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INTRODUCTION: Socioeconomic disadvantage has been associated with negative outcomes following total hip (THA) and knee arthroplasty (TKA). The Area Deprivation Index (ADI) and Distressed Community Index (DCI) are composite rankings that score socioeconomic status (SES) using patients' home addresses. The purpose of this study was to examine the association of ADI and DCI with outcomes following THA and TKA while controlling for potential confounding covariates. METHODS: A series of 4,146 consecutive patients undergoing primary THA and TKA between January 2018 and May 2023 were queried from our institutional total joint registry. The 90-day medical and surgical complications and resource utilization were collected. The ADI and DCI scores were obtained for each patient, and the association between these scores and postoperative outcomes was analyzed. RESULTS: The ADI and DCI were both associated with patient age, sex, race, comorbidity burden, and smoking status. After controlling for these variables, higher ADI and DCI scores were associated with increased length of stay (P = 0.003 and P = 0.008, respectively), but were not associated with the occurrence of any 90-day complication, reoperation, or revision. CONCLUSION: The SES, as quantified by ADI and DCI, was associated with multiple known risk factors for complications following THA and TKA, but was not independently associated with complications, reoperations, or revision surgeries at 90 days postoperatively. While convenient metrics for the quantification of SES, in some populations, ADI and DCI may not be independently associated with detrimental outcomes following THA and TKA.

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OBJECTIVE: Patients with brachial plexus birth injuries (BPBIs) are at risk for limitations in shoulder external rotation. The role of lower trapezius tendon transfer to restore shoulder external rotation in this population has not been well-characterized. This study aimed to evaluate the utility of lower trapezius tendon transfer for restoration of external rotation in a subset of pediatric patients. METHODS: Seventeen pediatric patients with BPBI were treated with lower trapezius tendon transfer to restore external rotation of the shoulder. Mean age at surgery was eight years, and 11 were female. Six patients had prior shoulder surgery to restore external rotation, while one had prior nerve surgery to restore shoulder function. Range of motion before lower trapezius transfer and at latest follow-up were obtained. Mean follow-up was 36 months. RESULTS: Active forward flexion did not significantly change from preoperative to final follow-up (mean, 147° and 141°; p=0.46). External rotation in adduction significantly changed from preoperative to final follow-up, (mean, 4° and 26°; p<0.001). External rotation in abduction significantly changed from preoperative to final follow-up (mean, 75° and 84°; p=0.048). Six patients (35%) had subsequent surgeries at average 17 months from this procedure. Significant univariate associations with subsequent surgery included certain intraoperative concomitant procedures-coracoid osteotomy/excision (p=0.02) and biceps tenodesis (p=0.04)-while bony glenoid augmentation/reconstruction trended toward significant association (p=0.05). CONCLUSION: Lower trapezius tendon transfer for BPBI showed a statistically significant but unlikely clinically meaningful improvement in external rotation with a high rate of reoperation.

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Disparities in mental health need and service use among racial and ethnic minoritized (REM) youth remain a pervasive public health concern in the United States. Cultural adaptations (CAs) have been put forth as a way to increase the cultural and contextual relevance of evidence-based psychological interventions (EBIs) to improve treatment outcomes among REM youth. Currently, no measure of CAs to EBIs for REM youth in the United States exists in the literature. Using a multistage method, this study sought to develop such a tool, the Cultural Adaptations Content Checklist (CACC). In a previous foundational study conducted via a systematic literature review, authors identified a comprehensive list of existing CAs. In the first two stages, we used a modified Delphi method as a part of which expert practice and research stakeholders (N = 17) provided feedback on CA types, definitions, and groupings via survey methodology. In the third stage, we conducted cognitive interviews with a subset of participants (n = 10) to assess participant comprehension of the CACC. The final CACC was developed and consists of 36 CA types organized into eight groups. Implications for use of the CACC in research and practice are presented. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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Sequestration, a condition where a section of bone becomes necrotic due to a loss of vascularity or thrombosis, can be a challenging complication of osteomyelitis. This review explores the pathophysiology of sequestration, highlighting the role of the periosteum in forming involucrum and creeping substitution which facilitate revascularization and bone formation. The authors also discuss the induced membrane technique, a two-stage surgical procedure for cases of failed healing of sequestration. Future directions include the potential use of prophylactic anticoagulation and novel drugs targeting immunocoagulopathy, as well as the development of advanced imaging techniques and single-stage surgical procedures.

