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John D Ralston,1 Ashutosh Raina,2,3 Brian W Benson,4,5 Ryan M Peters,6,7 Joshua M Roper,1 Andreas B Ralston1 1PROTXX, Inc., Menlo Park, CA 94025, USA; 2Center of Excellence for Pediatric Neurology, Rocklin, CA 95765, USA; 3Concussion Medical Clinic, Rocklin, CA 95765, USA; 4Benson Concussion Institute, Calgary, Alberta T3B 6B7, Canada; 5Canadian Sport Institute Calgary, Calgary, Alberta T3B 5R5, Canada; 6Faculty of Kinesiology, University of Calgary, Calgary, Alberta T2N 1N4, Canada; 7Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta T2N 1N4, CanadaCorrespondence: John D Ralston Tel +1 6502158418Email john.ralston@protxx.comObjective: To assess the utility of a head-mounted wearable inertial motion unit (IMU)-based physiological vibration acceleration (“phybrata”) sensor to support the clinical diagnosis of concussion, classify and quantify specific concussion-induced physiological system impairments and sensory reweighting, and track individual patient recovery trajectories.Methods: Data were analyzed from 175 patients over a 12-month period at three clinical sites. Comprehensive clinical concussion assessments were first completed for all patients, followed by testing with the phybrata sensor. Phybrata time series data and spatial scatter plots, eyes open (Eo) and eyes closed (Ec) phybrata powers, average power (Eo+Ec)/2, Ec/Eo phybrata power ratio, time-resolved phybrata spectral density (TRPSD) distributions, and receiver operating characteristic (ROC) curves are compared for individuals with no objective impairments and those clinically diagnosed with concussions and accompanying vestibular impairment, other neurological impairment, or both vestibular and neurological impairments. Finally, pre- and post-injury phybrata case report results are presented for a participant who was diagnosed with a concussion and subsequently monitored during treatment, rehabilitation, and return-to-activity clearance.Results: Phybrata data demonstrate distinct features and patterns for individuals with no discernable clinical impairments, diagnosed vestibular pathology, and diagnosed neurological pathology. ROC curves indicate that the average power (Eo+Ec)/2 may be utilized to support clinical diagnosis of concussion, while Eo and Ec/Eo may be utilized as independent measures to confirm accompanying neurological and vestibular impairments, respectively. All 3 measures demonstrate area under the curve (AUC), sensitivity, and specificity above 90% for their respective diagnoses. Phybrata spectral analyses demonstrate utility for quantifying the severity of concussion-induced physiological impairments, sensory reweighting, and subsequent monitoring of improvements throughout treatment and rehabilitation.Conclusion: Phybrata testing assists with objective concussion diagnosis and provides an important adjunct to standard concussion assessment tools by objectively ascertaining neurological and vestibular impairments, guiding targeted rehabilitation strategies, monitoring recovery, and assisting with return-to-sport/work/learn decision-making.Keywords: wearable sensor, physiological vibration acceleration, concussion, multi-system impairment, sensory reweighting

The purpose of this study was to develop and conduct preliminary psychometric assessment of instruments measuring knowledge and self-care practices regarding behaviors needed for blood pressure (BP) control among African Americans. Items were empirically derived and scored on a 7-point, bipolar scale. The instruments were evaluated in a sample of 306 community-dwelling African Americans. Results revealed acceptable reliability and validity of the BP Knowledge Scale. Results for the BP Self-Care Scale were mixed. A structural equation model of these scales, recorded BP, and covariates fit well. There was an unexpected positive correlation between self-care and BP suggesting a potential bi-directional relationship. The scales demonstrated acceptable psychometric properties and, with minor revisions, may have clinical utility as measures of BP knowledge and self-care. [ABSTRACT FROM AUTHOR]

The clinical significance of childhood hypertension is important as elevated pressures during childhood are found to follow a progressively increasing track into adulthood. Little work has been done to examine the relationship of emotions and emotional behavioral factors to the development of hypertension in children. Using the Roy Adaptation Model as a guide, this study investigated the relationship of anger expression and blood pressure (BP) among adolescents 16-18 years of age. Participants were 63 urban high school seniors. Measurements included the Anger Expression Inventory, a Demographic Questionnaire, and measures of systolic and diastolic blood pressure. Analysis revealed significant positive relationships between anger expression with blood pressure, and a significant inverse relationship between blood pressure and the control of anger for girls. No significant relationships between anger expression and blood pressure were noted for boys. The majority of students (53%) were found to have high normal or hypertensive blood pressure readings, putting them at increased cardiovascular risk. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We examined the relationships between risk factors amenable to intervention and the likelihood of dental care use during pregnancy. METHODS: We used data from the Washington State Department of Health's Pregnancy Risk Assessment Monitoring System. RESULTS: Of the women surveyed, 58% reported no dental care during their pregnancy. Among women with no dental problems, those not receiving dental care were at markedly increased risk of having received no counseling on oral health care, being overweight, and using tobacco. Among women who received dental care, those with dental problems were more likely to have lower incomes and Medicaid coverage than those without dental problems. CONCLUSIONS: There is a need for enhanced education and training of maternity care providers concerning oral health in pregnancy. [ABSTRACT FROM AUTHOR]

Differences in dissatisfaction with health care {prohlems with providers, geographic access and appointment availability), self-treating symptoms, personal health responsibility, and health service use were investigated in low income African American and White older persons. Data on these topics were collected from 103 African Americans and 101 Whites and analyzed using analysis of covariance and multiple regression. After controlling for variables that typically explain health service use, African Americans reported signifrcantly more dissatisfaction with health care (p< .01) and greater personal health responsibility (p < .01) than Whites, but did not differ in the degree to which they selftreated or used health care. Signifrcant predictors of health service use were declining health status and increasing levels of self-treatment for African Americans (R2 = .18) and declining health status and increasing age for Whites (R2 = .23). [ABSTRACT FROM AUTHOR]

