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Birth defects are the leading cause of infant mortality in the United States, accounting for more than 20% of all infant deaths.[1] Birth defects also contribute substantially to morbidity and […]

Purpose: Previous studies have reported low rates of screening for high cholesterol levels among young adults in the United States. Although recommendations for screening young adults without risk factors for coronary heart disease (CHD) differ, all guidelines recommend screening adults with CHD, CHD equivalents, or 1 or more CHD risk factors. This study examined national prevalence of CHD risk factors and compliance with the cholesterol screening guidelines among young adults.Methods: National estimates were obtained using results for 2,587 young adults (men aged 20 to 35 years; women aged 20 to 45 years) from the 1999-2006 National Health and Nutrition Examination Surveys. We defined high low-density lipoprotein cholesterol (LDL-C) as levels higher than the goal specific for each CHD risk category outlined in the National Cholesterol Education Program Adult Treatment Panel III guidelines.Results: About 59% of young adults had CHD or CHD equivalents, or 1 or more of the following CHD risk factors: family history of early CHD, smoking, hypertension, or obesity. In our study, the overall screening rate in this population was less than 50%. Moreover, no significant difference in screening rates between young adults with no risk factors and their counterparts with 1 or more risk factors was found even after adjustment for sociodemographic and health care factors. Approximately 65% of young adults with CHD or CHD equivalents, 26% of young adults with 2 or more risk factors, 12% of young adults with 1 risk factor, and 7% with no risk factor had a high level of LDL-C.Conclusions: CHD risk factors are common in young adults but do not appear to alter screening rates. Improvement of risk assessment and management for cardiovascular disease among young adults is warranted. [ABSTRACT FROM AUTHOR]

Family history is a risk factor for many chronic diseases, including cancer, cardiovascular disease, and diabetes. Professional guidelines usually include family history to assess health risk, initiate interventions, and motivate behavioral changes. The advantages of family history over other genomic tools include a lower cost, greater acceptability, and a reflection of shared genetic and environmental factors. However, the utility of family history in public health has been poorly explored. To establish family history as a public health tool, it needs to be evaluated within the ACCE framework (analytical validity; clinical validity; clinical utility; and ethical, legal, and social issues). Currently, private and public organizations are developing tools to collect standardized family histories of many diseases. Their goal is to create family history tools that have decision support capabilities and are compatible with electronic health records. These advances will help realize the potential of family history as a public health tool. [ABSTRACT FROM AUTHOR]

Antihypertensive agents are one of the most commonly prescribed classes of medications in the country, but patient adherence rates are low. To better understand why rates are low, the authors used data from the 2005 HealthStyles survey and found that among the 1432 respondents who received prescriptions for antihypertensive medications, 407 (28.4%) reported having difficulty taking their medication. "Not remembering'' was the most common reason reported (32.4%), followed by cost (22.6%), having no insurance (22.4%), side effects (12.5%), other reasons (12.3%), not thinking there is any need (9.3%), and having no health care provider (4.7%). In a multivariate model, younger age, lower income, having mental function impairment, and having had a blood pressure check more than 6 months earlier were factors significantly associated with reporting difficulty taking prescribed antihypertensive drugs. Control of hypertension is a significant public health issue, and alleviating barriers to medication adherence should be a major goal toward hypertension management. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to test the association between stratified levels of familial risk of diabetes and the prevalence of the disease in the U.S. population. RESEARCH DESIGN AND METHODS: This study includes 16,388 adults interviewed for the National Health and Nutrition Examination Survey between 1999 and 2004. Fasting glucose was available for a subsample of 6,004 participants. Familial risk of diabetes was classified as average, moderate, or high. The prevalence and the odds of having diabetes were estimated for each risk class after accounting for other risk factors. RESULTS: Overall, 69.8% of the U.S. adults were in the average, 22.7% in the moderate, and 7.5% in the high familial risk for diabetes. The crude prevalence of diabetes for each risk class was 5.9, 14.8, and 30%, respectively. The graded association between familial risk and prevalence of diabetes remained even after accounting for sex, race/ethnicity, age, BMI, hypertension, income, and education. Versus people in the average risk class, independently of other risk factors considered, the odds of having diabetes for people in the moderate and high familial risk categories were, respectively, 2.3 and 5.5 times higher. CONCLUSIONS: In the U.S. population, family history of diabetes has a significant, independent, and graded association with the prevalence of diabetes. This association not only highlights the importance of shared genes and environment in diabetes but also opens the possibility of formally adding family history to public health strategies aimed at detecting and preventing the disease. [ABSTRACT FROM AUTHOR]

BACKGROUND: Evaluations by learners are the most common sources of information on teaching. There is some debate about the role of these assessments, but the overall evaluation of faculty by learners was found to be valid and reliable. PURPOSE: The purpose of this study was to examine the relationship between the level of training of family medicine residents and their evaluation of emergency medicine clinical teachers over time. METHODS: A prospective cohort analysis of 6 years of faculty evaluation of 115 teachers was conducted. RESULTS: The 562 residents returned 3,046 valid individual evaluations. There was no significant association between the level of residents' training and the ratings for clinical instruction (p > .05). Resident evaluations did not vary by time of year (p > .05); however, they did significantly differ by year of evaluation, showing that ratings increased over the 6 years of the study (p < .0001). CONCLUSIONS: Neither the residents' level of training nor the timing during the academic year were significant independent predictors of perceived superior teaching performance, although ratings increased over the 6 years of the study. [ABSTRACT FROM AUTHOR]

The effects of nutritional status on diarrheal and acute lower respiratory infection (ALRI) mortality in children < 2 y of age were examined by using data from a 1988-1991 longitudinal study of 9942 children in Metro Cebu, Philippines. Cox regression methods were used to study the strengths of the associations, possible interactions with birth weight and breast-feeding status, and the effect of additional confounding factors. Nutritional status as measured by weight-for-age was a significant risk factor for both ALRI and diarrheal mortality in the first 2 y of life. Poor nutritional status resulted in a 1.6-fold increased risk of diarrheal mortality for each one-unit decrease in weight-for-age Z score. For ALRI mortality, a one-unit decrease in weight-for-age Z score resulted in a 1.7-fold increase in risk, and for mortality assciated with ALRI and diarrhea combined, the relative risk was 2.0. This study provides further evidence that malnutrition is a major determinant of mortality in very young children and it is one of the first longitudinal studies to estimate the magnitude of the effect on cause-specific mortality associated with nutritional status. (C) 1997 American Society for Clinical Nutrition [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe the prevalence and characteristics of persons with arthritis or hypertension who received advice from their health-care professional to manage their condition. METHODS: Data from 9 states were obtained from the 2007 Behavioral Risk Factor Surveillance System. Two modules (Arthritis Management and Actions to Control High Blood Pressure) were analyzed (sample sizes: arthritis 29,698, hypertension 29,783). RESULTS: Fifty-five percent of persons with arthritis and 75.8% of persons with hypertension reported that their health-care professional ever suggested physical activity or exercise to help manage their condition. Correlates for being less likely to receive advice were lower levels of education, longer time since last routine doctor visit, being physically inactive, and having lower body mass index. Among inactive, normal weight persons, 43.0% (95% CI: 38.7, 47.4) with arthritis and 50.0% (95% CI: 44.4, 55.6) with hypertension reported receiving advice; among inactive, obese patients, 59.1% (95% CI: 55.8, 62.3) with arthritis and 74.0% (95% CI: 70.5, 77.3) with hypertension reported receiving advice. CONCLUSIONS: Findings suggest that health-care professionals may base physical activity counseling more on body mass index than a patient's activity level. To manage chronic health conditions, health-care professionals should assess patient's physical activity and offer all patients appropriate counseling.Copyright © 2009 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Context: Family history is a risk factor for many common chronic diseases, yet it remains underutilized in primary care practice.Background: Family Healthware is a self-administered, web-based tool that assesses familial risk for CHD; stroke; diabetes; and colorectal, breast, and ovarian cancer, and provides a personalized prevention plan based on familial risk. The Family Healthware Impact Trial evaluated the tool.Design: In this cluster RCT, participants completed baseline and 6-month follow-up surveys. The intervention group used Family Healthware directly after the baseline survey. Controls used the tool after completing the follow-up survey.Setting/participants: Patients aged 35-65 years with no known diagnosis of these six diseases were enrolled from 41 primary care practices.Main Outcome Measures: The prevalence of family-history-based risk for coronary heart disease (CHD); stroke; diabetes; and colorectal, breast, and ovarian cancer was determined in a primary care population.Results: From 2005 to 2007, 3786 participants enrolled. Data analysis was undertaken from September 2007 to March 2008. Participants had a mean age of 50.6 years and were primarily white (91%) women (70%). Of the 3585 participants who completed the risk assessment tool, 82% had a strong or moderate familial risk for at least one of the diseases: CHD (strong=33%, moderate=26%); stroke (strong=15%, moderate=34%); diabetes (strong=11%, moderate=26%); colorectal cancer (strong=3%, moderate=11%); breast cancer (strong=10%, moderate=12%); and ovarian cancer (strong=4%, moderate=6%). Women had a significantly (p<0.04) higher familial risk than men for all diseases except colorectal and ovarian cancer. Overweight participants were significantly (pConclusions: This self-administered, online tool delineated a substantial burden of family-history-based risk for these chronic diseases in an adult, primary care population.Trial Registration: NCT00164658. [ABSTRACT FROM AUTHOR]