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Cervical ectopic pregnancy is a rare condition associated with significant morbidity. With early ultrasound, fertility preservation options have become more common. No consensus on treatment exists, but many treatment modalities have been reported with good outcomes. This case report exemplifies the advantages of combination treatment for a patient with difficult outpatient follow-up, achieving a rapid resolution without increased morbidity.

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BACKGROUND: As an illustrative example of COVID-19 pandemic community-based participatory research (CBPR), we describe a community-academic partnership to prioritize future research most important to people experiencing high occupational exposure to COVID-19 - food service workers. Food service workers face key challenges surrounding (1) health and safety precautions, (2) stress and mental health, and (3) the long-term pandemic impact. METHOD: Using CBPR methodologies, academic scientists partnered with community stakeholders to develop the research aims, methods, and measures, and interpret and disseminate results. We conducted a survey, three focus groups, and a rapid qualitative assessment to understand the three areas of concern and prioritize future research. RESULTS: The survey showed that food service employers mainly supported basic droplet protections (soap, hand sanitizer, gloves), rather than comprehensive airborne protections (high-quality masks, air quality monitoring, air cleaning). Food service workers faced challenging decisions surrounding isolation, quarantine, testing, masking, vaccines, and in-home transmission, described anxiety, depression, and substance use as top mental health concerns, and described long-term physical and financial concerns. Focus groups provided qualitative examples of concerns experienced by food service workers and narrowed topic prioritization. The rapid qualitative assessment identified key needs and opportunities, with help reducing in-home COVID-19 transmission identified as a top priority. COVID-19 mitigation scientists offered recommendations for reducing in-home transmission. CONCLUSIONS: The COVID-19 pandemic has forced food service workers to experience complex decisions about health and safety, stress and mental health concerns, and longer-term concerns. Challenging health decisions included attempting to avoid an airborne infectious illness when employers were mainly only concerned with droplet precautions and trying to decide protocols for testing and isolation without clear guidance, free tests, or paid sick leave. Key mental health concerns were anxiety, depression, and substance use. Longer-term challenges included Long COVID, lack of mental healthcare access, and financial instability. Food service workers suggest the need for more research aimed at reducing in-home COVID-19 transmission and supporting long-term mental health, physical health, and financial concerns. This research provides an illustrative example of how to cultivate community-based partnerships to respond to immediate and critical issues affecting populations most burdened by public health crises.

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This paper explores the dark core's role in an employee's evaluations of coworkers electronic multitasking behaviors. Using an experimental vignette design collected via Amazon's Mechanical Turk (N = 485), we demonstrate that employees high in the dark core report higher turnover intentions and more interpersonal conflict, regardless of the multitasking behavior relevance. A three-way interaction between multitasking relevance, perceived intentionality, and the dark core when predicting turnover intentions emerged. Perceived coworker intentions played the largest role in impacting turnover and interpersonal conflict. Implications for theory and practice are discussed below.

