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Background: Parkinson's disease is a relatively common problem in geriatric patients with an annual incidence rate of 20.5 per 100,000. These patients are at increased risk for falls and resultant fractures. Several reports suggest total shoulder arthroplasty in patients with fractures has a relatively high rate of complications. Whether hemiarthroplasty reduces the rate of complications or improves pain or function is not known.Questions/purposes: We therefore determined the ROM, pain, complications, and rate of failure of hemiarthroplasty for management of proximal humerus fractures in patients with Parkinson's disease.Patients and Methods: We retrospectively reviewed all eight hemiarthroplasties in patients with Parkinson's disease for fracture of the proximal humerus between 1978 and 2005. Seven patients (seven shoulders) had a minimum of 2 years followup (mean, 9.9 years; range, 2-16 years).Results: Postoperatively, the mean active abduction was 97 degrees , mean external rotation was 38 degrees , and internal rotation was a mean of being able to reach the level of the sacrum. The mean postoperative pain score was 2.5 points (on a scale of 1-5). There was a greater tuberosity nonunion in one patient and a superior malunion of the greater tuberosity in three patients. No patient had revision surgery.Conclusions: The benefit of hemiarthroplasty for proximal humerus fractures in patients with Parkinson's disease was marginal with three shoulders in seven patients having moderate to severe persistent pain and limited function postoperatively.Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The hip joint is a common location for metastatic disease. Actual as well as impending fractures at this site are frequently due to mechanical instability after tumor invasion and are usually treated surgically with hip arthroplasty. The objective of this study was to analyze survival and influences on survival after hip arthroplasty for metastatic hip disease.Methods: Two hundred and ninety-nine patients who had undergone a total of 306 hemiarthroplasty or total hip arthroplasty procedures for treatment of a pathologic or an impending pathologic hip fracture between 1969 and 1996 at our institution were included in this study. Data that had been acquired prospectively within the total joint registry of our institution were reviewed retrospectively.Results: The median duration of survival after the arthroplasty was 8.6 months. The duration of survival was significantly associated with the site of the fracture, location of the primary tumor, and time from the diagnosis of the primary tumor to the surgery for the fracture (p < or = 0.05). The time from the diagnosis to the arthroplasty was a significant independent predictor of survival.Conclusions: Patients undergoing hip arthroplasty for metastatic disease have a limited life expectancy, with only 40% (120) of the 299 patients in our series still alive at one year after the surgery. By identifying prognostic factors regarding life expectancy, this study provides surgeons and oncologists with information with which to weigh risks and benefits of hip arthroplasty for individual patients preoperatively. [ABSTRACT FROM AUTHOR]

Background: A widely variable prevalence of dislocation after total hip arthroplasty has been reported, partly because of varying durations of follow-up for this specific end-point. The effect of demographic factors on the long-term risk of dislocation as a function of time after total hip arthroplasty is not well understood. The purpose of the present study was to determine the risk of dislocation as a function of time after Charnley total hip arthroplasty and to investigate the demographic factors that influence the cumulative risk of dislocation.Methods: Six thousand six hundred and twenty-three consecutive primary Charnley total hip arthroplasties were performed in 5459 patients at one institution between 1969 and 1984. The patients included 2869 female patients and 2590 male patients with a mean age of sixty-three years. All procedures were performed with a 22-mm femoral head, and all femoral and acetabular components were fixed with cement. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation was calculated with use of the Kaplan-Meier method.Results: Three hundred and twenty hips (4.8%) dislocated. The cumulative risk of a first-time dislocation was 1% at one month and 1.9% at one year and then rose at a constant rate of approximately 1% every five years to 7% at twenty-five years for patients who were alive and had not had a revision by that time. Multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were seventy years old or more (as compared with those who were less than seventy years old) was 1.3. Three underlying diagnoses-osteonecrosis of the femoral head, acute fracture or nonunion of the proximal part of the femur, and inflammatory arthritis-were associated with a significantly greater risk of dislocation than osteoarthritis was.Conclusions: The cumulative long-term risk of dislocation after total hip arthroplasty is considerably greater than has been reported in short-term studies. The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are female patients and those with a diagnosis of osteonecrosis of the femoral head or an acute fracture or nonunion of the proximal part of the femur.Level Of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Hidradenitis suppurativa (HS) is associated with substantial morbidity. Few studies have addressed the natural history and mortality rates associated with HS. A higher risk of cardiovascular death in patients with HS has been reported. We investigated whether patients with HS have an increased overall risk of death compared with age- and gender-matched referents., Methods: We performed a retrospective cohort study of residents of Olmsted County, Minnesota, with incident HS between January 1, 1980, and December 31, 2008, and age- and gender-matched referents. The main outcomes and measures were the overall and cause-specific risks of death., Results: We identified 226 incident cases of HS and 678 age- and gender-matched referents among Olmsted County residents during the study period. Compared to referents, patients with HS had a significantly higher risk of all-cause death (hazard ratio [HR, 2.48; 95% CI, 1.53-4.03, P < 0.001) and cardiovascular- or cerebrovascular-related death (HR, 2.85; 95% CI, 1.10-7.40, P = 0.03). However, these risks were attenuated by adjusting for smoking history: all-cause HR, 1.65 (95% CI, 0.97-2.82, P = 0.07) and cardiovascular- or cerebrovascular-related HR, 2.03 (95% CI, 0.71-5.81, P = 0.18). The 71% of patients were former or current smokers at the time of HS diagnosis., Conclusions: Hidradenitis suppurativa patients have a substantially increased risk of death from any cause, including cardiovascular or cerebrovascular causes; the risk is especially dependent on smoking history., (© 2022 the International Society of Dermatology.)

Background: Chemoprevention for biliary tract cancers (BTC), which comprise intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma (eCCA), and gallbladder cancer, is controversial. We examined associations between low-dose aspirin, statins, NSAIDs, and metformin with BTC risk., Methods: We used a population-based cohort of 5.7 million persons over age 18 without personal history of cancer (except nonmelanoma skin cancer), receiving at least one commonly prescribed drug between July 1, 2005, and December 31, 2012, from the Swedish Prescribed Drug Registry. Hazard ratios (HR) were calculated using age-scaled multivariable-adjusted Cox models., Results: 2,160 individuals developed BTC. Low-dose aspirin was not associated with BTC risk [HR, 0.93; 95% confidence interval (CI), 0.81-1.07], iCCA (HR, 1.21; 95% CI, 0.93-1.57), eCCA (HR, 0.80; 95% CI, 0.60-1.07), or gallbladder cancer (HR, 0.87; 95% CI, 0.71-1.06). Statins were associated with lower risk of BTC (HR, 0.66; 95% CI, 0.56-0.78), iCCA (HR, 0.69; 95% CI, 0.50-0.95), eCCA (HR 0.54; 95% CI, 0.38-0.76), and gallbladder cancer (HR, 0.72; 95% CI, 0.57-0.91). For all BTC subtypes, combined low-dose aspirin and statins were not associated with lower risk than statins alone. NSAIDs were associated with higher risk of BTC and its subtypes. Metformin was not associated with BTC risk (HR, 0.98; 95% CI, 0.82-1.18), iCCA (HR, 1.06; 95% CI, 0.77-1.48), eCCA (HR, 1.15; 95% CI, 0.82-1.61), or gallbladder cancer (HR, 0.84; 95% CI, 0.63-1.11)., Conclusions: Statins were associated with a decreased risk of BTC and its subtypes. Low-dose aspirin alone was not associated with a decreased risk, and use of both was not associated with further decrease in risk beyond statins alone., Impact: Statins were most consistently associated with a decreased risk of BTC and its subtypes., (©2022 American Association for Cancer Research.)