Background : This study aimed to assess the reproducibility and reliability of Chat-Based GPT (ChatGPT)'s responses to 19 statements regarding the management of hip fractures in older adults as adopted by the American Academy of Orthopaedic Surgeons' (AAOS) evidence-based clinical practice guidelines. Methods : Nineteen statements were obtained from the 2021 AAOS evidence-based clinical practice guidelines. After generating questions based on these 19 statements, we set a prompt for both the GPT-4o and GPT-4 models. We repeated this process three times at 24 h intervals for both models, producing outputs A, B, and C. ChatGPT's performance, the intra-ChatGPT reliability, and the accuracy rates were assessed to evaluate the reproducibility and reliability of the hip fracture-related guidelines. Regarding the strengths of the recommendation compared with the 2021 AAOS guidelines, we observed accuracy of 0.684, 0.579, and 0.632 for outputs A, B, and C, respectively. Results : The precision was 0.740, 0.737, and 0.718 in outputs A, B, and C, respectively. For the reliability of the strengths of the recommendation, the Fleiss kappa was 0.409, indicating a moderate level of agreement. No statistical differences in the strengths of the recommendation were observed in outputs A, B, and C between the GPT-4o and GPT-4 versions. Conclusion : ChatGPT may be useful in providing guidelines for hip fractures but performs poorly in terms of accuracy and precision. However, hallucinations remain an unresolved limitation associated with using ChatGPT to search for hip fracture guidelines. The effective utilization of ChatGPT as a patient education tool for the management of hip fractures should be addressed in the future.

Background: Sarcopenia is an age-related progressive loss of muscle mass and function. Sarcopenia is a multifactorial disorder, including metabolic disturbance; therefore, metabolites may be used as circulating biomarkers for sarcopenia. We aimed to investigate potential biomarkers of sarcopenia using metabolomics., Methods: After non-targeted metabolome profiling of plasma from mice of an aging mouse model of sarcopenia, sphingolipid metabolites and muscle cells from the animal model were evaluated using targeted metabolome profiling. The associations between sphingolipid metabolites identified from mouse and cell studies and sarcopenia status were assessed in men in an age-matched discovery (72 cases and 72 controls) and validation (36 cases and 128 controls) cohort; women with sarcopenia (36 cases and 36 controls) were also included as a discovery cohort., Results: Both non-targeted and targeted metabolome profiling in the experimental studies showed an association between sphingolipid metabolites, including ceramides (CERs) and sphingomyelins (SMs), and sarcopenia. Plasma SM (16:0), CER (24:1), and SM (24:1) levels in men with sarcopenia were significantly higher in the discovery cohort than in the controls (all P < 0.05). There were no significant differences in plasma sphingolipid levels for women with or without sarcopenia. In men in the discovery cohort, an area under the receiver-operating characteristic curve (AUROC) of SM (16:0) for low muscle strength and low muscle mass was 0.600 (95% confidence interval [CI]: 0.501-0.699) and 0.647 (95% CI: 0.557-0.737). The AUROC (95% CI) of CER (24:1) and SM (24:1) for low muscle mass in men was 0.669 (95% CI: 0.581-0.757) and 0.670 (95% CI: 0.582-0.759), respectively. Using a regression equation combining CER (24:1) and SM (16:0) levels, a sphingolipid (SphL) score was calculated; an AUROC of the SphL score for sarcopenia was 0.712 (95% CI: 0.626-0.798). The addition of the SphL score to HGS significantly improved the AUC from 0.646 (95% CI: 0.575-0.717; HGS only) to 0.751 (95% CI: 0.671-0.831, P = 0.002; HGS + SphL) in the discovery cohort. The predictive ability of the SphL score for sarcopenia was confirmed in the validation cohort (AUROC = 0.695, 95% CI: 0.591-0.799)., Conclusions: SM (16:0), reflecting low muscle strength, and CER (24:1) and SM (16:0), reflecting low muscle mass, are potential circulating biomarkers for sarcopenia in men. Further research on sphingolipid metabolites is required to confirm these results and provide additional insights into the metabolomic changes relevant to the pathogenesis and diagnosis of sarcopenia., (© 2024 The Author(s). Journal of Cachexia, Sarcopenia and Muscle published by Wiley Periodicals LLC.)

Two-stage revision is generally preferred to eradicate chronic periprosthetic infections after total hip arthroplasty (THA) because of its good infection control and promising results. During two-stage revision, a temporary antibiotic-impregnated cement spacer was initially used for the local delivery of antibiotics, thereby reducing the risk of infection recurrence. Many researchers have reported various techniques for fabricating cemented spacers; however, there is no established standard technique. We share our cost-effective and easily reproducible technique for creating an articulated cemented spacer for managing infected THA., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

The present study aimed to compare clinical and radiological differences of ONFH patients who were treated with denosumab, and a control group. A total of 178 patients (272 hips) with symptomatic, nontraumatic ONFH were divided into a denosumab group (98 patients, 146 hips) and a control group (80 patients, 126 hips). Patients in the denosumab group received a 60 mg subcutaneous dose of denosumab every 6 months. For the clinical assessments, Harris hip scores (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were evaluated. Plain radiographs and MRI were performed before and a minimum of 1 year after administration of denosumab, which were evaluated for radiological results including femoral head collapse (≥ 2 mm) and volume change of necrotic lesion. Femoral head collapse occurred in 36 hips (24.7%) in the denosumab group, and 48 hips (38.1%) in the control group, which was statistically significant (P = 0.012). Twenty-three hips (15.8%) in the denosumab group and 29 hips (23%) in the control group required THA, which showed no significant difference (P = 0.086). At the final follow-up, 71.9% of hips in the denosumab group had a good or excellent HHS compared with 48.9% in the control group, showing a significant difference (P = 0.012). The denosumab group showed a significantly higher rate of necrotic lesion volume reductions compared with the control group (P < 0.001). Denosumab can significantly reduce the volume of necrotic lesions and prevent femoral head collapse in patients with ARCO stage I or II ONFH., (© 2024. The Author(s).)