Background: Recently, surgeons introduced a minimally invasive modification on the classic posterolateral approach (PLA) in total hip arthroplasty (THA): the direct superior approach (DSA). We investigated the association between surgeon's experience and the risk of early revision of the DSA in primary THA, using data from the Dutch Arthroplasty Register (LROI)., Methods: We retrieved all primary THAs performed using the DSA in 4 hospitals between 2016 and 2022 ( n  = 1551). Procedures were sorted in 5 groups using the date of operation and number of previous procedures per surgeon: 1-25; 26-50; 51-75; 76-100; >100. Subsequently, data from different surgeons were pooled together and the risk of revision was calculated via a multilevel time-to-event analysis., Results: The overall revision rate was 1.5% after a mean follow-up of 2 years. Patients from the 1-25 group had comparable risks of revision compared to patients in the >100 group (hazard ratio [HR] 1.0 [CI, 0.3-3.2]). The risk for patients in groups 26-50, 51-75 and 75-100 was also not statistically different from the >100 group (resp. HR 1.5 [CI, 0.5-5.0], 1.8 [CI, 0.5-6.4] and 0.5 [CI, 0.1-4.0]). Main reasons of revision were dislocation (0.5%) and infection (0.4%)., Conclusions: We did not identify an association between the surgeon's experience and the early risk of revision for the DSA in primary THA in the Netherlands. The DSA seems safe in the early adoption phases with a low risk of revision due to dislocation and revision for all other causes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Estimating the risk of revision after arthroplasty could inform patient and surgeon decision-making. However, there is a lack of well-performing prediction models assisting in this task, which may be due to current conventional modeling approaches such as traditional survivorship estimators (such as Kaplan-Meier) or competing risk estimators. Recent advances in machine learning survival analysis might improve decision support tools in this setting. Therefore, this study aimed to assess the performance of machine learning compared with that of conventional modeling to predict revision after arthroplasty., Question/purpose: Does machine learning perform better than traditional regression models for estimating the risk of revision for patients undergoing hip or knee arthroplasty?, Methods: Eleven datasets from published studies from the Dutch Arthroplasty Register reporting on factors associated with revision or survival after partial or total knee and hip arthroplasty between 2018 and 2022 were included in our study. The 11 datasets were observational registry studies, with a sample size ranging from 3038 to 218,214 procedures. We developed a set of time-to-event models for each dataset, leading to 11 comparisons. A set of predictors (factors associated with revision surgery) was identified based on the variables that were selected in the included studies. We assessed the predictive performance of two state-of-the-art statistical time-to-event models for 1-, 2-, and 3-year follow-up: a Fine and Gray model (which models the cumulative incidence of revision) and a cause-specific Cox model (which models the hazard of revision). These were compared with a machine-learning approach (a random survival forest model, which is a decision tree-based machine-learning algorithm for time-to-event analysis). Performance was assessed according to discriminative ability (time-dependent area under the receiver operating curve), calibration (slope and intercept), and overall prediction error (scaled Brier score). Discrimination, known as the area under the receiver operating characteristic curve, measures the model's ability to distinguish patients who achieved the outcomes from those who did not and ranges from 0.5 to 1.0, with 1.0 indicating the highest discrimination score and 0.50 the lowest. Calibration plots the predicted versus the observed probabilities; a perfect plot has an intercept of 0 and a slope of 1. The Brier score calculates a composite of discrimination and calibration, with 0 indicating perfect prediction and 1 the poorest. A scaled version of the Brier score, 1 - (model Brier score/null model Brier score), can be interpreted as the amount of overall prediction error., Results: Using machine learning survivorship analysis, we found no differences between the competing risks estimator and traditional regression models for patients undergoing arthroplasty in terms of discriminative ability (patients who received a revision compared with those who did not). We found no consistent differences between the validated performance (time-dependent area under the receiver operating characteristic curve) of different modeling approaches because these values ranged between -0.04 and 0.03 across the 11 datasets (the time-dependent area under the receiver operating characteristic curve of the models across 11 datasets ranged between 0.52 to 0.68). In addition, the calibration metrics and scaled Brier scores produced comparable estimates, showing no advantage of machine learning over traditional regression models., Conclusion: Machine learning did not outperform traditional regression models., Clinical Relevance: Neither machine learning modeling nor traditional regression methods were sufficiently accurate in order to offer prognostic information when predicting revision arthroplasty. The benefit of these modeling approaches may be limited in this context., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

The capacity to perceive tactile input at the fingertips, referred to as tactile sensitivity, is known to diminish with age due to regressive changes to mechanoreceptor density and morphology. Sensitivity is measured as perceptual responses to stimuli of varying intensity. Contrary to traditional sensitivity monitoring instruments, smartphones are uniquely suited for remote assessment and have shown to deliver highly calibrated stimuli along a broad spectrum of intensity, which may improve test reliability. The aim of this study was to evaluate a vibration-emitting smartphone application, the Vibratus App, as a mode of estimating tactile sensory thresholds in the aging adult. The peripheral nerve function of 40 neurologically healthy volunteers (ages 18-71) was measured using monofilaments, a 128-Hz tuning fork, the Vibratus App, and nerve conduction studies (NCS). Between group differences were analyzed to determine each measurement's sensitivity to age. Spearman correlation coefficients depicted the associative strength between hand-held measurements and sensory nerve action potential (SNAP) amplitude. Inter-rater reliability of traditional instruments and the software-operated smartphone were assessed by intraclass correlation coefficient (ICC 2,k ). Measurements taken with Vibratus App were significantly different between age groups (p < 0.001). The inter-rater reliability of monofilament, smartphone vibration, and tuning fork testing was moderate to good (ICC 2,k  = 0.65, 0.69, and 0.79, respectively). The findings of this study support further investigation of smartphones as sensitivity monitoring devices for at home monitoring of skin sensitivity., (© 2024. The Author(s).)

Background: Human trafficking affects nearly 1.1 million persons in the United States. Over 50% of victims will receive care in an emergency department (ED) during their exploitation., Purpose: The purpose of this study was to assess the effectiveness of a human trafficking protocol and electronic medical record screening and assessment tool in identifying victims of human trafficking in the ED., Methods: A 5-year, retrospective chart audit was conducted., Results: Over 2 million ED visits occurred during the 5-year study period. Less than 1% (n = 525) of those patients screened positive as potential victims, while 45 (8.6%) were confirmed trafficking victims. The number of victims identified dropped following the pandemic., Conclusions: Pandemic issues, staffing turnover, and lack of ongoing trafficking education impeded the identification of victims. Recommended changes to the protocol are presented., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective : Behavioral variant frontotemporal dementia (bvFTD) is a neurodegenerative condition characterized by progressive changes in behavior, cognition, and day-to-day functioning. Progression of the disease usually leads to death 3-5 years after diagnosis. However, there are reports of individuals who are initially diagnosed with bvFTD but fail to progress. These individuals are thought to have what is becoming known as phenocopy bvFTD (phFTD). Methods : This manuscript reviews a single case study of a 68-year-old male Veteran who was diagnosed with bvFTD in 2010, which has not progressed over time. Results : Review of serial neuropsychological evaluations was broadly normal with mild evidence of executive dysfunction with minimal reliable change in his performances from 2015, 2017, and 2022 evaluations. He also has not developed neuroimaging evidence of FTD. Conclusions : This case illustrates the importance of monitoring individuals over time and incorporating neuroimaging data into the diagnosis. We believe this Veteran's presentation is most consistent with what has been described as phFTD.

Background and Purpose: Although the Brief COPE is a widely used instrument to measure coping, its factor structure is understudied in young adults. The purpose of this article was to determine the psychometric properties of the dispositional version of the Brief COPE among young adults. Methods: Two hundred young adults completed the dispositional version of the Brief COPE. Measures of depression, anxiety, and stress tested predictive validity. Confirmatory factor analyses and exploratory structural equation modeling were conducted. Results: The final model achieved good fit (minimum discrepancy/degrees of freedom = 1.59; comparative fit index = .93; standardized root mean square residual = .07). Three second-order factors were identified: adaptive (α = .81), support (α = 78), and disengaged coping (α = 71). Adaptive and disengaged coping were differentially associated with mental health outcomes. Conclusions: The results are consistent with a growing body of evidence to support the construct validity of the Brief COPE., (© Copyright 2024 Springer Publishing Company, LLC.)