Objective: To explore the natural history of chronic unexplained gastrointestinal (GI) symptoms and to determine the longitudinal trends of prevalence during a 20-year period in a single US community., Methods: Between January 1, 1990, and December 31, 2009, valid self-report questionnaires of GI symptoms were mailed to randomly selected cohorts of a community. The study used respondents who answered questions on 1 or more of 3 surveys (initial, 1990-1992; second, 2003-2004; and third, 2008-2009). The trends of prevalence of GI symptoms over time were analyzed in responders who completed 3 surveys, and the natural history or transition was evaluated., Results: The overall prevalence of major symptom groupings including gastroesophageal reflux disease was consistent among residents in a community on 3 survey time points (1990-1992, 2003-2004, and 2008-2009). The transitions of GI symptoms were common in 228 patients who responded to all 3 surveys; only 29% had the same symptom category in 3 surveys; otherwise, symptoms changed over time, resolving, recurring, or transitioning to another disorder. Observed proportions of symptom transitions were significantly different from expected during 20 years (P<.001). Higher non-GI somatic symptom scores were significantly associated with both symptom transitions (odds ratio, 3.9; 95% CI, 1.38 to 10.77) and having sustained symptoms (odds ratio, 12.7; 95% CI, 4.62 to 34.90)., Conclusion: The overall population prevalence of chronic unexplained GI symptoms is stable, but in individuals, transitions seem to be the rule. As these various GI syndromes appear to be so intimately interconnected, the common underlying pathogenesis may account for a major subgroup of chronic unexplained GI disorders., (Copyright © 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background : Industry funding in continuing medical education has been extensively studied in the USA. Although continuing medical education is also a requirement for Chinese physicians, little is known about Chinese physician perceptions of industry support in continuing medical education. Objective : We aim to determine perceptions regarding industry support for CME among Chinese physicians at a large CME course, examine potential associations between Chinese physicians' perceptions and their demographic characteristics, and compare Chinese and US physicians' perceptions of industry support for CME. Design : We performed a cross-sectional survey of physicians at a nephrology continuing medical education conference in China. All participants received a previously published, anonymous survey consisting of 4 items, with questions asked in English and Mandarin Chinese. Responses were compared with those of a previous cohort in the USA. Results : The response rate was 24% (128/541). Most respondents were nephrologists (112/126, 89%), women (91/128, 71%), and aged 20 to 40 years (79/127, 62%). Most respondents preferred industry-supported continuing medical education (84/123, 68%) or had no preference (33/123, 27%). More clinicians than clinical researchers supported industry offsetting costs (76.9% vs 58.3%; P = .03). Almost half of participants (58/125, 46%) stated that industry-supported continuing medical education was biased in support of industry. Compared with US physicians, Chinese physicians were more likely to believe, or had no opinion, that industry-supported courses were biased (67.2% vs 47.0%; P < .001). Conclusions : Chinese continuing medical education participants preferred industry-sponsored continuing medical education and were strongly in favor of industry offsetting costs, but almost half believed that such education was biased in favor of supporting companies. Concern for bias was higher among Chinese than US physicians. Given participants' concerns, further study examining industry bias in Chinese continuing medical education is recommended. Abbreviations : CME: Continuing medical education; US: USA.

Background: Continuing medical education (CME) often uses passive educational models including lectures. However, numerous studies have questioned the effectiveness of these less engaging educational strategies. Studies outside of CME suggest that engaged learning is associated with improved educational outcomes. However, measuring participants' engagement can be challenging. We developed and determined the validity evidence for a novel instrument to assess learner engagement in CME., Methods: We conducted a cross-sectional validation study at a large, didactic-style CME conference. Content validity evidence was established through review of literature and previously published engagement scales and conceptual frameworks on engagement, along with an iterative process involving experts in the field, to develop an eight-item Learner Engagement Instrument (LEI). Response process validity was established by vetting LEI items on item clarity and perceived meaning prior to implementation, as well as using a well-developed online platform with clear instructions. Internal structure validity evidence was based on factor analysis and calculating internal consistency reliability. Relations to other variables validity evidence was determined by examining associations between LEI and previously validated CME Teaching Effectiveness (CMETE) instrument scores. Following each presentation, all participants were invited to complete the LEI and the CMETE., Results: 51 out of 206 participants completed the LEI and CMETE (response rate 25%) Correlations between the LEI and the CMETE overall scores were strong (r = 0.80). Internal consistency reliability for the LEI was excellent (Cronbach's alpha = 0.96). To support validity to internal structure, a factor analysis was performed and revealed a two dimensional instrument consisting of internal and external engagement domains. The internal consistency reliabilities were 0.96 for the internal engagement domain and 0.95 for the external engagement domain., Conclusion: Engagement, as measured by the LEI, is strongly related to teaching effectiveness. The LEI is supported by robust validity evidence including content, response process, internal structure, and relations to other variables. Given the relationship between learner engagement and teaching effectiveness, identifying more engaging and interactive methods for teaching in CME is recommended.

Background: Paralleling the increased utilization of shoulder arthroplasty, bundled-payment reimbursement is becoming increasingly common. An understanding of the costs of each element of care and detailed information on the frequency of and reasons for readmission and reoperation are keys to developing bundled-payment initiatives. The purpose of this study was to perform a comprehensive analysis of complications, readmission rates, and costs of primary shoulder arthroplasty at a high-volume institution., Methods: Between 2012 and 2016, 2 shoulder surgeons from a single institution performed 1794 consecutive primary shoulder arthroplasties: 636 anatomic total shoulder arthroplasties (TSAs), 1081 reverse shoulder arthroplasties (RSAs), and 77 hemiarthroplasties. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation., Results: The 90-day complication, reoperation, and readmission rates were 2.3%, 0.6%, and 1.8%, respectively. The 90-day readmission risk was higher among patients with an American Society of Anesthesiologists score of 3 or greater; a 1-unit increase in the American Society of Anesthesiologists score was associated with a $429 increase in index cost. Of the hospital readmissions, 10 were directly related to the index arthroplasty whereas 21 were not. The median standardized costs were as follows: preoperative evaluation, $481; index surgical hospitalization, $15,758; and postoperative care, $183. The median standardized costs for index surgical hospitalization were different for each procedure: TSA, $14,010; RSA, $16,741; and hemiarthroplasty, $12,709., Conclusion: In this study, primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. The median standardized costs inclusive of preoperative workup and 90-day postoperative recovery were $14,675 and $17,407 for TSA and RSA, respectively., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Single measurements of liver stiffness (LS) by magnetic resonance elastography (MRE) have been associated with outcomes of patients with primary sclerosing cholangitis (PSC), but the significance of changes in LS over time are unclear. We investigated associations between changes in LS measurement and progression of PSC., Methods: We performed a retrospective review of 204 patients with patients who underwent 2 MREs at a single center between January 1, 2007 and December 31, 2018. We collected laboratory data and information on revised Mayo PSC risk and model for end-stage liver disease scores, the PSC risk estimate tool, and levels of aspartate transferase at the time of each MRE. The ΔLS/time was determined by the change in LS between the second MRE compared to the first MRE divided by the time between examinations. The primary endpoint was development of hepatic decompensation (ascites, variceal hemorrhage or hepatic encephalopathy)., Results: The median LS measurement was 2.72 kPa (interquartile range, 2.32-3.44 kPa) and the overall change in LS was 0.05 kPa/y. However, ΔLS/y was 10-fold higher in patients anticipated to have cirrhosis (0.31 kPa/y) compared to patients with no fibrosis (0.03 kPa/y). The median LS increased over time in patients who ultimately developed hepatic decompensation (0.60 kPa/y; interquartile range, 0.21-1.26 kPa/y) vs but remained static in patients who did not (reduction of 0.04/y; interquartile range, reductions of 0.26 to 0.17 kPa/y) (P < .001). The ΔLS/y value associated with the highest risk of hepatic decompensation was Δ0.34 kPa/y (hazard ratio [HR], 13.29; 95% CI, 0.23-33.78). After we adjusted for baseline LS and other risk factors, including serum level of alkaline phosphatase and the Mayo PSC risk score, ΔLS/y continued to be associated with hepatic decompensation. The optimal single LS cut-off associated with the hepatic decompensation was 4.32 kPa (HR, 60.41; 95% CI, 17.85-204.47). A combination of both cut-off values was associated with risk of hepatic decompensation (concordance score, 0.93; 95% CI, 0.88-0.98) CONCLUSIONS: A single LS measurement and changes in LS over time are independently associated with hepatic decompensation in patients with PSC. However, changes in LS occur slowly in patients without advanced fibrosis or hepatic decompensation., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the injury rate during high-intensity functional training., Participants and Methods: Adults (N=100; 82 [82%] female) in group strength-endurance training at the Dan Abraham Healthy Living Center from January 9, 2017, through April 19, 2018, were recruited for the study. Participants were recruited before the class start date. Those who consented received a preclass survey and another survey 6 weeks after the class started to obtain data on demographic characteristics, baseline joint problems or pain, injuries in the preceding 6 weeks, class satisfaction, and exercise habits. Classes lasted 6 weeks and were led by a trainer for 60 minutes, once weekly. Participants were encouraged to perform similar exercise on 2 additional nonconsecutive days throughout the week. Injury was self-reported and defined as experiencing new pain or sustaining injury while exercising during the 6-week time frame. The primary outcome measure was the number of injuries per 1000 training hours., Results: The injury rate was 9.0 injuries per 1000 training hours (95% CI, 5.8-13.4 injuries per 1000 training hours) during the 6-week training and 5.0 injuries per 1000 training hours (95% CI, 2.8-8.2 injuries per 1000 training hours) during the 6 weeks preceding enrollment (P=.08). Injury occurred in 18 (18%) of participants during the 6-week training, and 9 of 24 injuries (37.5%) occurred during a training class. The most commonly injured regions were knees (n=7) and back (n=6). Burpees and squats were the most common movements causing injury., Conclusion: The increased injury rate during the study was not statistically significant. It was higher than rates reported in previous retrospective studies of high-intensity functional training, weight lifting, or power lifting but comparable with rates reported in prospective studies of novice and recreational runners., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Pediatric hematologists/oncologists face complex situations such as breaking bad news, treatment/clinical trials discussions, and end-of-life/hospice care. With increasing diversity in patient and physician populations, cultural competency and sensitivity training covering different aspects of pediatric hematology/oncology (PDHO) care can help improve health care delivery and reduce disparities. Though it is considered a required component of fellowship training, there is no clearly defined curriculum meant specifically for PDHO fellows-in-training (PDHO-F). A national online survey of 356 PDHO-F and 67 PDHO program directors (PDHO-PD) was conducted to assess the educational experience, perceptions about identifying barriers including one's own biases and trainee comfort in delivering culturally sensitive care in various PDHO relevant clinical situations. One hundred and eleven (31.2%) PDHO-F and 27 (40.3%) PDHO-PD responded. 30.6% of PDHO-F "strongly agreed/agreed" they received comprehensive cross-cultural communication (CCC) training. The top two teaching methods were faculty role modeling and informal teaching. Majority of CCC training is in medical school or residency and only 10.8% of PDHO-F reported that most of their CCC training was in fellowship. In most clinical situations, there was a modest direct correlation between the fellow's level of agreement that they received comprehensive CCC training and their comfort level. Comfort level with some clinical situations was also significantly different based on year of training. Fellowship training programs should have CCC curricula which use experiential learning models and lay the foundation for promoting cultural awareness, self-reflection, and better patient-physician partnerships which can eventually adapt to and surmount the challenges unique to the physician's chosen field of practice.

