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Water Cherenkov detectors like Super-Kamiokande, and the next generation Hyper-Kamiokande are adding gadolinium to their water to improve the detection of neutrons. By detecting neutrons in addition to the leptons in neutrino interactions, an improved separation between neutrino and anti-neutrinos, and reduced backgrounds for proton decay searches can be expected. The neutron signal itself is still small and can be confused with muon spallation and other background sources. In this paper, machine learning techniques are employed to optimize the neutron capture detection capability in the new intermediate water Cherenkov detector (IWCD) for Hyper-K. In particular, boosted decision tree (XGBoost), graph convolutional network (GCN), and dynamic graph convolutional neural network (DGCNN) models are developed and benchmarked against a statistical likelihood-based approach, achieving up to a 10% increase in classification accuracy. Characteristic features are also engineered from the datasets and analyzed using SHAP (SHapley Additive exPlanations) to provide insight into the pivotal factors influencing event type outcomes. The dataset used in this research consisted of roughly 1.6 million simulated particle gun events, divided nearly evenly between neutron capture and a background electron source. The current samples used for training are representative only, and more realistic samples will need to be made for the analyses of real data. The current class split is 50/50, but there is expected to be a difference between the classes in the real experiment, and one might consider using resampling techniques to address the issue of serious imbalances in the class distribution in real data if necessary.

The purpose of this study is to describe the types of injuries and surgical treatments associated with open knee dislocations and to present the functional outcomes of these patients. Between 2001 and 2005, the medical records of patients that sustained traumatic open knee dislocations at our Level 1 Trauma Center were retrospectively reviewed. Initial surgical intervention was performed in all patients including placement of spanning external fixator, repair of vascular injuries if necessary, and irrigation and debridement of the open wounds. Ligamentous reconstruction was delayed until after limb salvage. The Short Form-12 was the primary outcome measure. Seven patients (five male, two female) had a mean age of 31.9 years (range 22-44) at the time of injury (five right, two left). Motorcycle accident was the most common cause (57%). Follow-up was a mean 27.6 months. The PCL was damaged in all patients. Three patients underwent angiography for absent/diminished pulses on initial exam with two requiring operative intervention. Three patients had associated common peroneal nerve injury (one iatrogenic). Ten (10.7) operative procedures were performed per patient (range 5-18) with an average of 6.6 debridements (range 2-11). Infection rate was 43% with one patient undergoing amputation for infection. Good to excellent results were found in 33% of patients. Most patients (86%) report some residual symptomatic or functional deficit. Due to the injury complexity in open traumatic knee dislocations, the surgical treatment is extensive and challenging. While infection rates are high, aggressive, individualized treatment can lead to satisfactory outcome although full return to activity is difficult to achieve using current treatment methods. [ABSTRACT FROM AUTHOR]

Recent research suggests that men and boys are increasingly experiencing body dissatisfaction and may be at risk for developing other health problems resulting from exposure to idealized media images of the male body. On television, nowhere are men's bodies more prominently on display than in professional wrestling. Qualitative content analyses of 118 episodes of World Wrestling Entertainment (WWE) programming, focusing on images and commentaries of male wrestling performers' bodies, revealed that televised professional wrestling presents a 'hyper-male' body ideal that constructs men's bodies as big, strong, and muscular. The potential impact of exposure to such idealized body images on wrestling's primarily male viewing audience, including possible health consequences, are explored and discussed. Future research examining television portrayals of men's bodies, and the effects that such idealized male body media images may have on men and boys, is recommended. [ABSTRACT FROM AUTHOR]

Kinetic studies of biological macromolecules increasingly use microfluidic mixers to initiate and monitor reaction progress. A motivation for using microfluidic mixers is to reduce sample consumption and decrease mixing time to microseconds. Some applications, such as small-angle x-ray scattering, also require large (>10 micron) sampling areas to ensure high signal-to-noise ratios and to minimize parasitic scattering. Chaotic to marginally turbulent mixers are well suited for these applications because this class of mixers provides a good middle ground between existing laminar and turbulent mixers. In this study, we model various chaotic to marginally turbulent mixing concepts such as flow turning, flow splitting, and vortex generation using computational fluid dynamics for optimization of mixing efficiency and observation volume. Design iterations show flow turning to be the best candidate for chaotic/marginally turbulent mixing. A qualitative experimental test is performed on the finalized design with mixing of 10 M urea and water to validate the flow turning unsteady mixing concept as a viable option for RNA and protein folding studies. A comparison of direct numerical simulations (DNS) and turbulence models suggests that the applicability of turbulence models to these flow regimes may be limited.

Abstract Background In academic medicine, women physicians lag behind their male counterparts in advancement and promotion to leadership positions. Lack of mentoring, among other factors, has been reported to contribute to this disparity. Peer mentoring has been reported as a successful alternative to the dyadic mentoring model for women interested in improving their academic productivity. We describe a facilitated peer mentoring program in our institution's department of medicine. Methods Nineteen women enrolled in the program were divided into 5 groups. Each group had an assigned facilitator. Members of the respective groups met together with their facilitators at regular intervals during the 12 months of the project. A pre- and post-program evaluation consisting of a 25-item self-assessment of academic skills, self-efficacy, and academic career satisfaction was administered to each participant. Results At the end of 12 months, a total of 9 manuscripts were submitted to peer-reviewed journals, 6 of which are in press or have been published, and another 2 of which have been invited to be revised and resubmitted. At the end of the program, participants reported an increase in their satisfaction with academic achievement (mean score increase, 2.32 to 3.63; P = 0.0001), improvement in skills necessary to effectively search the medical literature (mean score increase, 3.32 to 4.05; P = 0.0009), an improvement in their ability to write a comprehensive review article (mean score increase, 2.89 to 3.63; P = 0.0017), and an improvement in their ability to critically evaluate the medical literature (mean score increased from 3.11 to 3.89; P = 0.0008). Conclusions This facilitated peer mentoring program demonstrated a positive impact on the academic skills and manuscript writing for junior women faculty. This 1-year program required minimal institutional resources, and suggests a need for further study of this and other mentoring programs for women faculty.