Introduction: Forte ceramic head on delta ceramic liner articulation showed satisfactory midterm results without ceramic-related complication. We aimed to investigate the clinical and radiological outcomes of cementless total hip arthroplasty (THA) with forte ceramic head on delta ceramic liner articulation., Materials and Methods: Overall, 107 patients (57 men, 50 women; 138 hips) who underwent cementless THA with forte ceramic head on delta ceramic liner articulation were enrolled. The mean follow-up duration was 11.6 years. For the clinical assessments, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), presence of thigh pain, and presence of squeaking were evaluated. Radiographs were assessed to search for osteolysis, stem subsidence, loosening of implants. Kaplan-Meier survival curves were evaluated., Results: The mean HHS and WOMAC improved from 57.1 and 28.1 preoperatively to 81.4 and 13.1 at the final follow-up, respectively. Nine revisions (6.5%) were performed; 5 hips for stem loosening, 1 hip for ceramic liner fracture, 2 hips for periprosthetic fracture, and 1 hip for progressive osteolysis around cup and stem. Thirty-two patients (37 hips) complained squeaking, in which 4 cases (2.9%) were identified as ceramic-related noises. After a mean follow-up period of 11.6 years, 91% (95% CI 87.8-94.2) were free from revision of both femoral and acetabular components due to any reason., Conclusions: Cementless THA with forte ceramic-on-delta ceramic articulation showed acceptable clinical and radiological results. Serial surveillance of these patients should be performed due to the possibility of cerami- related complications such as squeaking, osteolysis, and ceramic liner fracture., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Pelvic bone fractures may cause extensive bleeding; however, the efficacy of tranexamic acid (TXA) usage in pelvic fracture surgery remains unclear. In this systematic review and meta-analysis, we aimed to evaluate the efficacy of TXA in open reduction and internal fixation surgery for pelvic and acetabular fracture., Methods: MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 22, 2020, that investigated the effect of TXA in the treatment of pelvic and acetabular fracture with open reduction and internal fixation. A pooled analysis was used to identify the differences between a TXA usage group and a control group in terms of estimated blood loss (EBL), transfusion rates, and postoperative complications., Results: We included 6 studies involving 764 patients, comprising 293 patients who received TXA (TXA group) and 471 patients who did not (control group). The pooled analysis showed no differences in EBL between the groups (mean difference -64.67, 95% confidence interval [CI] -185.27 to -55.93, P = .29). The study period transfusion rate showed no significant difference between the groups (odds ratio [OR] 0.77, 95% CI 0.19-3.14, P = .71, I2 = 82%), nor in venous thromboembolism incidence (OR 1.53, 95% CI 0.44-5.25, P = .50, I2 = 0%) or postoperative infection rates (OR 1.15, 95% CI 0.13-9.98, P = .90, I2 = 48%)., Conclusions: Despite several studies having recommended TXA administration in orthopedic surgery, our study did not find TXA usage to be more effective than not using TXA in pelvic and acetabular fracture surgery, especially in terms of EBL reduction, transfusion rates, and the risk of postoperative complications., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: This study aimed to compare the clinical and radiological outcomes of patients who underwent total hip arthroplasty (THA) after failed osteosynthesis of acetabular fractures vs. fractures of the proximal femur., Methods: This is a retrospective comparative study in two centers. A total of 110 patients who underwent THA after osteosynthesis of acetabular or proximal femur fractures were categorized into groups: group 1 (53 patients with acetabular fracture) and group 2 (57 patients with proximal femur fracture). The mean follow-up period was 6.3 (range 2-16.5) years. The Harris hip scores (HHSs), complications, radiological results, and Kaplan-Meier survival curves were evaluated., Results: The mean preoperative HHSs of 39.4 (group 1) and 41.2 (group 2) were improved to 83.6 and 84.7 at the final follow-up (p < 0.001 and p < 0.001, respectively). There were two cases of aseptic cup loosening, two cases of septic cup loosening, two cases of deep infection, two cases of dislocation, two cases of sciatic nerve palsy, and one case of periprosthetic fracture in group 1, and one case of dislocation and two cases of infection in group 2, which showed a statistical difference in complication rate (p = 0.021). Total cup migration was significantly higher in group 1 (p = 0.015). After a mean follow-up period of 6.3 years, the survival rate was significantly lower in group 1 (69.4% vs. 97.1%, p = 0.015)., Conclusion: THA following osteosynthesis of acetabular fracture showed poorer survival, higher complication rate, and higher migration of the acetabular cup than THA following osteosynthesis of proximal femur fracture., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

A barbed suture is a self-anchoring knotless suture hypothesized to shorten suture time and reduce the tension point of the wound. The purpose of this study was to compare the barbed suture and the interrupted suture for fascial closure in total hip arthroplasty. We retrospectively reviewed patients who underwent total hip arthroplasty from March 2014 to June 2020. We evaluated 324 cases among 274 patients consisting of 188 males and 86 females. We collected the following data: demographics, time for wound closure, the number of threads used, hemoglobin level, surgical site pain, and wound complications. Variables were analyzed for their association with closure time using multiple regression analyses between the barbed suture (the SFX group) and the interrupted suture (the Vicryl group). Mean closure time was 5.8 min lower and the mean number of sutures used was 2.2 lower in the SFX group versus the Vicryl group (P < 0.01 and < 0.01, respectively). There were no statistical intergroup differences in the mean largest hemoglobin drop, the incidence of transfusion, surgical site pain, and the incidence of wound complications. The use of barbed sutures for fascial closure in total hip arthroplasty effectively reduces the surgical time without increasing wound complications., (© 2022. The Author(s).)

Background: With the increasing sport population, the number of patients with external snapping hip (ESH) has also increased. To detect and visualise pathological soft tissue changes, magnetic resonance imaging (MRI) has been 1 of the most useful modalities. However, only limited studies have investigated MRI and its clinical value in the treatment of ESH in the past., Materials and Methods: Between May 2017 and November 2018, 104 patients were diagnosed with ESH at our institution. We excluded patients who did not undergo an MRI ( n  = 11), had complaint of bilateral symptom ( n  = 17), were not diagnosed hip problems previously (n  = 2), and were lost-follow-up within 6 months ( n  = 19). After applying the exclusion criteria, 55 patients remained. We classified the patients into 2 groups according-MRI findings: tensed iliotibial band (ITB) and hypertrophied gluteus maximus (GM). We investigated the clinical findings, such as mean age, symptom duration, pain score, grading based on symptom severity, and other radiological findings such as soft tissue signal change and ITB thickness. The variables were compared between the groups., Results: Between the 2 groups defined by MRI findings, the group characterised by tense ITB showed a relatively short symptom duration than the hypertrophied GM group ( p  < 0.001). No significant differences in the other variables were found between the groups., Conclusions: ESH has 2 types of MRI features. Compared with the hypertrophied GM group, the tense ITB group showed a shorter symptom duration and a more reversible status.

Quadratus lumborum block (QLB) has been shown to be effective for pain relief after hip surgery. This study evaluated the efficacy of ultrasound-guided anterior QLB in pain control after total replacement hip arthroplasty (TRHA). A total of 115 patients receiving anterior QLB were propensity score-matched with 115 patients who did not receive the block. The primary outcome was opioid consumption at 24, 24-48, and 48 postoperative hours. Secondary outcomes included pain scores at the post-anesthesia care unit (PACU), 8, 16, 24, 32, 40, and 48 h length of hospital stay, time to first ambulation, and the incidence of opioid-related side effects. Postoperative opioid consumption 48 h after surgery was significantly lower in the QLB group. Resting, mean, worst, and the difference of resting pain scores compared with preoperative values were significantly lower in the QLB group during the 48 postoperative hours. The length of hospital stay was shorter in the QLB group. The incidence of postoperative nausea and vomiting was significantly lower in the QLB group during the 48 postoperative hours, except at the PACU. This study suggests that anterior QLB provides effective postoperative analgesia for patients undergoing THRA performed using the posterolateral approach.