Background: The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence., Methods: Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas., Results: Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not., Conclusions: With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Experiential learning has been suggested as a framework for planning continuing medical education (CME). We aimed to (1) determine participants' learning styles at traditional CME courses and (2) explore associations between learning styles and participant characteristics., Materials and Methods: Cross-sectional study of all participants (n = 393) at two Mayo Clinic CME courses who completed the Kolb Learning Style Inventory and provided demographic data., Results: A total of 393 participants returned 241 surveys (response rate, 61.3%). Among the 143 participants (36.4%) who supplied complete demographic and Kolb data, Kolb learning styles included diverging (45; 31.5%), assimilating (56; 39.2%), converging (8; 5.6%), and accommodating (34; 23.8%). Associations existed between learning style and gender (p = 0.02). For most men, learning styles were diverging (23 of 63; 36.5%) and assimilating (30 of 63; 47.6%); for most women, diverging (22 of 80; 27.5%), assimilating (26 of 80; 32.5%), and accommodating (26 of 80; 32.5%)., Conclusions: Internal medicine and psychiatry CME participants had diverse learning styles. Female participants had more variation in their learning styles than men. Teaching techniques must vary to appeal to all learners. The experiential learning theory sequentially moves a learner from Why? to What? to How? to If? to accommodate learning styles.

Background: Pregabalin is a calcium channel α2δ ligand that modifies visceral hypersensitivity in IBS patients. Clinical data for pregabalin in IBS are lacking., Aim: To test the efficacy of pregabalin on gastrointestinal symptoms in IBS patients., Methods: A double-blind, placebo-controlled trial was performed. Adults meeting IBS Rome III criteria with ≥3 pain attacks per month were randomised to pregabalin 225 mg vs placebo twice daily for 12 weeks. Questionnaires were completed weekly. The primary endpoint was average pain Bowel Symptom Scale (BSS) scores weeks 9-12. An intention-to-treat analysis of covariance evaluated treatment effects on quantitative endpoints, adjusting for age and gender. Adequate relief and change in pain score were assessed using a chi-squared test., Results: Eighty-five patients were recruited and randomised. Sample characteristics include: mean age 39.4 (SD = 14.6); 73 (86%) female; 37 (44%) IBS-D, 29 (35%) IBS-M, 18 (21%) IBS-C. The pregabalin arm had lower average pain-BSS scores weeks 9-12 (25 vs 42, P = 0.008). Compared with placebo, the overall IBS BSS severity score was lower in the pregabalin arm (26 vs 42, P = 0.009). Differences were observed for the diarrhoea-BSS and bloating-BSS scores (P = 0.049 and 0.016, respectively). No differences between groups were seen for constipation-BSS scores. Adequate relief was not different between the two arms (46% vs 36%, P = 0.35). 63% pregabalin vs 45% placebo had a change in pain score ≥30 at week 12 from baseline (P = 0.10). Post-treatment IBS-QoL scores did not differ between groups., Conclusion: This trial suggests that pregabalin may be beneficial for IBS abdominal pain, bloating and diarrhoea., (© 2019 John Wiley & Sons Ltd.)

Purpose: Reverse shoulder arthroplasty (RSA) improves pain and function with very good satisfaction. Concerns exist about some activities of daily living (ADLs) involving internal rotation. The purpose of this study was to report how patients with bilateral RSA perform various ADLs., Methods: Thirty-one primary bilateral RSA patients (average age 76 years; 21 women and 10 men) completed a survey to assess various outcomes. The average time between the second arthroplasty and the survey was 2.7 years (range 1.0-7.8 years)., Results: All clinical parameters were favorable. All patients reported being able to easily manage toileting and 87% reaching their back pocket. However, 29% found difficulty and 39% were unable to wash their back or put on bra. In comparison with various unilateral arthroplasty types, there was no statistical difference in overall activities ( p < 0.05)., Conclusion: Bilateral RSA can provide good functional outcome and high satisfaction. Patients manage most ADLs easily with some limitations in activities requiring extreme internal rotation.

Previous studies reported increased eosinophilic esophagitis (EoE) incidence in children. It is unclear whether this reported increased EoE incidence is true or due to increased recognition and diagnostic endoscopy among children. A population-based study that evaluated EoE incidence in OC, Minnesota, from 1976 to 2005 concluded that EoE incidence increased significantly over the past three 5-year intervals (from 0.35 [range: 0-0.87] per 100,000 person-years for 1991-1995 to 9.45 [range: 7.13-11.77] per 100,000 person-years for 2001-2005). The aim of this study is to assess the change of incidence and characteristics of EoE in children in the same population between 2005 and 2015 and compare the findings to those reported in the previous study. We retrospectively reviewed the electronic medical records from Olmsted Medical Center and Mayo Clinic between 2005 and 2015, using Rochester Epidemiology Project (REP) resources. All children with EoE diagnosis based on the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines were included. The incidence and characteristics of children with EoE during the study period were compared to those diagnosed between 1995 and 2005. The incidence of EoE in children adjusted for age and sex was 5.31 per 100,000 population person-years in 1995, 15.2 in 2005, and 19.2 in 2015. Change in annual incidence and seasonal variation were not significant, (P = .48) and (P = .32), respectively. Between 2005 and 2015, 73 children received an EoE diagnosis (boys 49; 67%) compared to 16 children (boys 10; 62.5) between 1995 and 2005. Mean (SD) age at diagnosis was 7.5 (5.2) and 12.8 (4.3) years, respectively. Symptoms differed by age of presentation, with vomiting the most common in children younger than 5 years (41.1% and 43.5%) and dysphagia in those older than 5 years (35.6% and 60.9%). The incidence of EoE was not increased for any specific age-group during the study period (P = .49). This study showed increased incidence of EoE in children in Olmsted County between 2005 and 2015 compared to the incidence between 1995 and 2005 (5.31 per 100,000 population person-years in 1995, 15.2 in 2005, and 19.2 in 2015). However, between 2005 and 2015, the change of incidence was not statically significant, (P = .48) despite the steady increase of EGD performed during the same time frame (64 in 2005 to 144 in 2015). By comparing children diagnosed between 2005 and 2015 to those diagnosed between 1995 and 2005, the mean age at diagnosis was younger in the former group, 7.5 versus 12.8 years. Vomiting replaced dysphagia as the most common clinical presentation. Otherwise, the presenting symptom of EoE in children remained consistent across specific age groups.

