients. These inconsistent practices highlight the need for further research that can establish guidelines for perioperative management of Xai patients undergoing spine surgery., Keywords: Anticoagulants; factor Xa inhibitors (factor Xai); spine; orthopedic surgery; neurosurgery., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jss-20-637). Dr. BC receives grants from AO Spine NA Institutional Fellowship support, royalties or licenses from DePuy Synthes, Zimmer Biomet, and Wolters Kluwer, consulting fees from Surgalign, patents with DePuy Synthes and Zimmer Biomet, and Stock with Spinology and Tenex. Dr. BE receives grants or contracts from NIH NIAMS, Stryker Spine, and SI Bone, consulting fees from DePuy Synthes, participates on Data Safety Monitoring Board of SI Bone and the Medical Advisory Board of Injectsense, has a leadership role in the International Society for Hydrocephalus and CSF Disorders, and receives stock or stock options for Injectsense. The other authors have no conflicts of interest to declare., (2021 Journal of Spine Surgery. All rights reserved.)

New Findings: What is the central question of this study? Do muscle size, maximal force and exercise intensity influence the recovery time constant for the finite impulse above critical torque (τ IET' )? What is the main finding and its importance? Muscle size and maximal strength have different influences on the parameters of the hyperbolic torque-time to task failure relationship. Greater muscle size and maximal strength, as well as exercise at an intensity of 60% MVC, prolong τ IET' during intermittent isometric exercise., Abstract: Muscle perfusion and O 2 delivery limitations through muscle force generation appear to play a major role in defining the hyperbolic torque-time to task failure (T lim ) relationship. Therefore, we aimed to determine the influence of muscle size and maximal strength on the recovery time constant for the finite impulse above critical torque (τ IET' ). Ten men participated in the study and performed intermittent isometric tests until task-failure (T lim ) for the knee-extensors (KE) (35% and 60% maximal voluntary contraction (MVC)) and plantar flexors (PF) (60% MVC). The τ IET' was determined for each of these T lim tests using the IET' BAL model. The IET' (9738 ± 3080 vs. 2959 ± 1289 N m s) and end-test torque (ET)(84.5 ± 7.1 vs. 74.3 ± 12.7 N m) were significantly lower for PF compared to KE (P < 0.05). Exercise tolerance (T lim ) was significantly longer for PF (239 ± 81 s) than KE (150 ± 55 s) at 60% MVC, and significantly longer for KE at 35% MVC (641 ± 158 s) than 60% MVC. The τ IET' was significantly faster at 35% MVC (641 ± 177 s) than 60% MVC (1840 ± 354 s) for KE, both of which were significantly slower than PF at 60% MVC (317 ± 102 s). This study showed that τ IET' during intermittent isometric exercise is slower with greater muscle size and maximal strength., (© 2021 The Authors. Experimental Physiology © 2021 The Physiological Society.)