Abstract Objective To examine the implications of an ontology of aggressive behavior which divides aggression into reactive, affective, defensive, impulsive (RADI) or "emotionally hot"; and planned, instrumental, predatory (PIP) or "emotionally cold." Recent epidemiological, criminological, clinical and neuroscience studies converge to support a connection between emotional and trauma related psychopathology and disturbances in the emotions, self-regulation and aggressive behavior which has important implications for diagnosis and treatment, especially for delinquent populations. Method Selective review of preclinical and clinical studies in normal, clinical and delinquent populations. Results In delinquent populations we observe an increase in psychopathology, and especially trauma related psychopathology which impacts emotions and self-regulation in a manner that hotly emotionally charged acts of aggression become more likely. The identification of these disturbances can be supported by findings in cognitive neuroscience. These hot aggressive acts can be delineated from planned or emotionally cold aggression. Conclusion Our findings support a typology of diagnostic labels for disruptive behaviors, such as conduct disorder and oppositional defiant disorder, as it appears that these acts of hot emotional aggression are a legitimate target for psychopharmacological and other trauma specific interventions. The identification of this subtype of disruptive behavior disorders leads to more specific clinical interventions which in turn promise to improve hitherto unimpressive treatment outcomes of delinquents and patients with disruptive behavior.

Abstract Background Gene duplication and gene loss during the evolution of eukaryotes have hindered attempts to estimate phylogenies and divergence times of species. Although current methods that identify clusters of orthologous genes in complete genomes have helped to investigate gene function and gene content, they have not been optimized for evolutionary sequence analyses requiring strict orthology and complete gene matrices. Here we adopt a relatively simple and fast genome comparison approach designed to assemble orthologs for evolutionary analysis. Our approach identifies single-copy genes representing only species divergences (panorthologs) in order to minimize potential errors caused by gene duplication. We apply this approach to complete sets of proteins from published eukaryote genomes specifically for phylogeny and time estimation. Results Despite the conservative criterion used, 753 panorthologs (proteins) were identified for evolutionary analysis with four genomes, resulting in a single alignment of 287,000 amino acids. With this data set, we estimate that the divergence between deuterostomes and arthropods took place in the Precambrian, approximately 400 million years before the first appearance of animals in the fossil record. Additional analyses were performed with seven, 12, and 15 eukaryote genomes resulting in similar divergence time estimates and phylogenies. Conclusion Our results with available eukaryote genomes agree with previous results using conventional methods of sequence data assembly from genomes. They show that large sequence data sets can be generated relatively quickly and efficiently for evolutionary analyses of complete genomes.

Abstract Background The pattern and timing of the rise in complex multicellular life during Earth's history has not been established. Great disparity persists between the pattern suggested by the fossil record and that estimated by molecular clocks, especially for plants, animals, fungi, and the deepest branches of the eukaryote tree. Here, we used all available protein sequence data and molecular clock methods to place constraints on the increase in complexity through time. Results Our phylogenetic analyses revealed that (i) animals are more closely related to fungi than to plants, (ii) red algae are closer to plants than to animals or fungi, (iii) choanoflagellates are closer to animals than to fungi or plants, (iv) diplomonads, euglenozoans, and alveolates each are basal to plants+animals+fungi, and (v) diplomonads are basal to other eukaryotes (including alveolates and euglenozoans). Divergence times were estimated from global and local clock methods using 20–188 proteins per node, with data treated separately (multigene) and concatenated (supergene). Different time estimation methods yielded similar results (within 5%): vertebrate-arthropod (964 million years ago, Ma), Cnidaria-Bilateria (1,298 Ma), Porifera-Eumetozoa (1,351 Ma), Pyrenomycetes-Plectomycetes (551 Ma), Candida-Saccharomyces (723 Ma), Hemiascomycetes-filamentous Ascomycota (982 Ma), Basidiomycota-Ascomycota (968 Ma), Mucorales-Basidiomycota (947 Ma), Fungi-Animalia (1,513 Ma), mosses-vascular plants (707 Ma), Chlorophyta-Tracheophyta (968 Ma), Rhodophyta-Chlorophyta+Embryophyta (1,428 Ma), Plantae-Animalia (1,609 Ma), Alveolata-plants+animals+fungi (1,973 Ma), Euglenozoa-plants+animals+fungi (1,961 Ma), and Giardia-plants+animals+fungi (2,309 Ma). By extrapolation, mitochondria arose approximately 2300-1800 Ma and plastids arose 1600-1500 Ma. Estimates of the maximum number of cell types of common ancestors, combined with divergence times, showed an increase from two cell types at 2500 Ma to ~10 types at 1500 Ma and 50 cell types at ~1000 Ma. Conclusions The results suggest that oxygen levels in the environment, and the ability of eukaryotes to extract energy from oxygen, as well as produce oxygen, were key factors in the rise of complex multicellular life. Mitochondria and organisms with more than 2–3 cell types appeared soon after the initial increase in oxygen levels at 2300 Ma. The addition of plastids at 1500 Ma, allowing eukaryotes to produce oxygen, preceded the major rise in complexity.

Abstract Background The complete genomes of three animals have been sequenced by global research efforts: a nematode worm (Caenorhabditis elegans), an insect (Drosophila melanogaster), and a vertebrate (Homo sapiens). Remarkably, their relationships have yet to be clarified. The confusion concerns the enigmatic position of nematodes. Traditionally, nematodes have occupied a basal position, in part because they lack a true body cavity. However, the leading hypothesis now joins nematodes with arthropods in a molting clade, Ecdysozoa, based on data from several genes. Results We tested the Ecdysozoa hypothesis with analyses of more than 100 nuclear protein alignments, under conditions that would expose biases, and found that it was not supported. Instead, we found significant support for the traditional hypothesis, Coelomata. Our result is robust to different rates of sequence change among genes and lineages, different numbers of taxa, and different species of nematodes. Conclusion We conclude that insects (arthropods) are genetically and evolutionarily closer to humans than to nematode worms.

Background: While combat spinal injuries have been documented since the fourth century BC, a comprehensive analysis of such injuries has not been performed for any American military conflict. Recent literature has suggested that spinal injuries account for substantial disability in wounded service members.Methods: The Joint Theater Trauma Registry was queried to identify all American military personnel who sustained injuries to the back, spinal column, and/or spinal cord in Iraq or Afghanistan from October 2001 to December 2009. Spinal injuries were categorized according to anatomic location, neurological involvement, mechanism of injury, and concomitant wounds.Results: Of 10,979 evacuated combat casualties, 598 (5.45%) sustained 2101 spinal injuries. Explosions accounted for 56% of spinal injuries, motor vehicle collisions for 29%, and gunshots for 15%. Ninety-two percent of all injuries were fractures, with transverse process, compression, and burst fractures the most common. Spinal cord injuries were present in 17% (104) of the 598 patients. Concomitant injuries frequently occurred in the abdomen, chest, head, and face.Conclusions: The incidence of spine trauma sustained by military personnel in Iraq and Afghanistan is higher than that reported for previous conflicts, and the nature of these injuries may be similar to those in severely injured civilians. Further research into optimal management and rehabilitation is critical for military service members and severely injured civilians with spine trauma. [ABSTRACT FROM AUTHOR]

