Biomechanical and ergonomic risks associated with cervical musculoskeletal dysfunction amongst surgeons: A systematic review

INTRODUCTION

Surgeons are at high risk of developing musculoskeletal symptoms due to a range of factors including, maladaptive positioning and surgical ergonomics. Cervical muscle strain and biomechanical load is most prevalent due to repetitive motions and prolonged static neck positioning. This issue is apparent through reports of prevalence between 10 and 74.4% among surgeons. The aim of this systematic review is to provide an objective assessment of the clinical evidence available and a descriptive analysis of the effects of kinematics and surgical ergonomics on the prevalence of surgeons' cervical musculoskeletal pain.

METHODS

This is PRISMA-compliant systematic review of clinical studies assessing the prevalence of cervical musculoskeletal dysfunction in surgeons by searching PUBMED and Ovid EMBASE databases from inception to 19th October 2023. Study quality was graded according to the National Institutes of Health study quality assessment tools.

RESULTS

A total of 9 studies were included in the final qualitative analysis. The use of loupes, open surgery and excessive neck flexion (>30°) were associated with cervical dysfunction. Comparison of study outcomes was challenging due to heterogeneity within study methods and the paucity of methodological quality.

CONCLUSION

The current literature assessing ergonomic and biomechanical factors predisposing surgeons to cervical musculoskeletal dysfunction is insufficient to provide reliable guidance for clinicians. Although the literature identifies factors contributing to work-related cervical dysfunction, few attempt to evaluate interventions for improved surgical ergonomics. An objective assessment of interventions that prompt postural correction with the aim to improve neck pain in surgeon cohorts is warranted.

Understanding the Influence of Single Payer Health Insurance on Socioeconomic Disparities in Total Hip Arthroplasty (THA) Utilization: A Transnational Analysis

OBJECTIVE

Access to care varies between countries. It is theorized that income-based disparities in access may be reduced in countries with universal health insurance relative to the United States, but data are currently limited. We hypothesized that income-based differences in total hip arthroplasty (THA) utilization and outcomes would be larger in the United States than in Canada.

METHODS

We retrospectively compared all patients undergoing THA from 2012 to 2018 in Pennsylvania, the United States, and Ontario, Canada. We compared age-standardized and sex-standardized per-capita THA utilization in the United States and Canada overall and across different income strata, where income strata were defined by neighborhood income quintile. We also examined income-based differences in rates of 1-year revision, 90-day mortality, and 90-day readmission.

RESULTS

Overall THA utilization per 10,000 people per year was higher across all income groups in Pennsylvania compared with Ontario (15.1 versus 8.8, P < 0.001 in lowest-income quintile; 21.4 versus 12.6, P < 0.001 in highest-income quintile). Income-based differences in utilization in the highest-income vs lowest-income quintile groups were greater in Ontario (43.2%) than Pennsylvania (41.7%). The adjusted odds for the lowest-income group compared with the highest-income group of 1-year revision were greater in Ontario compared with Pennsylvania (P = 0.03), and risk of 90-day mortality and 90-day readmission was similar between the regions.

CONCLUSION

Income-based differences in THA utilization were more notable in Ontario than in Pennsylvania. In addition, patients in low-income communities in Ontario were at equal or greater risk relative to high-income community patients for adverse outcomes compared with patients in Pennsylvania. Income-based disparities in THA utilization and outcomes were smaller in the United States than in Canada, in contrast to what might be expected.

LEVEL OF EVIDENCE

III.

A comprehensive investigation of Bi2O3 on the physical, structural, optical, and electrical properties of K2O.ZnO.V2O5.B2O3 glasses

The multi-component glass system has a composition of 10K2O-10ZnO-55 B2O3-(25-x)V2O5-xBi2O3 (x = 4, 5, 7.5, 9, 10 mol%) are synthesized by the melt-quenching method. Using X-ray diffraction examination, the amorphous phase in the material was confirmed. The physical characteristics of the produced compositions are examined using density (D) and molar volume (Vm). Calculations of physical properties showed that adding Bi2O3 from 4 to 10 mol% increased the glass density from 2.7878 to 3.3617 g cm-3 and decreased the molar volume from 40.4196 to 38.5895 cm3/mol. Studies of glass samples using the FTIR show bands of absorption for oxides in different structural groups. Octahedral [ BiO 6 ], [ BO 4 ], and tetrahedral [ BO 3 ] structural units are observed in the present glass matrices. The cutoff wavelength ( λ C ), and optical band gap energy were determined using UV absorption spectra. The increase in non-bridging oxygens can be linked to the decrease in optical band gap energy ( E opt ) (direct and indirect) and the increase in cutoff wavelength with an increase in Bi2O3 content. This is attributed to the existence of bismuth ions and the creation of non-bridging oxygens. Besides that, the values of optical parameters, viz., optical electronegativity, refractive index, and molar refractivity, are calculated. The metallization criterion values are less than 1 and the glass samples exhibit an increased tendency towards metallization. Both the conductivity and the dielectric constant increase with the rise in Bi2O3 content, however, the dielectric loss and the impedance reduce. The behavior and values of conductivity for the studied glasses reveal the semiconducting properties of all glass samples. These results suggest that the produced glass samples may be employed as amorphous semiconductors in electronics and memory switching devices.

Outcome of Endoprosthesis used in Limb Salvage Surgery in a Malaysian Orthopaedic Oncology Centre

Introduction

To describe the duration of survival among bone tumour patients with endoprosthesis reconstruction and to determine frequency of implant failure, revision of surgery, and amputation after endoprosthesis reconstruction.

Materials and methods

A retrospective cross-sectional review of all patients with either primary bone tumour or secondary bone metastases treated with en bloc resection and endoprosthesis reconstruction from January 2008 to December 2020.

Results

A total of 35 failures were recorded among the 27 (48.2%) patients with endoprostheses. Some of the patients suffered from one to three types of modes of failure on different timelines during the course of the disease. Up to eight patients suffered from more than one type of failure throughout the course of the disease. Out of all modes of failure, local recurrence (type 5 failure) was the most common, accounting for 25.0% of all failure cases. Four patients (7.1%) eventually underwent amputation, which were either due to infection (2 patients) or disease progression causing local recurrence (2 patients).

Conclusion

The overall result of endoprosthesis reconstruction performed in our centre was compatible with other centres around the world. Moreover, limb salvage surgery should be performed carefully in a selected patient group to maximise the benefits of surgery.

Predictors for Early Liver Cancer Survival After Ablation and Surgical Resection: A Surveillance, Epidemiology, and End Results Program-Medicare Study

OBJECTIVE

To identify independent predictors of all-cause and cancer-specific mortality after ablation or surgical resection (SR) for small hepatocellular carcinomas (HCCs), after adjusting for key confounders.

METHODS

Using Surveillance, Epidemiology, and End Results Program-Medicare, HCCs less than 5 cm treated with ablation or SR in 2009 to 2016 (n = 956) were identified. Univariate and multivariable Cox regression models for all-cause and cancer-specific mortality were performed including demographics, clinical factors (tumor size, medical comorbidities, and liver disease factors), social determinants of health, and treatment characteristics. We also determined the most influential predictors of survival using a random forest analysis.

RESULTS

Larger tumor size (3-5 cm) is predictive of all-cause (hazard ratio [HR] 1.31, P = .002) and cancer-specific mortality (HR 1.59, P < .001). Furthermore, chronic kidney disease is predictive of all-cause mortality (HR 1.43, P = .013), though it is not predictive of cancer-specific death. Multiple liver disease factors are predictive of all-cause and cancer-specific mortality including portal hypertension and esophageal varices (HRs > 1, P < .05). Though Asian race is protective in univariate models, in fully adjusted, multivariable models, Asian race is not a significant protective factor. Likewise, other social determinants of health are not significantly predictive of all-cause or cancer-specific mortality. Finally, treatment with SR, in later procedure years or at high-volume centers, is protective for all-cause and cancer-specific mortality. In machine learning models, year procedure was performed, ascites, portal hypertension, and treatment choice were the most influential factors.