Despite being the gold standard for diagnosis of osteoporosis, dual-energy X-ray absorptiometry (DXA) could not be widely used as a screening tool for osteoporosis. This study aimed to predict osteoporosis via simple hip radiography using deep learning algorithm. A total of 1001 datasets of proximal femur DXA with matched same-side cropped simple hip bone radiographic images of female patients aged ≥ 55 years were collected. Of these, 504 patients had osteoporosis (T-score ≤ - 2.5), and 497 patients did not have osteoporosis. The 1001 images were randomly divided into three sets: 800 images for the training, 100 images for the validation, and 101 images for the test. Based on VGG16 equipped with nonlocal neural network, we developed a deep neural network (DNN) model. We calculated the confusion matrix and evaluated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We drew the receiver operating characteristic (ROC) curve. A gradient-based class activation map (Grad-CAM) overlapping the original image was also used to visualize the model performance. Additionally, we performed external validation using 117 datasets. Our final DNN model showed an overall accuracy of 81.2%, sensitivity of 91.1%, and specificity of 68.9%. The PPV was 78.5%, and the NPV was 86.1%. The area under the ROC curve value was 0.867, indicating a reasonable performance for screening osteoporosis by simple hip radiography. The external validation set confirmed a model performance with an overall accuracy of 71.8% and an AUC value of 0.700. All Grad-CAM results from both internal and external validation sets appropriately matched the proximal femur cortex and trabecular patterns of the radiographs. The DNN model could be considered as one of the useful screening tools for easy prediction of osteoporosis in the real-world clinical setting., (© 2021. The Author(s).)

Backgroud: Outcomes of traditional treatment for osteonecrosis of the femoral head (ONFH) are not always satisfactory. Hence, cell-supplementation therapy has been attempted to facilitate necrotic-tissue regeneration. Adipose-derived mesenchymal stem cell (ADMSC) transplantation is potentially advantageous over bone marrow-derived MSC implantation, but its outcomes for ONFH remain unclear. The aim of this study was to determine 2-year radiological and clinical outcomes of culture-expanded autologous ADMSC implantation for ONFH., Methods: Eighteen hips with necrotic lesions involving ≥ 30% of the femoral head were included. ADMSCs were harvested by liposuction and culture expanded for 3 passages over 3 weeks. With a 6-mm single drilling, ADMSCs were implanted into the necrotic zone. All patients underwent magnetic resonance imaging (MRI), single-photon emission computed tomography/computed tomography (SPECT/CT) at screening and 6 months, 12 months, and 24 months postoperatively. The primary outcome was the change in the size of necrotic area on MRI. Secondary outcomes were changes in clinical scores and radioisotope uptake on SPECT/CT. Conversion total hip arthroplasty (THA) was defined as the endpoint., Results: Preoperatively, the necrotic lesion extent was 63.0% (38.4%-96.7%) of the femoral head. The mean Harris hip score was 89.2, the University of California at Los Angeles (UCLA) score was 5.6, and Western Ontario and McMaster Universities Arthritis index (WOMAC) was 79.4. Three patients underwent THA and 1 patient died in an accident. Finally, 11 patients (14 hips) were available for ≥ 2-year follow-up. At the last follow-up, no surgery-related complications occurred, and 14 of 17 hips (82%) were able to perform daily activities without THA requirement. There was no significant decrease in lesion size between any 2 intervals on MRI. However, widening of high signal intensity bands on T2-weighted images inside the necrotic lesion was observed in 9 of 14 hips (64%); 11 of 14 hips (79%) showed increased vascularity on SPECT/CT at 2 years postoperatively. No significant differences were observed between preoperative and 24-month mean Harris hip score (89.2 vs. 88.6), WOMAC (79.4 vs. 75.7), and UCLA score (5.6 vs. 6.2)., Conclusions: Our outcomes suggest that culture-expanded ADMSC implantation is a viable option for ONFH treatment without adverse events., Competing Interests: CONFLICT OF INTEREST: One of the institutions (Seoul National University Borame Hospital, Seoul, Korea) received funding for this study from R Bio Co.,Ltd., Seoul, Korea. No other potential conflict of interest relevant to this article was reported., (Copyright © 2021 by The Korean Orthopaedic Association.)

Tumor-induced osteomalacia (TIO) is an uncommon paraneoplastic syndrome presenting with sustained hypophosphatemia. Treatment of choice is removal of the tumor causing the TIO, but identification of the culprit tumor by routine imaging is challenging. This study aimed to assess the usefulness of somatostatin receptor imaging, called 68 Ga-DOTATOC PET/CT, in the management of patients with TIO. Twelve patients who were suspected of having TIO underwent 68 Ga-DOTATOC PET/CT. Lesion detectability and maximum standardized uptake value (SUV max ) were determined and retrospectively compared with the clinical/imaging surveillance and histopathologic diagnosis. The median duration of suspected TIO with hypophosphatemia was 7.8 years (range 2.1-21.0). Conventional radiologic and/or nuclear medicine images failed to identify the culprit tumors. However, 68 Ga-DOTATOC PET/CT scans showed that 8 of the 12 patients had positive lesions, suggesting the presence of focal culprit tumors. The SUV max of positive tumors was 1.9-45.7 (median: 11.5). Six skeletal lesions and two extra-skeletal lesions were identified. Seven of the lesions were pathologically confirmed as potential culprits of TIO. Hypophosphatemia was resolved in five patients who underwent lesion excision. The 68 Ga-DOTATOC PET/CT is a useful whole-body imaging modality for the detection of causative tumors in patients with suspected TIO.

In the 10 months since the first confirmed case of coronavirus disease 2019 (COVID-19) was reported in the United States on January 20, 2020 (1), approximately 13.8 million cases and 272,525 deaths have been reported in the United States. On October 30, the number of new cases reported in the United States in a single day exceeded 100,000 for the first time, and by December 2 had reached a daily high of 196,227.* With colder weather, more time spent indoors, the ongoing U.S. holiday season, and silent spread of disease, with approximately 50% of transmission from asymptomatic persons (2), the United States has entered a phase of high-level transmission where a multipronged approach to implementing all evidence-based public health strategies at both the individual and community levels is essential. This summary guidance highlights critical evidence-based CDC recommendations and sustainable strategies to reduce COVID-19 transmission. These strategies include 1) universal face mask use, 2) maintaining physical distance from other persons and limiting in-person contacts, 3) avoiding nonessential indoor spaces and crowded outdoor spaces, 4) increasing testing to rapidly identify and isolate infected persons, 5) promptly identifying, quarantining, and testing close contacts of persons with known COVID-19, 6) safeguarding persons most at risk for severe illness or death from infection with SARS-CoV-2, the virus that causes COVID-19, 7) protecting essential workers with provision of adequate personal protective equipment and safe work practices, 8) postponing travel, 9) increasing room air ventilation and enhancing hand hygiene and environmental disinfection, and 10) achieving widespread availability and high community coverage with effective COVID-19 vaccines. In combination, these strategies can reduce SARS-CoV-2 transmission, long-term sequelae or disability, and death, and mitigate the pandemic's economic impact. Consistent implementation of these strategies improves health equity, preserves health care capacity, maintains the function of essential businesses, and supports the availability of in-person instruction for kindergarten through grade 12 schools and preschool. Individual persons, households, and communities should take these actions now to reduce SARS-CoV-2 transmission from its current high level. These actions will provide a bridge to a future with wide availability and high community coverage of effective vaccines, when safe return to more everyday activities in a range of settings will be possible., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Presently, hip arthroscopy is a widely adopted surgical intervention for the treatment of femoroacetabular impingement (FAI). However, there is insufficient evidence regarding which between arthroscopy and nonoperative treatment is more optimal for symptomatic FAI., Methods: MEDLINE, Embase, Web of Science, and the Cochrane Library were systematically searched for studies that compared arthroscopy and nonoperative interventions for FAI treatment from inception to August 4, 2020. We included studies that directly compared surgical and nonsurgical treatment for symptomatic FAI and excluded those that did not use arthroscopic treatment as a surgical technique and studies performed on patients with concomitant diagnoses instead of pure FAI. We compared the following clinical outcome scores at 6 and 12 months of follow-up: International Hip Outcome Tool 33 (iHOT-33), hip outcome score (HOS), EuroQol-visual analog scale (EQ-VAS), modified Harris hip score (mHHS), and nonarthritic hip score (NAHS)., Results: Five studies totaling 838 patients were included in the qualitative and quantitative synthesis; 382 patients underwent hip arthroscopy, and 456 patients were treated by nonoperative interventions. At 6 months of follow-up, there were no statistically significant differences in iHOT-33 ratings (mean difference [MD] = 7.92, P = .15), HOS (MD of HOS-ADL = 5.15, P = .26 and MD of HOS-Sports = 2.65, P = .79, respectively), and EQ-VAS (MD = 1.22, P = .76) between the 2 treatment strategies. At 12 months of follow-up, the arthroscopy group had a greater mean improvement in iHOT-33 score than the conservative treatment group (MD = 8.42, P = .002), but there was no difference between the groups in terms of mHHS rating (MD = -0.24, P = .83) and NAHS (MD = -2.08, P = .09)., Conclusion: Despite arthroscopy being associated with significantly superior iHOT-33 scores after 12 months of follow-up, we were unable to discern the difference between the treatment strategies using other scoring methods, such as HOS, EQ-VAS, mHHS, and NAHS. Further studies will be needed to conclusively determine if 1 strategy is superior to the other for treating FAI.