Background and Purpose: This study aims to assess time trends in case-mix and to evaluate the risk of revision and causes following primary THA, TKA, and UKA in private and public hospitals in the Netherlands., Methods: We retrospectively analyzed 476,312 primary arthroplasties (public: n = 413,560 and private n = 62,752) implanted between 2014 and 2023 using Dutch Arthroplasty Register data. We explored patient demographics, procedure details, trends over time, and revisions per hospital type. Adjusted revision risk was calculated for comparable subgroups (ASA I/II, age ≤ 75, BMI ≤ 30, osteoarthritis diagnosis, and moderate-high socioeconomic status (SES)., Results: The volume of THAs and TKAs in private hospitals increased from 4% and 9% in 2014, to 18% and 21% in 2022. Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES compared with public hospital patients. In private hospitals, age and ASA II proportion increased over time. Multivariable Cox regression demonstrated a lower revision risk for primary THA (HR 0.7, CI 0.7-0.8), TKA (HR 0.8, CI 0.7-0.9), and UKA (HR 0.8, CI 0.7-0.9) in private hospitals. After initial arthroplasty in private hospitals, 49% of THA and 37% of TKA revisions were performed in public hospitals., Conclusion: Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES com-pared with public hospital patients. The number of arthroplasties increased in private hospitals, with a lower revision risk compared with public hospitals.

Background: Emerging evidence notes increased depression, anxiety, and stress among the general population during the COVID-19 pandemic. However, little is known about populations at increased risk for emotional distress as the pandemic continues. Persons with adverse childhood experiences (ACE) are one group that may be at higher risk for emotional distress., Aim: The aim of this study is to examine whether young adults, particularly Black young adults, with histories of ACEs report more emotional distress during the pandemic than those with no ACE exposure., Method: Using a cross-sectional, quota sampling approach, 100 Black and 100 White young adults were recruited using online sources (e.g., University website, Facebook). Due to the pandemic, participants were screened via Zoom and, if eligible, completed a demographic questionnaire, emotional distress measures (i.e., anxiety, depression, stress), and the ACE Questionnaire online via a Qualtrics survey. Structural equation modeling (SEM) analysis examined the ACE and emotional distress relationship, and multigroup SEM assessed racial differences., Results: High levels of both emotional distress and ACEs were observed. Black young adults reported significantly more ACEs than Whites. ACEs were significantly associated with each measure of emotional distress regardless of race or other covariates., Conclusions: Findings reveal that during the pandemic, persons exposed to ACEs reported greater emotional distress than those with no ACE exposure. Nurses must screen patients for both emotional distress and ACE to target those at higher risk for early intervention and initiate treatment as needed to mitigate long-term mental health consequences., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Marvin A. Solberg, Rosalind M. Peters, Thomas N. Templin, and Maha M. Albdour declare no conflicts of interest with the research writing of this paper.

Background: Evolution of the surgical approach for total hip arthroplasty (THA) has led to the development of the minimally invasive direct superior approach (DSA). It is hypothesized that the DSA reduces postoperative pain and hospital length of stay (LOS). We aimed to provide an overview of current evidence on clinical, functional, and radiological outcomes with respect to risk of revision, complications, pain scores, physical function, operative time, LOS, blood loss, radiological outcomes, and learning curve., Methods: A comprehensive search of Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar, reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension guidelines, was conducted to identify studies evaluating clinical, functional, and radiological outcomes of the DSA. Quality assessment was performed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale. The review protocol was prospectively registered in the International Prospective Registry of Systematic Reviews., Results: Seventeen studies were included, generally of moderate quality. Qualitative synthesis evidenced accurate implant positioning, short LOS, and a short learning curve. Conflicting findings were reported for postoperative complications compared with conventional approaches. Better functional outcomes were seen in the early postoperative period than the posterolateral approach (PLA). Outcomes such as blood loss and operative time exhibited conflicting results and considerable heterogeneity., Conclusion: Based on moderate-certainty evidence, it is uncertain if the DSA provides short-term advantages over conventional approaches such as PLA. There is limited evidence on long-term outcomes post-THA using the DSA. Further studies and ongoing registry monitoring is crucial for continuous evaluation of its long-term outcomes., Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B78)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: The use of dual mobility (DM) cups has increased quickly. It is hypothesized that femoral neck taper geometry may be involved in the risk of prosthetic impingement and DM cup revision. We aim to (1) explore the reasons for revision of DM cups or head/liners and (2) explore whether certain femoral neck characteristics are associated with a higher risk of revision of DM cups., Methods: Primary total hip arthroplasties with a DM cup registered in the Dutch Arthroplasty Register between 2007 and 2021 were identified (n = 7603). Competing risk survival analyses were performed, with acetabular component and head/liner revision as the primary endpoint. Reasons for revision were categorized in cup-/liner-related revisions (dislocation, liner wear, acetabular loosening). Femoral neck characteristics were studied to assess whether there is an association between femoral neck design and the risk of DM cup/liner revision. Multivariable Cox proportional hazard analyses were performed., Results: The 5- and 10-year crude cumulative incidence of DM cup or head/liner revision for dislocation, wear, and acetabular loosening was 0.5% (CI 0.4-0.8) and 1.9% (CI 1.3-2.8), respectively. After adjusting for confounders, we found no association between the examined femoral neck characteristics (alloy used, neck geometry, CCD angle, and surface roughness) and the risk for revision for dislocation, wear, and acetabular loosening., Conclusions: The risk of DM cup or head/liner revision for dislocation, wear, and acetabular loosening was low. We found no evidence that there is an association between femoral neck design and the risk of cup or head/liner revision., (© 2023 The Authors.)

Importance: With more than 6.2 million hospitalizations due to COVID-19 in the US, recognition of the average hospital costs to provide inpatient care during the pandemic is necessary to understanding the national medical resource use and improving public health readiness and related policies., Objective: To examine the mean cost to provide inpatient care to treat COVID-19 and how it varied through the pandemic waves and by important sociodemographic patient characteristics., Design, Setting, and Participants: This cross-sectional study used inpatient-level data from March 1, 2020, to March 31, 2022, extracted from a repository of clinical, administrative, and financial information covering 97% of academic medical centers across the US., Main Outcomes and Measures: Cost to produce care for each stay was calculated using direct hospital costs to provide care adjusted for geographic differences in labor costs using area wage indices., Results: The sample included 1 333 404 stays with a primary or secondary COVID-19 diagnosis from 841 hospitals. The cohort included 692 550 (52%) men, with mean (SD) age of 59.2 (17.5) years. The adjusted mean cost of an inpatient stay was $11 275 (95% CI, $11 252-$11 297) overall, increasing from $10 394 (95% CI, $10 228-$10 559) at the end of March 2020 to $13 072 (95% CI, $12 528-$13 617) by the end of March 2022. Patients with specific comorbidities had significantly higher mean costs than their counterparts: those with obesity incurred an additional $2924 in inpatient stay costs, and those with coagulation deficiency incurred an additional $3017 in inpatient stay costs. Stays during which the patient required extracorporeal membrane oxygenation (ECMO) had an adjusted mean cost of $36 484 (95% CI, $34 685-$38 284)., Conclusions and Relevance: In this cross-sectional study, an adjusted mean hospital cost to provide care for patients with COVID-19 increased more than 5 times the rate of medical inflation overall. This appeared to be explained partly by changes in the use of ECMO, which increased over time.

Recent research focused on farmed deer has exposed many knowledge gaps regarding health assessment protocols for white-tailed deer (WTD). The objectives of this study were to establish de novo blood analyte reference intervals for farmed WTD fawns at birth (1-2 days of age; n  = 84) and again at weaning (76-125 days of age; n  = 28), to compare data at birth and at weaning to understand how these analytes are affected by the intrinsic factors age and sex in clinically normal WTD fawns, and to compare between clinically normal and sick WTD weanlings (respiratory disease n  = 12; orbivirus-infected n  = 6). Reference intervals were established for WTD fawns at birth and weaning. Female WTD neonates had significantly higher red blood cell counts, hematocrit, and hemoglobin compared to males. Most blood analytes were significantly different in clinically normal WTD neonates compared to weanlings, suggesting an effect of age. The observed sex- and age-related variations in WTD highlight the need to establish reference intervals that account for intrinsic factors. The comparison of clinically normal and sick WTD weanlings in this study identified higher MCHC and absolute monocytes in sick weanlings but these findings were presumably not biologically relevant given the small sample size for sick fawns. While the reference interval data presented herein will be useful for the veterinary care of WTD fawns at critical time periods in a high-density farm setting, this study also demonstrates the need to identify more sensitive and specific biomarkers for the assessment of health status in farmed WTD with specific underlying diseases.