DISCUSSION

Treatment characteristics, liver disease factors, and tumor size are more important predictors of all-cause and cancer-specific death than social determinants of health for small HCCs.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Impact of Pre-operative Opioid Use on Racial Disparities in Adverse Outcomes Post Total Knee and Hip Arthroplasty

INTRODUCTION

The growing opioid epidemic in the USA has underlying racial disparities dimensions. Also, studies have shown that patients from minority racial groups are at higher risk of adverse events following major orthopedic surgery. The aim of our study was to determine whether pre-operative opioid-use disorders (OUDs) impacted racial disparities in the likelihood of patients experiencing adverse post-operative outcomes following TKA and THA.

METHODS

Data about patients undergoing TKA and THA were collected from the 2005-2014 National Inpatient Sample databases. Regression modeling was used to assess the impact of OUDs on odds of adverse outcomes comparing racial groups. The adverse outcomes included any in-hospital post-surgical complications, prolonged length of stay (LOS), and nonhome discharge.

RESULTS

In our fully adjusted regression models using White patients as the reference group, we found that OUDs were associated with racial disparities in prolonged LOS and nonhome discharge. In the non-OUD group, Black patients had significantly higher odds of longer LOS (OR: 1.35, 95% CI: 1.26-1.46, p-value: < 0.0001), whereas those with history of OUD had non-significantly lower odds of longer LOS (OR: 0.94, 95% CI: 0.69-1.29, p-value: 0.71). Similarly, for the outcome of nonhome discharges, Black patients in the non-OUD group had significantly higher odds (OR: 1.31, 95% CI: 1.21-1.43, p-value: < 0.0001) and those with a history of OUD had non-significantly lower odds (OR: 0.91, 95% CI: 0.64-1.29, p-value: 0.59).

CONCLUSIONS

Significant racial disparities are present in adverse events among patients in the non-OUD group, but those disparities attenuated in the OUD group.

Beyond Survival: Adverse Events and Care Delivery Outcomes after Early Liver Cancer Treatment in a Nationally Representative Cohort

PURPOSE

To compare secondary outcomes after ablation (AB), surgical resection (SR), and liver transplant (LT) for small hepatocellular carcinomas (HCCs), including resource utilization and adverse event (AE) rates.

MATERIALS AND METHODS

Using Surveillance, Epidemiology, and End Results Program (SEER)-Medicare, HCCs <5 cm that were treated with AB, SR, or LT in 2009-2016 (n = 1,067) were identified using Healthcare Common Procedure Coding System codes through Medicare claims. Index procedure length of stay, need for intensive care unit (ICU) level care, readmission rates, and AE rates at 30 and 90 days were compared using chi-square tests or Fisher exact tests. Examined AEs included hemorrhage, abscess formation, biliary injury, pneumonia, sepsis, liver disease-related AEs, liver failure, and anesthesia-related AEs, identified by International Classification of Diseases, Ninth/10th Revision, codes.

RESULTS

The median length of stay for initial treatment was 1 day, 6 days, and 7 days for AB, SR, and LT, respectively (P < .001). During initial hospital stay, 5.0%, 40.8%, and 63.4% of AB, SR, and LT cohorts, respectively, received ICU-level care (P < .001). By 30 and 90 days, there were significant differences among the AB, SR, and LT cohorts in the rate of postprocedural hemorrhage, abscess formation, biliary injury, pneumonia, sepsis, liver disease-related AEs, and anesthesia-related AEs (P < .05). By 90 days, the readmission rates after AB, SR, and LT were 18.6%, 28.2%, and 40.6% (P < .001), respectively.

CONCLUSIONS

AB results in significantly less healthcare utilization during the initial 90 days after procedure compared with that after SR and LT due to shorter length of stay, lower intensity care, fewer readmissions, and fewer AEs.

Preference Elicitation and Treatment Decision-Making Among Men Diagnosed With Prostate Cancer: Randomized Controlled Trial Results of Healium

BACKGROUND

Elicitation of patients' preferences is an integral part of shared decision-making, the recommended approach for prostate cancer decision-making. Existing decision aids for this population often do not specifically focus on patients' preferences. Healium is a brief interactive web-based decision aid that aims to elicit patients' treatment preferences and is designed for a low health literate population.

OBJECTIVE

This study used a randomized controlled trial to evaluate whether Healium, designed to target preference elicitation, is as efficacious as Healing Choices, a comprehensive education and decision tool, in improving outcomes for decision-making and emotional quality of life.

METHODS

Patients diagnosed with localized prostate cancer who had not yet made a treatment decision were randomly assigned to the brief Healium intervention or Healing Choices, a decision aid previously developed by our group that serves as a virtual information center on prostate cancer diagnosis and treatment. Assessments were completed at baseline, 6 weeks, and 3 months post baseline, and included decisional outcomes (decisional conflict, satisfaction with decision, and preparation for decision-making), and emotional quality of life (anxiety/tension and depression), along with demographics, comorbidities, and health literacy.

RESULTS

A total of 327 individuals consented to participate in the study (171 were randomized to the Healium intervention arm and 156 were randomized to Healing Choices). The majority of the sample was non-Hispanic (272/282, 96%), White (239/314, 76%), married (251/320, 78.4%), and was on average 62.4 (SD 6.9) years old. Within both arms, there was a significant decrease in decisional conflict from baseline to 6 weeks postbaseline (Healium, P≤.001; Healing Choices, P≤.001), and a significant increase in satisfaction with one's decision from 6 weeks to 3 months (Healium, P=.04; Healing Choices, P=.01). Within both arms, anxiety/tension (Healium, P=.23; Healing Choices, P=.27) and depression (Healium, P=.001; Healing Choices, P≤.001) decreased from baseline to 6 weeks, but only in the case of depression was the decrease statistically significant.

CONCLUSIONS

Healium, our brief decision aid focusing on treatment preference elicitation, is as successful in reducing decisional conflict as our previously tested comprehensive decision aid, Healing Choices, and has the added benefit of brevity, making it the ideal tool for integration into the physician consultation and electronic medical record.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05800483; https://clinicaltrials.gov/study/NCT05800483.

Risk-Stratification using the 40-Gene Expression Profile (40-GEP) Test Identifies Patients with Node Negative Cutaneous Squamous Cell Carcinoma (cSCC) at Higher Risk of Metastasis Who May Benefit from Adjuvant Radiation Therapy (ART)

PURPOSE/OBJECTIVE(S)

ART is a standard treatment used to reduce the risk of metastasis and recurrence in moderate‒to‒high-risk cSCC patients. Indications for ART have been largely based on pathologic risk factors and informed by staging systems, and while radiation oncologists generally designate a >10% risk threshold for usage of ART, there is no consensus on which groups of tumors may benefit from ART. The 40-GEP test has been independently validated to predict a cSCC patient's risk for regional/distant metastasis in patients with one or more high-risk clinicopathologic factors and reports three biologic risk groups: Class 1 (low, ∼7%), Class 2A (moderate, 20-25%), and Class 2B (high risk, >50%) for metastasis. This study aims to evaluate whether a biomarker informed risk stratification approach using a 40-GEP result could refine the ability to select patients with node negative cSCC at higher risk of metastasis who are most likely to benefit from ART.

MATERIALS/METHODS

In this retrospective study, all patients had primary cSCC tissue with verified clinicopathologic information of tumors with one or more high-risk factors, met clinical testing criteria, were comprehensively staged, and had outcomes data (n = 954). Patients with node positive disease, or those with nodal failure within 3 months of diagnosis were excluded (n = 19). From the n = 935, an intermediate risk population wherein ART is often considered was defined as Brigham and Women's Hospital (BWH) ≥T2a (n = 489). Kaplan-Meier survival analysis and log-rank test were used to assess metastasis free survival (MFS). Univariate Cox regression compared metastasis rates between 40-GEP results.