Aim: The purpose of this study was to investigate the demographic characteristics and prevalence of postoperative venous thromboembolism (VTE) in delayed hip fracture patients referred to our hospital (a tertiary referral center), and further verify the effect of intensive prophylaxis protocol in preventing the occurrence of VTE., Methods: We retrospectively evaluated 264 hip fracture patients whose surgery was delayed by >24 h. The patients were divided into two groups, according to the VTE prophylaxis protocol (conventional vs intensive). We evaluated the time from injury to surgery, and analyzed the prevalence of postoperative symptomatic VTE between the groups. The patient outcome measures, including in-hospital mortality and 30-day-mortality after hip surgery, were also evaluated., Results: The mean time from injury to operation was 127.4 h (95% confidence interval 92.2-162.7 h). The incidence of postoperative symptomatic VTE was 5.9% in the conventional prophylaxis group and 0.8% in the intensive prophylaxis group. The intensive prophylaxis group had a significantly lower incidence of postoperative VTE (P = 0.036). Eight patients with deep vein thrombosis on preoperative screening who underwent inferior vena cava filter insertion did not develop postoperative symptomatic VTE. Logistic regression analysis results also showed that the protocol statistically reduced the development of VTE (odds ratio 0.14, 95% CI 0.02-1.21, P = 0.042)., Conclusions: Delayed hip fracture surgery resulted in a higher incidence of VTE in patients who received conventional prophylaxis; however, our intensive prophylaxis protocol successfully prevented postoperative symptomatic VTE, including pulmonary embolism. Geriatr Gerontol Int 2020; 20: 1151-1156., (© 2020 Japan Geriatrics Society.)

Introduction: We aimed to present the clinical outcomes of multiple drilling and multiple matchstick-like bone allograft for large osteonecrotic lesions of the femoral head as a joint-preserving surgery., Materials and Methods: Between March 2014 and March 2018, 57 patients (77 hips) who underwent multiple drilling and multiple matchstick-like bone allograft for large lesions (≥ 30%) in osteonecrosis of the femoral head (ONFH) were included. Harris hip scores (HHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were obtained preoperatively and at the latest follow-up. Plain radiographs were obtained every 3 months. Femoral head collapse ≥ 2 mm was defined as a radiological failure, and conversion to total hip arthroplasty (THA) was regarded as a clinical failure., Results: After exclusion of 5 patients (5 hips) who lost to follow-up, 52 patients (34 men, 18 women; 72 hips) were finally enrolled. The mean follow-up period was 3.4 (range 2-4.5) years. Nineteen hips (28.4%) required conversion to THA at a mean of 21.6 (range 6-42) months postoperatively. In the remaining 53 hips (71.6%) with clinical success, the mean HHS and WOMAC improved from 63 and 31.3 preoperatively to 80.6 and 16.3 at the final follow-up, respectively (p < 0.001). Radiological failure occurred in four hips (6%). The overall failure rate was 31.9% (23/72 hips), and the mean survival duration until failure was 21.2 months (6-42 months). The lesion size, lesion location, and the use of corticosteroids as the cause of ONFH were associated with clinical failure., Conclusion: Multiple drilling and multiple matchstick-like bone allograft may be a useful treatment option for alleviating the symptoms in ONFH patients with large lesions who want to preserve their hips.

Background: Acetabular labral tears cause of pain in patients with symptomatic hip dysplasia. To date, no structured grading system has been developed to evaluate labral tears in these patients. The present study describes a new system of grading labral tears in patients with acetabular dysplasia., Methods: The data of 66 patients who underwent hip arthroscopy for symptomatic hip dysplasia from March 2014 to February 2018 were reviewed. Labral tears were classified into four groups, based on the occurrence of chondrolabral junction (CLJ) disruption, capsulolabral recess (CLR) disruption, and labral displacement. Labral tears without instability were classified as grade 1 or 2. Partial delamination or blistering of the labrum with minimal fraying at the CLJ was classified as grade 1, whereas labral tears with CLJ disruption were classified as grade 2. Unstable labral tears with CLR disruption followed by CLJ disruption, but without labral displacement, were classified as grade 3, whereas unstable labral tears with CLR and CLJ disruption, but with labral displacement, were classified as grade 4. The radiological and clinical characteristics of patients in each grade were determined including by simple radiographs and MRI/MR arthrography, as were concomitant findings, including rupture of the ligamentum teres, articular cartilage damage, and presence of a paralabral cyst. The surgical options selected for each grade and clinical outcomes, including modified Harris hip scores (mHHS) and Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) scores, were evaluated. Spearman's correlation analyses were performed to assess whether labral tear grade correlated with baseline characteristics, the incidence of concomitant injuries, and the severity of osteoarthritis (OA). The Wilcoxon test for paired data was performed to compare treatment results with pain scores., Results: The study cohort included six men and 53 women of mean ± SD age 39.9 ± 13.0 years (range, 15-66 years). Of the 66 hips, seven (10.6%), 10 (15.2%), 30 (45.5%), and 19 (28.8%) were classified as grades 1-4, respectively. Symptom duration (P = 0.017), preoperative Tönnis OA grade (P < 0.001), cartilage damage (P < 0.001), and the presence of a paralabral cyst (P = 0.001) correlated significantly with baseline tear grade. In all groups, mHHS and WOMAC scores improved after surgical treatment., Conclusions: Arthroscopic findings of labral tears in patients with hip dysplasia differed from the conventional classification. The classification system proposed in this study will likely be useful for determining the degree of labral tear in patients with hip dysplasia and for predicting treatment outcomes., Competing Interests: The authors have declared that no competing interests exist.

Backgrounds: One of the most significant complications after a femoral neck fracture is osteonecrosis of the femoral head (ONFH). The concomitant use of single-photon emission computed tomography (SPECT) with computed tomography (CT) increases the sensitivity for detecting the anatomic location and severity of ONFH. In this study, we evaluated the diagnostic value of SPECT/CT for the occurrence of ONFH by quantifying the perfusion status of the femoral head., Methods: A total of 30 patients who had multiple pinnings for femur neck fractures were included in this study. We classified the perfusion status into three groups: normal perfusion, decreased perfusion, and avascular groups, and compared the occurrence of femoral head necrosis between them. For quantitative analysis, we evaluated the uptake ratio of both femur heads (head-to-head uptake ratio). If the patient's contralateral hip was incomparable, we measured the uptake ratio from the superior dome of the ipsilateral acetabulum (head-to-acetabulum uptake ratio)., Results: Twenty-four patients out of 30 achieved bone union, whereas the others developed ONFH. When the population was divided into intact and defective perfusion groups on scintigraphy, the sensitivity, specificity, and accuracy of the test were 83.3, 75.0, and 76.7%, respectively. The mean head-to-head uptake ratio value with a 95% confidence interval (CI) was 1.10 (95% CI: 0.85-1.36). In the osteonecrosis group, the mean value of the head-to-head uptake ratio was 0.33 (95% CI: 0.28-0.38). In contrast, the ratio was 1.30 (95% CI: 1.03-1.57) in the non-osteonecrosis group, demonstrating a significant difference in the uptake ratio (P < 0.001). When the cutoff value of the uptake ratio was set to 0.5, both the sensitivity and specificity were 100%. There was also a significant difference in the head-to-acetabulum uptake ratio between the two groups (P <  0.001)., Conclusions: SPECT/CT was useful in evaluating the perfusion status of the femoral head, showing high accuracy in predicting the occurrence of avascular necrosis. To demonstrate the reliability and validity of SPECT/CT, further prospective studies on a larger scale are warranted.