Extensive nutritional analyses were conducted for palm kernel meal (PKM) sourced from 5 countries. Two precision-fed rooster trials were conducted to evaluate the nitrogen-corrected true metabolizable energy (TME n ) and standardized amino acid (AA) digestibility of 10 PKM samples (PKM 1 to 10). The TME n was determined using conventional Single Comb White Leghorn roosters, and standardized AA digestibility was determined using cecectomized roosters. Roosters were fasted for 26 h prior to crop intubation with 25 g of each PKM. Excreta were then collected for 48 h post-intubation and freeze dried for analysis. Statistical analyses were conducted using a one-way ANOVA for a completely randomized design. The least significant difference test was conducted to determine if differences between or among individual treatments were significant at P < 0.05. The PKM samples were found to have an average (DM basis) of 14% CP, 7.5 % fat, and 64% neutral detergent fiber, 0.4% Ca, 0.7% P, and 1.3% phytic acid. Average TME n for PKM samples was 2082 kcal/kg (DM basis)(range was 1,644 to 2,511). Average Lys, Met, Cys, and Thr digestibility values (%), with ranges in parentheses, for PKM samples were 47 (34 to 60), 73 (66 to 80), 47 (29 to 58), and 65 (54 to 77), respectively. The PKM samples contained highly variable levels of TME n and digestible AA within and among countries. Nutrient composition also varied substantially among PKM samples., Competing Interests: Declaration of competing interest There is no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Protein misfolding and aggregation are cardinal features of neurodegenerative disease (NDD) and they contribute to pathophysiology by both loss-of-function (LOF) and gain-of-function (GOF) mechanisms. This is well exemplified by TDP-43 which aggregates and mislocalizes in several NDDs. The depletion of nuclear TDP-43 leads to reduction in its normal function in RNA metabolism and the cytoplasmic accumulation of TDP-43 leads to aberrant protein homeostasis. A modifier screen found that loss of rad23 suppressed TDP-43 pathology in invertebrate and tissue culture models. Here we show in a mouse model of TDP-43 pathology that genetic or antisense oligonucleotide (ASO)-mediated reduction in rad23a confers benefits on survival and behavior, histological hallmarks of disease and reduction of mislocalized and aggregated TDP-43. This results in improved function of the ubiquitin-proteasome system (UPS) and correction of transcriptomic alterations evoked by pathologic TDP-43. RAD23A-dependent remodeling of the insoluble proteome appears to be a key event driving pathology in this model. As TDP-43 pathology is prevalent in both familial and sporadic NDD, targeting RAD23A may have therapeutic potential.

Aim: The treatment of massive diaphyseal tibial bone defects remains challenging with poor results seen from treatment modalities other than bone transport (BT). Current methods of BT require lengthy periods in a circular external fixator. Despite recent modifications in BT techniques via circular external fixator such as multifocal transport and immediate intramedullary nailing after docking, circular external fixation remains poorly tolerated with a high complication profile. Newer technologies such as magnetic lengthening nails have shown promise to provide alternatives to BT without resorting to long-term circular external fixation. Plate-assisted bone segment transport (PABST) has demonstrated success as an all-internal BT technique. Prior case reports have shown a modest ability to treat massive defects with varying success., Technique: A novel all-internal cable and pulley augmentation to a PABST technique for a massive (185 mm) tibial defect was utilised during a retrograde transport. The authors describe a patient scenario in which this augment allowed continued transport that could not be treated with an additional Precice nail recharge., Conclusion: Augmentation of PABST with a cable and pulley construct can successfully treat massive diaphyseal defects., Clinical Significance: This cable and pulley modification to PABST allows for the treatment of massive tibial defects without the need for magnetic lengthening nail exchange or conversion to external fixation., How to Cite This Article: Lance D, Morpeth B, Faith H, et al. Massive Tibial Defect Treated with Plate-assisted Bone Segment Transport and A Novel Internal Cable-Pulley System. Strategies Trauma Limb Reconstr 2024;19(2):118-124., Competing Interests: Source of support: Nil Conflict of interest: None Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.Conflict of interest: None, (Copyright © 2024; The Author(s).)

Mammals are protected from changes in environmental temperature by altering energetic processes that modify heat production. Insulin is the dominant stimulus of glucose uptake and metabolism, which are fundamental for thermogenic processes. The purpose of this work was to determine the interaction of ambient temperature induced changes in energy expenditure (EE) on the insulin sensitivity of glucose fluxes. Short-term and adaptive responses to thermoneutral temperature (TN, ∼28 °C) and room (laboratory) temperature (RT, ∼22 °C) were studied in mice. This range of temperature does not cause detectable changes in circulating catecholamines or shivering and postabsorptive glucose homeostasis is maintained. We tested the hypothesis that a decrease in EE that occurs with TN causes insulin resistance and that this reduction in insulin action and EE is reversed upon short term (<12h) transition to RT. Insulin-stimulated glucose disposal (Rd) and tissue-specific glucose metabolic index were assessed combining isotopic tracers with hyperinsulinemic-euglycemic clamps. EE and insulin-stimulated Rd are both decreased (∼50%) in TN-adapted vs RT-adapted mice. When RT-adapted mice are switched to TN, EE rapidly decreases and Rd is reduced by ∼50%. TN-adapted mice switched to RT exhibit a rapid increase in EE, but whole-body insulin-stimulated Rd remains at the low rates of TN-adapted mice. In contrast, whole body glycolytic flux rose with EE. This higher EE occurs without increasing glucose uptake from the blood, but rather by diverting glucose from glucose storage to glycolysis. In addition to adaptations in insulin action, 'insulin-independent' glucose uptake in brown fat is exquisitely sensitive to thermoregulation. These results show that insulin action adjusts to non-stressful changes in ambient temperature to contribute to the support of body temperature homeostasis without compromising glucose homeostasis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Introduction: The incidence of pelvic ring injuries is 34.3% per 100,000 capita. No studies have determined the ability of a female patient to have a vaginal delivery after undergoing pelvic fracture fixation. However, many obstetricians are generally unwilling to have their patients attempt a vaginal delivery in the setting of symphyseal or sacroiliac fixation., Methods: An exhaustive search of the National Library of Medicine database was performed, and it is hypothesized that cesarean section rates would be higher for women who have a child after one of these pelvic ring injuries., Results: There is a 15% increase in cesarean rates using data from the National Center for Health Statistics. In addition, there is an observable increase in new cesarean rates., Discussion: Currently, there is no clear evidence to support an elective cesarean section as the sole indication after a prior pelvic fracture. To date, no studies have determined the ability of a female patient to have a vaginal delivery after undergoing pelvic fracture fixation., Conclusion: Thus, until the increased cesarean section rate has been explained, it could be problematic to counsel the patient to avoid a vaginal delivery after sustaining a pelvic ring fracture. Hence, conducting additional studies on this topic would deem to be necessary., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