RESULTS

The 3-year MFS rate for this eligible for ART cohort was 82.4% The 40-GEP demonstrated statistically significant risk stratification with MFS rates of 92.4%, 76.1% and 59.4% for Class 1, Class 2A and Class 2B, respectively (p<0.0001). Cox regression was significant for Class 2A and 2B compared to Class 1, with a 3.2-fold and 6.4-fold increase in metastasis, respectively (p<0.0001). 64% (59/92) of all metastases received a Class 2A result, and 44% (14/32) of Class 2B patients metastasized. 46% (223/489) of the cohort received a Class 1 result. Of patients staged BWH T1 (n = 446), those with a Class 2A and 2B had an 88.7% and 66.7% MFS rate, respectively.

CONCLUSION

Within this eligible for ART population, patients with Class 2A or 2B 40-GEP results have inferior rates of MFS, while Class 1 patients have <10% risk of metastasis. Nearly half of this population received a 40-GEP Class 1 result and could be considered for treatment de-intensification trials. Conversely, patients with low-risk BWH T1 stage, who are traditionally not considered for ART, that received a Class 2A or 2B (>10% risk of metastasis) could be considered for adjuvant therapy.

Online harms? Suicide-related online experience: a UK-wide case series study of young people who die by suicide

BACKGROUND

Few studies have examined online experience by young people who die by suicide.

METHODS

A 3-year UK-wide consecutive case series of all young people aged 10-19 who died by suicide, based on national mortality data. We extracted information on the antecedents of suicide of 544 of these 595 deaths (91%) from official investigations, mainly inquests.

RESULTS

Suicide-related online experience was reported in 24% (n = 128/544) of suicide deaths in young people between 2014 and 2016, equivalent to 43 deaths per year, and was more common in girls than boys (OR 1.87, 95% CI 1.23-2.85, p = 0.003) and those identifying as LGBT (OR 2.35, 95% CI 1.10-5.05, p = 0.028). Searching for information about method was most common (n = 68, 13%), followed by posting suicidal ideas online (n = 57, 10%). Self-harm, bereavement (especially by suicide), social isolation, and mental and physical ill-health were more likely in those known to have suicide-related online experience compared to those who did not. 29 (5%) were bullied online, more often girls (OR 2.84, 1.34-6.04, p = 0.007). Online bullying often accompanied face-to-face bullying (n = 16/29, 67%).

CONCLUSIONS

Suicide-related online experience is a common, but likely underestimated, antecedent to suicide in young people. Although its causal role is unclear, it may influence suicidality in this population. Mental health professionals should be aware that suicide-related online experience - not limited to social media - is a potential risk for young patients, and may be linked to experiences offline. For public health, wider action is required on internet regulation and support for children and their families.

Genome-wide mapping of gene-microbe interactions in the murine lung microbiota based on quantitative microbial profiling

BACKGROUND

Mammalian lungs comprise a complex microbial ecosystem that interacts with host physiology. Previous research demonstrates that the environment significantly contributes to bacterial community structure in the upper and lower respiratory tract. However, the influence of host genetics on the makeup of lung microbiota remains ambiguous, largely due to technical difficulties related to sampling, as well as challenges inherent to investigating low biomass communities. Thus, innovative approaches are warranted to clarify host-microbe interactions in the mammalian lung.

RESULTS

Here, we aimed to characterize host genomic regions associated with lung bacterial traits in an advanced intercross mouse line (AIL). By performing quantitative microbial profiling (QMP) using the highly precise method of droplet digital PCR (ddPCR), we refined 16S rRNA gene amplicon-based traits to identify and map candidate lung-resident taxa using a QTL mapping approach. In addition, the two abundant core taxa Lactobacillus and Pelomonas were chosen for independent microbial phenotyping using genus-specific primers. In total, this revealed seven significant loci involving eight bacterial traits. The narrow confidence intervals afforded by the AIL population allowed us to identify several promising candidate genes related to immune and inflammatory responses, cell apoptosis, DNA repair, and lung functioning and disease susceptibility. Interestingly, one genomic region associated with Lactobacillus abundance contains the well-known anti-inflammatory cytokine Il10, which we confirmed through the analysis of Il10 knockout mice.

CONCLUSIONS

Our study provides the first evidence for a role of host genetic variation contributing to variation in the lung microbiota. This was in large part made possible through the careful curation of 16S rRNA gene amplicon data and the incorporation of a QMP-based methods. This approach to evaluating the low biomass lung environment opens new avenues for advancing lung microbiome research using animal models.

Acute Postoperative Pain Due to Dental Extraction in the Adult Population: A Systematic Review and Network Meta-analysis

This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.

Fetal and maternal morbidity in pregnant patients with Lupus: a 10-year US nationwide analysis

OBJECTIVE

To evaluate and quantify the indicators of fetal and maternal morbidity in deliveries for patients with systemic lupus erythematosus (SLE) compared with deliveries in patients without SLE.

METHODS

We used retrospective data from the National Inpatient Sample (NIS) to identify all delivery related hospital admissions of patients with and without SLE from 2008 to 2017 using ICD-9/10 codes. Fetal morbidity indicators included pre-term delivery and intrauterine growth restriction (IUGR). 21 indicators of severe maternal morbidity were identified using standard Centers for Disease Control and Prevention (CDC) definitions. Descriptive statistics, including 95% confidence intervals, were calculated using sample weights from the NIS dataset.

RESULTS

Among the 40 million delivery-related admissions, 51 161 patients were reported to have SLE. Patients with SLE had a higher risk of fetal morbidity, including IUGR (8.0% vs 2.7%) and pre-term delivery (14.5% vs 7.3%), than patients without SLE. During delivery, mothers with SLE were nearly four times as likely to require a blood transfusion or develop a cerebrovascular disorder, and 15 times as likely to develop acute renal failure than those without SLE.

CONCLUSION

Our study demonstrates that fetal morbidity and severe maternal morbidity occur at a higher rate in patients with SLE compared with those without. This quantitative work can help inform and counsel patients with SLE during pregnancy and planning.

Comparing Hospital Length of Stay Risk-Adjustment Models in US Value-Based Physician Payments

BACKGROUNG AND OBJECTIVES

Under the Affordable Care Act, the US Centers for Medicare & Medicaid Services created the Physician Value-Based Payment Modifier Program and its successor, the Merit-Based Incentive Payment System, to tie physician payments to quality and cost. The addition of hospital length of stay (LOS) to these value-based physician payment models reflects its increasing importance as a metric of health care cost and efficiency and its association with adverse health outcomes. This study compared the Centers for Medicare & Medicaid Services-endorsed LOS risk-adjustment methodology with a novel methodology that accounts for pre-hospitalization clinical, socioeconomic status (SES), and admission-related factors as influential factors of hospital LOS.

METHODS

Using the 2014 New York, Florida, and New Jersey State Inpatient Database, we compared the observed-to-expected LOS of 2373102 adult admissions for 742 medical and surgical diagnosis-related groups (DRGs) by 3 models: ( a ) current risk-adjustment model (CRM), which adjusted for age, sex, number of chronic conditions, Elixhauser comorbidity score, and DRG severity weight, ( b ) CRM but modeling LOS using a generalized linear model (C-GLM), and (c) novel risk-adjustment model (NRM), which added to the C-GLM covariates for race/ethnicity, SES, discharge destination, weekend admission, and individual intercepts for DRGs instead of severity weights.