Background: Dilute povidone-iodine (PI) lavage, a simple disinfection method, could reduce postoperative infection risk. However, there is no clinical consensus regarding its efficacy in total joint arthroplasties (TJAs). This systematic review and meta-analysis evaluated PI lavage's efficacy in preventing infection after TJA., Methods: MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before November 22, 2019, that compared postoperative infection rates in patients who underwent TJA with or without PI lavage before wound closure. Subgroup analyses were designed to identify the differences in infection site (overall or deep), type of surgery (total hip arthroplasty or total knee arthroplasty), time until diagnosis of infection (3 or 12 months postoperatively), and primary/aseptic revision arthroplasties., Results: We included 7 studies with 31,213 TJA cases, comprising 8861 patients who received PI lavage and 22,352 who did not. Pooled odds ratio for overall infection rate for the PI and non-PI lavage groups was 0.67 (95% confidence interval, 0.38-1.19, P = .17) and for the deep infection rate was 0.90 (95% confidence interval, 0.27-2.98, P = .86). Subgroup analyses revealed no differences in postoperative infection rates between the PI and non-PI lavage groups in terms of total hip arthroplasty and total knee arthroplasty, diagnosis of infection at 3 and 12 months postoperatively, or primary and aseptic revision arthroplasties., Conclusion: We detected no differences in the overall postoperative infection rates between the PI and non-PI lavage groups before wound closure in TJA including all studies in the subgroup analyses., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: The present study investigated the minimum 2-year outcomes of hip arthroscopy for femoroacetabular impingement (FAI) and concomitant labral tears in Asian patients., Methods: Patients who underwent hip arthroscopy for both FAI and concomitant labral tears between January 2012 and December 2017 were included. Patients with hip osteoarthritis of Tönnis grade ≥2, previous hip surgery, or followed for less than 2 years were excluded. Clinical assessments were performed using the modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the rates of achieving threshold values of the minimal clinically important difference and patient acceptable symptomatic state at the latest follow-up. Plain radiographs were acquired pre- and postoperatively for radiologic assessments., Results: A total of 73 patients (90 hips, 58 male, 15 female; mean age 34.4 years) who underwent hip arthroscopy for FAI and concomitant labral tears were enrolled. Forty-three hips (47.8%) had cam-type, 7 (7.8%) had pincer-type, and 40 (44.4%) had mixed-type FAI. The mean follow-up duration was 5.2 years. In cam- and mixed-type FAI hips, the mean α angle significantly decreased from 66.7 ± 8.28° preoperatively to 44.9 ± 3.78° postoperatively (95% confidence interval [CI] 19.6°-22.8°; P < .001). The mean modified Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index increased from 74.8 ± 13.2 and 75 ± 12.7 preoperatively to 93 ± 8.1 (95% CI 15.4-20.9; P = .001) and 89.4 ± 8.4 postoperatively (95% CI 11.8-17; P = .001), respectively. Seventy-four hips (82.2%) crossed the minimal clinically important difference, and 85 hips (94.4%) had achieved the patient acceptable symptomatic state. There were 2 cases of pudendal nerve palsy and 1 case of sciatic nerve palsy. No additional surgeries were required., Conclusions: Hip arthroscopy can be an effective treatment for FAI and concomitant labral tears in Asian patients as demonstrated in this study, with improved PRO scores and reoperation rates. Longer-term studies with larger cohorts are necessary., Level of Evidence: Level IV, case series., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Introduction: We evaluated the clinical and radiological outcomes of patients following total hip arthroplasty (THA) for acetabular fracture., Materials and Methods: This was a retrospective cohort study in a single center. The medical records of patients who underwent THA from March 2002 to March 2017 were reviewed. Inclusion criteria were THA and a history of open reduction and internal fixation of acetabular fractures. Thirty-seven patients with a mean age of 56.2 years were enrolled. The Harris hip score (HHS), acetabular fracture classification, time interval between acetabular fracture and THA, cause of THA, surgical approach, implant type, complications, radiographic results, and Kaplan-Meier survival curves were analyzed., Results: All patients were followed up for an average of 6.6 years. The mean preoperative HHS of 42.5 had improved to 83.5 at the final follow-up (p < 0.05). There were 29 cases of post-traumatic arthritis, 6 cases of avascular necrosis, and 4 cases of non-union. The average interval from injury to THA was 58 months (range 4-336 months). The re-admission rate was 18.9%. Patients who underwent conversion to THA due to post-traumatic arthritis combined with non-union acetabular fracture developed clinical failure more frequently than patients with post-traumatic arthritis (p = 0.037). At 12 years, 83.4% of patients were free from revision of femoral and acetabular components., Conclusion: THA secondary to an operatively treated acetabular fracture provides good symptomatic relief, but shows relatively inferior survival rates, and clinical failure was related to post-traumatic arthritis with acetabular non-union.

Case: A 20-year-old military recruit presented with pain in his left hip. He was referred by the military hospital for osteonecrosis of the femoral head in both hip joints. Plain radiographs and magnetic resonance imaging showed a marked collapse in the left femoral head; however, the patient was diagnosed as having subchondral fatigue fractures of the femoral head (SFFFH) after a thorough review of previous sequential images. Arthroscopic debridement and labral repair were performed. At 3 years after surgery, the patient was symptom-free and second-look hip arthroscopy revealed the articular defect filling with fibrocartilage on the femoral head., Conclusion: In a young patient, hip arthroscopy can be a successful joint preserving treatment option even for collapsed SFFFH.