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OBJECTIVES: This study aimed to review clinical practice outcomes of early pregnancy loss (EPL) medical management using mifepristone and misoprostol outside of a clinical trial setting. STUDY DESIGN: In this retrospective cohort study, we reviewed a deidentified database of patients who received mifepristone-misoprostol for EPL from May 2018 to May 2021 at our academic center-based clinic, which was a study site for a multicenter mifepristone-misoprostol EPL trial completed in March 2018. All patients received mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, with clinic follow-up typically scheduled within 1 week. The primary outcome was successful medical management, defined as management without the need for aspiration, and the secondary outcomes included additional interventions and indications, follow-up ultrasonography findings, and adverse events requiring treatment. RESULTS: We treated 90 patients with a median ultrasound-measured gestational size of 49 (range 30-80) days and median time from mifepristone to misoprostol of 24 (range 8-66) hours. Follow-up was completed in clinic by 80 (88.9%), completed remotely by five (5.6%), and not completed by five (5.6%) patients. Overall, 76 (95% CI 82.9%-96.0%) of 85 patients (89.4%) with follow-up were successfully managed without uterine aspiration. Eighty patients had initial follow-up ultrasonography interpreted as gestational sac expulsion; seven (8.8%) of these ultimately underwent aspiration, including one patient who had a previously undiagnosed cesarean scar ectopic pregnancy. Two patients had significant safety outcomes: one pelvic infection and one blood transfusion during aspiration in the patient with a cesarean scar ectopic pregnancy. CONCLUSIONS: Outside of a clinical trial setting, medical management of EPL with mifepristone and misoprostol remains effective and safe. IMPLICATIONS: Medical management of EPL with mifepristone and misoprostol is effective and safe outside of a clinical trial setting. A standardized protocol based on the best available clinical trial evidence can be used in clinical practice for the medical management of EPL.

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OBJECTIVE: To describe experiences with abortion counseling and access in patients with lethal or life-limiting fetal diagnoses in Texas after enactment of Senate Bill 8 (SB8). METHODS: In this qualitative study, we interviewed patients who obtained abortions after enactment of SB8, using semi-structured interviews to explore how restrictions affected abortion care. Two researchers coded all transcripts using an inductive technique and analyzed themes in an iterative approach. RESULTS: We interviewed 16 participants who reported gestational durations from 13 to 29 weeks at the time of abortion. Participants described loss of the therapeutic patient-physician relationship and feelings of isolation while pursuing abortion due to the limitations imposed by SB8. For example, participants felt there was a physician "gag rule" regarding abortion ("the unspoken word of termination"), resulting in the need to find information about pregnancy options outside of the medical community and further highlighting the privilege of financial resources necessary to obtain an abortion on their own. Participants also expressed fears regarding confidentiality with their support systems and clinicians ("I would joke around and say, well don't sue me, but halfway mean it") and personal safety when self-referring for abortion ("…am I making the right choice on where I need to go? Is it safe?"). CONCLUSION: Abortion restrictions and bans such as SB8 erode the patient-physician relationship, evoking fear and safety concerns during a vulnerable time for those undergoing abortion for lethal or life-limiting fetal diagnoses. They force patients to shoulder the significant burden of understanding pregnancy options and navigating the process of abortion alone, which is likely to have greater effects on those with fewer resources.

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BACKGROUND: Perioperative medical management during total hip arthroplasty (THA) is continuously improving, allowing an increasing number of medically complex patients to undergo total joint arthroplasty. This study examined mortalities, medical complications, implant survivorships, and clinical outcomes of THA in patients who have pulmonary hypertension (HTN). METHODS: We identified 638 patients who had pulmonary HTN and underwent 508 primary THAs and 191 revision THAs from 2000 to 2016 at a tertiary care center. Patients were followed up at regular intervals until death, revision surgery, or last clinical follow-up. Perioperative medical complications were individually reviewed. The risk of death was examined by calculating standardized mortality ratios and Cox proportional hazards regression models. Cumulative incidence analyses were used for reporting mortality, reoperation, and revision with death as a competing risk. RESULTS: The 90-day mortality was 1.8% and 3.1% for primary and revision THAs, respectively. The risk of death was approximately two-fold higher compared to primary (hazard ratio 2.69) and revision (hazard ratio 2.04) THA patients who did not have pulmonary HTN. Rate of medical complications within 90 days from surgery were 6.2% and 13.1% in primary and revision THAs, respectively. The 10-year cumulative incidence of any revision was 9% and 14% following primaries and revisions, respectively. CONCLUSION: Patients who had pulmonary HTN undergoing primary and revision THAs had an increased risk of death and experienced a high rate of medical complications within 90 days of surgery. Counseling of risks, medical optimization, and referral to medical centers expert at managing complex medical problems should be considered. LEVEL OF EVIDENCE: Level IV.