RESULTS

The NRM disadvantaged physicians for fewer medical and surgical DRGs, compared with both the C-GLM and CRM models (medical DRGs: 0.49% vs 13.17% and 10.89%, respectively; surgical DRGs: 0.30% vs 13.17% and 10.98%, respectively). In subgroup analysis, the NRM reduced the proportion of physician-penalizing DRGs across all racial/ethnic and socioeconomic groups, with the highest reduction among Whites, followed by low SES patients, and the lowest reduction among Hispanic patients.

CONCLUSIONS

After accounting for pre-hospitalization socioeconomic and clinical factors, the adjusted LOS using the NRM was lower than estimates from the current Centers for Medicare & Medicaid Services-endorsed model. The current model may disadvantage physicians serving communities with higher socioeconomic risks.

Monkeypox Virus: A comprehensive narrative review

Monkeypox virus, now known as Mpox virus is a large, enveloped, double stranded deoxyribonucleic acid (DNA) virus belonging to the Orthopox viridae genus of the Poxviridae family. Though, Mpox, have earlier been endemic to only African countries, the 2022 outbreak has shown its rapid spread throughout the world. The May 2022 outbreak have shown primarily human to human transmission in contrast to animal to human transmission that had been seen previously. Recent data also suggest a possibility of a pre symptomatic spread. After an incubation period of 9 days, patients with Mpox can present with a prodrome of symptoms followed by a rash. If untreated, severe complications develop in the high-risk groups especially children and pregnant woman. Such groups of people will benefit from antiviral treatments. The current approach to prevent against it is pre-exposure and post exposure prophylaxis with vaccines. The vaccines that have been approved by Food and Drug Administration to date is ACAM2000 and JYNNEOS. Several diagnostic methods exist, among which polymerase chain reaction has proven to be the most specific and sensitive. In this review, we will discuss its epidemiology, the clinical manifestations, diagnostic modalities, complications, treatment approaches and preventive measures.

Production of tailored hydroxylated prodiginine showing combinatorial activity with rhamnolipids against plant-parasitic nematodes

Bacterial secondary metabolites exhibit diverse remarkable bioactivities and are thus the subject of study for different applications. Recently, the individual effectiveness of tripyrrolic prodiginines and rhamnolipids against the plant-parasitic nematode Heterodera schachtii, which causes tremendous losses in crop plants, was described. Notably, rhamnolipid production in engineered Pseudomonas putida strains has already reached industrial implementation. However, the non-natural hydroxyl-decorated prodiginines, which are of particular interest in this study due to a previously described particularly good plant compatibility and low toxicity, are not as readily accessible. In the present study, a new effective hybrid synthetic route was established. This included the engineering of a novel P. putida strain to provide enhanced levels of a bipyrrole precursor and an optimization of mutasynthesis, i.e., the conversion of chemically synthesized and supplemented monopyrroles to tripyrrolic compounds. Subsequent semisynthesis provided the hydroxylated prodiginine. The prodiginines caused reduced infectiousness of H. schachtii for Arabidopsis thaliana plants resulting from impaired motility and stylet thrusting, providing the first insights on the mode of action in this context. Furthermore, the combined application with rhamnolipids was assessed for the first time and found to be more effective against nematode parasitism than the individual compounds. To obtain, for instance, 50% nematode control, it was sufficient to apply 7.8 μM hydroxylated prodiginine together with 0.7 μg/ml (~ 1.1 μM) di-rhamnolipids, which corresponded to ca. ¼ of the individual EC₅₀ values. In summary, a hybrid synthetic route toward a hydroxylated prodiginine was established and its effects and combinatorial activity with rhamnolipids on plant-parasitic nematode H. schachtii are presented, demonstrating potential application as antinematodal agents. Graphical Abstract.

A Novel Fusion Partner in a Case of Myeloid/Lymphoid Neoplasm with FGFR1 Rearrangement

Introduction/Objective

Myeloid/lymphoid neoplasms with rearrangement of FGFR1 are uncommon and heterogeneous group of hematological malignancies that may present as myeloproliferative neoplasm, acute myeloid leukemia, T or B lymphoblastic lymphoma/leukemia, or mixed phenotypic acute leukemia. Patients can present with lymphadenopathy, mediastinal mass, or systemic symptoms. Eosinophilia is common in peripheral blood or bone marrow. Several chromosomal rearrangements and fusion genes have been described with FGFR1 rearrangement and all of them encode an aberrant tyrosine kinase. Tyrosine kinase inhibitors may offer a prospective therapeutic approach although specific targeted therapies have yet to be established.

Methods/Case Report

We present a case of a 14-year-old male who presented with rapid neck pain and swelling. Imaging revealed a 15 x 8 x 6 cm neck mass extending into the anterior mediastinum. Laboratory evaluation revealed anemia, thrombocytopenia, and leukocytosis (41.7 K/mm3), with absolute eosinophilia and blasts of 50%. Flow cytometry of peripheral blood demonstrated a population of T-lymphoblasts comprising about 60% of the cellularity with dim CD45, cytoplasmic CD3, CD7, TdT, CD38, CD4, CD5, CD10, and CD15, supporting T-lymphoblastic leukemia/lymphoma. The patient received induction chemotherapy, and subsequent bone marrow biopsy showed morphologic remission. Six weeks from diagnosis, the patient developed a gluteal mass with an atypical T-cell infiltrate that was negative for TdT; and at 15 weeks from diagnosis, developed an enlarging abdominal mass, also with an atypical T-cell infiltrate also negative for TdT and CD1a. At that time molecular diagnostic studies of the abdominal wall mass discovered a previously unpublished ATG16L1-FGFR1 fusion, supporting myeloid/lymphoid neoplasm with FGFR1 rearrangement, T-lymphoblastic leukemia/lymphoma.

Results (if a Case Study enter NA)

NA.

Conclusion

Although a variety of translocations have been identified with FGFR1 rearrangement, the novel fusion partner ATG16L1 has not been previously reported. The case also illustrates an unusual extramedullary recurrence of the T-cell lymphoblastic leukemia/lymphoma with significant antigenic shift including loss of TdT and CD1a.

Does Value-Based Care Threaten Joint Arthroplasty Access for Vulnerable Patient Populations?: AOA Critical Issues

Health-care expenses have been projected to increase from 17.7% of the U.S. gross domestic product (GDP) in 2014 to 19.6% in 2024. The unsustainable increase in health-care costs has contributed toward support for value-based health care (VBHC) reform. Contemporary VBHC reform programs relevant to orthopaedic surgery include the voluntary Bundled Payments for Care Improvement initiatives (BPCI and BPCI-Advanced) and the Comprehensive Care for Joint Replacement (CJR) program, a mandatory bundled payment program.The purported benefits of transitioning from volume-based reimbursement to value-based reimbursement include moving from a fragmented provider-centered care model to a patient-centered model, with greater care coordination and alignment among providers focused on improving value. VBHC models allow innovative strategies to proactively invest resources to promote value (e.g., the use of nurse navigators) while eliminating unnecessary resources that do not promote value. However, major concerns regarding VBHC include the absence of medical and socioeconomic risk stratification as well as decreased access for higher-risk patients.This article identifies the benefits and potential unintended consequences of VBHC reform, with a focus on joint arthroplasty. We also discuss some potential strategies to promote innovation and improve value without compromising access for vulnerable patients.

Long-Term Survival After Surgery Versus Ablation for Early Liver Cancer in a Large, Nationally Representative Cohort

OBJECTIVE

To compare survival outcomes (all-cause, cancer-specific, and disease-free) for small hepatocellular carcinomas (HCCs), less than or equal to 5 cm, after ablation (AB) and surgical resection (SR) after adjusting for key confounders. Secondarily, to understand differential survival outcomes of liver transplant (TR) compared with SR and AB.