Problem/condition: A 2017 report quantified the higher percentage of potentially excess (or preventable) deaths in nonmetropolitan areas (often referred to as rural areas) compared with metropolitan areas. In that report, CDC compared national, regional, and state estimates of potentially excess deaths among the five leading causes of death in nonmetropolitan and metropolitan counties for 2010 and 2014. This report enhances the geographic detail by using the six levels of the 2013 National Center for Health Statistics (NCHS) urban-rural classification scheme for counties and extending estimates of potentially excess deaths by annual percent change (APC) and for additional years (2010-2017). Trends were tested both with linear and quadratic terms., Period Covered: 2010-2017., Description of System: Mortality data for U.S. residents from the National Vital Statistics System were used to calculate potentially excess deaths from the five leading causes of death among persons aged <80 years. CDC's NCHS urban-rural classification scheme for counties was used to categorize the deaths according to the urban-rural county classification level of the decedent's county of residence (1: large central metropolitan [most urban], 2: large fringe metropolitan, 3: medium metropolitan, 4: small metropolitan, 5: micropolitan, and 6: noncore [most rural]). Potentially excess deaths were defined as deaths among persons aged <80 years that exceeded the number expected if the death rates for each cause in all states were equivalent to those in the benchmark states (i.e., the three states with the lowest rates). Potentially excess deaths were calculated separately for the six urban-rural county categories nationally, the 10 U.S. Department of Health and Human Services public health regions, and the 50 states and District of Columbia., Results: The number of potentially excess deaths among persons aged <80 years in the United States increased during 2010-2017 for unintentional injuries (APC: 11.2%), decreased for cancer (APC: -9.1%), and remained stable for heart disease (APC: 1.1%), chronic lower respiratory disease (CLRD) (APC: 1.7%), and stroke (APC: 0.3). Across the United States, percentages of potentially excess deaths from the five leading causes were higher in nonmetropolitan counties in all years during 2010-2017. When assessed by the six urban-rural county classifications, percentages of potentially excess deaths in the most rural counties (noncore) were consistently higher than in the most urban counties (large central metropolitan) for the study period. Potentially excess deaths from heart disease increased most in micropolitan counties (APC: 2.5%) and decreased most in large fringe metropolitan counties (APC: -1.1%). Potentially excess deaths from cancer decreased in all county categories, with the largest decreases in large central metropolitan (APC: -16.1%) and large fringe metropolitan (APC: -15.1%) counties. In all county categories, potentially excess deaths from the five leading causes increased, with the largest increases occurring in large central metropolitan (APC: 18.3%), large fringe metropolitan (APC: 17.1%), and medium metropolitan (APC: 11.1%) counties. Potentially excess deaths from CLRD decreased most in large central metropolitan counties (APC: -5.6%) and increased most in micropolitan (APC: 3.7%) and noncore (APC: 3.6%) counties. In all county categories, potentially excess deaths from stroke exhibited a quadratic trend (i.e., decreased then increased), except in micropolitan counties, where no change occurred. Percentages of potentially excess deaths also differed among and within public health regions and across states by urban-rural county classification during 2010-2017., Interpretation: Nonmetropolitan counties had higher percentages of potentially excess deaths from the five leading causes than metropolitan counties during 2010-2017 nationwide, across public health regions, and in the majority of states. The gap between the most rural and most urban counties for potentially excess deaths increased during 2010-2017 for three causes of death (cancer, heart disease, and CLRD), decreased for unintentional injury, and remained relatively stable for stroke. Urban and suburban counties (large central metropolitan and large fringe metropolitan, medium metropolitan, and small metropolitan) experienced increases in potentially excess deaths from unintentional injury during 2010-2017, leading to a narrower gap between the already high (approximately 55%) percentage of excess deaths in noncore and micropolitan counties., Public Health Action: Routine tracking of potentially excess deaths by urban-rural county classification might help public health departments and decision-makers identify and monitor public health problems and focus interventions to reduce potentially excess deaths in these areas., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Purpose: There are concerns that administration of bisphosphonate (BP) can substantially suppress bone turnover, potentially interfering with fracture healing. We investigated the effects of preoperative BP administration before internal fixation of intertrochanteric femoral fractures using fracture healing and clinical outcomes., Materials and Methods: We retrospectively analyzed data from 130 patients who underwent internal fixation for osteoporotic intertrochanteric femoral fractures between March 2012 and July 2016. Patients previously treated with BPs for at least 3 months (BP group; n=29) were compared with the remaining patients (BP-naïve group; n=101). Radiographs were used to assess and compare fracture healing 3 months and 1 year postsurgery. The primary clinical outcome measure assessed was change in Koval score., Results: Fracture union at 3 months after surgery was verified in 72.4% of patients (21/29) in the BP group and 90.1% of patients (91/101) in the BP-naïve group ( P =0.027). Fracture union at 1 year postsurgery (BP group, 93.1% [27/29] vs. BP-naïve group, 97.0% [98/101], P =0.310) and change in Koval score (1.1 vs. 1.0, P =0.694) were not significantly different between the groups. Multivariable logistic regression analysis revealed that a history of BP administration was associated with an increased risk of delayed union at 3 months postsurgery ( P =0.014)., Conclusion: Preoperative administration of BP was associated with a decreased fracture healing rate 3 months after internal fixation, compared with BP-naïve patients. Therefore, patients previously treated with a BP should be carefully allowed to wean off walking aids and transition to full weight-bearing in the early postoperative period., Competing Interests: CONFLICT OF INTEREST: The study was funded by Hanmi Pharmaceutical. The authors declare that there is no potential conflict of interest relevant to this article.

Background/objective: A stem sitting proud (SP) or that above the final rasp position remains in some patients who undergo hip replacement using proximally coated tapered wedge stems. Surgeons may face challenges providing the best fit because of unpredictable SP of proximally coated tapered wedge stems. Zimmer Inc. introduced a new rasp to solve this issue but the clinical results of this rasp have not yet been published. Therefore, our aim was to address the following: (1) What is the stem SP incidence using a proximally coated cementless tapered wedge stem? (2) Does the new rasp system (0-mm rasp) improve seating height? and (3) What are the risk factors of stem SP?, Methods: We performed a retrospective study with 338 hips, in which Tri-Lock Bone Preservation Stem (BPS) was used in 181 hips and M/L Taper stem was used in 157 hips (82 hips before and 75 hips after 0-mm rasp use). A positive stem SP was defined as a stem proud height of >2 mm. We analysed and compared SP incidence in two stems and M/L Taper stems before and after the 0-mm rasp use., Results: An incidence of stem SP was 13% in the Tri-Lock BPS and 15% in the M/L Taper stem before the 0-mm rasp use. Stem SP incidence in the M/L Taper stem substantially decreased after the 0-mm rasp use (4%). The significant risk factor for stem SP was use of the high offset option in Tri-Lock BPS., Conclusion: The proximally coated tapered wedge stems present potential problems related to stem SP. The new rasp of the M/L Taper stem showed significant improvement in initial seating height., The Translational Potential of This Article: This study was conducted to understand "stem sitting proud" in proximally coated tapered wedge stem as one of the most popular designs nowadays in adult hip joint arthroplasty field. In this study, we aimed to address the incidence of stem proud, investigated the risk factor and introduced the effect of new rasp system which improve stem seating height., (© 2019 The Authors.)

Background: Long-term trends in serum metal ion concentration after metal-on-metal (MoM) total hip arthroplasty (THA) are unclear. In most studies, serum metal ion levels increase initially and remain constant during follow-up. However, there are no previous studies that evaluate the metal ion level longitudinally at multiple intervals over the long term. Increasing metal ion levels during the long-term follow-up of patients who underwent cementless MoM THA has been seen, so this study investigated those trends., Methods: Seventy-one patients were followed for a minimum of 10 years (range, 10.0-18.6 years). All underwent unilateral THA with MoM bearings. Serum cobalt (Co) and chromium (Cr) levels were measured preoperatively and annually after surgery. Trends and differences in serum levels based on sex, mean age, body mass index, cup inclination, and implant selection were analyzed., Results: Within 5 years after the operation, the mean Co and Cr levels peaked postoperatively at 3-4 years (4.14 and 6.89 μg/L, respectively). Between 5 and 10 years postoperatively, the serum levels showed 2 tendencies. One group (62) showed a constant range, but a smaller group (9) showed increasing serum metal ion levels. The only factor which showed a difference between the 2 groups was body mass index (P = .030), which was lower in the increasing serum metal ion level group., Conclusion: At a medium-term to long-term follow-up period, serum Co and Cr levels are not always constant. This should be considered when seeing patients with MoM THA, and laboratory tests may be needed for long-term follow-up., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The purpose of this study was to evaluate the prevalence of acetabular dysplasia in an asymptomatic Asian population as one of the most important risk factors of hip osteoarthritis. From December 2014 to March 2015, we investigated the data of 200 asymptomatic volunteers (400 hips) aged 18-50 years recruited from our institution. Pelvic radiographs were taken and reviewed by two experienced orthopaedic surgeons. Lateral centre-edge (LCE) angle, Sharp angle, Tonnis angle and acetabular depth-to-width ratio (AD/WR) were measured. We investigated the mean values and identified the statistical differences between the sexes and evaluated the prevalence and bilaterality of acetabular dysplasia defined by each parameter. Mean LCE angle, Sharp angle, Tonnis angle and AD/WR were 26.2°, 41.3°, 8.5° and 0.28, respectively. All parameters showed more dysplastic results in females than in males and were statistically significantly different, except for AD/WR. When defined acetabular dysplasia as LCE angle <20°, Sharp angle >45°, Tonnis angle >14° or AD/WR <0.25, the prevalence of acetabular dysplasia by each parameter was 15.0%, 12.8%, 13.3% and 12.8%, respectively. There was a higher prevalence in females than in males; however, only Sharp and Tonnis angles showed significant differences. The bilaterality of acetabular dysplasia was 18.6-39.5% for all subjects. There is high prevalence of asymptomatic dysplastic hips in the Asian population.