Background: Increasing body mass index (BMI) has been shown to correlate with increased rates of complications after total knee arthroplasty. To our knowledge, body surface area, body mass, and height have not been investigated in this manner. BMI and body surface area are affected differently by changes in height, and they are affected similarly by changes in weight. The purpose of this study was to quantify revision for any reason, mechanical failure, aseptic loosening, polyethylene wear, reoperation, and any infection after total knee arthroplasty using BMI, body surface area, body mass, and height as continuous variables., Methods: Prospectively collected data from a single institution's total joint registry were used to analyze 22,243 consecutive knees, in 16,106 patients, treated with a primary total knee arthroplasty from 1985 to 2012. The Kaplan-Meier survival method was used to evaluate revision and other common complications, with outcomes assessed using Cox regression analysis. Smoothing spline parameterization was used on physical parameters in these models., Results: Increasing BMI, body surface area, body mass, and height were associated with an increased risk of any revision surgical procedure, mechanical failure, and aseptic loosening after total knee arthroplasty. The risk of a revision surgical procedure was directly associated with each 1 standard deviation increase in BMI (hazard ratio [HR], 1.19; p < 0.01), body surface area (HR, 1.37; p < 0.01), body mass (HR, 1.30; p < 0.01), and height (HR, 1.22; p < 0.01). This association was especially demonstrated with revision for mechanical failure (BMI: HR, 1.15; p < 0.01; body surface area: HR, 1.35; p < 0.01; body mass: HR, 1.27; p < 0.01; and height: HR, 1.23; p < 0.01). The risk of failure in the subgroups of mechanical failure including a revision surgical procedure for aseptic loosening or polyethylene wear was also associated with increasing body surface area, body mass, and height. Increasing BMI (HR, 1.22; p < 0.01), body surface area (HR, 2.56; p < 0.01), and body mass (HR, 2.54; p < 0.01) were also associated with increased risk of any infection., Conclusions: Increasing BMI, body surface area, body mass, and height were strongly associated with the rates of revision, aseptic loosening, and other common complications following total knee arthroplasty. Body surface area and body mass appear to correlate more strongly with mechanical failure outcomes than BMI or height., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: To determine the incidence and temporal trends of food allergies., Patients and Methods: We performed a historical cohort study to describe the epidemiology of food allergies among residents of all ages in Olmsted County, Minnesota, during a 10-year period from January 2, 2002, through December 31, 2011, using the Rochester Epidemiology Project database. Overall incidence and trends in biannual incidence rates over time were evaluated., Results: During the 10-year study period, 578 new cases of food allergies were diagnosed. The average annual incidence rate was significantly higher among males compared with females (4.1 [95% CI, 3.6-4.5] vs 3.0 [95% CI, 2.7-3.4]; P<.001; per 10,000 person-years; 3.6 per 10,000 person-years overall). The pediatric incidence rate of food allergy increased from 7.0 (95% CI, 6.2-8.9) to 13.3 (95% CI, 10.9-15.7) per 10,000 person-years between the 2002-2003 and 2006-2007 calendar periods and then stabilized at 12.5 and 12.1 per 10,000 person-years in the last 2 calendar periods. Milk, peanut, and seafood were the most common allergen in infancy, in children between ages 1 and 4 years, and in the adult population, respectively., Conclusion: This is one of the first population-based studies to examine the temporal trends of food allergies. The incidence of food allergies increased markedly between 2002 and 2009, with stabilization afterward. Additional longitudinal studies are warranted to assess for epidemiological evidence of changes in food allergy incidence with changing recommendations for allergenic food introduction., (Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the value of perioperative tests for the diagnosis of infection in revision shoulder arthroplasty., Methods: A retrospective analysis was performed on 537 shoulder arthroplasties (429 patients) that underwent revision shoulder arthroplasty at our institution. Periprosthetic tissue cultures were positive in 169/537 surgeries., Results: White-blood cell count (WBC) was elevated in 3.8% revision arthroplasties. Erythrocyte sedimentation rate (ESR) was elevated in 23.1% revision arthroplasties. The C-reactive protein (CRP) was elevated in 20.8% revision arthroplasties. Bone scans (technetium, indium) were performed on 9.9% patients and it was positive for osteomyelitis in just one revision arthroplasty. Intra-operative pathology was read as consistent with acute inflammation in 11.9% revision arthroplasties. The positive and negative predictive values for intra-operative pathology were 56.7% and 71.6% respectively., Conclusion: All of the perioperative tests had a high specificity and negative predictive value, but low sensitivity and positive predictive value.

Objective: Little is known about factors associated with effective continuing medical education (CME) in psychiatry. The authors aimed to validate a method to assess psychiatry CME teaching effectiveness and to determine associations between teaching effectiveness scores and characteristics of presentations, presenters, and participants., Methods: This cross-sectional study was conducted at the Mayo Clinic Psychiatry Clinical Reviews and Psychiatry in Medical Settings. Presentations were evaluated using an eight-item CME teaching effectiveness instrument, its content based on previously published instruments. Factor analysis, internal consistency and interrater reliabilities, and temporal stability reliability were calculated. Associations were determined between teaching effectiveness scores and characteristics of presentations, presenters, and participants., Results: In total, 364 participants returned 246 completed surveys (response rate, 67.6%). Factor analysis revealed a unidimensional model of psychiatry CME teaching effectiveness. Cronbach α for the instrument was excellent at 0.94. Item mean score (SD) ranged from 4.33 (0.92) to 4.71 (0.59) on a 5-point scale. Overall interrater reliability was 0.84 (95% CI, 0.75-0.91), and temporal stability was 0.89 (95% CI, 0.77-0.97). No associations were found between teaching effectiveness scores and characteristics of presentations, presenters, and participants., Conclusions: This study provides a new, validated measure of CME teaching effectiveness that could be used to improve psychiatry CME. In contrast to prior research in other medical specialties, CME teaching effectiveness scores were not associated with use of case-based or interactive presentations. This outcome suggests the need for distinctive considerations regarding psychiatry CME; a singular approach to CME teaching may not apply to all medical specialties.

Background: Two-stage subpectoral implant-based breast reconstruction is the most common method for breast reconstruction. Recent advances in surgical techniques and technology have made prepectoral implant-based breast reconstruction feasible. There are limited data on outcomes after prepectoral implant-based breast reconstruction and postmastectomy radiation therapy., Methods: A retrospective review of consecutive patients undergoing immediate two-stage prepectoral implant-based breast reconstruction with postmastectomy radiation therapy was performed. Outcomes of irradiated breasts were compared with nonirradiated breasts in bilateral cases., Results: Ninety-three cases of prepectoral implant-based breast reconstruction in 54 women who underwent immediate two-stage reconstruction (39 bilateral and 15 unilateral) and unilateral postmastectomy radiation therapy were identified. Mean follow-up was 19 months from mastectomy and tissue expander reconstruction and 9 months from implant placement. Crude complication rates in irradiated versus nonirradiated sides were as follows: surgical-site infection, 18.5 percent versus 7.7 percent; seroma, 5.6 percent versus 5.1 percent; mastectomy skin flap necrosis, 1.9 percent versus 2.6 percent; wound dehiscence, 1.9 percent versus 7.7 percent; capsular contracture, 1.9 percent versus 0 percent; hematoma, 1.9 percent versus 2.6 percent; and extrusion, 1.9 percent versus 0 percent. On univariate analysis, there were no risk factors associated with any complication, including radiation therapy, surgical-site infection, unplanned readmissions, and unplanned return to the operating room. To date, reconstruction has been completed in 96 percent of patients, with successful implant-based breast reconstruction in 81 breasts (45 irradiated breasts and 36 nonirradiated breasts)., Conclusions: Early data of prepectoral implant-based breast reconstruction in patients with postmastectomy radiation therapy show promising results. Postmastectomy radiation therapy should not be an absolute contraindication to prepectoral implant-based breast reconstruction., Clinical Question/level of Evidence: Therapeutic, IV.

Background: We conducted a prospective validation study to develop a physician assistant (PA) clinical rotation evaluation (PACRE) instrument. The specific aims of this study were to 1) develop a tool to evaluate PA clinical rotations, and 2) explore associations between validated rotation evaluation scores and characteristics of the students and rotations., Methods: The PACRE was administered to rotating PA students at our institution in 2016. Factor analysis, internal consistency reliability, and associations between PACRE scores and student or rotation characteristics were determined., Results: Of 206 PACRE instruments sent, 124 were returned (60.2% response). Factor analysis supported a unidimensional model with a mean (SD) score of 4.31 (0.57) on a 5-point scale. Internal consistency reliability was excellent (Cronbach α=0.95). PACRE scores were associated with students' gender (P = .01) and rotation specialty (P = .006) and correlated with students' perception of being prepared (r = 0.32; P < .001) and value of the rotation (r = 0.57; P < .001)., Conclusions: This is the first validated instrument to evaluate PA rotation experiences. Application of the PACRE questionnaire could inform rotation directors about ways to improve clinical experiences. The findings of this study suggest that PA students must be adequately prepared to have a successful experience on their rotations. PA programs should consider offering transition courses like those offered in many medical schools to prepare their students for clinical experiences. Future research should explore whether additional rotation characteristics and educational outcomes are associated with PACRE scores.