METHODS

Using Surveillance, Epidemiology, and End Results Program-Medicare, HCCs less than 5 cm that were treated with AB, SR, or TR in 2009 to 2016 (n = 1,215) were identified using Healthcare Common Procedure Coding System codes through Medicare claims. The TR group was subdivided into two groups: TR with prior treatment and TR without prior treatment. All-cause survival, cancer-specific survival, and disease-free survival were analyzed using Kaplan-Meier curves and compared between groups using log-rank tests and Cox regression analyses. Propensity score-matched comparison of AB and SR groups was performed, with groups matched on demographics, social determinants of health, medical comorbidities, and liver disease severity prognostic indicators.

RESULTS

Median study follow-up time was 2.71 years (interquartile range 1.25-3.83). Unadjusted 1-, 3-, and 5-year cancer-specific survivals were 85.9%, 67.6%, and 56.3% for the AB group; 91.7%, 82.6%, and 81.7% for the SR group; 93.5%, 88.7%, and 79.4% for TR without prior treatment group; and 96.4%, 93.2%, and 93.2% for TR with prior treatment group (P < .0001). With SR as the reference group, the propensity-matched hazard ratios for AB were 2.04 (95% confidence interval: 1.51-2.77) for all-cause mortality, 2.44 (95% confidence interval: 1.56-3.80) for cancer-specific mortality, and 2.12 (95% confidence interval: 1.61-2.78) for disease recurrence.

DISCUSSION

SR is superior to AB for small HCCs in a large, nationally representative, modern cohort, and in secondary analysis TR was superior to both.

Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada

BACKGROUND

Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking.

QUESTIONS/PURPOSES

(1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario?

METHODS

We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups.

RESULTS

TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05).

CONCLUSION

These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

COVID-19 Knowledge, Attitudes, and Preventive Measures of University Students in Bahrain

BACKGROUND

The severe, acute respiratory syndrome COVID-19 that was first reported in China in December 2019 quickly became a global pandemic that has resulted in over 100 million infections and more than 2 million deaths.

STUDY DESIGN

This study aimed to assess the awareness level of university students regarding the possibility of becoming infected with COVID-19. In order to achieve this objective, we assessed the students' knowledge, attitudes, and behaviors using an online survey questionnaire offered to a total of 300 students.

RESULTS

A positive response regarding awareness of COVID-19 symptoms was registered by more than 70% of the students, whereas 62% felt that wearing a mask did not give full protection against infection, approximately 30% agreed that antibiotics and antivirals did not treat COVID-19, and 62% agreed that vitamin C was helpful in treating common symptoms of COVID-19. Moreover, around 31% of the students believed that COVID-19 is a man-made virus. Students who had gotten infected with SARS-CoV-2 believed that wearing a mask gives full protection (p=0.018). In response to survey questions related to attitude, 80% of students cancelled and postponed meetings with friends, and 90% agreed that mask-wearing is the most precautionary measure used to prevent the infection. In addition, 82% avoided coughing in public, 82% avoided contact if they felt flu-like symptoms and 80% washed their hands far more often due to the pandemic. Interestingly, 76% carried hand sanitizer, 66.5% avoided shaking hands, and 42.7% were taking vitamin C supplements.

CONCLUSIONS

This study showed that the participants had a positive awareness of COVID-19 transmission, symptoms, and treatments misconceptions and mistaken beliefs related to treatments and the origin of the virus were also common and should be addressed. This study thus provides a baseline for a population-based surveillance program that could help local authorities to improve pandemic preparation plans, particularly with regard to governmental education and media campaigns.

Classification of organised atrial arrythmias using explainable artificial intelligence

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BHF

NIHR

Background

Accurately determining atrial arrhythmia mechanisms from a 12-lead ECG can be challenging. Given the high success rate of cavotricuspid isthmus (CTI) ablation, accurate identification of CTI-dependent typical atrial flutter (AFL) is important for treatment decisions and procedure planning. Machine learning, with convolutional neural networks (CNNs) in particular, has been used to classify arrhythmias using the 12-lead ECG with great accuracy. However, most studies use human interpretation of the ECG as the ground truth to label the arrhythmia ECGs. Therefore, these neural networks can only ever be as good as expert human interpretation. We hypothesised a convolutional neural network could be trained to match or even exceed expert human performance in classifying CTI-dependent AFL vs. non-CTI dependent atrial tachycardia (AT), when using findings from the invasive electrophysiology (EP) study as the gold standard.

Methods

Figure 1 summarises the study methodology. We trained a CNN on data from 231 patients undergoing EP studies for atrial tachyarrhythmia. A total of 13500 5-second 12-lead ECG segments were used for training. Each case was labelled CTI-dependent AFL or non-CTI dependent AT based on the findings of the EP study. The model performance was evaluated against a test set of 57 patients. A survey of electrophysiologists and cardiologists in Europe was undertaken on the same 57 ECGs.

Results

The model had an accuracy of 86% (95% CI 0.77-0.95). The F1 score was 0.87.The AT/AFL network correctly identified AT 82% and AFL 90% of the time.

A saliency map can be used to help understand why a CNN predicted a particular outcome. This is achieved by mapping the outcome back to key areas of the input that most influenced the network in producing the classification result. Figure 2 presents the saliency mappings of an example 12-lead ECG for each class of AFL and AT. The network used the expected sections of the ECGs for diagnoses; these were the P-wave segments and not the QRS or other unexpected segments.

There were twelve respondents in the clinician survey. These respondents included nine electrophysiologists. The median accuracy was 78% (range 70-86%). The electrophysiologists had a median accuracy of 79%, (range 70-84%). Humans were more likely to incorrectly diagnose AFL as AT (on average incorrect diagnoses: 9 AFL, 1 AT). In comparison, the neural network most often incorrectly diagnosed AT as AFL (incorrect diagnoses: 5 AT, 3 AFL).

Conclusion

We describe the first neural network trained to differentiate CTI-dependent AFL from other atrial tachycardias. We found that our model surpassed expert human performance. Automated artificial intelligence enhanced ECG analysis could help guide treatment decisions and plan ablation procedures for patients with organised atrial arrhythmias.

Medicare/Medicaid Insurance Status Is Associated With Reduced Lower Bilateral Knee Arthroplasty Utilization and Higher Complication Rates

Whether to undergo bilateral total knee arthroplasty (BTKA) depends on patient and surgeon preferences. We used the National Inpatient Sample to compare temporal trends in BTKA utilization and in-hospital complication rates among TKA patients ≥50 with Medicare/Medicaid versus private insurance from 2007 to 2016. We used multivariable logistic regression to assess the association between insurance type and trends in utilization and complication rates adjusting for individual-, hospital-, and community-level covariates, using unilateral TKA (UTKA) for reference. Discharge weights were used for nationwide estimates. About 132,400 (49.5%) Medicare/Medicaid patients and 135,046 (50.5%) privately insured patients underwent BTKA. Among UTKA patients, 62.7% had Medicare/Medicaid, and 37.3% had private insurance. Over the study period, BTKA utilization rate decreased from 7.18% to 5.63% among privately insured patients and from 4.59% to 3.13% among Medicaid/Medicare patients (P trend difference <0.0001). In multivariable analysis, Medicare/Medicaid patients were less likely to receive BTKA than privately insured patients. Although Medicare/Medicaid patients were more likely to develop in-hospital complications after UTKA (adjusted odds ratio, 1.06; 95% confidence interval, 1.002 to 1.12; P = 0.04), this relationship was not statistically significant for BTKAs. In this nationwide sample of TKA patients, BTKA utilization rate was higher in privately insured patients compared with Medicare/Medicaid patients. Furthermore, privately insured patients had lower in-hospital complication rates than Medicare/Medicaid patients.

Association Between Patient Diversity in Hospitals and Racial/Ethnic Differences in Patient Length of Stay

BACKGROUND

Hospitals serving a disproportionate share of racial/ethnic minorities have been shown to have poorer quality outcomes. It is unknown whether efficiencies in inpatient care, measured by length of stay (LOS), differ based on the proportion patients served by a hospital who are minorities.