Background and Purpose: The direct superior approach (DSA) is a modification of the posterolateral approach (PLA) for total hip arthroplasty (THA). Patient-reported outcome measures (PROMs) of the DSA have not been investigated previously using nationwide data. Our aim was to assess PROMs after THA using the DSA compared with the PLA and, secondarily, with the anterior approach (DAA)., Patients and Methods: In this population-based cohort study we included 37,976 primary THAs performed between 2014 and 2020 (PLA: n = 22,616; DAA: n = 15,017; DSA: n = 343) using Dutch Arthroplasty Registry data. PROMs (NRS pain, EQ-5D, HOOS-PS, and OHS) were measured preoperatively, and at 3 and 12 months postoperatively. Repeated measurements were analyzed using mixed-effects models, adjusted for confounders, to investigate the association between surgical approach and PROMs over time., Results: From baseline to 3 and 12 months, improvements for NRS pain scores, EQ-5D, and OHS were comparable for the DSA compared with the PLA or DAA. No difference was found in HOOS-PS improvement 3 months postoperatively between DSA and PLA (-0.2, 95% confidence interval [CI] -2.4 to 1.9) and between DSA and DAA (-1.7, CI -3.9 to 0.5). At 12 months postoperatively, patients in the DSA group had improved -2.8 points (CI -4.9 to -0.6) more in HOOS-PS compared with the DAA, but not with the PLA group (-1.0, CI -3.2 to 1.1)., Conclusion: Our study showed no clinically meaningful differences between the DSA and either PLA or DAA.

Current research indicates a strong association between adverse childhood experiences (ACEs) and adverse health outcomes. Participants in frequently cited ACE research are predominantly heterosexual and cis gendered; the extent to which ACEs affect health outcomes among sexual and gender minorities (SGMs) is unclear. This systematic review examined the frequency of, and relationship between, ACEs and negative health outcomes among SGM. CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Scopus, and PubMed databases were searched with no date restriction. After eliminating duplicates, titles and abstracts were reviewed resulting in 22 articles to be critiqued using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. A total of 22 studies met final inclusion criteria. The frequency of reporting at least one ACE among SGMs ranged from 51.4 to 91.6%, while the frequency of reporting four or more ACEs ranged from 18.1 to 60.7%. SGMs reported a higher frequency of ACEs than non-SGM. ACEs were associated with poorer mental and physical health outcomes, as well as increased risky behavior among SGMs. SGMs report a high frequency of ACEs, but current studies did not include data regarding ongoing stigma and adversities that may further contribute to their negative health outcomes. Further research is needed to fully understand the impact of adversities experienced due to the sexual and/or gender orientation of this minority group., Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-023-00576-4., Competing Interests: Conflict of interestMarvin A. Solberg, Kafi D. Carr, and Rosalind M. Peters declare no conflicts of interest with the research writing of this paper., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Height-induced postural threat affects emotional state and standing balance behaviour during static, voluntary, and dynamic tasks. Facing a threat to balance also affects sensory and cortical processes during balance tasks. As sensory and cognitive functions are crucial in forming perceptions of movement, balance-related changes during threatening conditions might be associated with changes in conscious perceptions. Therefore, the purpose of this study was to examine the changes and potential mechanisms underlying conscious perceptions of balance-relevant information during height-induced postural threat. A combination of three experimental procedures utilized height-induced postural threat to manipulate emotional state, balance behavior, and/or conscious perceptions of balance-related stimuli. Experiment 1 assessed conscious perception of foot position during stance. During continuous antero-posterior pseudorandom support surface rotations, perceived foot movement was larger while actual foot movement did not change in the High (3.2 m, at the edge) compared to Low (1.1 m, away from edge) height conditions. Experiment 2 and 3 assessed somatosensory perceptual thresholds during upright stance. Perceptual thresholds for ankle rotations were elevated while foot sole vibrations thresholds remained unchanged in the High compared to Low condition. This study furthers our understanding of the relationship between emotional state, sensory perception, and balance performance. While threat can influence the perceived amplitude of above threshold ankle rotations, there is a reduction in the sensitivity of an ankle rotation without any change to foot sole sensitivity. These results highlight the effect of postural threat on neurophysiological and cognitive components of balance control and provide insight into balance assessment and intervention., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Cleworth, Peters, Chua, Inglis and Carpenter.)

Imperceptible tactile noise applied to the skin of the feet enhances posture-correcting cutaneous reflexes. This sensory augmentation technique, stochastic resonance (SR), has not been tested in the less-sensitive hairy skin of the leg for its reflex-enhancement ability. The objectives of this study were to determine whether calf skin stimulation produces cutaneous reflexes and whether noise can modify the reflex. In 20 participants, electrotactile pulse trains were applied at the calf while participants performed submaximal isometric knee extension. To test SR, five different levels of vibrotactile noise were applied simultaneously to the test input. Muscle activity from the vastus lateralis (VL) was analyzed 60-110 ms after stimulation. Reflex ratios were calculated by dividing the reflex peak activity by the prestimulation background muscle activity. A significant reflex response was evoked in 16/20 participants (5.41 ± 2.6% of background muscle activity); these responses varied between individuals with eight being facilitatory and eight being inhibitory. In half of the participants, a new reflex appeared at some level of added noise ( n = 10). The average reflex ratio of the study population was significantly higher at the "optimal" noise level (8.61 ± 4.5) than at "baseline" (4.70 ± 5.6) ( P = 0.002); the optimal level varied across participants. These results suggest that cutaneous reflexes exist at the VL in response to calf skin stimulation and that SR can change cutaneous reflexes at the leg. This study provides an important first step toward SR application in clinical populations with sensory loss such as individuals with lower extremity amputation. NEW & NOTEWORTHY Our work showed that cutaneous reflexes, known to be present in response to foot sole stimulation, can also be evoked by stimulation of hairy leg skin. In addition, we demonstrated that adding tactile noise can enhance this reflex response. These findings demonstrate proof-of-concept for potential future applications where tactile stimulation, applied to the leg of an individual with amputation, can enhance postural-relevant reflexes. Improving postural control may reduce the risk of falls in this high-risk population.

Background and Purpose: Periprosthetic femoral fracture (PPF) after total hip arthroplasty (THA) is a serious complication, as it often is followed by functional deficits and morbidity. There is no consensus regarding the optimal stem fixation method and whether additional cup replacement is beneficial. The aim of our study was to perform a direct comparison of reasons and risk of re-revision between cemented and uncemented revision THAs following PPF using registry data., Patients and Methods: 1,879 patients registered in the Dutch Arthroplasty Registry (LROI) who underwent a first-time revision for PPF between 2007 and 2021 (cemented stem: n = 555; uncemented stem: n = 1,324) were included. Competing risk survival analysis and multivariable Cox proportional hazard analyses were performed., Results: 5- and 10-year crude cumulative incidence of re-revision following revision for PPF was similar between cemented (resp. 13%, 95% CI 10-16 and 18%, CI 13-24) and uncemented (resp. 11%, CI 10-13 and 13%, CI 11-16) revisions. Multivariable Cox regression analysis, adjusting for potential confounders, showed a similar risk of revision for uncemented and cemented revision stems. Finally, we found no difference in risk of re-revision between a total revision (HR 1.2, 0.6-2.1) compared with a stem revision., Conclusion: We found no difference in the risk of re-revision between cemented and uncemented revision stems after revision for PPF.