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Long-acting reversible contraceptive (LARC) methods are effective options for pregnancy prevention. Currently available products in the United States include an etonogestrel implant, a copper intrauterine device (IUD), and several levonorgestrel IUDs. With increasing prevalence and duration of use, our understanding of efficacy, risks, and benefits has evolved. In addition to a brief discussion on nomenclature and LARC use within a framework of bodily autonomy and reproductive justice, this review covers clinical challenges with placement and removal, evidence-based duration of use, and how to mitigate side effects. Although all obstetrician-gynecologists as well as primary care clinicians can safely provide LARCs, complex family planning specialists are an expert referral source for challenging cases and evidence-based care as contraceptive technology continues to develop.

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Purpose of Review: In this review, we discuss the efficacy, safety, and benefits of four new contraceptive products available in the USA, specifically Annovera, Phexxi, Slynd, and Twirla. Recent Findings: Annovera is a vaginal ring releasing ethinyl estradiol and segesterone acetate that can be used for up to one year (13 cycles), offering patients an effective, user-controlled option that may improve contraceptive access for those in low-resource settings or those with barriers to retrieving monthly prescriptions; however, given limited efficacy and safety data in people with body mass index (BMI) > 29 kg/m2, clinicians may consider whether Annovera is an appropriate contraceptive method for obese patients if there are other acceptable alternatives. Phexxi prescription-only vaginal gel is a user-controlled, non-hormonal, on-demand contraceptive method that represents a novel addition to the market with its additional uses as a personal lubricant and as a potential microbicide for urogenital infection prevention. Slynd, a drospirenone-only pill, provides more flexibility for delayed or missed pills while maintaining efficacy and a more favorable bleeding profile compared with previously available progestin-only pills. Lastly, Twirla is a transdermal patch releasing ethinyl estradiol and levonorgestrel that offers users an additional option for a user-controlled, combined hormonal contraceptive method without daily dosing; however, prescription is limited to patients with BMI < 30 kg/m2 due to decreased efficacy and VTE events in people with obesity. Summary: The addition of these products expands the available options for pregnancy prevention to address unmet contraceptive needs.

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BACKGROUND: Contemporary total hip arthroplasty (THA) often employs larger femoral heads to optimize hip stability. However, pairing 40-mm femoral heads with the smallest compatible acetabular components poses a potential risk for implant failure. The purpose of this study is to evaluate the outcomes of primary THAs using 40-mm femoral heads and the smallest compatible acetabular components. METHODS: Between 2007 and 2018, 177 primary THAs involving 40-mm femoral heads and acetabular components ≤56 mm with highly cross-linked polyethylene liners were identified. Mean age was 61 years, 56% were females, and mean body mass index was 32 kg/m2. Cumulative incidences of dislocation, any revision, and any reoperation were determined utilizing a competing risk model. Osteolysis and femoral head penetration were assessed at minimum 8-year follow-up (n = 16). Mean follow-up was 6 years. RESULTS: There were no cases of liner fractures or dissociations. The 10-year cumulative incidences of dislocation, any revision, and any reoperation were 3.6%, 4.2%, and 6.8%, respectively. Mean linear femoral head penetration was 0.01 mm/y and mean volumetric wear rate was 50 mm3/y. One THA demonstrated stable, asymptomatic periacetabular radiolucent lines at most recent follow-up. CONCLUSION: In 177 primary THAs pairing 40-mm femoral heads with the smallest compatible acetabular components, there were no liner fractures or dissociations. The cumulative incidence of dislocation was modest at 10 years. The cumulative incidences of any revision and any reoperation were low at mid-term. LEVEL OF EVIDENCE: IV.

