bluuebunny/crossref_metadata_2025 huggingface dataset:
A multi-strategy enhanced African vultures optimization algorithm for global optimization problems
Authors: Zheng Rong , Hussien Abdelazim G , Qaddoura Raneem , Jia Heming , Abualigah Laith , Wang Shuang , Saber Abeer
Published: February 2023

The African vultures optimization algorithm (AVOA) is a recently proposed metaheuristic inspired by the African vultures’ behaviors. Though the basic AVOA performs very well for most optimization problems, it still suffers from the shortcomings of slow convergence rate and local optimal stagnation when solving complex optimization tasks. Therefore, this study introduces a modified version named enhanced AVOA (EAVOA). The proposed EAVOA uses three different techniques namely representative vulture selection strategy, rotating flight strategy, and selecting accumulation mechanism, respectively, which are developed based on the basic AVOA. The representative vulture selection strategy strikes a good balance between global and local searches. The rotating flight strategy and selecting accumulation mechanism are utilized to improve the quality of the solution. The performance of EAVOA is validated on 23 classical benchmark functions with various types and dimensions and compared to those of nine other state-of-the-art methods according to numerical results and convergence curves. In addition, three real-world engineering design optimization problems are adopted to evaluate the practical applicability of EAVOA. Furthermore, EAVOA has been applied to classify multi-layer perception using XOR and cancer datasets. The experimental results clearly show that the EAVOA has superiority over other methods.
Magnetospheric accretion at the late phases of the pre-main-sequence evolution: the case of RZ Psc
Authors: Dmitriev D V , Ermolaeva T A , Grinin V P , Potravnov I S
Published: February 2023

It has been shown that during the burst of accretion activity observed in UX Ori-type star RZ Psc in 2013, the accretion rate increased approximately by an order of magnitude. This means that the accretion process at the late stages of the pre-main sequence evolution is very unstable. Using the spectra obtained during this episode, we have studied the magnetospheric emission in the H α line. Models of magnetospheric accretion are calculated to obtain the parameters of the magnetosphere from this observation. In this work, we have taken into account the influence of the recombination delay effect during gas motion in the stellar magnetosphere. The accounting for this effect and the presence of the magnetospheric absorption in the IR Ca ii triplet lines and its absence in D Na i resonance lines allowed us to place a lower limit on the temperature in the magnetosphere at $\approx 10\, 000$ K, which significantly improved precision of our estimate of accretion rate. According to the best-fitting model, the logarithm of accretion rate is $\log \dot{M} = -10.1\pm 0.3$ ($\dot{M} \approx 7\times 10^{-11}\ \mathrm{M_\odot \, yr^{-1}}$) and the inclination angle of RZ Psc is 43° ± 3°. It is less than the inclination, typical for the UX Ori stars (about 70°), that explains the weak photometric variability of this star. Using the obtained accretion rate and magnetosphere radius, we estimate the strength of the dipole component of the magnetic field of RZ Psc ≈ 0.1 kGs.
Dust-scattering rings of GRB 221009A as seen by the Neil Gehrels Swift X-ray Observatory: can we count them all?
Authors: Vasilopoulos Georgios , Karavola Despina , Stathopoulos Stamatios I , Petropoulou Maria
Published: February 2023

We present the first results for the dust-scattering rings of GRB 221009A, coined as the gamma-ray bursts (GRBs) of the century, as observed by the Neil Gehrels Swift Observatory. We perform analysis of both time resolved observations and stacked data. The former approach enable us to study the expansion of the most prominent rings, associate their origin with the prompt X-ray emission of the GRB and determine the location of the dust layers. The stacked radial profiles increase the signal-to-noise ratio of the data and allows detection of fainter and overlapping peaks in the angular profile. We find a total of 16 dust concentrations (with hints of even more) that span about 15kpc in depth and could be responsible for the highly structured X-ray angular profiles. By comparing the relative scattered fluxes of the five most prominent rings we show that the layer with the largest amount of dust is located at about 0.44 kpc away from us. We finally compare the location of the dust layers with results from experiments that study the 3D structure of our Galaxy via extinction or CO radio observations, and highlight the complementarity of dust X-ray tomography to these approaches.
Enhancing the Effectiveness of Public Sector Performance Regimes: A Proposed Causal Model for Aligning Governance Design with Performance Logics
Authors: Virani Altaf , van der Wal Zeger
Published: February 2023

The ability of public organizations to effectively leverage performance-enhancing interventions depends on their alignment with the institutional and motivational determinants of public sector performance and on how these are reflected in governance design choices. A mismatch between performance logics and governance design may potentially render interventions ineffective or even detrimental. In this article, we deconstruct the theoretical foundations of such a mismatch and propose an interactional causal model to examine how governance design can either effectuate or inhibit the institutional and individual motivational determinants affecting performance. In doing so, we evaluate the fitness of governance designs against public sector attributes and constraints and identify actionable managerial interventions for improving the fit. The article argues that alignment between governance design and the logics underpinning public sector performance regimes is critical for producing outcomes that are effective and consistent with the traits and value systems of the public sector.
Access to the memorandum of wishes by a beneficiary of a discretionary trust—an analysis of the law in New Zealand
Authors: McCrae Rebekah
Published: February 2023