Background and Purpose: The direct superior approach (DSA) is a modification of the classic posterolateral approach (PLA) for total hip arthroplasty (THA), in which the iliotibial band and short external rotators are spared. The revision rate of the DSA has not been investigated previously using arthroplasty registry data. We examined the reasons and risk of revision of the DSA, compared with the direct anterior approach (DAA) and PLA., Patients and Methods: In this population-based cohort study we included 175,543 primary THAs performed between 2014 and 2020 (PLA, n = 117,576; DAA, n = 56,626; DSA, n = 1,341). Competing risk survival analysis and multivariable Cox proportional hazard analyses, adjusted for potential confounders, were performed., Results: After 3 years, crude revision rates due to any reason were 2.1% (95% confidence interval [CI] 1.3-3.3) for DSA, and 2.9% (CI 2.8-3.0) for PLA. Crude dislocation revision rates were 0.3% (CI 0.1-0.8) for DSA, versus 1.0% (CI 0.9-1.0) for PLA. Dislocation revision rate for DSA did not differ from DAA (0.3% [CI 0.2-0.3]). Multivariable Cox regression analysis demonstrated no overall difference in revision rates for the DSA (HR 0.6 [CI 0.4-1.09) compared with the PLA. Lower risk of revision due to dislocation was found in patients operated on through the DSA (HR 0.3 [0.1-0.9]) compared with the PLA., Conclusion: Early nationwide results suggest that the DSA for total hip arthroplasty seems to show a tendency towards a lower risk of revision for dislocation but no overall reduced revision risk compared with the PLA.

Introduction: The mechanisms regulating neuromuscular control of standing balance can be influenced by visual sensory feedback and arousal. Virtual reality (VR) is a cutting-edge tool for probing the neural control of balance and its dependence on visual feedback, but whether VR induces neuromodulation akin to that seen in real environments (eyes open vs. closed or ground level vs. height platform) remains unclear., Methods: Here we monitored 20 healthy young adults (mean age 23.3 ± 3.2 years; 10 females) during four conditions of quiet standing. Two real world conditions (eyes open and eyes closed; REO and REC) preceded two eyes-open virtual ' low ' (ground level; VRL) and ' high ' (14 m height platform; VRH) conditions. We measured arousal via electrodermal activity and psychosocial questionnaires rating perceived fear and anxiety. We recorded surface electromyography over the right soleus, medial gastrocnemius, and tibialis anterior, and performed force plate posturography. As a proxy for modulations in neural control, we assessed lower limb reflexive muscle responses evoked by tendon vibration and electrical stimulation., Results: Physiological and perceptual indicators of fear and anxiety increased in the VRH condition. Background soleus muscle activation was not different across conditions; however, significant increases in muscle activity were observed for medial gastrocnemius and tibialis anterior in VRH relative to REO. The mean power frequency of postural sway also increased in the VRH condition relative to REO. Finally, with a fixed stimulus level across conditions, mechanically evoked reflexes remained constant, while H-reflex amplitudes decreased in strength within virtual reality., Discussion: Notably, H-reflexes were lower in the VRL condition than REO, suggesting that these ostensibly similar visual environments produce different states of reflexive balance control. In summary, we provide novel evidence that VR can be used to modulate upright postural control, but caution that standing balance in analogous real and virtual environments may involve different neural control states., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Hodgson, King, Darici, Dalton, Cleworth, Cluff and Peters.)

Adverse childhood experiences (ACEs) affect 22-75% of American young adults. ACEs are associated with adverse health outcomes that begin in young adulthood. Yet, scant research has examined if coping can mediate the relationship between ACEs and adverse outcomes. The current study determined if coping mediates the relationship between ACEs and body mass index (BMI), substance use, and mental health outcomes in young adults. A community sample of 100 White and 100 Black young adults 18-34 years of age participated in a cross-sectional study conducted via Zoom conferencing. Participants provided demographic data, height/weight, and completed measures of ACEs, coping, substance use, and mental health outcomes. Coping was measured using an established three-factor model consisting of adaptive, support, and disengaged coping. Structural equation modeling (SEM) examined the relationships of ACEs to outcomes as mediated by coping. Participants were predominantly female ( n  = 117; 58.5%) and mid-young adult ( M  = 25.5 years; SD  = 4.1). SEM results indicated good model fit: (CMIN/ df  = 1.52, CFI = 0.94, RMSEA = 0.05 [90% CI = 0.03-0.07], SRMR = 0.06). Only disengaged coping mediated the ACE and substance use (β = 0.36, p  = .008), smoking (β = 0.13, p  = .004), and mental health (β=-0.26, p  = .008) relationships. Disengaged coping styles may be a critical mechanism in developing adverse mental health and substance use outcomes among ACE-exposed individuals. Future ACE and health outcomes research should examine the role of coping. Interventions focusing on adaptive coping may improve the health of individuals exposed to ACEs., Competing Interests: Conflict of InterestMarvin A. Solberg, Rosalind M. Peters, Stella M. Resko, and Thomas N. Templin declare no conflicts of interest with the research writing of this paper., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background and Purpose: In the last decade, the direct anterior approach (DAA) for total hip arthroplasty (THA) has become more popular in the Netherlands. Therefore, we investigated the learning curve and survival rate of the DAA in primary THA, using data from the Dutch Arthroplasty Register (LROI)., Patients and Methods: We identified all patients who received a primary THA using the DAA in several high-volume centers in the Netherlands between 2007 and 2019 (n = 15,903). Procedures were ordered per surgeon, using date of operation. Using the procedure number, operations were divided into 6 groups based on the number of previous procedures per surgeon (first 25, 26-50, 51-100, 101-150, 151-200, > 200). Data from different surgeons in different hospitals was pooled together. Revision rates were calculated using a multilevel time-to-event analysis., Results: Patients operated on in group 1-25 (hazard ratio [HR] 1.6; 95% CI 1.1-2.4) and 26-50 (HR 1.6; CI 1.1-2.5) had a higher risk for revision compared with patients operated on in group > 200 THAs. Between 50 and 100 procedures the revision risk was increased (HR 1.3; CI 0.9-1.9), albeit not statistically significant. From 100 procedures onwards the HR for revision was respectively 1.0 (CI 0.6-1.6) and 0.8 (CI 0.5-1.4) for patients in operation groups 101-150 and 151-200. Main reasons for revision were loosening of the stem (29%), periprosthetic infection (19%), and dislocation (16%)., Interpretation: We found a 64% increased risk of revision for patients undergoing THA using the DAA for the first 50 cases per surgeon. Between 50 and 100 cases, this risk was 30% increased, but not statistically significant. From 100 cases onwards, a steady state had been reached in revision rate. The learning curve for DAA therefore is around 100 cases.