Objective: Attempts to categorize distinct functional gastrointestinal disorders based on reported symptoms continue but symptoms frequently overlap. The study objective was to use latent class analysis (LCA) which accommodates both continuous and discrete manifest variables to determine mutually exclusive subgroup assignments of a population-based sample using gastrointestinal symptom and patient data., Materials and Methods: A validated bowel disease questionnaire and somatic symptom questionnaire were mailed to an age and gender stratified randomly selected community sample. Responses to the symptom questions were dichotomized as frequent vs. infrequent based on Rome IV criteria. A LCA model was developed using a calibration subset and the results applied to the validation subset., Results: There were 3831 total respondents (48%) with 3425 having complete data. The LCA algorithm was run for each of 10 (random) splits of the dataset and 2-6 latent classes were specified. Using the values of Akaike's Information Criterion coefficient c to determine fit of the data, 4 latent classes yielded better values resulting in four subgroups: 'asymptomatic,' 'upper' abdominal symptoms, 'lower' abdominal symptoms, and 'mixed' (upper and lower abdomen)., Conclusions: Latent class analysis identified 4 groups based on symptoms. This approach resulted in differentiation by anatomical region rather than the Rome IV classification of symptoms.

Background & Aims: Tricyclic antidepressants are effective in reducing symptoms of functional dyspepsia (FD). We performed a post hoc analysis of data from a previous randomized clinical trial to determine whether the benefits of an antidepressant on gastrointestinal symptoms in patients with FD were mediated by improving sleep or reducing anxiety. We explored the relationships between psychological measures, quality of sleep, and relief of symptoms., Methods: We analyzed data from a multicenter, double-blind trial that evaluated the efficacy of antidepressants on symptoms of FD, from October 2006 through October 2012. Patients (n = 292) were randomly assigned to groups given 50 mg amitriptyline, 10 mg escitalopram, or placebo for 12 weeks. During the study, participants completed the following validated psychological questionnaires: Symptom Check List 90, Symptom Somatic Checklist, Hospital Anxiety Depression Scale, Profile of Mood States, State Trait Anxiety Inventory, and Pittsburgh Sleep Quality Index at baseline and 12 weeks following treatment., Results: Baseline scores for the psychological and sleep measures were similar among groups; after 12 weeks there were no significant differences in scores among groups. Baseline mean global Pittsburgh Sleep Quality Index scores indicated poor sleep quality in all groups at baseline and after 12 weeks. Overall, antidepressants affected sleep duration scores: patients given amitriptyline had lower (better) scores than patients given placebo or escitalopram (P = .019). In all groups, responders had decreased anxiety and improvements in some sleep components., Conclusions: In a post hoc analysis of data from a clinical trial that evaluated the effects of antidepressants in patients with FD, amitriptyline was found to reduce symptoms of FD, but its mechanism is unlikely to involve reductions in psychological distress. The drug may modestly improve sleep. Clinicaltrials.gov no: NCT00248651., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Proton pump inhibitors (PPI) are inconsistently associated with osteoporotic fractures. Barrett's oesophagus (BO) patients are treated with high PPI doses for prolonged periods, but there are limited data on the incidence of osteoporosis and fractures in this group pf patients., Aim: To estimate the incidence of (and risk factors for) low bone mass (osteoporosis and/or osteopenia) related fractures in a population-based BO cohort., Methods: All subjects with BO and a diagnosis of osteoporosis and fractures were identified using Rochester Epidemiology Project resources. The incidence rates of all and osteoporotic fractures in these subjects were compared to an age- and gender similar population in Olmsted County to determine standardised incidence ratios (SIR). Predictors were assessed using Cox proportional hazards models., Results: Five hundred and twenty-one patients were included (median [IQR] age 61 [52, 72] years; 398 [76%] men) of whom 113 (21.7%) had fractures, and 46 (8.8%) had osteoporotic fractures. The incidence of all fractures and osteoporotic fractures was comparable to that of an age- and gender-matched population (SIR 1.09; 95% CI 0.92-1.29: SIR 1.05; 95% CI 0.85-1.29). PPI use, dose or duration of use was not associated with osteoporotic fracture risk (HR 0.87; 95% CI 0.12-6.39). Independent risk factors for osteoporotic fractures included older age, female gender and higher co-morbidity index., Conclusions: The incidence of osteoporotic fractures was not increased in BO patients compared to the general population. In addition, PPI use was not associated with increased fracture risk regardless of the duration of therapy or dose., (© 2017 John Wiley & Sons Ltd.)