This article considers whether the memorandum of wishes is trust information that should be disclosed to a beneficiary of a discretionary trust. The memorandum of wishes makes for interesting discussion as it is generally a non-binding document that can assist trustees when they exercise their discretionary power. To answer the question whether and when the memorandum of wishes should be made available to beneficiaries is not straightforward. The theory of why beneficiaries have the right to access trust information, case law that has unfolded on this issue, and the impacts of the Trust Act 2019 all play a role in making this assessment.
Exploring Health Care Disparities in Maternal-Child Simulation-Based Education
Authors: Díaz Desiree A. , Todd Andrew , Gilbert Gregory E. , Harris Martina , Kubiet Leslee , Jarocha Madison , Lee Michelle H. , Kurtek Anna , Jaromin Gabrielle M. , Newhouse Brandon , Magaña Christina L.
Published: February 2023

AIM

The purpose of this study was to explore student experiences within a health care disparity simulation, embedded in maternal-child content.

BACKGROUND

Health care disparities related to race and ethnicity in the maternal-child population are daunting among African American and Hispanic women.

METHOD

Participants completed the Simulation Effectiveness Tool-Modified, a rapid-fire huddle questionnaire, and a demographic instrument. All students participated in structured debriefing.

RESULTS

Student responses (n = 69) demonstrated effectiveness in learning via this scenario.

CONCLUSION

The rapid-fire huddle and debriefing are important elements when health care disparities are introduced into nursing curricula.
The Impact of Therapy Dogs on Prelicensure Baccalaureate Nursing Student Test Anxiety
Authors: Walker Cristen
Published: February 2023

AIM

This study examined the impact of a therapy dog intervention on baccalaureate nursing student test anxiety.

BACKGROUND

Nursing student test anxiety may hinder academic performance and program outcomes. Considering this negative impact, it is essential to implement anxiety-reducing strategies. Interaction with therapy dogs is linked with test anxiety reduction; however, minimal studies have explored this topic.

METHOD

A pretest/posttest quasi-experimental design was used to examine the impact of a therapy dog intervention on test anxiety. Repeated measures included the State-Trait Anxiety Inventory, heart rate, and cortisol levels. The multisite convenience sample included 91 junior-level prelicensure BSN students.

RESULTS

The intervention had a statistically significant impact on test anxiety reduction, noted by a decrease in State-Trait Anxiety Inventory scores, heart rate, and salivary cortisol levels (p = .00).

CONCLUSION

Therapy dog interactions are an effective strategy to reduce test anxiety. The findings from this study may assist educators to implement future interventions.
Barriers to Accessing Mental Health Support Services in Undergraduate Medical Training: A Multicenter, Qualitative Study
Authors: Ye Wen Qing Wendy , Rietze Bradley A. , McQueen Sydney , Zhang Kevin , Quilty Lena C. , Wickens Christine M.
Published: February 2023

Purpose

Medical students report higher levels of burnout, anxiety, and depression compared with age-matched peers. These mental health challenges have been linked to reduced workplace productivity, empathy, and professionalism. Yet, students experiencing mental health issues often decide not to access mental health resources, citing limited time and concerns about confidentiality, stigma, and the cost of private therapy. This study aimed to provide a framework for understanding barriers medical students face regarding access to mental health resources.

Method

A constructivist grounded theory approach was employed, with 24 students from 6 medical schools in Ontario, Canada, participating in semistructured telephone interviews between May 2019 and February 2020. Participants were purposively sampled to capture a broad range of experiences, institutional contexts, and training levels. The authors then developed a framework to conceptualize the barriers that medical students face while accessing mental health resources.

Results

The information obtained from the interviews revealed that the barriers were both overt and covert. Overt barriers were primarily administrative challenges, including restrictive leave of absence policies and sick days, mandatory reporting of extended sick leave time during the residency selection process, time-restricted academic and clinical schedules, and difficulty in accessing mental health supports during distance education. Covert barriers to accessing mental health supports included a medical culture not conducive to mental health, felt stigma (i.e., fear of stigma and being labeled as weak), and the hidden curriculum (i.e., the unofficial or unintended rules and mannerisms propagated within medical education systems).

Conclusions

Better understanding the overt and covert barriers that medical students to face while accessing mental health supports may help guide and inspire new advocacy efforts to enhance medical student well-being.
Alternative blood products in trauma
Authors: Jan Kathryn M. , Mohapatra Shweta , Moon Tiffany S.
Published: February 2023

Purpose of review

Hemorrhage and trauma-induced coagulopathy cause significant morbidity and mortality in trauma patients. Although blood products are the cornerstone of resuscitation, these resources are scarce, necessitating alternatives. This review examines the use of alternative blood products in trauma as well as the literature supporting their use.

Recent findings

There is no single true blood product alternative. In recent years, there has been great progress in understanding trauma-induced pathophysiology and blood component alternatives. Products such as tranexamic acid and prothrombin complex concentrate have become well established and are frequently utilized in trauma centers, and many more alternatives are still undergoing further research and development.