The purpose of this study is to determine the financial practicality for the use of nasal povidone-iodine (NP-I) in the preoperative holding area in attempt to decrease the rate of infection that is associated with operative fixation of closed pilon fractures. Institutional costs for treating postoperative infection following a closed pilon fracture, along with costs associated with preoperative NP-I use, were obtained. A break-even equation was used to analyze these costs to determine if the use of NP-I would decrease the current infection rate (17%) enough to be financially beneficial for routine use preoperatively. The total cost of treating a postoperative infection was found to be $18,912, with the cost of NP-I being $30 per patient dose. Considering a 17% infection rate and utilizing the break-even equation, NP-I was found to be economically viable if it decreased the current infection rate by 0.0016% (Number Needed to Treat = 63,051.7). This break-even model suggests that the use of NP-I in the preoperative holding area is financially beneficial for decreasing the rate of infection associated with the treatment of closed pilon fractures., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Mammals are protected from changes in environmental temperature by altering energetic processes that modify heat production. Insulin is the dominant stimulus of glucose uptake and metabolism, which are fundamental for thermogenic processes. The purpose of this work was to determine the interaction of ambient temperature induced changes in energy expenditure (EE) on the insulin sensitivity of glucose fluxes. Short-term and adaptive responses to thermoneutral temperature (TN, ~28°C) and room (laboratory) temperature (RT, ~22°C) were studied in mice. This range of temperature does not cause detectable changes in circulating catecholamines or shivering and postabsorptive glucose homeostasis is maintained. We tested the hypothesis that a decrease in EE that occurs with TN causes insulin resistance and that this reduction in insulin action and EE is reversed upon short term (<12h) transition to RT. Insulin-stimulated glucose disposal (Rd) and tissue specific glucose uptake were assessed combining isotopic tracers with hyperinsulinemic-euglycemic clamps. EE and insulin-stimulated Rd are both decreased (~50%) in TN-adapted vs RT-adapted mice. When RT-adapted mice are switched to TN, EE rapidly decreases and Rd is reduced by ~50%. TN-adapted mice switched to RT exhibit a rapid increase in EE, but whole body insulin-stimulated Rd remains at the low rates of TN-adapted mice. In contrast, whole body glycolytic flux rose with EE. This higher EE occurs without increasing glucose uptake from the blood, but rather by diverting glucose from glucose storage to glycolysis. In addition to adaptations in insulin action, 'insulin-independent' glucose uptake in brown fat is exquisitely sensitive to thermoregulation. These results show that insulin action adjusts to non-stressful changes in ambient temperature to contribute to the support of body temperature homeostasis without compromising glucose homeostasis.

Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Complement factor 5 of the innate immune system generates C5a and C5b ligands, which initiate inflammatory and cell lysis events, respectively. C5 activation has been linked with obesity-associated metabolic disorders; however, whether it has a causative role is unclear. We generated a C5 null (C5 -/- ) mouse using CRISPR-Cas9 gene editing to determine whether loss of C5 improves obesity-linked metabolic dysfunction. Generation of a new mouse model was prompted in part by the observation of off-target gene mutations in commercially available C5 -/- lines. Male and female wild-type (WT), heterozygous (Het), and C5 -/- mice were fed low-fat diet (LFD) or high-fat diet (HFD) for 22 wk. Body weight gain did not differ between genotypes on LFD or HFD. In lean animals, male C5 -/- mice had similar glucose tolerance compared with WT controls; however, in obese conditions, glucose tolerance was worsened in C5 -/- compared with controls. In contrast, female mice did not exhibit differences in glucose tolerance between genotypes under either dietary paradigm. Fasting insulin was not different between genotypes, whereas diet-induced obese male C5 -/- mice had lower fed insulin concentrations compared with WT controls. No differences in adipose tissue inflammation or adipocyte size were identified between groups. Similarly, susceptibility to fatty liver and hepatic inflammation was similar between WT and C5 -/- mice. However, the systemic cytokine response to acute endotoxin exposure was decreased in C5 -/- mice. Together, these data suggest that loss of C5 worsens glucose tolerance in obese male but not female mice. Additional work is required to pinpoint the mechanisms by which loss of C5 amplifies glucose intolerance in obesity. NEW & NOTEWORTHY We generated a new mouse model of complement factor 5 deficiency. This work was prompted by a need for improved transgenic mouse lines of C5, due to off-target gene mutations. We find that loss of C5 worsens glucose tolerance in a sex-dependent manner. Though the mechanisms evoking glucose intolerance are not clear, we are confident this model will be useful in interrogating complement activation in obesity-associated diseases.

Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed., Competing Interests: Funding Support and Author Disclosures Dr Samuels has served as a consultant and on a Speakers Bureau for Abbott Vascular and Philips. Dr Shah has received research support from Abbott Vascular and the Food and Drug Administration of the U.S. Department of Health and Human Services. Dr Widmer has served on advisory boards for Abbott Vascular, Philips, and Medtronic; and has received research support from Cardiol Therapeutics. Dr Kobayashi has served as a consultant for Abbott Vascular. Dr Miner has received investigator-initiated research support from Abbott Vascular. Dr Jeremias has served as a consultant for Philips, Abbott Vascular, ACIST, Neovasc, and CathWorks. Dr Blair has received research support from Abbott Vascular and Philips; and is on a Speakers Bureau for Abbott Vascular. Dr Kearney has served as a consultant for Abbott Vascular, Abiomed, Boston Scientific, CSI, Medtronic, Teleflex, and Philips. Dr Wei has served on an advisory board for Abbott Vascular. Dr Park has received honoraria from Abbott Vascular and CSI. Dr Kesarwani has served as a consultant for Abbott Vascular. Dr Lerman has served on an advisory board for Philips/Volcano. Dr Prasad has served on an advisory board and/or as a consultant for Abbott Vascular, Boston Scientific, Cardiol Therapeutics, Conavi, Chiesi, and Neovasc. Dr Quesada has received partial support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) (award K23HL151867). Dr Reynolds has received research support from Abbott Vascular, Philips, and Siemens. Dr Smilowitz has served on an advisory board for Abbott Vascular; and has received partial support from the National Heart, Lung, and Blood Institute of the NIH (award K23HL150315). Dr Sutton has received honoraria for speaking or consulting from Abbott, Philips, Zoll, and Shockwave. Dr Sweeny has received honoraria from Abbott Vascular. Dr Henry has received research support and honoraria from Neovasc. Dr Moses has served as a consultant for Covanos; and has held equity in Orchestra BioMed and Covanos. Dr Fearon has received institutional research support from Abbott Vascular, Medtronic, and the NIH (5R33HL139929-05); has served as a consultant for CathWorks and Siemens; and has held stock options with HeartFlow. Dr Tremmel has received honoraria from and served on advisory boards for Abbott Vascular; has received honoraria and research funding from Boston Scientific; and has received honoraria from Shockwave. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Centers specializing in coronary function testing are critical to ensure a systematic approach to the diagnosis and treatment of angina with nonobstructive coronary arteries (ANOCA). Management leveraging lifestyle, pharmacology, and device-based therapeutic options for ANOCA can improve angina burden and quality of life in affected patients. Multidisciplinary care teams that can tailor and titrate therapies based on individual patient needs are critical to the success of comprehensive programs. As coronary function testing for ANOCA is more widely adopted, collaborative research initiatives will be fundamental to improve ANOCA care. These efforts will require standardized symptom assessments and data collection, which will propel future large-scale clinical trials., Competing Interests: Funding Support and Author Disclosures Dr Smilowitz has served on an advisory board for Abbott Vascular and is supported, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K23HL150315. Dr Prasad has served on an advisory board and/or as a consultant for Abbott Vascular, Boston Scientific, Cardinol, CONAVI, Chiesi, and Neovasc. Dr Widmer has served on advisory boards for Abbott Vascular, Philips, and Medtronic; and has received research support from Cardiol Therapeutics. Dr Quesada is supported, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K23HL151867. Dr Sutton has received honoraria for speaking or consulting from Abbott, Philips, Zoll, and Shockwave. Dr Lerman has served on an advisory board for Philips/Volcano. Dr Reynolds has received research support from Abbott Vascular, Philips, and Siemens. Dr Kesarwani has a consulting agreement with Abbott Vascular. Dr Sweeny has received honoraria from Abbott Vascular. Dr Park has received honoraria from Abbott Vascular and CSI. Dr Blair has received research support from Abbott Vascular and Philips; and is on a Speakers Bureau for Abbott Vascular. Dr Jeremias has consulting agreements with Philips, Abbott Vascular, ACIST, Neovasc, and CathWorks. Dr Kearney has consulting agreements with Abbott Vascular, Abiomed, Boston Scientific, CSI, Medtronic, Teleflex, and Philips. Dr Kobayashi has a consulting agreement with Abbott Vascular. Dr Miner has received investigator-initiated research support from Abbott Vascular. Dr Samuels has served as a consultant and has served on a Speaker’s Bureau for Abbott Vascular and Philips. Dr Shah has received research support from Abbott Vascular and the FDA of the U.S. Department of Health and Human Services (HHS). Dr Wei has served on an advisory board for Abbott Vascular. Dr Fearon has received institutional research support from Abbott Vascular, Medtronic, and the NIH (5R33HL139929-05); has a consulting agreement with CathWorks and Siemens; and has stock options with HeartFlow. Dr Henry has received research support and honoraria from Neovasc. Dr Moses has served as a consultant for Covanos; and has equity in Orchestra BioMed and Covanos. Dr Tremmel has received honoraria from and served on advisory boards for Abbott Vascular; has received honoraria and research funding from Boston Scientific; and has received honoraria from Shockwave. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Soft tissue defects involving the distal lower extremity present challenging problems for orthopaedic surgeons to manage. Historically, wounds not amenable to primary closure have necessitated assistance from multidisciplinary teams using plastic surgeons to obtain adequate soft tissue coverage through rotational flap or free tissue transfer procedures. Techniques related to soft tissue rearrangement and local rotational flap coverage have advanced over the years with a growing knowledge of local anatomy and vasculature. The reverse sural flap may be performed to cover soft tissue defects within 10 cm of the foot or ankle region, negating the need for microvascular intervention. The simplistic nature of the reverse sural flap is appealing to orthopaedic surgeons as a means to provide timely patient care without additional support because it does not require microvasculature work or the need for intraoperative microscopes and has been popularized among orthopaedic trauma surgeons as a necessary tool to possess. Here, we discuss the reverse sural flap to include history, relevant anatomy, clinical indications, and a description of the technique for application., Competing Interests: Dr. J. A. Blair is a consultant for Stryker, Inc., Smith & Nephew, Inc, Integra Lifesciences, Corporation, and NuVasive Specialized Orthopaedics. The remaining authors have no relevant disclosures., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Summary: A single implant all-internal magnet-driven bone transport nail (BTN-NuVasive Specialized Orthopaedics Inc) has recently been introduced as a treatment method for segmental tibial bone defects. This innovation provides promise in the management of segmental bone defects because it negates numerous complications associated with circular external fixation and the need for multiple implants when considering hybrid