Objective: To study associations between extreme erythrocyte sedimentation rate (ESR) elevations (≥100 mm/h) and diseases, age, sex, race, Charlson Comorbidity Index (CCI), and C-reactive protein (CRP) level., Patients and Methods: This was a retrospective cohort study of 4807 patients with extreme ESR values examined at Mayo Clinic, Rochester, Minnesota, from January 1, 2002, through December 31, 2011. Independent variables included diseases (infection, autoimmune, malignancy, renal disease, or miscellaneous), subcategories of diseases, patient demographic characteristics (age, sex, and race), CRP level, and CCI. The Wilcoxon rank sum test was used to assess comparisons of ESR between patients with and without disease as well as relationships between extreme ESR values and demographic characteristics of patients within disease categories. Associations between ESR and CRP level were determined using the Pearson correlation coefficient., Results: The leading diagnosis associated with extreme ESR elevations (n [%]) was infection (1932 [40]), followed by autoimmune (1839 [38]) and malignancy (1736 [36]) (P<.01). Extreme elevations in ESR varied by sex, with higher ESRs in men (mean, 117±13.3 mm/h) than in women (mean, 115.9±12.5 mm/h) (P=.008). Extreme ESR elevations correlated inversely with the CCI (P=.008) and did not correlate with the CRP level. There were no correlations between extreme elevations in ESR and age or race., Conclusion: We found that almost all patients have an identifiable etiology for extreme ESR elevations and that infection is the most common disease association. Unlike previous research, we identified higher ESRs in men than in women and no associations with age, race, and comorbid illness. These findings may enhance the diagnostic evaluation of patients with extreme ESR elevations., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Context: There are no studies on the effect of volunteer-provided hand massage in a busy chemotherapy outpatient practice., Objective: To assess the feasibility of introducing hand massage therapy into an outpatient chemotherapy unit and to evaluate the effect of the therapy on various symptoms experienced by cancer patients., Design: A pilot, quasi-experimental, pretest-posttest study., Setting: Chemotherapy outpatient clinic of a large tertiary care academic medical center., Patients/participants: Forty chemotherapy outpatients., Intervention: After being approached by a trained volunteer from a hand massage team, patients consented to receive a 20-minute hand massage before chemotherapy that was individualized according to patient preference and expressed needs., Main Outcome Measures: The visual analog scale (VAS) was used to measure pain, fatigue, anxiety, muscular discomfort, nervousness, stress, happiness, energy, relaxation, calmness, and emotional well-being (on a scale from 0-10) before and after the intervention; a satisfaction survey was administered after the therapy. Patients' demographic data were summarized with descriptive statistics, and VAS total scores were compared between groups at each time point with the two-group t test. Feasibility was evaluated from the number of patients who were approached, received a hand massage, and completed the study surveys., Results: Of the 40 participants, 19 were men (mean age, 59.5 years). Significant improvement after hand massage was indicated by VAS scores for fatigue, anxiety, muscular discomfort, nervousness, stress, happiness, energy, relaxation, calmness, and emotional well-being (P < .05). Pain scores also improved, but the difference was not statistically significant (P = .06). All patients indicated that they would recommend hand massage to other patients, and 37 were interested in receiving it during their next chemotherapy treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Patient-reported outcomes are increasingly used to capture the patients' perspective in total hip arthroplasty (THA). They can potentially be used to streamline post-THA follow-up to high-risk patients. We aimed to determine whether the long-term revision risk in THA relates to patient-reported measures at 2 and 5 years., Methods: In a single-institution cohort of primary THA procedures, we examined the association between 2-year and 5-year pain and Mayo Hip Scores and the risk of revision., Results: The absolute scores at 2 and 5 years were both significantly associated with the risk of revisions. Every 10-unit decline in the 2-year Mayo Hip Score <60 was associated with a significant 50% increase in the risk of revision (hazard ratio, 1.5 per 10 units; 95% confidence interval, 1.3-1.8). Similarly, every 10-unit decline in the 5-year Mayo Hip Score <60 was associated with almost doubling of the risk of revision (hazard ratio, 1.9 per 10 units; 95% confidence interval, 1.7-2.1)., Conclusion: We conclude that patient-reported outcomes in THA have prognostic importance and can be taken into account when planning frequency of aftercare. This will improve the efficiency of follow-up in large registry-based follow-up efforts., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: This investigation used age as a continuous variable to estimate implant survival and the risk of complications., Methods: Prospectively collected data were used to analyze 5494 consecutive shoulder arthroplasties performed from 1970 to 2012. Patients were a mean age of 67 years. The association between the age at the index procedure and the risk for each outcome was assessed using Cox regression and smoothing spline analysis., Results: Older age was associated with a decreased risk of revision surgery, revision for mechanical failure, and reoperation but with a higher risk for thromboembolic events. Reoperation rates also decreased in a linear fashion with older ages (P < .001). The risk of revision surgery decreased in a linear fashion between the ages of 40 and 85, with a 3% decreased risk of revision per 1-year increase in age (P < .01). This association held true in a multivariate model and when specific procedures were separated out. Compared with patients aged <50 years, patients aged from 50 to 65 years (P < .001) and those >65 years (P < .001) have decreased risks of revision surgery. The risk of a revision surgery in a patient aged >50 years was significantly decreased (~13% reduction in risk for each year; P < .001). There was a subtle association between older age and decreased rates of infection (P = .01)., Conclusions: There is a strong association between older age and decreased rates of revision surgery and reoperation after shoulder arthroplasty, with a striking association with decreased rates of mechanical failure. These are important considerations when counseling younger patients regarding their risks., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: It is unknown to what extent diabetes mellitus modifies the long-term risk of aseptic loosening in total hip arthroplasty (THA) and total knee arthroplasty (TKA). We examined the association between diabetes mellitus, perioperative hyperglycemia, and the likelihood of revisions for aseptic loosening., Methods: We studied 16,085 primary THA and TKA procedures performed at a large tertiary care hospital between 2002 and 2009. All blood glucose values around the time of surgery (within 1 week) were retrieved. Subsequent revision surgeries and the reasons for revision were ascertained through the institutional joint registry. Multivariate Cox models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for aseptic loosening associated with diabetes mellitus and hyperglycemia adjusting for age, gender, body mass index, and surgery type., Results: A total of 2911 (18%) surgeries had a diagnosis of diabetes mellitus at the time of surgery. Glucose testing was performed at least once in 7055 (44%) procedures within ±1 week of surgery. Although diabetic patients did not experience a higher risk of revision for aseptic loosening (HR, 0.87; 95% CI, 0.55-1.38), higher preoperative glucose values on the day before surgery were significantly associated with both the overall risk of revisions (HR, 2.80; 95% CI, 1.00-7.85) and revisions for aseptic loosening (HR, 4.95; 95% CI, 1.26-19.54)., Conclusion: High preoperative hyperglycemia is a potential risk factor for aseptic loosening in THA and TKA., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Glenohumeral subluxation and glenoid morphology are commonly evaluated in primary osteoarthritis by use of the Walch classification. The reliability of this classification system has been analyzed only by computed tomography (CT). The purpose of this study was to determine the reliability of plain axillary radiographs compared with CT scans., Methods: Three shoulder surgeons blindly and independently evaluated the radiographs and CT scans of 75 consecutive shoulders with primary glenohumeral osteoarthritis. Each observer classified all shoulders according to Walch in 4 separate sessions, each 6 weeks apart. There were 2 sessions using only radiographs and 2 using only CT scans. The order of shoulders evaluated was randomized., Results: The first reading by the most senior observer based on CT was arbitrarily used as the "gold standard" (A1, 21; A2, 13; B1, 12; B2, 28; C, 1). The average intraobserver agreement for radiographs was 0.66 (substantial; 0.66, 0.59, and 0.74 for each observer). The average intraobserver agreement for CT scans was 0.60 (moderate; 0.53, 0.61, and 0.65). Pairwise comparisons between observers showed higher agreement for radiographs than for CT scans (0.48 vs. 0.39). The average agreement for observations on radiographs and CT scans was 0.42 (moderate; 0.40, 0.37, and 0.50)., Conclusion: In this study, intraobserver agreement using the Walch classification based on axillary radiographs was substantial and compared favorably with agreement based on CT scans. The Walch classification provides a useful frame of reference when assessing subluxation and glenoid morphology in primary glenohumeral osteoarthritis, but not unlike other classification systems, it does not allow perfect agreement among observers., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Loosening of the glenoid component is a primary reason for failure of an anatomic shoulder arthroplasty. Pegged glenoids were designed in an effort to outperform keeled components. This study evaluated the midterm clinical and radiographic survival of a single implant design with implantation of an in-line pegged glenoid component and identified risk factors for radiographic loosening and clinical failure., Materials and Methods: There were 330 total shoulder arthroplasties that had been implanted with a cemented, all-polyethylene, in-line pegged glenoid component evaluated with an average clinical follow-up of 7.2 years. Of these shoulders, 287 had presurgical, initial postsurgical, and late postsurgical radiographs (mean radiographic follow-up, 7.0 years)., Results: At most recent follow-up, 30 glenoid components had been revised for aseptic loosening. This translated to a rate of glenoid component survival free from revision for all 330 shoulders of 99% at 5 years and 83% at 10 years. Of 287 glenoid components, 120 were considered loose on the basis of radiographic evaluation. Four humeral components were considered loose. Component survival (Kaplan-Meier) free from radiographic failure at 5 and 10 years was 92% and 43%. Severe presurgical glenoid erosion (Walch A2, B2, C) and patient age <65 years were risk factors for radiographic failure. Late humeral head subluxation was associated with radiographic failure., Conclusion: Despite the predominant thinking that pegged glenoid components may be superior to keeled designs, midterm radiographic and clinical failure rates were high with this pegged component design, particularly after 5 years. Advanced presurgical glenoid erosion and younger patient age are risk factors for radiographic loosening. Revision rates underestimate radiographic glenoid loosening., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Effective medical educators can engage learners through self-reflection. However, little is known about the relationships between teaching effectiveness and self-reflection in continuing medical education (CME). We aimed to determine associations between presenter teaching effectiveness and participant self-reflection in conference-based CME. This cross-sectional study evaluated presenters and participants at a national CME course. Participants provided CME teaching effectiveness (CMETE) ratings and self-reflection scores for each presentation. Overall CMETE and CME self-reflection scores (five-point Likert scale with one as strongly disagree and five as strongly agree) were averaged for each presentation. Correlations were measured among self-reflection, CMETE, and presentation characteristics. In total, 624 participants returned 430 evaluations (response, 68.9%) for the 38 presentations. Correlation between CMETE and self-reflection was medium (Pearson correlation, 0.3-0.5) or large (0.5-1.0) for most presentations (n = 33, 86.9%). Higher mean (SD) CME reflection scores were associated with clinical cases (3.66 [0.12] vs. 3.48 [0.14]; p = 0.003) and audience response (3.66 [0.12] vs. 3.51 [0.14]; p = 0.005). To our knowledge, this is the first study to show a relationship between teaching effectiveness and participant self-reflection in conference-based CME. Presenters should consider using clinical cases and audience response systems to increase teaching effectiveness and promote self-reflection among CME learners.

Background: It is unknown why functional gastrointestinal disorders (FGIDs) overlap and limited information exists on risk factors for those with overlap. Our aim was to estimate the prevalence of combinations of FGIDs including reflux (FGIDs-gastroesophageal reflux [GER]), and evaluate potential risk factors for people with multiple disorders in a representative US community., Methods: A population-based study was conducted by mailing a valid GI symptom questionnaire to an age- and gender-stratified random sample of residents of Olmsted County, MN. Rome III definitions were used to identify people with FGIDs, and GER was defined by weekly or more frequent heartburn or acid regurgitation. The prevalence of people meeting multiple symptom complexes was estimated. Moreover, potential risk factors for people with multiple disorders were evaluated., Key Results: A total of 3548 people provided data for each of the necessary symptom questions (mean age: 61±16 years, 54% female). Among these 3548 subjects, 2009 (57%) had no FGIDs-GER, 906 (26%) had a pure FGID-GER, 372 (10%) had 2 FGIDs-GER, and 261 (7%) had 3 or more FGIDs-GER. Somatization as assessed by a higher Somatic Symptom Checklist score (OR=3.3, 95% CI [2.7,4.1]) was associated with an increased odds for those with 3 or more FGIDs-GER compared to subjects with a pure FGID-GER adjusting for age and gender., Conclusions and Inferences: Symptom complex overlap is common rather than rare in the community. GER is an integral symptom complex associated with both upper and lower FGIDs. Somatization is a strong risk factor for multiple FGIDs., (© 2017 John Wiley & Sons Ltd.)