Stabilization of hemorrhage and resuscitation is priority in trauma-induced coagulopathy treatment. Alternative products such as tranexamic acid, recombinant factors, prothrombic complex concentrate, fibrinogen concentrates, and desmopressin may also be considered based on the clinical context. Viscoelastic hemostatic assays such as rotational thromboelastometry and thromboelastography can help guide these efforts. Following initial stabilization, additional interventions such as iron supplementation, erythropoietin stimulating agents, and vitamin D may help with chronic sequela.
A review of the utility of high-frequency oscillatory ventilation in burn and trauma ICU patients
Authors: Dilday Joshua , Leon David , Kuza Catherine M.
Published: February 2023

Purpose of review

The purpose was to examine the utility of high-frequency oscillatory ventilation (HFOV) in trauma and burn ICU patients who require mechanical ventilation, and provide recommendations on its use.

Recent findings

HFOV may be beneficial in burn patients with smoke inhalation injury with or without acute lung injury/acute respiratory distress syndrome (ARDS), as it improves oxygenation and minimizes ventilator-induced lung injury. It also may have a role in improving oxygenation in trauma patients with blast lung injury, pulmonary contusions, pneumothorax with massive air leak, and ARDS; however, the mortality benefit is unknown.

Although some studies have shown promise and improved outcomes associated with HFOV, we recommend its use as a rescue modality for patients who have failed conventional ventilation.
Outcomes in pediatric anesthesia: towards a universal language
Authors: Marchesini Vanessa , Disma Nicola
Published: February 2023

Purpose of review

The identification of valid, well defined and relevant outcomes is fundamental to provide a reliable and replicable measure that can be used to improve quality of clinical care and research output. The purpose of this review is to provide an update on what the pediatric anesthesia research community is pursuing on standardized and validated outcomes.

Recent findings

Several initiatives by different research groups have been established during the last years. They all aim to find validated outcomes using the standardized methodology of COMET (https://www.comet-initiative.org/). These initiatives focus on clinical and research outcomes on the field of anesthesia, perioperative medicine, pain and sedation in pediatric age.

Clinical outcomes are measurements of changes in health, function or quality of life and they help evaluating quality of care. In order for them to be relevant in quantifying quality improvement, they need to be well defined, standardized and consistent across trials. A great effort from researchers has been made towards the identification of set of outcomes with these features.
Pregnancy, Opioid Use Disorder and COVID-19: An Evaluation of Acute Care Presentations During a Pandemic
Authors: Gill Elizabeth , Ghimire Anupa D. , Robinett Derek A. , Booth James S. , Walter Lauren A.
Published: February 2023

Introduction

The opioid epidemic has been exacerbated by the COVID-19 pandemic, resulting in increased acute care opioid-related and overdose visits. We sought to assess how the pandemic may have impacted an obstetric cohort impacted by opioid misuse in the acute care context.

Methods

A retrospective review of acute care presentations of patients with concomitant pregnancy (Z33.1) and opioid-related diagnostic codes (T10 codes and/or F11) was conducted over a 24-month period (pre-COVID = March 2019 through February 2020, post-COVID = March 2020 through February 2021). Descriptive statistics and χ
2 analysis of pre- versus post-COVID presentations were performed.

Results

A total of 193 individuals, 104 (53.9%) pre- and 89 (46.1%) post-COVID, accounting for 292 total encounters, 160 (54.8%) pre- and 132 (45.2%) post-COVID, were seen for acute care visits (P = 0.84). Age (P = 0.15), race (P = 0.59), and insurance status (P = 0.17) were similar pre- versus post-COVID. The majority of presentations, pre- (40.4%) and post-COVID (44.9%), were for opioid withdrawal (P = 0.74). Although post-COVID individuals were more likely to lack prenatal care (48.3% versus 39.4% pre-COVID), this trend was not significant (P = 0.19). Similar proportions of individuals were affected by pregnancy complications (51.9% pre-, 44.9% post-COVID; P = 0.30). Similar proportions of individuals were affected by adverse pregnancy outcomes (44.2% pre-, 48.3% post-COVID; P = 0.64).

Conclusion

The COVID-19 pandemic did not have a statistically significant effect on opioid-related acute care presentations or outcomes for obstetric patients. In this acute care cohort, however, opioid misuse had significant general impact on pregnancy complications and outcomes, suggesting unmet needs in this population.
Investigating Secondary Alcohol Outcomes in a Contingency Management Intervention among American Indian and Alaska Native Adults
Authors: Hirchak Katherine A. , Kordas Gordon , Lyons Abram J. , Herron Jalene , Jansen Kelley , Shaw Jennifer , McPherson Sterling M. , Roll John , Buchwald Dedra , McDonell Michael G. ,   the HONOR Study Team
Published: February 2023

Objective

The aim of the study is to investigate clinically meaningful, secondary outcomes in a randomized trial of a culturally adapted contingency management (CM) intervention for alcohol use in 3 diverse American Indian and Alaska Native communities.

Methods

Three American Indian and Alaska Native communities located in the Northern Plains, Alaska, and the Inland Northwest were partnering sites. A total of 158 individuals were randomized to either a 12-week CM intervention or a noncontingent (NC) control group. The CM group received reinforcers for providing alcohol-negative ethyl glucuronide (EtG < 150 ng/mL) urine samples, while the NC group received reinforcers unconditionally. Outcomes included EtG as a continuous measure (range, 0–2,000 ng/mL), EtG > 499 ng/mL (a measure of higher levels of recent alcohol use), longest duration of abstinence, and time-to-first alcohol-positive EtG during the trial. Generalized estimating equations along with Cox proportional hazard and negative binomial regressions were used.