Background: Tarsal coalitions are an important reason for foot pain in children. Early estimates placed the prevalence at up to 2%, while more recent data suggest that it is as high as 11% to 13%. To our knowledge, there have been no population-based studies to determine the true incidence of symptomatic tarsal coalitions in a pediatric population., Methods: A population-based database was used to identify all new diagnoses of symptomatic tarsal coalitions in children 18 years old or younger between 1966 and 2018. Patient records were reviewed for clinical data, and comparisons were made between the types and characteristics of the coalitions identified to determine differences in the affected populations. The annual age-specific, sex-specific, and type-specific incidence rates were estimated., Results: During the study period, 58 patients with a total of 79 symptomatic tarsal coalitions were identified (annual incidence = 3.5 per 100,000 children). There were 43 calcaneonavicular (CN) coalitions (annual incidence = 1.9 per 100,000 children), 27 talocalcaneal (TC) coalitions (annual incidence = 1.2 per 100,000 children), as well as 9 other coalitions (7 talonavicular, 1 naviculocuboid, and 1 naviculocuneiform) (annual incidence = 0.4 per 100,000 children). The overall incidence peaked between the ages of 10 and 14 years for both boys and girls (8.1 per 100,000 and 7.4 per 100,000 children, respectively). Statistical differences were identified between the types of tarsal coalitions. TC coalitions present at an older age relative to CN and other coalitions (mean,13.9, 12.7, and 11.4 years, respectively; p = 0.02). While CN and TC coalitions were similar in composition (23% and 30%, respectively, were osseous as opposed to fibrocartilaginous), other coalitions were more likely to be osseous (78%) (p = 0.0035). Other coalitions were also less likely to require surgery than CN and TC coalitions (11%, 74%, and 56%, respectively; p = 0.0015)., Conclusions: This population-based study demonstrates differences in the clinical presentation of tarsal coalitions and provides an estimate of the true incidence of symptomatic tarsal coalitions in a pediatric population., Competing Interests: Disclosure: This study was made possible using the resources of the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health (NIH) under Award Number R01AG034676. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G197)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Tarsal coalitions are congenital fusions of two or more tarsal bones and can lead to foot pain and stiffness. Few studies examine the long-term reoperation rates following paediatric tarsal coalition surgery., Methods: A population-based database, linking medical records at all medical centres to capture the entire medical history of the full population of a Midwest county, was used to identify tarsal coalitions in children between 1966 and 2018. Records were reviewed for clinical data, surgical records and followed up to identify any subsequent surgical interventions., Results: A total of 58 patients (85 coalitions) were identified; 46 calcaneonavicular (CN) coalitions, 30 talocalcaneal (TC) coalitions and nine other coalitions (seven talonavicular, one naviculocuboid, one naviculocuneiform). In all, 46 coalitions were treated surgically (43 coalition resections, three arthrodeses) and 39 were treated nonoperatively. Patients treated surgically were less likely to report ongoing symptoms at final follow-up compared with patients managed nonoperatively (33% versus 67%; p = 0.0017). With a median 14.4 years (interquartile range 9.3 to 19.7) follow-up, there was an overall re-operation rate of 8.7% (4/46). Differences in reoperation rates by initial surgery (resection versus arthrodesis; p = 0.2936), coalition type (CN versus TC versus Other; p = 0.6487) or composition (osseous versus fibrocartilaginous; p = 0.29) did not reach statistical significance., Conclusion: This is the first population-based study demonstrating the durability of surgical management of tarsal coalitions in a paediatric population. At final follow-up, patients treated surgically are less likely to report persistent symptoms compared with patients managed nonoperatively. Long-term reoperation rates appear to be low (8.7%)., Level of Evidence: III., (Copyright © 2020, The author(s).)

Population health is changing the focus of nursing practice as nurses are challenged to focus on health promotion and education for communities rather than limiting their practice to restorative care for individual acute care patients. This new focus is necessary to improve knowledge of maternal and infant health among vulnerable populations. One particularly vulnerable population is members of Old Order Mennonite communities, who frequently rely on self-trained local midwives in the community for home births and home remedies when caring for their infants. Providing evidence-based education to members of this isolated population can be a challenge because they do not typically access information outside of the community. The purpose of this article is to share the process of developing, publishing, and disseminating a culturally sensitive infant care manual for an Old Order Mennonite community using a community-based participatory model and to highlight the impact nursing outreach can have on improving health knowledge., (Copyright © 2020 AWHONN. Published by Elsevier Inc. All rights reserved.)

Background: Limb salvage of the proximal tibia can be difficult due to the growth potential of and functional demands of the pediatric patients. Multiple reconstruction techniques exist, however, the ideal form of reconstruction is yet to be elucidated. The purpose of the current study is to evaluate outcomes in patients with an intercalary resection of the proximal tibia reconstructed with an allograft with or without a free vascularized fibula flap (FVF)., Methods: Seventeen pediatric patients (9 males, 8 females) underwent lower extremity limb salvage with the use of intercalary cadaveric allograft at a mean age of 12±4 years. The most common diagnoses were osteosarcoma (n=6) and Ewing sarcoma (n=6). Patients were reconstructed with an allograft alone (n=6) or supplemented with an FVF (n=11)., Results: All surviving patients had at least 2 years of clinical follow-up, with the mean follow-up of 12±7 years. The mean time to union of the allograft was 11±4 months, with 6 patients requiring additional bone grafting. There was no difference in the need for an additional bone graft (odds ratio=1.14, P=1.0) between patients with an FVF and those without. Four patients underwent an amputation, all with an allograft alone, due to disease recurrence (n=2) and due to infection (n=2). As such, there was a higher 10-year overall limb-salvage rate when the allograft was combined with an FVF compared with an allograft alone (100% vs. 33%, P=0.001). At last follow-up, the mean Mankin and Musculoskeletal Tumor Society rating was 86%, with a higher mean score in patients reconstructed with an FVF (94% vs. 70%, P=0.002)., Conclusion: Use of an intercalary allograft supplemented with an FVF to reconstruct the proximal tibia provides a durable means of reconstruction with an excellent functional outcome following oncologic proximal tibia resection in a pediatric population., Level of Evidence: Level III-therapeutic level.

Objective: The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization., Methods: A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ -2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) "expanded spine" criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or "degraded" TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit., Results: Two hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors' proposed "expanded spine" criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools., Conclusions: Limitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.