Objectives: The Functional Dyspepsia Treatment Trial reported that amitriptyline (AMI) was associated with adequate relief of functional dyspepsia (FD) symptoms, but the pharmacogenetics of antidepressant response in FD are not known. GNβ3 825C>T CC genotype has been previously linked to FD and TT genotype to antidepressant response in depression. The ss genotype of the 5-HTT LPR variant of the serotonin transporter gene (SLC6A4) has been linked to selective serotonin reuptake inhibitor (SSRI) response. We aimed to examine whether GNβ3 825C>T and 5-HTT LPR polymorphisms result in differential treatment effects in FD patients receiving antidepressant therapy., Methods: Participants were randomized to receive placebo, 50 mg AMI, or 10 mg escitalopram (ESC). The primary end point was adequate relief for ≥5 weeks of the last 10 weeks. Genotyping of GNβ3 825C>T and 5-HTT LPR was performed utilizing PCR-based methods., Results: GNβ3 825C>T and 5-HTT LPR genotype data were available for 256 (88%) and 246 (84%) patients, respectively. Both polymorphisms were in Hardy-Weinberg equilibrium. In tests for differential treatment, neither 5-HTT LPR nor GNβ3 825C>T genotype influenced response to therapy (P=0.89 and P=0.54, respectively). Although there was a tendency for a more favorable response to ESC in the SS/LS genotype compared to the LL genotype groups (40% vs. 31% reporting adequate relief of FD symptoms) among those in the ESC treatment arm, this was not significant (P=0.43)., Conclusions: GNβ3 825C>T and 5-HTT LPR genetic variants do not alter treatment response to tricyclic and SSRI antidepressants in FD.

Background: With increases in both total shoulder arthroplasty (TSA) volumes and patient life expectancies, the number of patients requiring follow-up after shoulder arthroplasty continues to grow exponentially. The purpose of this study is to establish a data-based follow-up schedule minimizing unnecessary patient and health care system costs without sacrificing patient care., Methods: Between January 1975 and January 2013, 2786 consecutive anatomic TSAs were performed at our institution. All shoulders undergoing reoperation/revision were reviewed to identify the common modes of failure and times to failure., Results: A total of 208 shoulders (7.5%) required reoperation. Early failure mechanisms included instability, rotator cuff tears, and infection, with 63% of these reoperations occurring within 2 years. Later failures included mechanical failures (including component loosening) and periprosthetic fractures, with no identifiable peak occurrence. After 2 years, TSA failed at an average rate 1.1% per year., Conclusions: TSA failure after 2 years is uncommon and triggers surgical intervention in approximately 1% of patients per year. Routine in-person surveillance of all patients on a scheduled basis may not be necessary and would increase patient and other health care costs. We recommend in-person visits to assess healing, direct rehabilitation, and manage soft tissue or infectious issues until 2 years, with planned, periodic patient contact by mail and radiographic evaluation of patients with poor or worsening outcomes thereafter, unless patient concerns arise or a newer implant design warrants closer clinical assessment., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: While studies have demonstrated that mortality after total hip (THA) and total knee (TKA) arthroplasty is better than the general population, the causes of death are not well established. We evaluated cause-specific mortality after THA and TKA., Methods: The study included population-based cohorts of patients who underwent THA (N = 2019) and TKA (N = 2259) between 1969 and 2008. Causes of death were classified using the International Classification of Diseases 9th and 10th editions. Cause-specific standardized mortality ratios (SMR) and 95% confidence intervals (CI) were calculated by comparing observed and expected mortality. Expected mortality was derived from mortality rates in the United States white population of similar calendar year, age, and sex characteristics., Results: All-cause mortality was lower than expected following both THA and TKA. However, there was excess mortality due to mental diseases such as dementia following both THA (SMR 1.40, 95% CI 1.08, 1.80) and TKA (SMR 1.49, 95% CI 1.19, 1.85). There was also excess mortality from inflammatory musculoskeletal diseases in THA (SMR 3.50, 95% CI 2.11, 5.46) and TKA (SMR 4.85, 95% CI 3.29, 6.88). When the cohorts were restricted to patients with osteoarthritis as the surgical indication, the excess risk of death from mental diseases still persisted in THA (SMR 1.36, 95% CI 1.02, 1.78) and TKA (SMR 1.52, 95% CI 1.20, 1.91)., Conclusion: THA and TKA patients experience a higher risk of death from mental and inflammatory musculoskeletal diseases. These findings warrant further research to identify drivers of mortality and prevention strategies in arthroplasty patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Despite the large increase in total hip arthroplasties and total knee arthroplasties, the incidence and prevalence of additional contralateral or ipsilateral joint arthroplasty are poorly understood. The purpose of this study was to determine the rate of additional joint arthroplasty after a primary total hip arthroplasty or total knee arthroplasty., Methods: This historical cohort study identified population-based cohorts of patients who underwent primary total hip arthroplasty (n = 1,933) or total knee arthroplasty (n = 2,139) between 1969 and 2008. Patients underwent passive follow-up through their medical records beginning with the primary total hip arthroplasty or total knee arthroplasty. We assessed the likelihood of undergoing a subsequent total joint arthroplasty, including simultaneous and staged bilateral procedures. Age, sex, and calendar year were evaluated as potential predictors of subsequent arthroplasty., Results: During a mean follow-up of 12 years after an initial total hip arthroplasty, we observed 422 contralateral total hip arthroplasties (29% at 20 years), 76 contralateral total knee arthroplasties (6% at 10 years), and 32 ipsilateral total knee arthroplasties (2% at 20 years). Younger age was a significant predictor of contralateral total hip arthroplasty (p < 0.0001), but not a predictor of the subsequent risk of total knee arthroplasty. During a mean follow-up of 11 years after an initial total knee arthroplasty, we observed 809 contralateral total knee arthroplasties (45% at 20 years), 31 contralateral total hip arthroplasties (3% at 20 years), and 29 ipsilateral total hip arthroplasties (2% at 20 years). Older age was a significant predictor of ipsilateral or contralateral total hip arthroplasty (p < 0.001)., Conclusions: Patients undergoing total hip arthroplasty or total knee arthroplasty can be informed of a 30% to 45% chance of a surgical procedure in a contralateral cognate joint and about a 5% chance of a surgical procedure in noncognate joints within 20 years of initial arthroplasty. Increased risk of contralateral total knee arthroplasty following an initial total hip arthroplasty may be due to gait changes prior to and/or following total hip arthroplasty. The higher prevalence of bilateral total hip arthroplasty in younger patients may result from bilateral disease processes that selectively affect the young hip, such as osteonecrosis, or structural hip problems, such as acetabular dysplasia or femoroacetabular impingement., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Patients who travel a significant distance to obtain surgical treatment typically experience better outcomes. This is called the referral bias and can limit the generalizability of studies performed at large tertiary care centers. We explored the influence of referral bias by comparing the clinical characteristics and outcomes of total knee arthroplasty (TKA) at a large tertiary care hospital in the United States., Methods: The study cohort included 22,614 primary TKA procedures performed between 1985 and 2010. Patients were stratified into 5 groups using home address zip codes and according to travel distance from the hospital. Clinical characteristics and the risk of TKA complications and surgical outcomes (instability, surgical-site infections, and thrombovascular complications within the first year, reoperations, revisions, and mortality) were compared across the 5 groups., Results: Compared with local patients, patients who traveled from other parts of the United States were significantly younger (mean age 67.8 vs 68.5 years; P < .05), were more likely to be male (47% vs 38%, P < .001), had lower body mass index (mean 30.4 vs 31.8 kg/m 2 ; P < .001), were more likely to have inflammatory arthritis or neoplasms as surgical indications (P < .05), and were more likely to have a history of prior surgeries on the same knee (20% vs 14%; P < .001). Referral patients also had significantly higher American Society of Anesthesiologists scores and longer operative times (mean 173 vs 156 minutes P < .001). Despite these differences, the risk of instability, surgical-site infections, thrombovascular complications, reoperations, and revision surgeries were similar across the 5 groups., Conclusion: Although referral patients differ from local patients, the groups seem to experience largely similar complication and revision rates after TKA., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Predictors of erosive esophagitis (EE) and Barrett's esophagus (BE) and the influence of number of risk factors in the community are not well defined., Methods: Rates of BE and EE among community residents identified in a randomized screening trial were defined. The risk of EE and BE associated with single and multiple risk factors (gender, age, GERD, Caucasian ethnicity, ever tobacco use, excess alcohol use, family history of BE or EAC, and central obesity) was analyzed., Results: Sixty-eight (33 %) of 205 subjects had EE and/or BE. BE prevalence was 7.8 % with dysplasia present in 1.5 %. Rates were comparable between subjects with and without GERD. Male sex and central obesity were independent risk factors. The odds of EE or BE were 3.7 times higher in subjects with three or four risk factors and 5.7 times higher in subjects with five or more risk factors compared with those with two or less factors., Conclusions: EE and BE are prevalent in the community regardless of the presence of GERD. Risk appeared to be additive, increasing substantially with three or more risk factors., Competing Interests: Potential competing interests: No authors have any conflicts to declare.