Results

Participants randomized to the CM group had lower mean EtG levels (−241.9 ng/mL; 95% confidence interval [CI], −379.0 to −104.8 ng/mL) and 45.7% lower odds (95% CI, 0.31 to 0.95) of providing an EtG sample indicating higher levels of alcohol use during the intervention. Longest duration of abstinence was 43% longer for the CM group than the NC group (95% CI, 1.0 to 1.9). Risk of time-to-first drink during treatment did not differ significantly.

Conclusions

These secondary outcome analyses provide evidence that CM is associated with reductions in alcohol use and longer durations of abstinence (as assessed by EtG), both clinically meaningful endpoints and analyses that differ from the primary study outcome.
Examining Racial/Ethnic and Income Disparities on Tobacco Product Use Among US Adults Within Wave 5 of the PATH Study
Authors: Sun Ruoyan , Chana Sofia Mildrum , Hawes Elizabeth , Hendricks Peter S. , Cropsey Karen L. , Gaggar Amit , Scarinci Isabel C.
Published: February 2023

Objective

The aim of this study was to examine the interactions between race/ethnicity and income across different types of tobacco products.

Methods

The prevalence of past 30-day use of cigarettes, traditional cigars, cigarillos, filtered little cigars, and electronic nicotine delivery systems (ENDS) among adults was examined by race/ethnicity and income levels based on wave 5 (2018–2019) data of the Population Assessment of Tobacco and Health study.

Results

Multivariate analysis across race/ethnicity and income showed that, although non-Hispanic Blacks (NHBs) were significantly more than likely to smoke cigarettes than non-Hispanic Whites (NHWs) at low- and high-income levels, such disparity only applied to low-income Hispanics compared with low-income NHWs. NHBs were significantly more likely to smoke traditional cigars, cigarillos, and filtered little cigars than NHWs at low and high incomes. No differences were found between Hispanics and NHWs with regard to traditional cigars and cigarillos. However, low-income Hispanics were significantly less likely to smoke filtered little cigars than NHWs, whereas high-income Hispanics were more likely to do so than NHWs. With regard to ENDS, significant differences were only found at the low-income bracket with NHBs and Hispanics being less likely to smoke these products than NHWs.

Conclusions

Our findings highlight significant interactions between race/ethnicity and income in the use of tobacco products, suggesting that income should be taken into account when designing interventions targeting different racial/ethnic groups.
Pandemics Interlaced: The Impact of the COVID-19 Pandemic on the Wellbeing of Sober Living Home Residents
Authors: Noonan Grace , Glenn Jason
Published: February 2023

Objectives

This study aimed to discover how the COVID-19 pandemic altered the implementation of the social model of recovery in sober living homes (SLHs). Researchers analyzed associations between residents’ feelings of interconnectedness, social service utilization, and relapse predictors throughout the pandemic. This study provides an understanding of how the COVID-19 pandemic impacted treatment of substance use disorder (SUD).

Methods

This study used retrospective surveyed data from 105 SLH residents. Correlational analysis was used to determine the relationship between social service use, social connectivity, and relapse predictors at three different time points: February 2020, December 2020, and June 2021. Three residents underwent additional interviews.

Results

There was a decline in social service utilization from February 2020 to December 2020 with an associated decline in feelings of social connectivity. From December 2020 to June 2021, there was an increase in residents’ use of social services with an associated increase in connectivity. There was a significant negative correlation between relapse predictors and number of supportive services used in February 2020 (r = −0.217, P < 0.05) and in December 2020 (r = −0.352, P < 0.001). In June 2020, there was a significant negative correlation between interconnectedness and relapse predictors (r = −0.297, P < 0.05). The number of interviews was not sufficient for formal qualitative analysis.

Conclusions

The results suggest the COVID-19 pandemic possibly interrupted the course of recovery in SLHs. These findings offer insight to how the pandemic impacted individuals recovering from SUD and suggest that SUD treatment professionals should develop interventions to enhance social connectivity to deploy in response to global stressors.
Community Pharmacists’ Knowledge and Perceptions of Buprenorphine for Patients with Opioid Use Disorder
Authors: Tutag Lehr Victoria , Nolan Claire
Published: February 2023

Objectives

The aims of the study are to evaluate community pharmacists’ knowledge and perceptions regarding buprenorphine for opioid use disorder and their willingness to dispense buprenorphine and to identify opportunities for education.

Methods

An electronic survey of Michigan pharmacists (n = 11,123) assessed demographics, training, buprenorphine knowledge, dispensing, perceptions of stigma, diversion, and confidence in patient/provider interactions. Composite scores for knowledge, stigma, diversion, and confidence were calculated. Cross-tabulations and logistic regressions examined associations.

Results

There were 775 surveys returned (response 7%, n = 11,123) with 390 community pharmacists completing the survey. Twenty-five percent practiced in a rural area. Common practice sites were chain or independent pharmacies (30% each). Ninety-seven percent had buprenorphine training, 50% from Accredited Continuing Pharmacy Education. Eighty percent reported that their pharmacy dispensed buprenorphine with 90% of rural pharmacists compared with 71% urban responding yes. Composite knowledge scores did not differ between urban or rural location (P > 0.05). Predictors of willingness to dispense buprenorphine were urban location (odds ratio, OR, 0.55; 95% confidence interval [CI], 0.34–0.91; P = 0.01), independent pharmacy (OR, 0.53; 95% CI, 0.30–0.94; P = 0.03), Accredited Continuing Pharmacy Education training (OR, 0.54; 95% CI, 0.34–0.87; P = 0.01), low stigma/diversion (OR, 0.51; 95% CI, 0.37–0.70; P = 0.00), and confidence in patient/provider interactions (OR, 0.14; 95% CI, 0.10–0.19; P = 0.00).