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OBJECTIVES: To evaluate mifepristone impact on osmotic dilator placement and procedural outcomes when given 18 to 24 hours before dilator placement for dilation and evacuation (D&E) at 18 weeks 0 days to 23 weeks 6 days gestation. STUDY DESIGN: We performed a randomized, double-blind, placebo-controlled trial from April 2019 through February 2021, enrolling participants undergoing osmotic dilator (Dilapan) placement for a planned, next-day D&E. Participants took mifepristone 200 mg or placebo orally 18 to 24 hours before dilator placement. We used a gestational age-based protocol for minimum number of dilators. Our primary outcome was the proportion of participants for whom 2 or more additional dilators could be placed compared to the minimum gestational age-based standard. We secondarily evaluated cervical dilation after dilator removal in the operating room, subjective procedure ease, and complication rates (cervical laceration, uterine perforation, blood transfusion, infection, hospitalization, or extramural delivery). RESULTS: Of the planned 66 participants, we enrolled 44 (stopped due to coronavirus disease 2019-related obstacles), and 41 (19 mifepristone; 22 placebo) completed the study. We placed 2 or more additional dilators compared to standard in 7 (36.8%) and 3 (13.6%) participants after mifepristone and placebo, respectively (p = 0.14). We measured greater median initial cervical dilation in the mifepristone (3.2 cm[2.6-3.6]) compared to placebo (2.6 cm[2.2-3.0]) group, p = 0.03. Surgeon's perception of procedure being "easy" (8/19[42.1] vs 9/22[40.9], respectively, p = 1.00) and complication rate (3/19[15.8%] vs 3/22[13.6], respectively, p = 1.00) did not differ. CONCLUSION: Our underpowered study did not demonstrate a difference in cervical dilator placement, but mifepristone 18 to 24 hours prior to dilators increases cervical dilation without increasing complications. IMPLICATIONS: Mifepristone 18 to 24 hours prior to cervical dilator placement may be a useful adjunct to cervical dilators based on increased cervical dilation at time of procedure; however, logistical barriers, such as an additional visit, may preclude routine adoption without definite clinical benefit.

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BACKGROUND: Data regarding opioid prescribing patterns following pediatric orthopaedic procedures is limited. The aim of this work was to evaluate the effects of tiered guidelines for discharge opioid prescriptions following common pediatric orthopaedic procedures. METHODS: Quality improvement project conducted at a single academic institution. Guidelines for discharge opioid prescriptions were implemented January 2018 and established 4 tiers of increasing invasiveness for 28 common pediatric orthopaedic procedures. Patients who underwent these procedures in 2017 comprised the preguideline cohort (N=258), while patients treated in 2019 comprised the postguideline cohort (N=212). Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of the guidelines. RESULTS: There was a significant decrease in OME prescribed between preguideline and postguideline cohorts (median OME 97.5 vs. 37.5). When analyzed according to procedure tiers, tiers 1, 2, and 4 showed significant decreases in OME prescribed between 2017 and 2019. The rate of no opioids prescribed at discharge increased from 13% to 23% between preguideline and postguideline cohorts. The 30-day refill rate did not significantly change. After implementation of guidelines, 91% of all prescriptions were within the guideline parameters, and there was a significant reduction in prescription variability. In tier 4 procedures, median OME prescribed decreased from 375 preguideline to 188 postguideline, but was associated with greater opioid refills within 30 days of discharge (10.2% preguideline vs. 28.8% postguideline). CONCLUSIONS: Tiered guidelines for discharge opioid prescriptions following pediatric orthopaedic procedures can significantly decrease the quantity of opioids prescribed. Furthermore, we noted excellent adherence and no overall increase in the rates of narcotic refills. Such guidelines may improve pediatric orthopaedists' ability to responsibly treat postoperative pain while limiting the distribution of unneeded opioids. LEVEL OF EVIDENCE: Level IV-quality improvement project.