The instability of human bipedalism demands that the brain accurately senses balancing self-motion and determines whether movements originate from self-generated actions or external disturbances. Here, we challenge the longstanding notion that this process relies on a single representation of the body and world to accurately perceive postural orientation and organize motor responses to control balance self-motion. Instead, we find that the conscious sense of balance can be distorted by the corrective control of upright standing. Using psychophysics, we quantified thresholds to imposed perturbations and balance responses evoking cues of self-motion that are (in)distinguishable from corrective balance actions. When standing immobile, participants clearly perceived imposed perturbations. Conversely, when freely balancing, participants often misattributed their own corrective responses as imposed motion because their balance system had detected, integrated, and responded to the perturbation in the absence of conscious perception. Importantly, this only occurred for perturbations encoded ambiguously with balance-correcting responses and that remained below the natural variability of ongoing balancing oscillations. These findings reveal that our balance system operates on its own sensorimotor principles that can interfere with causal attribution of our actions, and that our conscious sense of balance depends critically on the source and statistics of induced and self-generated motion cues., (© The Author(s) 2022. Published by Oxford University Press on behalf of the National Academy of Sciences.)

Background: Studies of the early months of the coronavirus disease 2019 (COVID-19) pandemic indicate that patient outcomes may be adversely affected by surges. However, the impact on in-hospital mortality during the largest surge to date, September 2020-March 2021, has not been studied. This study aimed to determine whether in-hospital mortality was impacted by the community surge of COVID-19., Methods: This is a retrospective cohort study of 416 962 adult COVID-19 patients admitted immediately before or during the surge at 229 US academic and 432 community hospitals in the Vizient Clinical Database. The odds ratios (ORs) of death among hospitalized patients during each phase of the surge was compared with the corresponding odds before the surge and adjusted for demographic, comorbidity, hospital characteristic, length of stay, and complication variables., Results: The unadjusted proportion of deaths among discharged patients was 9% in both the presurge and rising surge stages but rose to 12% during both the peak and declining surge intervals. With the presurge phase defined as the referent, the risk-adjusted ORs (aORs) for the surge periods were rising, 1.14 (1.10-1.19), peak 1.37 (1.32-1.43), and declining, 1.30 (1.25-1.35). The surge rise in-hospital mortality was present in 7 of 9 geographic divisions and greater for community hospitals than for academic centers., Conclusions: These data support public policies aimed at containing pandemic surges and supporting healthcare delivery during surges., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

The Brief COPE is a widely used measure of coping that contains 28 items on 14 factors. Researchers have shortened the inventory, but the factor structure remains debated. A systematic review of peer-reviewed studies published in English between 1997 and 2021 was conducted to determine if a more parsimonious number of factors could be identified. Cumulative Index for Nursing and Allied Health, PsycINFO, PsycARTICLES, Medline, PubMed, and Scopus databases were searched using keywords "Brief COPE" and " factor, valid* , or psychometric .*" Searching yielded 1,303 articles; cited references added 38; 85 articles met inclusion criteria. Principal components analysis and confirmatory factor analysis were major analytic strategies used (28% and 27%, respectively). Only eight studies analyzed the original 14-factor structure. Factors identified ranged from 2 to 15, with dichotomous factors most frequently identified (25%; n = 21). A smaller number of factors may be able to represent the Brief COPE. Research is needed to test a condensed instrument.

Background: Physiological trauma that requires admission to an emergency department may result in psychological distress. As many as 20%-40% of civilians who experience trauma develop traumatic stress disorders and depression postinjury. Yet, less than 10% of trauma centers implement screening for traumatic stress and depression risk., Objective: This project aimed to develop, implement, and evaluate a traumatic stress and depression risk screening policy., Methods: Twelve trauma advanced practice providers implemented the newly developed traumatic stress and depression risk screening policy at an American College of Surgeons verified Level II trauma center. Trauma patients admitted for greater than 24 hr, 14 years of age or older, with a Glasgow Coma Scale score greater than 13 were eligible for screening using the Injured Trauma Survivor Screen., Results: During the 6-week data collection period, 114 trauma patients presented to the emergency department. Of those, 82 (72%) met inclusion criteria, 77 (94%) eligible trauma patients were screened, and seven (9%) patients screened positive. Patients not eligible for screening were discharged within 24 hr or were too confused to answer questions. An evaluation survey revealed that the advanced practice providers thought that the screening policy was easy to use, feasible, not very time-consuming, and should be continued in the future., Conclusion: This project demonstrated the ease and effectiveness of implementing a traumatic stress and depression risk screening policy and that only minor changes are needed to make it sustainable., Competing Interests: The authors have no conflicts of interest or funding to disclose., (Copyright © 2022 Society of Trauma Nurses.)

We investigated the impairment of position sense associated with muscle fatigue. In Experiment 1 , participants performed learned eccentric extension (22°/s) movements of the elbow as the arm was pulled through the horizontal plane without vision of the arm. They opened their closed right hand when they judged it to be passing through a target. Dynamic position sense was assessed via accuracy of limb position to the target at the time of hand opening. Eccentric movements were performed against a flexion load [10% of flexion maximum voluntary contractions (MVCs)]. We investigated performance under conditions with and without biceps vibration, as well as before and after eccentric exercise. In Experiment 2 , a motor was used to extend the participant's limb passively. We compared conditions with and without vibration of the lengthening but passive biceps, before and after exercise. In Experiment 1 , vibration of the active biceps resulted in participants opening their hands earlier [mean, [Formula: see text] (95% confidence interval, CI) -5.52° (-7.40, -3.63)] compared with without vibration. Exercise reduced flexion MVCs by ∼44%, and participants undershot the target more [-5.51° (-9.31, -1.70)] in the post-exercise block during control trials. Exercise did not influence the persistence of the vibratory illusion. In Experiment 2 , vibration resulted in greater undershooting [-2.99° (-3.99, -1.98)] compared with without vibration, before and after exercise. Although exercise reduced MVCs by ∼50%, the passive task showed no effects of exercise. We suggest that the central nervous system continues to rely on muscle spindles for limb position sense, even when they reside in a muscle exposed to fatiguing eccentric contractions. NEW & NOTEWORTHY Dynamic position errors were examined in an eccentric and a passive elbow extension proprioceptive-targeting task, before and after eccentric exercise, with and without muscle vibration. Participants actively undershot the target more when fatigued while fatigue did not exacerbate task accuracy during passive movement. Vibration caused undershoots regardless of fatigue state during active and passive movements. We propose that the central nervous system continues to rely on muscle spindles for kinesthesia, even when they reside in a fatigued muscle.

Foot sole skin interfaces with the ground and contributes to successful balance. In situations with reduced sensitivity in the glabrous foot skin, stochastic resonance (SR) improves skin sensitivity by adding tactile noise. Some situations, however, involve an interface comprised of hairy skin, which has higher thresholds for sensitivity. For example, in lower extremity amputation the residual limb is comprised of hairy leg skin. The main objective of this study was to determine if SR improves skin sensitivity in hairy skin, and whether a specific intensity of noise is most effective. Secondary objectives were to compare the effect between locations, ages and modalities. In 60 healthy participants a vibrotactile (test) input was delivered at the lower extremity concurrently with a second, noisy stimulus applied more proximally. The presence of a remote SR effect was tested in 15 young participants using electrotactile noise at the calf. Secondary objectives were tested in separate groups of 15 subjects and differed by substituting for one of the three variables: vibrotactile noise, heel site, and with older participants. A forced-choice protocol was used to determine detection ability of the subthreshold vibration test input with varying noise levels applied simultaneously (0, 20, 40, 60, 80, and 100% of perceptual threshold). An SR effect was identified when increased detection of the input was obtained at any level of noise versus no noise. It was found that all four test groups demonstrated evidence of SR: 33-47% of individuals showed better detection of the input with added noise. The SR effect did not appear consistently at any specific noise level for any of the groups, and none of the variables showed a superior ability to evoke SR. Interestingly, in approximately 33% of cases, threshold values fluctuated throughout testing. While this work has provided evidence that SR can enhance the perception of a vibrotactile input in hairy skin, these data suggest that the ability to repeatably show an SR effect relies on maintaining a consistent threshold., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Plater, Seto, Peters and Bent.)