OBJECTIVE

To examine the association between the racial/ethnic diversity of a hospital's patients and disparities in LOS.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

One million five hundred forty-six thousand nine hundred fifty-five admissions using the 2017 New York State Inpatient Database from the Healthcare Cost and Utilization Project.

MAIN MEASURE

Differences in mean adjusted LOS (ALOS) between White and Black, Hispanic, and Other (Asian, Pacific Islander, Native American, and Other) admissions by Racial/Ethnic Diversity Index (proportion of non-White patients admitted to total patients admitted to that same hospital) in quintiles (Q1 to Q5), stratified by discharge destination. Mean LOS was adjusted for patient demographic, clinical, and admission characteristics and for individual intercepts for each hospital.

KEY RESULTS

In both unadjusted and adjusted analysis, Black-White and Other-White mean LOS differences were smallest in the most diverse hospitals (Black-White: unadjusted, -0.07 days [-0.1 to -0.04], and adjusted, 0.16 days [95% CI: 0.16 to 0.16]; Other-White: unadjusted, -0.74 days [95% CI: -0.77 to -0.71], and adjusted, 0.01 days [95% CI: 0.01 to 0.02]). For Hispanic patients, in unadjusted analysis, the mean LOS difference was greatest in the most diverse hospitals (-0.92 days, 95% CI: -0.95 to -0.89) but after adjustment, this was no longer the case. Similar patterns across all racial/ethnic groups were observed after analyses were stratified by discharge destination.

CONCLUSION

Mean adjusted LOS differences between White and Black patients, and White and patients of Other race was smallest in most diverse hospitals, but not differences between Hispanic and White patients. These findings may reflect specific structural factors which affect racial/ethnic differences in patient LOS.

Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis

BACKGROUND

Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care.

METHODS

We performed a cross-sectional analysis of visits in the United States' National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use.

RESULTS

About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics.

CONCLUSIONS

Practices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models.

Effect of Agaricus blazei Murill on exploratory behavior of mice-model

Increased anxiety and depressive symptoms have reported to be its association with long term illness. Because of having unwanted effects of newly available drugs, patients administering anxiolytic drugs usually discontinue the treatment before they are completely recovered. Therefore, there is a serious need to develop new anxiolytic drugs. The anxiolytic effect of hydro-alcoholic extract of Agaricus blazei in animal models was assessed. 24 male mice (Mus musculus genus) were included in the study. Four groups were prepared and each group contained six animals. The groups were vehicle control, positive control (diazepam 1.0 mg/kg, i.p.) as well as two treatment groups receiving Agaricus blazei hydro-alcoholic extract at a dose of 136.50 mg/kg and 273.0 mg/kg orally. The Marble burying test, Nestlet shredding test and Light and Dark box test used to assess anxiolytic activity. Mice administered with diazepam 1.0 mg/kg, i.p. while hydro-alcoholic extract of AbM (136.50 and 273.0 mg/kg, respectively) was administered via oral route which exhibited marked reduction in number of marbles-burying as compared to vehicle control group. Mice administered with diazepam 1.0 mg/kg, i.p. and Oral administration of hydro-alcoholic extract of AbM (136.50 and 273.0 mg/kg, respectively) exhibited significant decrease in nestlet shredding in comparison to vehicle control group. The oral administration of hydro-alcoholic extract at a dose of 136.5mg/kg and 273mg/kg showed elevation in time spent in light box and was comparable to standard treated group while time spent by mice following oral administration of hydro-alcoholic extract of Agaricus blazei at a dose of 273.0 mg/kg also showed elevation and was found to be more near to standard treated group (diazepam 1 mg/kg, i.p.).

Association between overcrowded households, multigenerational households, and COVID-19: a cohort study

OBJECTIVES

The role of overcrowded and multigenerational households as a risk factor for COVID-19 remains unmeasured. The objective of this study is to examine and quantify the association between overcrowded and multigenerational households and COVID-19 in New York City (NYC).

STUDY DESIGN

Cohort study.

METHODS

We conducted a Bayesian ecological time series analysis at the ZIP Code Tabulation Area (ZCTA) level in NYC to assess whether ZCTAs with higher proportions of overcrowded (defined as the proportion of the estimated number of housing units with more than one occupant per room) and multigenerational households (defined as the estimated percentage of residences occupied by a grandparent and a grandchild less than 18 years of age) were independently associated with higher suspected COVID-19 case rates (from NYC Department of Health Syndromic Surveillance data for March 1 to 30, 2020). Our main measure was an adjusted incidence rate ratio (IRR) of suspected COVID-19 cases per 10,000 population. Our final model controlled for ZCTA-level sociodemographic factors (median income, poverty status, White race, essential workers), the prevalence of clinical conditions related to COVID-19 severity (obesity, hypertension, coronary heart disease, diabetes, asthma, smoking status, and chronic obstructive pulmonary disease), and spatial clustering.

RESULTS

39,923 suspected COVID-19 cases were presented to emergency departments across 173 ZCTAs in NYC. Adjusted COVID-19 case rates increased by 67% (IRR 1.67, 95% CI = 1.12, 2.52) in ZCTAs in quartile four (versus one) for percent overcrowdedness and increased by 77% (IRR 1.77, 95% CI = 1.11, 2.79) in quartile four (versus one) for percent living in multigenerational housing. Interaction between both exposures was not significant (β_interaction = 0.99, 95% CI: 0.99-1.00).

CONCLUSIONS

Overcrowdedness and multigenerational housing are independent risk factors for suspected COVID-19. In the early phase of the surge in COVID cases, social distancing measures that increase house-bound populations may inadvertently but temporarily increase SARS-CoV-2 transmission risk and COVID-19 disease in these populations.

Anxiety Reaction in Children During Cast Removal using Oscillating Saw versus Cast Shear - A Randomised, Prospective Trial

Introduction:

To compare the anxiety levels demonstrated by children during cast removal procedure between oscillating saw vs cast shear methods.

Material and methods:

A randomised prospective study of 102 children (mean age 8.3 ± 3.5 years) with fractures involving upper or lower limbs. Children undergoing removal of cast were divided into 2 groups; either by an oscillating saw or a cast cutting shear. The level of anxiety was assessed by recording the heart rate with a portable fingertip pulse oximeter before, during and after removal of the cast. Objective assessment was performed by documenting the fear level on Children’s Fear Scale (CFS).

Results:

There was a significant increase in the heart rate of children during cast removal while using the oscillating saw compared to cast shear (p<0.05). The noise level produced by the saw exceeded 80 dB (mean 103.3 dB). The fear level was significantly lower in the cast shear group (p<0.05).

Conclusion:

The noise produced by the oscillating saw was associated with an increased anxiety level in children undergoing cast removal. Cast shear is a simple and inexpensive instrument that can be used for cast removal in overly anxious children.

Angular Deformities of the Knee in Children Treated with Guided Growth

Introduction:

The guided growth technique is an alternative to corrective osteotomy for treating angular deformities of the extremities. It has the advantage of being minimally invasive and is effective in a growing child. This study reports on the outcome of guided growth technique using a plate in correcting knee angular deformities.

Material and Methods:

We conducted a retrospective study of children with angular deformity of the knee treated by the guided growth technique from January 2010 to December 2015 in a tertiary centre. The guided growth technique was done using either the flexible titanium plate (8-plate) or the 2-hole reconstruction plate. Correction of deformity was assessed on radiographs by evaluating the mechanical axis deviation and tibiofemoral angle. The implants were removed once deformity correction was achieved.