Cobalt-induced cardiomyopathy is a well-known but uncommon disease, and the physician must maintain a high index of suspicion in order to make a timely diagnosis. We report two patients with cobalt-induced cardiomyopathy. Both patients developed progressively worsening symptoms of cobalt toxicity following revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. In both patients, echocardiography showed LV hypertrophy, biventricular systolic dysfunction, and a large amount of pericardial effusion. Due to decompensated heart failure, both patients were initially considered candidates for heart transplantation. One patient was diagnosed with cobalt-induced cardiomyopathy before transplantation. He received cobalt chelation therapy and revision surgery, which led to complete recovery of heart function. In the other patient, the diagnosis was not made until the time of heart transplantation. The gross examination of the explanted heart revealed typical features of cobalt cardiotoxicity, which was then diagnosed as cobalt-induced cardiomyopathy. These cases emphasise the importance of early diagnosis and prompt treatment of cobalt intoxication.

The incidence of atypical femoral fractures (AFFs) was 2.95% among 6644 hip and femoral fractures. Independent risk factors included the use of bisphosphonates (BPs), osteopenia or osteoporosis, rheumatoid arthritis, increased femoral curvatures, and thicker femoral cortices. Patients with AFFs and BP treatment were more likely to have problematic healing than those with typical femoral fractures (TFFs) and no BP treatment., Introduction: To determine the incidence and risk factors of atypical femoral fractures (AFFs), we performed a multicenter case-control study. We also investigated the effects of bisphosphonates (BPs) on AFF healing., Methods: We retrospectively reviewed the medical records and radiographs of 6644 hip and femoral fractures of patients from eight tertiary referral hospitals. All the radiographs were reviewed to distinguish AFFs from TFFs. Univariate and multivariate logistic regression analyses were performed to identify risk factors, and interaction analyses were used to investigate the effects of BPs on fracture healing., Results: The incidence of AFFs among 6644 hip and femoral fractures was 2.95% (90 subtrochanter and 106 femoral shaft fractures). All patients were females with a mean age of 72 years, and 75.5% were exposed to BPs for an average duration of 5.2 years (range, 1-17 years). The use of BPs was significantly associated with AFFs (p < 0.001, odds ratio = 25.65; 95% confidence interval = 10.74-61.28). Other independent risk factors for AFFs included osteopenia or osteoporosis, rheumatoid arthritis, increased anterior and lateral femoral curvatures, and thicker lateral femoral cortex at the shaft level. Interaction analyses showed that patients with AFFs using BPs had a significantly higher risk of problematic fracture healing than those with TFFs and no BP treatment., Conclusions: The incidence of AFFs among 6644 hip and femoral fractures was 2.95%. Osteopenia or osteoporosis, use of BPs, rheumatoid arthritis, increased anterior and lateral femoral curvatures, and thicker lateral femoral cortex were independent risk factors for the development of AFFs. Patients with AFFs and BP treatment were more likely to have problematic fracture healing than those with TFFs and no BP treatment.

Purpose: To describe the outcomes of 7 cases of psoas abscess concurrent with septic arthritis of the hip treated by hip arthroscopy alone., Methods: We retrospectively collected the data of patients who underwent arthroscopic drainage of psoas abscess concurrent with septic arthritis of the hip. Arthroscopic debridement was performed in both the central and peripheral hip joint compartments. In all cases, the iliopsoas compartment was accessed from the peripheral compartment through an anterior capsulotomy without limb traction. After debridement and drainage of the iliopsoas compartment, a suction drain tube was placed in the iliopsoas compartment through an enlarged anterior capsulotomy and another tube in the peripheral compartment. Postoperative intravenous antibiotics were administered on the basis of culture results; in cases with no positive culture, empirical antibiotics were administered for 4 to 6 weeks after surgery., Results: 7 patients underwent arthroscopic debridement and drainage for a psoas abscess concurrent with hip joint septic arthritis. Laboratory tests were normalized within 4 weeks after hip arthroscopy in all patients. At a median follow-up of 16 months (range, 13-30 months) after surgery, infection recurrence was absent in all patients., Conclusions: Arthroscopic debridement alone could be an effective treatment alternative to open surgery for psoas abscess concurrent with hip joint septic arthritis.

Objective: Evaluating public health surveillance systems is critical to ensuring that conditions of public health importance are appropriately monitored. Our objectives were to qualitatively evaluate 6 state and local health departments that were early adopters of syndromic surveillance in order to (1) understand the characteristics and current uses, (2) identify the most and least useful syndromes to monitor, (3) gauge the utility for early warning and outbreak detection, and (4) assess how syndromic surveillance impacted their daily decision making., Design: We adapted evaluation guidelines from the Centers for Disease Control and Prevention and gathered input from the Centers for Disease Control and Prevention subject matter experts in public health surveillance to develop a questionnaire., Participants: We interviewed staff members from a convenience sample of 6 local and state health departments with syndromic surveillance programs that had been in operation for more than 10 years., Results: Three of the 6 interviewees provided an example of using syndromic surveillance to identify an outbreak (ie, cluster of foodborne illness in 1 jurisdiction) or detect a surge in cases for seasonal conditions (eg, influenza in 2 jurisdictions) prior to traditional, disease-specific systems. Although all interviewees noted that syndromic surveillance has not been routinely useful or efficient for early outbreak detection or case finding in their jurisdictions, all agreed that the information can be used to improve their understanding of dynamic disease control environments and conditions (eg, situational awareness) in their communities., Conclusion: In the jurisdictions studied, syndromic surveillance may be useful for monitoring the spread and intensity of large outbreaks of disease, especially influenza; enhancing public health awareness of mass gatherings and natural disasters; and assessing new, otherwise unmonitored conditions when real-time alternatives are unavailable. Future studies should explore opportunities to strengthen syndromic surveillance by including broader access to and enhanced analysis of text-related data from electronic health records. Health departments may accelerate the development and use of syndromic surveillance systems, including the improvement of the predictive value and strengthening the early outbreak detection capability of these systems. These efforts support getting the right information to the right people at the right time, which is the overarching goal of CDC's Surveillance Strategy.

Background: Femoroacetabular impingement (FAI) can be managed either conservatively or by a surgical correction of the deformity causing impingement. However, there is insufficient evidence to justify an immediate surgical treatment in all symptomatic patients, and the role of a nonoperative treatment is unclear. This study evaluates the role of conservative treatment for FAI., Materials and Methods: 87 patients (102 hips) diagnosed as FAI between January 2011 and May 2012 were included in this retrospective study. All patients underwent an initial 3-month conservative treatment followed by arthroscopic hip surgery if symptoms did not improve. Clinical outcome scores (modified Harris Hip Score, nonarthritic hip score, and Western Ontario and McMaster Universities Arthritis Index) were evaluated at baseline and at the end of followup, and scores were compared between the nonsurgical and surgical groups., Results: The final analysis included 83 patients (55 men, 28 women; 97 hips) because four patients were lost to followup. The average age was 45.1 years and 14 patients had bilateral symptomatic FAI. After an initial conservative treatment averaging 27.5 months (range 24-36 months), 53 hips (54.6%) could perform normal daily activities. The nonsurgical group had significant improvements in all clinical scores at the end of followup ( P < 0.001). Forty four hips (45.4%) were unresponsive to conservative treatment and underwent arthroscopic hip surgery with subsequent significant improvements in clinical scores ( P < 0.001). At the end of followup, there were no significant differences in clinical scores between the two groups., Conclusion: An initial trial of conservative treatment of sufficient length should be considered for FAI patients before surgical intervention., Competing Interests: There are no conflicts of interest.