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BACKGROUND: Although perioperative medical management during total knee arthroplasty (TKA) has improved, there is limited literature characterizing outcomes of patients with pulmonary hypertension (HTN). This study examined mortality, medical complications, implant survivorship, and clinical outcomes in this medically complex cohort. METHODS: We identified 887 patients with pulmonary HTN who underwent 881 primary TKAs and 228 revision TKAs from 2000 to 2016 at a tertiary care center. Patients were followed up at regular intervals until death, revision surgery, or last clinical follow-up. Perioperative medical complications were individually reviewed. The risk of death was examined by calculating standardized mortality ratios and Cox proportional hazards regression models. Cumulative incidence analysis was used for reporting mortality, revision, and reoperation with death as a competing risk. RESULTS: The 90-day mortality was 0.7% and 4.8% for primary and revision TKAs, respectively. The risk of death was 2-fold higher compared to primary (hazard ratio 2.54, 95% confidence interval [CI] 2.12-3.05) and revision (hazard ratio 2.16, 95% CI 1.78-2.62) TKA patients without pulmonary HTN. Rate of medical complications within 90 days from surgery was 6.5% and 14% in primary and revision TKAs. The 10-year cumulative incidence of any revision was 5% and 16% in primaries and revisions, respectively. CONCLUSION: Patients with pulmonary HTN undergoing primary and revision TKAs had excess risk of death and experience a high rate of medical complications within 90 days of surgery. Counseling of risks, medical optimization, and referral to tertiary centers should be considered. LEVEL OF EVIDENCE: Level IV.

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Objective: Adverse childhood experiences are linked with poorer physical, social, and psychological well-being, especially for individuals who live in poverty. As adverse childhood experiences accumulate, risk for poor outcomes increases. Therefore, it is imperative that preschools and elementary schools are equipped to prevent and intervene upon traumatic stress. Trauma Smart is an organizational change intervention designed to build trauma-informed knowledge, attitudes, skills, and resources within schools serving young children. Method: The current study evaluates the effectiveness of Trauma Smart staff training in 42 preschools and elementary schools with 2,418 staff using a 1-year, longitudinal, prepost design. Trauma Smart implementation occurred during scale-up, under real world conditions. Satisfaction, posttraining knowledge about trauma-informed approaches, and pre-to-posttraining changes in attitudes favorable to trauma-informed care were evaluated. Results: As hypothesized, staff were highly satisfied with the training (mean ratings indicate 92% satisfied), demonstrated knowledge of core concepts related to trauma-informed care (mean quiz scores were scored 90% correct), and developed more favorable attitudes toward trauma-informed care following training, with medium-large effect sizes. Conclusions: Trauma Smart staff training is feasible, acceptable, and has the potential to improve the knowledge and attitudes relevant to trauma-informed approaches within preschool and elementary school staff, including those who serve children who live in poverty. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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Anterior vertebral body tether (AVBT) is a nonfusion surgical procedure for correction of scoliosis in skeletally immature individuals. With US Food and Drug Administration approval in 2019, AVBT technology is spreading and early to midterm reports are being published. Early clinical reports are promising while precise indications, outcomes, complication profiles, and best practices are being established. Patients who are skeletally immature and wish to avoid a fusion surgery may benefit from this procedure. This article highlights the translational science foundation, early to midterm clinical reports, and future directions for this growing technique in pediatric spinal deformity surgery.

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BACKGROUND: HCT leaves patients in a relative state of immune deficiency both during their initial transplant admission and for several years following discharge. NTM are generally harmless colonizers of the outside environment, but for immunocompromised patients, they can cause significant disease due to a paucity of T-cell defense. While routine prophylaxis against NTM is recommended for patients with low CD4 counts in certain clinical settings (eg, AIDS), this is not yet established for HCT patients despite their higher risk. METHODS: Here we build upon our prior work to determine risk factors for NTM in pediatric HCT patients by comparing NTM patient characteristics to matched HCT controls. RESULTS: We followed 272 patients across a 13-year time period, with 11 cases of NTM. Patients with NTM had a significantly lower CD4 count at Day 365 than matched HCT controls (105.5 ± 97.0 cells/µl vs. 856.2 ± 446.1 cells/µl, respectively; p = .001). No other potential risk factors (eg, CMV, GvHD, disease type) were found to be statistically significant, including use of T-cell depleting agents. This is consistent with an average diagnosis of NTM at Day +323 (ie, outside immediate post-transplant period). All-cause mortality was similar between NTM and control HCT groups, with an NTM attributable mortality of <10%. CONCLUSION: Since reduced CD4 counts are associated with NTM, and cost and morbidity are high, azithromycin prophylaxis for CD4 count <200 cells/µl in high-risk patients should be considered.

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