Conclusions

Most survey pharmacists practice at pharmacies that dispense buprenorphine for opioid use disorder, with a larger proportion from rural pharmacies reporting availability. Pharmacists at independent pharmacies in urban locations have increased willingness to dispense buprenorphine, with urban pharmacists having lower perceptions of diversion compared with rural. Differences in buprenorphine availability, pharmacist willingness to dispense, and perceptions are opportunities for education. Limitations include one state, response bias, self-assessed competencies, and small samples.
Unitary Appreciative Nursing Praxis
Authors: Cowling W. Richard
Published: February 2023

The purposes of this article encompass describing the development of unitary appreciative nursing praxis since the conception of a unitary pattern-based nursing practice over 30 years ago; explicating unitary appreciative nursing praxis in its current state; and clarifying the elements and dimensions of a unitary appreciative nursing praxis model. The body of this work is linked to a greater call for nursing care that transcends the fragmentation and medicalization of the human experience and advocates for nursing that liberates rather than manipulates those who are most vulnerable. Further exploration of praxiological knowing and refinement in conceptual-theoretical development is advocated.
Financial Toxicity Is Common in Patients After Tibia Fracture
Authors: Mundy Lily R. , Zingas Nicolas H. , McKibben Natasha , Healey Kathleen , O'Hara Nathan N. , O'Toole Robert V. , Pensy Raymond A.
Published: February 2023

Objectives:

To evaluate the presence of financial distress and identify risk factors for financial toxicity in patients after tibial shaft fracture.

Design:

A cross-sectional analysis.

Setting:

Level I trauma center.

Patients:

All patients within 4 years after tibial shaft fracture (open, closed, or fracture that required flap reconstruction).

Intervention:

Injury-related financial distress.

Main Outcome Measurements:

Financial distress related to the injury, as reported by the patient in a binary question. Financial toxicity using the LIMB-Q, scored from 0 to 100, with higher scores indicating more financial toxicity.

Results:

Data were collected from 142 patients after tibial shaft fracture [44% closed (n = 62), 41% open (n = 58), and 15% flap (n = 22)]. The mean age was 44 years (SD 17), 61% were men, and the mean time from injury was 15 months. Financial distress was reported by 64% of patients (95% confidence interval, 56% to 72%). Financial toxicity did not differ by fracture severity (P = 0.12). Medical complications were associated with a 14-point increase in financial toxicity (P = 0.04). Age older than 65 years (−15 points, P = 0.03) and incomes of $70,000 or more ($70,000–$99,999, −15 points, P = 0.02; >$100,000, −19 points, P < 0.01) protected against financial toxicity.

Conclusion:

We observed financial distress levels more than twice the proportion observed after cancer. Medical complications, lower incomes, and younger age were associated with increased financial toxicity.

Level of Evidence:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
New Versus Old—How Reliable Is the New OTA/AO Classification for Trochanteric Hip Fractures?
Authors: Davidson Amit , Revach Yuval , Rodham Paul , Mosheiff Rami , Kandel Leonid , Weil Yoram A.
Published: February 2023

Objective:

To evaluate the intraobserver and interobserver reliability of the 2018 OTA/AO trochanteric hip fracture (THF) classification compared with the 1983 OTA/AO Muller classification system. To further delineate the reliability of classifying stable and unstable THF using the 2 classification systems.

Design:

Radiographic observational study.

Setting:

Multicenter, one Level 1 and one Level 2 trauma centers.

Participants/Patients:

Seventy-three radiographic series of patients treated operatively for THF were evaluated by 6 orthopaedic surgeons.

Intervention:

The OTA/AO THF classification system was applied by each surgeon to 73 cases in 2 independent assessments performed 4 weeks apart: once by the old classification followed by the new 2018 OTA/AO classification. Each radiographic series included lateral hip and anteroposterior initial radiographs. Eight random cases were duplicated in each of the surveys to evaluate the intraobserver reliability.

Main Outcome Measurements:

Intraobserver and interobserver of the group, subgroup and fracture stability classification determined by the interclass coefficient (ICC) and Cohen kappa values.

Results:

The interobserver reliability for the group classification (31A1/A2/A3) was moderate using the new classification, whereas substantial agreement was shown using the old classification (0.49 and 0.69, respectively). The reliability of the fracture stability classification was higher using the old classification (0.70 vs. 0.52). Subgroup classifications interobserver agreement was fair for both classification systems, although lower reliability was shown in the old classification (0.34 vs. 0.31).

Conclusions:

The new OTA/AO classification has a lower interobserver reliability for THF classification when compared with the old one.
Optimizing Orthopaedic Trauma Implant Pricing Through a Data-Driven and Surgeon-Integrated Approach
Authors: Seltzer Ryan , Johnson Joseph R. , McFarlane Kelly , Chawla Amanda , Chamberlain Stephanie , Kohler Michael , Sheth Kunj , Wall James K. , Bishop Julius , Gardner Michael , Shea Kevin G.
Published: February 2023

Objective:

To determine whether market-based pricing could be coupled with surgeon integration into negotiation strategies to achieve lower pricing levels for orthopaedic trauma implants. A secondary aim was to identify specific types of implants that may offer larger opportunities for cost savings.