plate-assisted bone segment transport constructs. Given the novelty of the BTN, description of the surgical application and patient outcome measures are scarce in the current literature. To date, we have treated 4 patients with an average age of 27 years (range 19-44 years) using the BTN for segmental tibial defects ranging from 50 to 128 mm. We have accumulated data over an average follow-up of 18.07 months (range 12.96-25.13 months), demonstrating good patient tolerance of the device. Three patients successfully completed their treatment course with a calculated average bone healing index of 41.4 days/cm (range 31.41-54.82 days/cm). One patient was noted to experience an asymptomatic docking site nonunion requiring subsequent surgery for nonunion repair. Implant-associated complications included symptomatic implant, axial malalignment, docking site nonunion, and external remote control technical malfunction. Injury-related complications were encountered and noted to include: superficial infection, wound dehiscence, peroneal tendonitis, and joint rigidity. In this study, the authors present a case series using this implant to date and discuss our experiences with the BTN with reference to clinical indications, tibial bone preparation, BTN implantation, transport protocol, docking site procedure, and clinical/radiographic outcomes., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The US Department of Homeland Security has reported increases in encounters and apprehensions at the US Southwest border for the past several years. The purposes of this study were to assess the demographics, patterns of injuries, and surgical interventions, associated with falls from height along the US-Mexico border., Methods: A prospective cohort study was conducted at a Level I trauma center from January 2016 through December 2021 of all patients who fell from height crossing the US-Mexico border and presented with injuries requiring admission., Results: A total of 448 patients were admitted with a median age of 30 years (interquartile range [IQR] 16, range 6 to 65). Monthly frequency of admissions increased markedly with a median of 18.5 (IQR 5.3) in 2021. Patients presented with limited health data, and comorbidities were identified in 111 patients (24.7%). Median height fallen was 5.5 m (18 ft). Patients sustaining a fall from ≥ 5.5 m were markedly more likely to have an Injury Severity Score (ISS) of > 15. Median length of stay was 9 days (IQR 11). There were a total of 1,066 injuries with 723 extremity and pelvic; 236 spine; and 107 head or neck, face, thorax, or abdominal injuries. Median ISS was 9.0 (IQR 7, range 1 to 75, 33% > 15). Tibial plafond fracture and spine injury were markedly associated with longer lengths of stay and ISS > 15. All injuries resulted in 635 separate surgical events and 930 procedures. Clinical follow-up occurred in 55 patients (12.2%), with median duration of 28 days (range 6 days to 8 months)., Discussion: Injuries associated with border crossings and falls from height were serious and increased in frequency. As the US policy on border security evolves, surgeons in these regions should be prepared to handle the associated injuries and sequelae. Prevention of these serious and debilitating injuries should be undertaken to decrease the burden of disease., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Aims & Objectives: YouTube is a non-peer-reviewed platform with a large library of healthcare-related videos which attempt to provide educational content. The goal of this study is to analyze the quality, absorbability, and educational content of videos available to patients on YouTube regarding ankle fractures., Materials & Methods: On May 31, 2022, over 550 videos populated the initial search of "ankle fracture" within YouTube's platform. The first 100 videos were reviewed, and 62 videos were included in the final analysis. Video characteristics were recorded and evaluated. Videos were assessed using three objective scoring systems: (1) the Journal of American Medical Association (JAMA) benchmark criteria, (2) the Patient Education Materials Assessment Tool for audio and visual materials (PEMAT), and (3) the novel Ankle Fracture Content Score (AFCS)., Results: Each scoring system had high internal consistency and interrater reliability. The mean JAMA, PEMAT understandability, PEMAT actionability, and AFCS were 2.92, 61.85%, 16.38%, and 4.67, respectively. No association was seen between video popularity metrics and quality of information. The understandability of the patient-targeted videos was greater than those targeted at healthcare professionals ( P  = 0.049)., Conclusion: The information regarding ankle fractures available on YouTube for patient education is poor with no correlation between quality and popularity. This study illustrates the need for future collaboration between YouTube and trusted medical societies to provide patients with the highest quality information., Competing Interests: None, (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: The purpose of this study was to assess trends in ABOS part II candidate's operative management of geriatric (≥65 years) proximal humerus fractures over the 2010-2020 decade., Methods: This retrospective database cohort study utilized the American Board of Orthopaedic Surgery (ABOS) database for candidates taking Part II of their boards. Surgical coding was reviewed and the ICD10 data was correlated to the CPT code for shoulder arthroplasty or open reduction internal fixation. We investigated the number of proximal humerus fracture operative cases per year, the percent arthroplasty used per year, the stratification of percent arthroplasty per orthopaedic fellowship subspecialty and geographic region., Results: A total of 2,409 operative cases for proximal humerus fractures in patients 65 years of age and older were submitted by 1,420 ABOS candidates. There was a 37% reduction in operatively managed proximal humerus fractures among ABOS part II candidates between the first half of the decade (2010-2015, 263.2 +/- 13.4) and the second half of the decade (2016-2020, 166 +/- 31.2; p<.05). There also was a downward trend with a 53% reduction in percent treated with arthroplasty as compared to ORIF during those same windows (2010-2015, 34.4 +/-11.7) and (2016-2020, 16.2 +/- 6.4; p<.5). Partitioned by single fellowship training, Shoulder and Elbow (S&E) surgeons performed the highest percent arthroplasty at 25.2%, followed by Sports at 23.1% and the lowest percent arthroplasty was Trauma at 11.7%. The Southeast United States had the lowest percentage arthroplasty at 15.8% as compared to the Midwest (23.8%) and Northeast (25.8%)., Conclusion: Despite the rapid growth of both the elderly population and related geriatric proximal humerus fractures, ABOS candidates are treating less with surgery. There has been approximately a 37% decrease in the total number of operatively treated proximal humerus fractures between the first and second half 2010-2020 decade. When operative treatment is performed, there is a trend towards ORIF over an arthroplasty. Trauma fellowship trained surgeons are less likely to perform an arthroplasty as compared to other subspecialties. The Southeast region is least likely to perform an arthroplasty as compared to the Midwest or Northeast., Competing Interests: Declarations of Competing Interest The authors have no financial disclosures. The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of William Beaumont Army Medical Center, Department of the Army, Defense Health Agency, or the US Government., (Copyright © 2022. Published by Elsevier Ltd.)