Results:

A total of 17 patients (27 knees) were evaluated. Twenty-two knees (81.5%) achieved complete correction of the deformity. The median age was 4.0 (interquartile range 3.0-6.0) years and the median Body Mass Index (BMI) was 26.0 (25.0-28.0). There were 7 unilateral and 10 bilateral deformities with different pathologies (14 tibia vara, 3 genu valgus). The median rate of correction was 0.71° per month. One patient (1 knee) had screw pull-out and two patients (4 knees) had broken screws in the proximal tibia. Three patients (5 knees) failed to achieve complete correction and were subsequently treated with corrective osteotomies. Out of five patients (8 knees) who were followed-up for at least 12 months after removal of hardware, two had rebound deformities. No permanent growth retardation occurred in our patients.

Conclusion:

Our outcome for guided growth to correct knee angular deformity was similar to other studies. Guided growth is safe to perform in children below 12 years old and has good outcome in idiopathic genu valgus and Langeskiold II for tibia vara. Patients should be observed for recurrence until skeletal maturity following implant removal.

Primary Care Provider Density and Elective Total Joint Replacement Outcomes

BACKGROUND

Primary care physicians (PCPs) are often gatekeepers to specialist care. This study assessed the relationship between PCP density and total knee (TKA) and total hip arthroplasty (THA) outcomes.

METHODS

We obtained patient-level data from an institutional registry on patients undergoing elective primary TKA and THA for osteoarthritis, including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at baseline and 2 years. Using geocoding, we identified the number of PCPs in the patient's census tract (communities). We used Augmented Inverse Probability Weighting and Cross-validated Targeted Minimum Loss-Based Estimation to compare provider density and outcomes adjusting for potential confounders.

RESULTS

Our sample included 3606 TKA and 4295 THA cases. The median number of PCPs in each community was similar for both procedures: TKA 2 (interquartile range 1, 6) and for THA 2 (interquartile range 1, 7). Baseline and 2-year follow-up WOMAC pain, function, and stiffness scores were not statistically significantly different comparing communities with more than median number of PCPs to those with less than median number of PCPs. In sensitivity analyses, adding 1 PCP to a community with zero PCPs would not have statistically significantly improved baseline or 2-year follow-up WOMAC pain, function, and stiffness scores.

CONCLUSIONS

In this sample of patients who underwent elective TKA or THA for osteoarthritis, we found no statistically significant association between PCP density and pain, function, or stiffness outcomes at baseline or 2 years. Further studies should examine what other provider factors affect access and outcomes in THA and TKA.

Postoperative Radiation Therapy Refusal in Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma

OBJECTIVES/HYPOTHESIS

Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct clinical entity with good prognosis, unique demographics, and a trend toward treatment deintensification. Patients with this disease may opt out of recommended postoperative radiation therapy (PORT) for a variety of reasons. The aim of this paper was to examine factors that predict patient refusal of recommended PORT in HPV-associated OPSCC, and the association of refusal with overall survival.

STUDY DESIGN

Retrospective population-based cohort study of patients in the National Cancer Database.

METHODS

We conducted a retrospective cohort study of patients in the National Cancer Database diagnosed with OPSCC between January 2010 and December 2015. We primarily assessed overall survival and the odds of refusing PORT based on demographic, socioeconomic, and clinical factors. Analysis was conducted using multivariable logistic regression and multivariable Cox proportional hazards model.

RESULTS

A total of 4229 patients were included in the final analysis, with 156 (3.7%) patients opting out of recommended PORT. On multivariable analysis, patient refusal of PORT was independently associated with a variety of socioeconomic factors such as race, insurance status, comorbidity, treatment at a single facility, and margin status. Lastly, PORT refusal was associated with significantly lower overall survival compared to receipt of recommended PORT (hazard ratio 1.69, confidence interval 1.02-2.82).

CONCLUSIONS

Patient refusal of recommended PORT in HPV-associated OPSCC is rare and associated with variety of disease and socioeconomic factors. PORT refusal may decrease overall survival in this population. Our findings may help clinicians when counseling patients and identifying those who may be more likely to opt out of recommended adjuvant therapy.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Association between overcrowded households, multigenerational households, and COVID-19: a cohort study

Introduction

The role of overcrowded and multigenerational households as a risk factor for COVID-19 remains unmeasured. The objective of this study is to examine and quantify the association between overcrowded and multigenerational households, and COVID-19 in New York City (NYC).

Methods

We conducted a Bayesian ecological time series analysis at the ZIP Code Tabulation Area (ZCTA) level in NYC to assess whether ZCTAs with higher proportions of overcrowded (defined as proportion of estimated number of housing units with more than one occupant per room) and multigenerational households (defined as the estimated percentage of residences occupied by a grandparent and a grandchild less than 18 years of age) were independently associated with higher suspected COVID-19 case rates (from NYC Department of Health Syndromic Surveillance data for March 1 to 30, 2020). Our main measure was adjusted incidence rate ratio (IRR) of suspected COVID-19 cases per 10,000 population. Our final model controlled for ZCTA-level sociodemographic factors (median income, poverty status, White race, essential workers), prevalence of clinical conditions related to COVID-19 severity (obesity, hypertension, coronary heart disease, diabetes, asthma, smoking status, and chronic obstructive pulmonary disease), and spatial clustering.

Results

39,923 suspected COVID-19 cases presented to emergency departments across 173 ZCTAs in NYC. Adjusted COVID-19 case rates increased by 67% (IRR 1.67, 95% CI = 1.12, 2.52) in ZCTAs in quartile four (versus one) for percent overcrowdedness and increased by 77% (IRR 1.77, 95% CI = 1.11, 2.79) in quartile four (versus one) for percent living in multigenerational housing. Interaction between both exposures was not significant (β _interaction = 0.99, 95% CI: 0.99-1.00).

Conclusions

Over-crowdedness and multigenerational housing are independent risk factors for suspected COVID-19. In the early phase of surge in COVID cases, social distancing measures that increase house-bound populations may inadvertently but temporarily increase SARS-CoV-2 transmission risk and COVID-19 disease in these populations.

Racial/ethnic and socioeconomic variations in hospital length of stay: A state-based analysis

Disparities by race/ethnicity and socioeconomic status (SES) exist in rehospitalization rates and inpatient mortality rates. Few studies have examined how length of stay (LOS, a measure of hospital efficiency/quality) differs by race/ethnicity and SES.This study's objective was to determine whether differences in risk-adjusted LOS exist by race/ethnicity and SESUsing a retrospective cohort of 1,432,683 medical and surgical discharges, we compared risk-adjusted LOS, in days, by race/ ethnicity and SES (median household income by patient ZIP code in quartiles), using generalized linear models controlling for demographic and clinical factors, and differences between hospitals and between diagnoses.White patients were on average older than both Black and Hispanic patients, had more chronic conditions, and had a higher inpatient mortality risk. In adjusted analyses, Black patients had a significantly longer LOS than White patients (0.25-day difference when discharged to home and 0.23-day difference when discharged to non-home destinations, both P<.001); there was no difference between Hispanic and White patients. Wealthier patients had a shorter LOS than poorer patients (0.16-day difference when discharged to home and 0.06-day difference when discharged to nonhome destinations, both P<.001). These differences by race/ethnicity reversed for Medicaid patients.Disparities in LOS exist based on a patient's race/ethnicity and SES. Black and poorer patients, but not Hispanic patients, have longer LOS compared to White and wealthier patients. In aggregate, these differences may be related to trust and implicit bias and have implications for use of LOS as a quality metric. Future research should examine the drivers of these disparities.

Social and Clinical Determinants of COVID-19 Outcomes: Modeling Real-World Data from a Pandemic Epicenter

IMPORTANCE

As the United States continues to accumulate COVID-19 cases and deaths, and disparities persist, defining the impact of risk factors for poor outcomes across patient groups is imperative.

OBJECTIVE

Our objective is to use real-world healthcare data to quantify the impact of demographic, clinical, and social determinants associated with adverse COVID-19 outcomes, to identify high-risk scenarios and dynamics of risk among racial and ethnic groups.