Methods:

Market pricing levels were reviewed from 2 industry implant databases. This information was used by surgeons and supply chain management at our institution to select appropriate target pricing levels (25th percentile) for commonly used orthopaedic trauma implants. Target price values were provided to the existing 12 vendors used by our institution with a clear expectation that vendors meet these thresholds.

Results:

Benchmark modeling projected a potential savings of 20.0% over our prior annual spend on trauma implants. After 2 rounds of negotiation, savings amounted to 23.0% of prior annual spend. Total savings exceeded 1,000,000 USD with 11 of 12 vendors (91.7%) offering net savings. Total percent savings were highest for external fixators, drill bits, and K-wires. Plates and screws comprised the greatest proportion of our prior annual spend and achieved similar savings.

Conclusion:

A surgeon and supply chain coordinated effort led to major cost savings without a need for consolidation of vendors.

Level of Evidence:

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Does the Option to Keep Explanted Orthopaedic Trauma Implants Influence Patient Satisfaction and Perception of Care? Results of a Survey Study
Authors: Mavrommatis Sophia , LaRoque Michael C. , Yang Gaonhia , Brahme Indraneel S. , Cole Peter A.
Published: February 2023

Objective:

Orthopaedic trauma implants may be electively explanted after fracture healing; reasons include symptomatic implants, cosmetic/functional concerns, or personal expectations. Certain institutions provide the option to keep implants after removal, although this has been retracted in others. This study examines patients' desire for return of implants, reasons for desiring return, and influence of return on perceptions of care.

Methods:

A cohort of adult patients who underwent elective orthopaedic implant removal by a single surgeon at a Level I trauma center between 2008 and 2019, with the option to keep their removed implants, was identified. Surveys were sent to patients with contact information. Demographics, reasons for removal, satisfaction, and perceptions of care were studied.

Results:

The overall response rate was 47.4% (117 of 247). Respondents' mean age was 46.9 years, and 50% were female. Ninety-one percent kept their implants. Eighty-nine percent of patients felt that removal achieved their desired outcome, with decreasing pain cited as primary motivation for explantation (62%). Forty-five percent reported a strong desire to keep their implants, most commonly to show to family (49%). Seventy-four percent were happy to have this option. Thirty-seven percent of patients reported respecting their provider more for having this option, and 27% reported that this positively impacted their satisfaction.

Conclusions:

Patients perceive elective implant removal as highly effective. A majority were pleased to have the option to keep their implants, and many reported increased respect and satisfaction. Thus, providing patients with this option should be strongly considered to honor patient choice and optimize outcomes when feasible.
Do Adolescent Idiopathic Scoliosis Patients With Vitamin D Deficiency Have Worse Spine Fusion Outcomes?
Authors: Beling Alexandra , Hresko M. Timothy , Verhofste Bram , Miller Patricia E. , Pitts Sarah A. , Glotzbecker Michael P.
Published: February 2023

Background:

Prior research has shown that patients with adolescent idiopathic scoliosis (AIS) have a higher prevalence of vitamin D deficiency compared with healthy peers. In adult orthopaedic populations, vitamin D deficiency has been shown to be a risk factor for higher reported pain and lower function. We investigated whether there was an association between vitamin D levels and AIS patient-reported outcomes, as measured by the Scoliosis Research Society (SRS-30) questionnaire.

Methods:

This was a single-center, cross-sectional study. Postoperative AIS patients were prospectively recruited during routine follow-up visits, 2 to 10 years after spine fusion. Vitamin D levels were measured by serum 25-hydroxyvitamin D (ng/mL). Patients were categorized based on vitamin D level: deficient (<20 ng/mL), insufficient (20 to 29 ng/mL), or sufficient (≥30 ng/mL). The correlation between vitamin D levels and SRS-30 scores was analyzed using multivariable analysis and pair-wise comparisons using Tukey method.

Results:

Eighty-seven AIS patients (83% female) were enrolled who presented at median 3 years (interquartile range: 2 to 5 y; range: 2 to 10 y) after spine fusion. Age at time of surgery was mean 15 (SD±2) years. Major coronal curves were a mean of 57 (SD±8) degrees preoperatively and 18 (SD±7) degrees postoperatively. It was found that 30 (34%) of patients were vitamin D sufficient, 33 (38%) were insufficient, and 24 (28%) were deficient. Although there was no correlation between vitamin D level and Pain, Mental Health, or Satisfaction domains (P>0.05), vitamin D–deficient patients were found to be younger (P<0.001) and had lower SRS-30 function (P=0.002), Self-image (P<0.001), and total scores (P=0.003).

Conclusions:

AIS patients with vitamin D deficiency (<20 ng/mL) are more likely to be younger age at time of surgery, and report lower Function, Self-image, and Total SRS-30 scores postoperatively. Further work is needed to determine whether vitamin D supplementation alters curve progression and patient outcomes.