Change in fatigue within a hemodialysis (HD) session has not been established previously. A total of 55 cognitively intact adults on HD were included; individuals with mobility/hemodynamic issues were excluded. Measures included the Piper Fatigue Scale-12 (PFS-12), 6-Minute Walk Test (6MWT), demographic and clinical. Descriptive statistics, ANOVA, and stepwise regression were used. Mean age was 57 years. Mean change in PFS-12 was -4.56 ± 27.85. Mean change in walk distance was -16.26 ± 43.87 meters (p = 0.03). The change in the PFS-12 accounted for 47% quadratic trend in the change in 6MWD (p < 0.001). Both fatigue measures (PFS-12 and 6MWT) can be useful for examining changes in fatigue levels within an HD session. Our findings speak to the convergent validity of these two measures of fatigue., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this nursing continuing professional development (NCPD) activity., (Copyright© by the American Nephrology Nurses Association.)

Optimal feedback control is a prominent theory used to interpret human motor behaviour. The theory posits that skilled actions emerge from control policies that link voluntary motor control (feedforward) with flexible feedback corrections (feedback control). It is clear the nervous system can generate flexible motor corrections (reflexes) when performing actions with different goals. We know little, however, about shared features of voluntary actions and feedback control in human movement. Here we reveal a link between the timing demands of voluntary actions and flexible responses to mechanical perturbations. In two experiments, 40 human participants (21 females) made reaching movements with different timing demands. We disturbed the arm with mechanical perturbations at movement onset (Experiment 1) and at locations ranging from movement onset to completion (Experiment 2). We used the resulting muscle responses and limb displacements as a proxy for the control policies that support voluntary reaching movements. We observed an increase in the sensitivity of elbow and shoulder muscle responses and a reduction in limb motion when the task imposed greater urgency to respond to the same perturbations. The results reveal a relationship between voluntary actions and feedback control as the limb was displaced less when moving faster in perturbation trials. Muscle responses scaled with changes in the displacement of the limb in perturbation trials within each timing condition. Across both experiments, human behaviour was captured by simulations based on stochastic optimal feedback control. Taken together, the results highlight flexible control that links sensory processing with features of human reaching movements., (Copyright © 2021 IBRO. Published by Elsevier Ltd. All rights reserved.)

A middle-range theory of heart failure self-care, derived from the self-care deficit theory of nursing, was tested among 175 Arab American older adults with heart failure. The middle-range theory achieved good statistical fit, but not all hypothesized relationships were supported. Specifically, conceptualizing basic conditioning factors as a single latent variable was not supported. However, individual factors of depression, social support, and time living with heart failure had a direct effect on both self-care agency and quality of life. Understanding predictors and outcomes of self-care within a theoretical framework is essential in caring for patients with heart failure.

Background: Patient-reported outcome measures (PROMs) after total hip arthroplasty (THA), can be influenced by patient characteristics (case-mix factors). We used the Dutch Arthroplasty Register (LROI) to determine the effect of case-mix on improvement of PROMs after primary THA., Methods: We included all primary THAs ( n  = 22,357) performed in the Netherlands between 2014 and 2018. The Hip disability and Osteoarthritis Outcome Score Physical function short form (HOOS-PS), Oxford Hip Score (OHS), EQ-5D index score and thermometer, and Numeric Rating Scales (NRS) measuring pain during activities and at rest, were recorded. The difference between preoperative and 3- and 12-month postoperative scores was calculated (delta-PROM) and used as primary outcome variable. Multivariable linear regression was used to examine the association between patient characteristics (age, sex, ASA score, body mass index (BMI), Charnley class, smoking, and previous operations to the affected hip) and PROMs. Cohens' d was used to measure effect size., Results: Postoperative improvement (delta-PROM) on HOOS-PS, OHS, EQ-5D, and pain relief were significantly higher in patients <60 years, in patients with female gender, a high ASA score (III-IV), a BMI >30 kg/m 2 , and patients without a previous operation to the hip. Cohen's d indicated clinically small differences (0.2)., Conclusions: Patients benefiting most in terms of postoperative improvement of self-reported physical functioning, pain relief and quality of life after primary THA were young, female, with a high ASA or BMI score, and without previous operations to the hip.

Combat sports pose a risk for accumulative injuries to the nervous system, yet fighters have remained an understudied population. Here, our purpose was to determine whether repetitive blows to the head have an effect on vestibular balance reflexes in combat sports athletes. We compared lower-limb muscle responses evoked with electrical vestibular stimuluation (EVS) between fighters (boxing/muay thai) and non-fighter controls. Each participant received stochastic vestibular stimulation (0-25 Hz, ±3 mA) over their mastoid processes while they stood relaxed with their head to the left or right. Surface electromyography was recorded from the medial gastrocnemius and soleus muscles bilaterally. Short and medium latency response (SLR/MLR) peaks were significantly delayed in the fighter group compared to controls. SLR and MLR peak amplitudes were also significantly lower in fighters. Fighter-estimated cumulative repetitive head impact (RHI) events demonstrated strong positive correlations with the timing of SLR and MLR peaks. Cumulative RHI events also negatively correlated with peak MLR amplitude and response gain at frequencies above 5 Hz. Our results provide evidence of a progressive vestibular impairment in combat sports athletes, potentially resulting from blows to the head accumulated in sparring practice and competitive bouts throughout their careers. Taken together, EVS-based vestibular assessments may provide a valuable clinical diagnostic tool and help better inform "return-to-play" and career-length decisions for not only combat sports athletes, but potentially other populations at risk of RHIs.

Human standing balance relies on self-motion estimates that are used by the nervous system to detect unexpected movements and enable corrective responses and adaptations in control. These estimates must accommodate for inherent delays in sensory and motor pathways. Here, we used a robotic system to simulate human standing about the ankles in the anteroposterior direction and impose sensorimotor delays into the control of balance. Imposed delays destabilized standing, but through training, participants adapted and re-learned to balance with the delays. Before training, imposed delays attenuated vestibular contributions to balance and triggered perceptions of unexpected standing motion, suggesting increased uncertainty in the internal self-motion estimates. After training, vestibular contributions partially returned to baseline levels and larger delays were needed to evoke perceptions of unexpected standing motion. Through learning, the nervous system accommodates balance sensorimotor delays by causally linking whole-body sensory feedback (initially interpreted as imposed motion) to self-generated balance motor commands., Competing Interests: BR, PF, RP, OO, IF, JI, RC, JB No competing interests declared, (© 2021, Rasman et al.)