Objective: To evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures., Methods: A break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6-33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT)., Results: Financial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714)., Conclusion: This break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022. Published by Elsevier Ltd.)

Objectives: To review and evaluate the validity of common perceptions and practices regarding radiation safety in orthopaedic trauma., Design: Retrospective study., Setting: Level 1 trauma center., Subjects: N/A., Intervention: The intervention involved personal protective equipment., Main Outcome Measurements: The main outcome measurements included radiation dose estimates., Results: Surgeon radiation exposure estimates performed at the level of the thyroid, chest, and pelvis demonstrate an estimated total annual exposure of 1521 mR, 2452 mR, and 1129 mR, respectively. In all cases, wearing lead provides a significant reduction (90% or better) in the amount of radiation exposure (in both radiation risk and levels of radiation reaching the body) received by the surgeon. Surgeons are inadequately protected from radiation exposure with noncircumferential lead. The commonly accepted notion that there is negligible exposure when standing greater than 6 feet from the radiation source is misleading, particularly when cumulative exposure is considered. Finally, we demonstrated that trauma surgeons specializing in pelvis and acetabular fracture care are at an increased risk of exposure to potentially dangerous levels of radiation, given the amount of radiation required for their caseload., Conclusion: Common myths and misperceptions regarding radiation in orthopaedic trauma are unfounded. Proper use of circumferential personal protective equipment is critical in preventing excess radiation exposure., Competing Interests: All authors have no conflicts of interest. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, and patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Soft tissue reconstructive techniques are powerful tools for the orthopedic surgeon caring for lower extremity trauma. This article seeks to inform orthopedic surgeons about useful techniques for skin closure, secondary wound closure techniques, and rotational flaps of the lower leg. Split thickness skin grafting, piecrusting, and the use of negative pressure wound therapy for skin closure, as well as rotational gastrocnemius, soleus, and reverse sural artery flaps are discussed with emphasis on techniques for the nonvascular and nonmicrovascular orthopedic surgeon., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Literature evaluating outcomes following operative fixation of Lisfranc injuries has demonstrated high rates of chronic disability, particularly in those returning to prior levels of physical function. The purpose of this study is to evaluate the occupational outcomes and return to running after open reduction and internal fixation (ORIF) or arthrodesis for Lisfranc fracture-dislocations in a moderate- to high-demand military cohort. Methods: All active-duty servicemembers undergoing ORIF or primary arthrodesis (Current Procedural Terminology 28615 and 28730, respectively) for confirmed Lisfranc fracture-dislocations (International Classification of Diseases, Ninth Revision codes 838.03 or 838.13) with minimum 2-year follow-up were isolated from the Military Health System. Demographic and surgical variables were recorded. Return to military function, return to running, perioperative morbidity, and rates of reoperation for complication were the outcomes of interest. Univariate analysis followed by multivariate logistic regression determined the association between patient demographics, type of fracture fixation (ie, ORIF vs arthrodesis) and functional outcomes, including medical separation. Results: Among Lisfranc injuries, 64 patients underwent ORIF while 6 underwent primary arthrodeses with a mean age of 28.1 years. At mean follow-up of 3.5 years (range, 2.0-6.3 years), 20% of servicemembers underwent medical separation due to limitations related to their injuries. body mass index (BMI) ≥30 kg/m 2 (OR 17.67; 95% CI, 3.69-84.53) and Army or Marines service branch (OR 3.86; 95% CI, 1.08-13.86) were significant independent predictors for medical separation. Among servicemembers undergoing ORIF or primary arthrodeses, 69% returned to occupationally required daily running during the follow-up period. Servicemembers with a BMI <30 kg/m 2 were more likely to return to running (OR 13.14, 95% CI, 2.50-69.19). Radiographic evidence of posttraumatic Lisfranc osteoarthritis occurred in 10 (16%) servicemembers who underwent internal fixation, and 82% of ORIF patients underwent implant removal. Conclusions: At mean 3.5-year follow-up, 80% of servicemembers undergoing ORIF or primary arthrodeses for Lisfranc injuries remained on active duty or successfully completed their military service, and 69% were able to resume occupationally required daily running. Surgeons should preoperatively counsel patients with these injuries on the possibility of persistent long-term disability. Levels of Evidence: Level IV: Retrospective series.

Introduction: Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour.", Materials and Methods: The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour., Results: Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified., Conclusions: Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Orthopaedic trauma results in significant patient morbidity. Autonomous vehicle (AV) companies have invested over $100 billion in product development. Successful AVs are projected to reduce motor vehicle collision (MVC)-related injuries by 94%. The purpose of this study was to estimate the timing and magnitude of AV impact on orthopaedic trauma volume., Methods: ICD 9 codes consistent with acetabulum (OTA 62), pelvis (OTA 61), hip (OTA 31), femur (OTA 32-33), tibia (OTA 41-43), ankle (OTA 44), and calcaneus (OTA 82) fractures and the proportion of cases caused by MVC were taken from the National Trauma Databank (NTDB) 2009-2016. Regression was performed on estimates of market penetration for autonomous vehicles taken from the literature., Results: For NTDB years 2009 to 2016, 300,233 of 987,610 fractures of interest were the result of MVC (30.4%). However, the percentage of MVC mechanism of injury ranged from 9% to 53% depending on fracture type. Regression of estimates of AV market penetration predicted an increase of 2.2% market share per year. In the next 15 years we project 22% market penetration resulting in a 6% reduction in orthopaedic lower extremity trauma volume., Conclusion: Adoption of AVs will result in a projected 8% reduction in MVC-related orthopaedic trauma-related injuries over a 15-year period. Although this represents a significant reduction in morbidity, the advent of AVs will not eliminate the need for robust orthopaedic trauma programs. The gradual rate of injury reduction will allow hospitals to adapt and reallocate resources accordingly., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: To determine the optimal patient-oriented treatment between open reduction and internal fixation (ORIF) with or without primary subtalar arthrodesis (PSTA) for patients with displaced intraarticular calcaneus fractures (DIACFs, OTA 82-C3 and C4)., Design: Expected value decision analysis., Setting: Academic military treatment facility., Participants: One hundred randomly selected volunteers., Intervention: Hypothetical clinical scenario involving ORIF versus ORIF with PSTA., Main Outcome Measurements: Decision analysis was used to elucidate the superior treatment option based on expected patient values, composed of: the product of the average outcome probabilities established by previously published studies and the average ascribed patient utility values for each outcome probability. One-way sensitivity analysis was performed to quantify the amount of change required for the inferior treatment to equal or surpass the superior option., Results: Expected values for ORIF and ORIF with PSTA were 8.96 and 18.06, respectively, favoring ORIF with PSTA. One-way sensitivity analysis was performed by artificially decreasing the rate of secondary fusion following isolated ORIF thus increasing its overall expected value. Adjusting the rate of secondary fusion to 0%, the expected value of ORIF with PSTA nearly doubled that of ORIF (18.06 vs 9.45). Similarly, when adjusting the moderate and severe complication rates following ORIF with PSTA to 100%, the expected value of ORIF with PSTA still exceeded that of ORIF (15.45 vs 8.96, and 13.52 vs 8.96, respectively)., Conclusion: Expected value decision analysis favors ORIF with PSTA as the optimal treatment for complex DIACF., Competing Interests: The authors have no conflicts of interest to disclose. This article was partially funded by an OTA Award, based on the merit of the submission., (Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Introduction: To examine prognostic factors that influence complications after hip fracture surgery. To summarize proposed underlying mechanisms for their influence., Methods: We reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Scoping Review extension. We searched MEDLINE, Embase, CINAHL, AgeLine, Cochrane Library, and reference lists of retrieved studies for studies of prognostic factor/s of postoperative in-hospital medical complication/s among patients 50 years and older treated surgically for non-pathological closed hip fracture, published in English on January 2008-January 2018. We excluded studies of surgery type or in-hospital medications. Screening was duplicated by two independent reviewers. One reviewer completed the extraction with accuracy checks by the second reviewer. We summarized the extent, nature, and proposed underlying mechanisms for the prognostic factors of complications narratively and in a dependency graph., Results: We identified 44 prognostic factors of in-hospital complications after hip fracture surgery from 56 studies. Of these, we identified 7 patient factors-dehydration, anemia, hypotension, heart rate variability, pressure risk, nutrition, and indwelling catheter use; and 7 process factors-time to surgery, anesthetic type, transfusion strategy, orthopedic versus geriatric/co-managed care, multidisciplinary care pathway, and potentially modifiable during index hospitalization. We identified underlying mechanisms for 15 of 44 factors. The reported association between 12 prognostic factors and complications was inconsistent across studies., Conclusions: Most factors were reported by one study with no proposed underlying mechanism for their influence. Where reported by more than one study, there was inconsistency in reported associations and the conceptualization of complications differed, limiting comparison across studies. It is therefore not possible to be certain whether intervening on these factors would reduce the rate of complications after hip fracture surgery.