Level of Evidence:

Level II—prognostic study.
Slipped Capital Femoral Epiphysis, Food Deserts, Poverty, and Urban/Rural Residence: Is There a Link?
Authors: Luster Taylor , Gunderson Zachary J. , Sun Seungyup , Loder Randall T.
Published: February 2023

Background:

Childhood obesity is increased in food deserts, a community with little to no access to healthy food. As obesity is associated with slipped capital femoral epiphysis (SCFE), it was the purpose of this study to analyze the prevalence of SCFE patients by food desert location and its interaction with rural/urban location.

Methods:

A retrospective review of all consecutive patients with idiopathic SCFE treated at our institution over 11 years was performed. From the patient’s address, the US Census Bureau tract in which the patient resided was determined. Using the census tract code, it was ascertained if the patient lived in a food desert and urban or rural location. Standard statistical analyses were performed; a P<0.05 was considered statistically significant.

Results:

There were 177 SCFE patients: 79 girls, 98 boys, 106, White, and 69 nonWhite. The average age at diagnosis was 12.1±1.7 years, the average symptom duration 4.1±5.1 months, and the average weight percentile 94±10. Of these 177 patients, 26.5% lived in a food desert, which was higher than the expected 17.5% (P=0.023). Those living in a food desert were more commonly nonWhite (60% vs. 32%, P=0.0014). There were 25% from rural areas and 75% from urban areas. No rural SCFE patients lived in food deserts whereas 34% of urban patients lived in food deserts. The average poverty rate of the SCFE patient census tracts was 19%, no greater than the expected 15% (P=0.32). SCFE patients living in rural census tracts had a lower poverty rate (P<10-6).

Conclusions:

There is a correlation with the prevalence of SCFE patients by residence in a “food desert”, but not with rural/urban locale or poverty status in Indiana. Further research will be needed to see if these findings apply to other states within the United States and other parts of the world.

Level of Evidence:

III.
Higher Grit Scores Are Associated With Earlier Increases in Knee Flexion Following Anterior Cruciate Ligament Reconstruction With Meniscus Repair in Pediatric Patients
Authors: Pascual-Leone Nicolas , Mackie Alexandra T. , Gross Preston W. , Kelly Anne M. , Green Daniel W. , Fabricant Peter D.
Published: February 2023

Background:

The Grit Scale is used to measure grit, defined by Duckworth and colleagues as the disposition to show perseverance and passion for long-term goals. It has been shown that psychological factors like motivation, coachability, and coping with adversity are correlated with faster readiness for return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction (ACLR). This study investigates the association between pediatric patients’ baseline grit scores and; preoperative Patient-reported Outcomes Measurement Information System (PROMIS) Pain scores and the recovery of range of motion (ROM) after ACLR. The investigators hypothesized that higher preoperative grit scores would predict lower preoperative pain scores and earlier return of knee ROM in patients undergoing ACLR.

Methods:

This is a retrospective cohort study. Pediatric patients who underwent primary ACLR were assigned the pediatric Grit Scale. Patients were subdivided by meniscal procedures due to differences in postoperative protocols. ACLR alone or with meniscectomy (ACLR ± meniscectomy) were grouped together and ACLR with meniscal repair (ACLR + meniscus repair) represented the other cohort. Patients above the 50th grit percentile were considered “high grit”. Patients below the 50th percentile were considered “low grit”. Baseline PROMIS pain intensity and interference were collected. ROM was compared by grit cohort using the Mann-Whitney U test with a significance threshold of P ≤ 0.05.

Results:

A total of 58 patients undergoing ACLR were analyzed: 20 ACLR ± meniscectomy and 38 ACLR + meniscus repair. The mean age was 15.0 ± 2.1 years with 41.4% of participants identifying as females. No significant difference was noted between baseline PROMIS pain intensity and interference and grit score (P = 0.82, P = 0.91, respectively). Three months postoperatively, for those in the ACLR + meniscus repair cohort, low grit ROM was 130 degrees (interquartile range = 10 degrees), whereas high grit ROM was 135 degrees (interquartile range = 8 degrees) (P = 0.006).

Conclusions:

This study found no differences in pain scores at presentation between grit cohorts but found that patients with grit scores below the 50th percentile undergoing ACLR + meniscus repair have 5 degrees less total ROM at 3 months compared with those with high grit scores. Quicker ROM recovery in patients with high grit may be a leading indicator of these patients’ likelihood to achieve other postoperative milestones and meet criteria for RTS more quickly; the relationship between grit and readiness for RTS should be further investigated.

Level of Evidence:

Level IV; retrospective cohort study.
Deterioration After Surgery for Degenerative Cervical Myelopathy: An Observational Study From the Canadian Spine Outcomes and Research Network
Authors: Evaniew Nathan , Burger Lukas D. , Dea Nicolas , Cadotte David W. , Bailey Christopher S. , Christie Sean D. , Fisher Charles G. , Rampersaud Y Raja , Paquet Jérôme , Singh Supriya , Weber Michael H. , Attabib Najmedden , Johnson Michael G. , Manson Neil , Phan Philippe , Nataraj Andrew , Wilson Jefferson R. , Hall Hamilton , McIntosh Greg , Jacobs W. Bradley ,   On behalf of the Canadian Spine Outcomes and Research Network (CSORN)
Published: February 2023

Study Design.

A Prospective cohort study.

Objective.

To investigate the incidence, etiology, and outcomes of patients who experience neurological deterioration after surgery for Degenerative Cervical Myelopathy (DCM).