Key Points: We examined the influence of cutaneous feedback from the heel and metatarsal regions of the foot sole on the soleus stretch reflex pathway during standing. We found that heel electrical stimuli suppressed and metatarsal stimuli enhanced the soleus vibration response. Follow-up experiments indicated that the interaction between foot sole cutaneous feedback and the soleus vibration response was likely not mediated by presynaptic inhibition and was contingent upon a modulation at the ⍺-motoneuron pool level. The spatially organized interaction between cutaneous feedback from the foot sole and the soleus vibration response provides information about how somatosensory information is combined to appropriately respond to perturbations during standing., Abstract: Cutaneous feedback from the foot sole provides balance-relevant information and has the potential to interact with spinal reflex pathways. In this study, we examined how cutaneous feedback from the foot sole (heel and metatarsals) influenced the soleus response to proprioceptive stimuli during standing. We delivered noisy vibration (10-115 Hz) to the right Achilles tendon while we intermittently applied electrical pulse trains (five 1-ms pulses at 200 Hz, every 0.8-1.0 s) to the skin under either the heel or the metatarsals of the ipsilateral foot sole. We analysed time-dependent (referenced to cutaneous stimuli) coherence and cross-correlations between the vibration acceleration and rectified soleus EMG. Vibration-EMG coherence was observed across a bandwidth of ∼10-80 Hz, and coherence was suppressed by heel but enhanced by metatarsal cutaneous stimuli. Cross-correlations showed soleus EMG was correlated with the vibration (∼40 ms lag) and cross-correlations were also suppressed by heel (from 104-155 ms) but enhanced by metatarsal (from 76-128 ms) stimuli. To examine the neural mechanisms mediating this reflex interaction, we conducted two further experiments to probe potential contributions from (1) presynaptic inhibition, and (2) modulations at the ⍺- and γ-motoneuron pools. Results suggest the cutaneous interactions with the stretch reflex pathway required a modulation at the ⍺-motoneuron pool and were likely not mediated by presynaptic inhibition. These findings demonstrate that foot sole cutaneous information functionally tunes the stretch reflex pathway during the control of upright posture and balance., (© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society.)

Air pollution is associated with preterm birth (PTB), potentially via inflammation. We recently showed the mixture benzene, toluene, ethylbenzene, and xylene (BTEX) is associated with PTB. We examined if ambient BTEX exposure is associated with mid-pregnancy inflammation in a sample of 140 African-American women residing in Detroit, Michigan. The Geospatial Determinants of Health Outcomes Consortium study collected outdoor air pollution measurements in Detroit; these data were coupled with Michigan Air Sampling Network measurements to develop monthly BTEX concentration estimates at a spatial density of 300 m 2 . First trimester and mid-pregnancy BTEX exposure estimates were assigned to maternal address. Mid-pregnancy (mean 21.3 ± 3.7 weeks gestation) inflammatory biomarkers (high-sensitivity C-reactive protein, interleukin [IL]-6, IL-10, IL-1β, and tumor necrosis factor-α) were measured with enzyme immunoassays. After covariate adjustment, for every 1-unit increase in first trimester BTEX, there was an expected mean increase in log-transformed IL-1β of 0.05 ± 0.02 units (P = 0.014) and an expected mean increase in log-transformed tumor necrosis factor-α of 0.07 ± 0.02 units (P = 0.006). Similarly, for every 1-unit increase in mid-pregnancy BTEX, there was a mean increase in log IL-1β of 0.06 ± 0.03 units (P = 0.027). There was no association of either first trimester or mid-pregnancy BTEX with high-sensitivity C-reactive protein, IL-10, or IL-6 (all P > 0.05). Ambient BTEX exposure is associated with inflammation in mid-pregnancy in African-American women. Future studies examining if inflammation mediates associations between BTEX exposure and PTB are needed., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Middle-range nursing theories provide a bridge between the more abstract grand nursing theories, research, and clinical practice. As such, middle-range nursing theories derived from extant nursing theories are critical for developing and advancing both nursing science and practice. This paper describes the strategy used in developing a middle-range theory of heart failure self-care. After integrating theoretical and empirical literature, a hypothetico-deductive approach was used to develop the middle-range theory of heart failure self-care from Orem's theory of self-care. Theoretical substruction was used to provide a graphic representation of the conceptual-theoretical-empirical structure demonstrating the congruence between the theoretical and operational systems.

Epizootic hemorrhagic disease virus (EHDV) causes serious disease in wild and privately ranched white-tailed deer ( Odocoileus virginianus ) in the United States. In Florida, there is high EHDV prevalence, yet no treatments. There are few management strategies for the disease due to limited knowledge of virus-vector-host interactions. We conducted a telemetry study on white-tailed deer to examine resource use by wild and ranched animals in the Florida panhandle during the 2016 transmission risk period. We built generalized linear mixed models (GLMMs) to estimate resource selection and map habitat preferences for wild and ranched deer in the study area to reveal how second-order selection may relate to higher disease prevalence in ranched deer. Wild deer preferred areas closer to tertiary roads and supplementary food sources but farther from permanent water. Ranched deer selected bottomland mixed forest and areas closer to tertiary roads, supplementary food sources, and permanent water. Ranched deer behaviors may increase the likelihood of EHDV vector encounters, as these deer selected preferred habitats of several putative vector species, which may increase vector blood meal success and viral transmission risk. Disparate resource selection behaviors may be a factor in observed differential EHDV exposure risk between ranched and wild white-tailed deer in Florida.

This paper describes the assessment of the psychometric properties of the Brief COPE in a sample of 189 pregnant African-American women. Confirmatory factor analysis (CFA) tested the original 14-factor model, and exploratory structural equation modeling (ESEM) determined whether a reduced number of factors still accounted for inter-item covariances. The CFA replicated 13 of the 14 original factors. After deleting substance use items and allowing for correlated error across the support factors, the 13-factor model achieved an acceptable fit (CMIN/ df = 1.77; RMSEA = 0.06, 95% CI = 0.05-0.07). ESEM resulted in three second-order factors: disengaged, active, and social support coping. Factor items were summed to create subscales with good internal consistency reliability (α = .74-.89). Social support coping and active coping were strongly correlated and accounted for nearly the same variance in four different psychological/affect scales, while disengaged coping was clearly distinct.

Objective: Medical students have higher rates of depression than age-matched peers. Given the societal stigma against mental illness, students with depression often seek guidance on disclosing this in residency applications. This study aimed to answer whether disclosing a mental illness during the residency application process affects an applicant's success in the National Resident Matching Program. The authors hypothesized candidates disclosing mental illness would receive fewer interviews and would be ranked lower than those disclosing physical illness., Methods: The authors randomized program directors from residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) to receive one of two surveys. Both surveys included similar demographic information and three applicant vignettes, varying only in presence and type of illness disclosed (major depression or diabetes mellitus). The authors analyzed data using the Generalized Estimating Equation method for ordinal logistic regression., Results: Out of 3838 ACGME residency programs, 596 responded (16.9%). A total of 380 (10.7%) program directors (survey 1, n = 204, 5.3%; survey 2, n = 176, 4.6%) completed the survey. Applicants who disclosed a history of depression had higher odds of being in a lower category of receiving an invitation (OR = 3.60, p < .001 for a "perfect" applicant, OR = 2.39, p < .001 for a "good" applicant with leave of absence) and a lower category for match ranking (OR = 1.94, p = .01 for a perfect applicant, OR = 2.30, p < .001 for a good applicant with leave of absence) compared with the candidate who disclosed a history of diabetes. However, strong applicants who disclosed depression still fared better in the application process than an average applicant without disclosed illness (OR = 0.13, p < .001 for invite and OR = 0.04, p < .001 for rank)., Conclusion: Disclosing depression during the residency application process puts an applicant at a notable, however not insurmountable, disadvantage compared with applicants who do not disclose mental illness.