DESIGN

A retrospective cohort of COVID-19 patients diagnosed between March 1 and August 20, 2020. Fully adjusted logistical regression models for hospitalization, severe disease and mortality outcomes across 1-the entire cohort and 2- within self-reported race/ethnicity groups.

SETTING

Three sites of the NewYork-Presbyterian health care system serving all boroughs of New York City. Data was obtained through automated data abstraction from electronic medical records.

PARTICIPANTS

During the study timeframe, 110,498 individuals were tested for SARS-CoV-2 in the NewYork-Presbyterian health care system; 11,930 patients were confirmed for COVID-19 by RT-PCR or covid-19 clinical diagnosis.

MAIN OUTCOMES AND MEASURES

The predictors of interest were patient race/ethnicity, and covariates included demographics, comorbidities, and census tract neighborhood socio-economic status. The outcomes of interest were COVID-19 hospitalization, severe disease, and death.

RESULTS

Of confirmed COVID-19 patients, 4,895 were hospitalized, 1,070 developed severe disease and 1,654 suffered COVID-19 related death. Clinical factors had stronger impacts than social determinants and several showed race-group specificities, which varied among outcomes. The most significant factors in our all-patients models included: age over 80 (OR=5.78, p= 2.29x10-24) and hypertension (OR=1.89, p=1.26x10-10) having the highest impact on hospitalization, while Type 2 Diabetes was associated with all three outcomes (hospitalization: OR=1.48, p=1.39x10-04; severe disease: OR=1.46, p=4.47x10-09; mortality: OR=1.27, p=0.001). In race-specific models, COPD increased risk of hospitalization only in Non-Hispanics (NH)-Whites (OR=2.70, p=0.009). Obesity (BMI 30+) showed race-specific risk with severe disease NH-Whites (OR=1.48, p=0.038) and NH-Blacks (OR=1.77, p=0.025). For mortality, Cancer was the only risk factor in Hispanics (OR=1.97, p=0.043), and heart failure was only a risk in NH-Asians (OR=2.62, p=0.001).

CONCLUSIONS AND RELEVANCE

Comorbidities were more influential on COVID-19 outcomes than social determinants, suggesting clinical factors are more predictive of adverse trajectory than social factors.

Subcapital Femoral Neck Tension Stress Fracture - A Rare Injury in A Child: A Case Report

Femoral neck stress fractures are rare in children. To the best of our knowledge, the tension type stress fracture has been reported only twice in the English language literature. We report on a five years follow-up of a 10-year-old boy with this injury which was initially missed. The fracture healed after screw fixation. We highlight the importance of considering stress fracture as a differential diagnosis in a child with chronic hip pain. A careful physical examination and the appropriate imaging will avoid missing the diagnosis.

Histopathological changes associated with exposure to metal welding fumes in some organs of Rattus norvegicus in Kano, Nigeria

Welding fumes has been known to cause release of reactive oxygen species which stands to be cytotoxic. The study aims to assess the histopathological changes of some organs associated with exposure to welding fumes in experimental animals. The metal fumes were obtained from sites of welding. A total of 130 male albino rats were engaged and divided into a 13 groups. Out of which 12 were given respective doses calculated to be equivalent to worker's real life exposure times and 1 as control. The doses were intratracheally administered weekly following anesthetization for a period of 12 weeks. The laboratory rats were then sacrificed and target organs were examined. Histopathological examination reveals normal feature for brain tissues in all treated animals. However, there was lymphocyte hyperplasia and necrosis in heart, kidney, liver and lungs tissues which at lower doses were slight and became moderate at higher doses. In addition, there were'nt pathological changes in tissues of the control animals. Thus, exposure to metal welding fumes has caused damages that have translated into lesions and several pathologies in kidney, lungs, liver and heart tissues of the test animals. Regulation and control should be imposed on exposure to welding fumes by metal workers.

Echocardiographic features and behavior of cardiac structural abnormalities in mucopolysaccharidosis

Funding Acknowledgements

Type of funding sources: None.

Mucopolysaccharidosis (MPS) is a rare genetic lysosomal storage disorder with a wide variability of phenotype. A systematic descriptive study dealing with the echocardiographic (E) features of valvular involvement and their evolution over the time in adolescent and adult patients, whose number is growing up in adult echocardiographic laboratory, is lacking in the medical literature.

Purpose

To detect the E features of valvular involvement and their evolution in adolescent and adult patients.

Method

Study design: observational descriptive retrospective. Study group: 142 E studies in 17 adolescent and adult patients with diagnosis of MPS from 2001 until 2020. Mitral (M), aortic (A), tricuspid (T) valves (V) E features (thickness, mobility, calcification, and function), their evolution over the time and the behaviour with Enzyme replacement therapy (ERT) or bone marrow transplant (BMT) were assessed.

Result

52% male, mean age 21 yrs ranges 16 to 48 yrs. 5% of the patient had MPS type I, 11% MPS type II, 29% MPS type IV, and 52% MPS type VI. 70% received ERT and 11% BMT.

In the severe case all the valves were involved (panel A, B, C; white arrows point to valve leaflets; yellow arrows MV apparatus) the whole MV apparatus was involved since the earlier stage and in the latest stage the calcification was massive (panel C). The predominant valvular dysfunction was the regurgitation followed by mixed disorder while the most frequent severe lesion was the stenosis; the echocardiographic pattern differs from the classical hockey stick appearance of the early phase of rheumatic MV and the thickening is different from the myxomatous MV for the reduced mobility and the presence of calcification. The reduced mobility of the TV (panel C) also differs from the Loeffler syndrome because of the restriction of the leaflets and the association with thickening and calcification. Under treatment, the MV thickening was found to have a slow progression of less than 1 mm yearly in 61% cases.

Conclusion

Our results showed that all the valves are affected mainly the MV; the echocardiographic pattern of MPS, different from other valvular diseases of adolescent and adult age, can help in avoiding misdiagnose. Our observations also suggest that the cardiac involvement show slow rate of progression after the initiation of the therapy. Further studies are required to confirm our results.

Type of valve % of valve thickness % of reduced mobility % calcification diffuse % valve lesion Mitral valve 88% 65% 47% 75% Aortic valve 76% 23% 41% 57% Tricuspid valve 82% 47% 17% 52% Abstract Figure. Echocardiographic features

Food and Drug Administration Safety Communication on the Use of Transvaginal Mesh in Pelvic Organ Prolapse Repair Surgery: The Impact of Social Determinants of Health

OBJECTIVE

This study was to examine the impact of the July 2011 Food and Drug Administration (FDA) safety communication on the use of transvaginal mesh in pelvic organ prolapse (POP) repair by patients' race and ethnicity.

METHODS

We conducted an observational cohort study of women undergoing POP repairs in 2008 to 2015 in New York State. We examined the changes in transvaginal mesh use in POP repairs before and after the FDA communication by patients' race and ethnicity. Piecewise logistic regression models were used to assess the trends of mesh use, adjusting for patient characteristics. We performed a subgroup analysis of the trends of transvaginal mesh use by racial groups, stratifying by patients' neighborhood socioeconomic status.

RESULTS

We included 49,848 women (78% white, 7% black, and 15% Hispanic) with an average ± SD age of 60.2 ± 13.0 years. After the safety communication, the use of transvaginal mesh in POP repairs decreased among white women (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.41-0.50) and African Americans (OR, 0.48; 95% CI, 0.35-0.67) but remained stable among Hispanic women (OR, 0.88; 95% CI, 0.70-1.11). Only in the subgroup of patients from high-income areas, there was a trend toward decreasing mesh use among Hispanic patients after 2011 (OR, 0.71; 95% CI, 0.49-1.04).

CONCLUSIONS

The communications related to the safety of transvaginal mesh did not have an equal impact across racial groups. Mesh use decreased among white and African American women but not among Hispanic women after the 2011 FDA safety communication. Particular attention is warranted for patients from disadvantaged groups, especially low-income minorities, when disseminating medical device safety messages.