Background: Early life events have been found to be associated with irritable bowel syndrome (IBS) suggesting a role in development of functional disorders. The study aim was to identify potential perinatal risk factors for adult IBS., Methods: Utilizing a population-based nested case-control design, cases who met modified Rome III criteria for IBS and age- and-gender matched controls were identified using responses from prior mailed surveys to a random sample of Olmsted County residents. Medical records of eligible respondents were reviewed for perinatal events of interest. The association of early life events with subsequent case status was assessed using conditional logistic regression., Key Results: Of 3 417 respondents, 513 were born in Olmsted County and 108 met criteria for IBS. Due to missing records, 89 pairs were included in the final analyses. Logistic regression revealed only birth weight as a predictor of IBS. Lower birth weight increased the odds for IBS (OR = 1.54 [95% CI = (1.12, 2.08), p = 0.008]). Median birth weight was 3.35 kg (range: 1.96-5.24) and 3.57 kg (range: 2.18-4.59) for cases and controls, respectively. Maternal age, delivery method, and antibiotic exposure were not associated with IBS status but this study was only powered to detect large odds ratios., Conclusions and Inferences: Lower birth weight was observed as a risk factor for IBS. It is not clear if in utero developmental delays directly lead to IBS or if low birth weight is a prospective marker for subsequent early life problems leading to IBS., (© 2016 John Wiley & Sons Ltd.)

Background: Mortality after total hip and knee arthroplasty is lower than that in the general population, but it is unknown whether there are differences by surgery type, demographics, and calendar year. Our objective was to evaluate trends and determinants of long-term mortality among patients with total hip and knee arthroplasties., Methods: Using a historical cohort study design, we passively followed up population-based cohorts of total hip and total knee arthroplasty patients with degenerative arthritis who underwent surgery between January 1, 1969 and December 31, 2008. Patients were followed up until death or August 31, 2014. Observed and expected survival was compared using standardized mortality ratios (SMRs). Poisson regression models were used to examine relative mortality patterns by surgery type, age, sex, calendar year, and time since surgery., Results: The overall age- and sex-adjusted mortality was significantly lower than that in the general population after both total hip (SMR: 0.82, 95% CI: 0.76-0.88) and total knee (SMR = 0.80, 95% CI: 0.75-0.86) arthroplasties. Despite the low relative mortality within the first 8 years of surgery, we observed a worsening of relative mortality beyond 15 years after total knee arthroplasty surgery. Both short- and long-term mortality improved over calendar time, and the improvement occurred about a decade earlier in total knee arthroplasty than in total hip arthroplasty., Conclusion: Survival after total hip and total knee arthroplasties is better than that in the general population for about 8 years after surgery. Secular trends are encouraging and suggest that survival after both procedures has been improving even further in recent years., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To determine the incidence of major adverse events related to a large volume of image-guided liver biopsies performed at our institution over a 12-year period and to identify risk factors for major bleeding events., Patients and Methods: A retrospective analysis of an internally maintained biopsy registry was performed. The analysis revealed that 6613 image-guided liver biopsies were performed in 5987 adult patients between December 7, 2001, and December 31, 2013. Liver biopsies were performed using real-time ultrasound guidance and a spring-loaded biopsy device, with rare exceptions. Adverse events considered major and included in this study were hematoma, infection, pneumothorax, hemothorax, and death. Using data from the biopsy registry, we evaluated statistically significant risk factors (P<.05) for hematoma related to image-guided liver biopsy, including coagulation status, biopsy technique, and medications., Results: A total of 49 acute and delayed major adverse events (0.7%) occurred after 6613 liver biopsy events. The incidence of hematoma requiring transfusion and/or angiographic intervention was 0.5% (34 of 6613). The incidence of infection was 0.1% (8 of 6613), and that of hemothorax was 0.06% (4 of 6613). No patient (0%) incurred a pneumothorax after biopsy. Three patients (0.05%) died within 30 days of liver biopsy, 1 being directly related to biopsy. Thirty-eight of 46 major adverse events (83%) presented acutely (within 24 hours). More than 2 biopsy passes, platelets 50,000/μL or less, and female sex were statistically significant risk factors for postbiopsy hemorrhage., Conclusion: Image-guided liver biopsy performed by subspecialized interventionalists at a tertiary medical center is safe when the platelet count is greater than 50,000/μL. With appreciation of specific risk factors, safety outcomes of this procedure can be optimized in both general and specialized centers., (Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: This study aims to determine the association of preexisting cardiovascular risk factors and cardiovascular diseases with hysterectomy with bilateral ovarian conservation using a case-central design., Methods: Using the Rochester Epidemiology Project records-linkage system, we identified all Olmsted County, MN women who underwent hysterectomy with ovarian conservation between January 1, 1965 and December 31, 2002 (cases). Each case was age-matched (± 1 y) with a randomly selected woman who resided in the county and did not undergo hysterectomy or oophorectomy before the index date (date of hysterectomy in her matched case). Using electronic codes, we identified cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, obesity, metabolic syndrome, and polycystic ovary syndrome) and cardiovascular diseases (coronary artery disease, congestive heart failure, myocardial infarction, and stroke) that occurred before the index date. Analyses were stratified by age at hysterectomy and indication for surgical operation., Results: During the study period, 3,816 women underwent hysterectomy with ovarian conservation for a benign indication. Preexisting hyperlipidemia, obesity, and metabolic syndrome were significantly more frequent in cases than in controls in univariable analyses. In multivariable analyses, obesity remained significantly associated overall, for nearly all age groups, and across all indications. Stroke was significantly more frequent in cases than in controls among women younger than 36 years. Congestive heart failure and stroke were significantly less common in cases than in controls among women older than 50 years., Conclusions: Hysterectomy with ovarian conservation is associated with cardiovascular risk factors, particularly obesity. Obesity may contribute to underlying gynecologic conditions leading to hysterectomy; however, surgical selection may also play a role.

Background: Chronic constipation (CC) is common in the community but surprisingly little is known about relevant gastro-intestinal (GI) and non-GI co-morbidities., Objective: The purpose of this study was to assess the epidemiology of CC and in particular provide new insights into the co-morbidities linked to this condition., Methods: In a prospective, population-based nested case-control study, a cohort of randomly selected community residents (n = 8006) were mailed a validated self-report gastrointestinal symptom questionnaire. CC was defined according to Rome III criteria. Medical records of each case and control were abstracted to identify potential CC comorbidities., Results: Altogether 3831 (48%) subjects returned questionnaires; 307 met criteria for CC. Age-adjusted prevalence in females was 8.7 (95% confidence interval (CI) 7.1-10.3) and 5.1 (3.6-6.7) in males, per 100 persons. CC was not associated with most GI pathology, but the odds for constipation were increased in subjects with anal surgery relative to those without (odds ratio (OR) = 3.3, 95% CI 1.2-9.1). In those with constipation vs those without, neurological diseases including Parkinson's disease (OR = 6.5, 95% CI 2.9-14.4) and multiple sclerosis (OR = 5.5, 95% CI 1.9-15.8) showed significantly increased odds for chronic constipation, adjusting for age and gender. In addition, modestly increased odds for chronic constipation in those with angina (OR = 1.4, 95% CI 1.1-1.9) and myocardial infarction (OR = 1.5, 95% CI 1.0-2.4) were observed., Conclusions: Neurological and cardiovascular diseases are linked to constipation but in the community constipation is unlikely to account for most lower GI pathology.