Ovariectomy (OVX), a menopause model, leads to cognition and neuronal plasticity deficits that are rescued by estrogen administration or downregulation of pituitary luteinizing hormone (LH). LH is present in the brain. However, whether LH levels differ across brain regions, change across reproductive stages, or whether brain-specific LHR signaling play a role in OVX-related cognitive and neuroplasticity losses is completely unknown. To address this, we measured brain LH in cycling and OVX C57Bl/6 across brain regions and determined whether OVX-related functional and plasticity deficits could be rescued by intracerebroventricular administration of the LHR agonist (hCG). Here, we show that while pituitary LH is increased in OVX, brain LH is decreased, primarily in spatial memory and navigation areas. Furthermore, intracerebroventricular hCG delivery after OVX rescued dendritic spine density and spatial memory. In vitro, we show that hCG increased neurite outgrowth in primary hippocampal neurons in a receptor-specific manner. Taken together, our data suggest that loss of brain LH signaling is involved in cognitive and plasticity losses associated with OVX and loss of ovarian hormones., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Timing of definitive fixation of femoral shaft fractures is a subject of continued controversy. The purpose of this study was to determine if early definitive fixation of femoral shaft fractures in the setting of polytrauma decreased the risk of pulmonary complications and mortality. The 2009-2012 National Sample Program of the National Trauma Data Bank was queried for all patients 18 to 65 years with Injury Severity Scores (ISS) >15 who underwent definitive fixation of femoral shaft fractures. Mortality, perioperative complications, and length of intensive care unit (ICU) and hospital stay were the primary outcome measures of interest. Following multivariate analyses, increased time to surgery was found to portend a statistically significant increased risk of acute respiratory distress syndrome(ARDS), mean ventilator time, length of ICU and hospital stay, and mortality. Earlier definitive fixation of femoral shaft fractures in the setting of polytrauma is associated with significantly decreased risk of ARDS, mean ventilator time, length of ICU and hospital stay, and mortality. (Journal of Surgical Orthopaedic Advances 28(2):137-143, 2019).

Pervasive age-related dysfunction in hypothalamic-pituitary-gonadal (HPG) axis is associated with cognitive impairments in aging as well as pathogenesis of age-related neurodegenerative diseases such as the Alzheimer's disease (AD). As a major regulator of the HPG axis, the steroid hormone estrogen has been widely studied for its role in regulation of memory. Although estrogen modulates both cognition as well as cognition associated morphological components in a healthy state, the benefits of estrogen replacement therapy on cognition and disease seem to diminish with advancing age. Emerging data suggests an important role for luteinizing hormone (LH) in CNS function, which is another component of the HPG axis that becomes dysregulated during aging, particularly in menopause. The goal of this review is to highlight the current existing literature on LH and provide new insights on possible mechanisms of its action.

Background: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay., Methods: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram., Results: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%)., Interpretation: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons., Competing Interests: Competing interests: Boris Sobolev, Pierre Guy and the Collaborative report receiving grants from the Canadian Institutes of Health Research related to this work. Pierre Guy reports receiving grants from the Natural Sciences and Engineering Research Council of Canada, the Canadian Foundation for Innovation and the British Columbia Specialists Services Committee for work regarding hip fracture care, outside the submitted work. He has also received fees from the BC Specialists Services Committee (for a provincial quality improvement project on redesign of hip fracture care) and from Stryker Orthopaedics (as a product development consultant), outside the submitted work. He is a board member and shareholder in Traumis Surgical Systems Inc. and a board member for the Canadian Orthopaedic Foundation. He also serves on the speakers’ bureaus of AOTrauma North America and Stryker Canada. Suzanne Morin reports research grants from Amgen Canada, outside the submitted work. Jason Kim and Lisa Kuramoto report receiving grants from the Canadian Institutes of Health Research, during the conduct of the study. No other competing interests were declared., (© 2018 Joule Inc. or its licensors.)

Current literature is deficient in its description of acute complications following major traumatic upper extremity amputations (UEAs). This study sought to identify acute complications following major UEAs by the 2009-2012 National Trauma Databank to extract demographics, comorbidities, concomitant injuries, and surgical characteristics for major traumatic UEA patients. Multivariate analyses identified significant predictors of mortality and major systemic complications. Major traumatic upper extremity amputations were identified in 1190 patients. Major systemic complications occurred in 13% of patients and most often involved pulmonary (7.4%) or renal (4.7%) systems. Overall in-hospital mortality rate was 11%. Male sex, prehospital systolic blood pressure less than 90, Injury Severity Score > 16, and initial Glasgow Coma Scale > 8 were risk factors for complications or in-hospital mortality. Acute replantation was performed in 0.12%. Systemic complications following major traumatic UEA typically affect the pulmonary system. Injury or patient-dependent factors did not influence acute treatment with revision amputation versus replantation. (Journal of Surgical Orthopaedic Advances 27(2):113-118, 2018).

The purpose of this study was to compare the exposure of the posterior facet with the extensile lateral (EL) approach compared with the sinus tarsi (ST) approach. We hypothesized that the ST approach will provide a similar exposure of the posterior calcaneal facet. A total of 8 sequential ST then EL approaches were performed on cadavers. Calcaneal landmarks were identified by visualization or palpation. Calibrated digital photographs of the posterior facet and lateral calcaneal body were obtained from standardized positions and used to calculate the exposed surface area. No significant difference was found in the average square area of the posterior facet exposed with the 2 approaches. Significantly more of the lateral calcaneal body was seen with the EL approach. Excluding the posterior facet superomedial quadrant, all the landmarks were visualized in 100% of approaches. The superomedial corner was visualized in significantly more of the cadavers with the EL approach and was palpable in 12.5% of the remaining cadavers in both approaches. Whereas the ST approach exposes less of the lateral wall of the calcaneus, it exposes similar amounts of the posterior facet when compared with the EL approach., Levels of Evidence: Therapeutic, Level V.