Summary of Background Data.

Postoperative neurological deterioration is one of the most undesirable complications that can occur after surgery for DCM.

Methods.

We analyzed data from the Canadian Spine Outcomes and Research Network DCM prospective cohort study. We defined postoperative neurological deterioration as any decrease in modified Japanese Orthopaedic Association (mJOA) score by at least one point from baseline to three months after surgery. Adverse events were collected using the Spinal Adverse Events Severity protocol. Secondary outcomes included patient-reported pain, disability, and health-related quality of life.

Results.

Among a study cohort of 428 patients, 50 (12%) deteriorated by at least one mJOA point after surgery for DCM (21 by one point, 15 by two points, and 14 by three points or more). Significant risk factors included older age, female sex, and milder disease. Among those who deteriorated, 13 experienced contributing intraoperative or postoperative adverse events, six had alternative non-DCM diagnoses, and 31 did not have an identifiable reason for deterioration. Patients who deteriorated had significantly lower mJOA scores at one year after surgery [13.5 (SD 2.7) vs. 15.2 (SD 2.2), P<0.01 and those with larger deteriorations were less likely to recover their mJOA to at least their preoperative baseline, but most secondary measures of pain, disability, and health-related quality of life were unaffected.

Conclusions.

The incidence of deterioration of mJOA scores after surgery for DCM was approximately one in 10, but some deteriorations were unrelated to actual spinal cord impairment and most secondary outcomes were unaffected. These findings can inform patient and surgeon expectations during shared decision-making, and they demonstrate that the interpretation of mJOA scores without clinical context can sometimes be misleading.
Medical Malpractice Litigation Due to Off-Label Use of Bone Morphogenetic Protein
Authors: Weldon Edward , Razzouk Jacob , Bohen Daniel , Ramos Omar , Danisa Olumide , Cheng Wayne
Published: February 2023

Study Design.

Retrospective cohort study.

Objective.

To analyze the incidence and characteristics of malpractice lawsuits pertaining to the off-label use of Bone morphogenetic protein (BMP).

Summary of Background Data.

BMP continues to be a popular alternative to the use of autologous bone graft during spinal fusion procedures. However, ~85% of BMP is used in an off-label manner, which may expose surgeons to claims of malpractice.

Methods.

Westlaw and VerdictSearch were queried for malpractice claims filed between 2000 and 2022 using the keywords “bone graft” and “spine.” Case inclusion criteria were defined as a plaintiff’s basis of litigation resting on a claim of medical malpractice due to off-label use of BMP. Additional collected data included the date of the case hearing, plaintiff's sex and age, defendants named in the lawsuit, verdict ruling, location of the filed claim, payment or settlement amount, sustained injuries, and additional allegations.

Results.

Of 971 claims reviewed, 89 cases were due to off-label BMP use. The posterior approach was identified as the most common approach among the 89 cases. Of the 30 cases naming a surgeon defendant, 50% included allegations of insufficient informed consent. The most frequent adverse events were ectopic bone growth resulting in chronic pain or nerve damage. Zero cases involved heterotopic ossification, wound dehiscence, graft subsidence, hematoma, bladder retention, or retrograde ejaculation.

Conclusion.

A clear understanding that on-label BMP use is specific to single-level, anterior or anterolateral approaches between L2-S1 with vendor-specific cages is crucial for mitigating malpractice disputes. Though off-label use of BMP may incite litigation, the findings suggest court rulings are favorable for defendants as zero cases, resulting in plaintiff verdicts. Nevertheless, surgeons should balance the potential benefits of off-label use of BMP with the increased risk of litigation, and it may be advisable to disclose the use of BMP, whether on-label or off-label, in the informed consent.
Thoracolumbar Injury Classification Systems
Authors: Lightsey IV Harry M. , Giberson-Chen Carew C. , Crawford Alexander M. , Striano Brendan M. , Harris Mitchel B. , Bono Christopher M. , Simpson Andrew K. , Schoenfeld Andrew J.
Published: February 2023

Study Design.

Narrative review.

Objective.

To describe the evolution of acute traumatic thoracolumbar (TL) injury classification systems; to promote standardization of concepts and vocabulary with respect to TL injuries.

Summary of Background Data.

Over the past century, numerous TL classification systems have been proposed and implemented, each influenced by the thought, imaging modalities, and surgical techniques available at the time. While much progress has been made in our understanding and management of these injuries, concepts, and terms are often intermixed, leading to potential confusion and miscommunication.

Methods.

We present a narrative review of the current state of the literature regarding classification systems for TL trauma.

Results.

The evolution of TL classification systems has broadly been characterized by a transition away from descriptive categorizations of fracture patterns to schema incorporating morphology, stability, and neurological function. In addition to these features, more recent systems have demonstrated the importance of predictive/prognostic capability, reliability, validity, and generalizability. The Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Thoracolumbar Injury Classification System/Thoracolumbar Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Injury Score represents the most modern and recently updated system, retiring past concepts and terminology in favor of clear, internationally agreed upon descriptors.

Conclusions.

Advancements in our understanding of blunt TL trauma injuries have led to changes in management. Such advances are reflected in modern, dedicated classification systems. Over time, various key factors have been acknowledged and incorporated. In an effort to promote standardization of thought and language, past ideas and terminology should be retired.