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This paper proposes a novel inductor-capacitor-inductor wireless power pickup with directional tuning control (DTC) for a magnetic amplifier. The proposed technique allows the power pickup to achieve full-range tuning/detuning operation to regulate power flow and maintain the output voltage to be constant. The method eliminates the tedious fine-tuning process associated with traditional fixed power pickup tuning methods and eases the component selection. Moreover, it can overcome the online circuit parameter variations and automatically achieve the maximum power transfer capacity when required. In order to meet dynamic load demands, a magnetic amplifier is used as a variable inductor and is controlled by a novel DTC algorithm to change the tuning condition of the power pickup. The effectiveness of the proposed power pickup and its applicability to general wireless power transfer applications have been demonstrated by both simulation and experimental results. Index Terms--Contactless power transfer, magnetic amplifiers, power flow control, resonant power converter, wireless power transfer.

Background: Bone and soft-tissue loss are common extremity injuries sustained in current military conflicts. Selected host national patients had their definitive orthopedic care performed at our combat support hospital. Soft-tissue reconstruction can be a challenging task in this environment. There are several situations in which free or rotational flap coverage is not possible, including the presence of a single vessel limb, local muscle damage, and/or nonavailability of an experienced flap surgeon. The technique of shortening and angulation for extremity soft-tissue reconstruction is described using tools available in a theater of operations.Methods: We treated 6 limbs in 5 patients with the technique of shortening and/or angulation to obtain soft-tissue coverage for extremity war wounds at our combat support hospital. Bony stabilization was accomplished using the standard Hoffman II external fixator (Stryker Orthopedics, Mahwah, NJ). The extremities treated included: 2 humerus fractures, 3 tibia fractures, and 1 ankle fracture. Two of the patients required vascular reconstruction. Patients were followed for as long as possible given individual circumstances.Results: One patient in the series died of multiple organ system failure because of intra-abdominal injuries. Average follow-up on the remaining patients was 7.03 weeks (1 to 14 weeks). In the patient with 1-week follow-up, the skin graft had 100% take. All other wounds were healed at the latest follow-up without signs of infection.Conclusion: Shortening and/or angulation of extremities with bone and soft-tissue loss is an effective means of obtaining soft-tissue coverage in a theater of operations. [ABSTRACT FROM AUTHOR]

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]

Objective: Determine the efficacy of a novel surgical technique to salvage a through-elbow amputation and avoid revision transhumeral amputation.Methods: A 23-year-old soldier presented after sustaining a through-elbow amputation in a close-range blast injury with inadequate soft tissues to obtain closure over the distal humerus. A 2-cm anterior incision was made and a shortening osteotomy with percutaneous submuscular osteosynthesis was done. A myodesis was performed and a tension-free primary closure of the soft tissue envelope obtained.Results: At 3 months postoperatively the osteotomy and soft tissue envelope were healed. At 2-year follow-up the patient reports using a body-powered prosthesis for ADLs and recreational hobbies, citing excellent rotational control and ease of prosthetic suspension.Conclusion: Minimally invasive shortening humeral osteotomy in the setting of a through-elbow amputation is a safe and effective procedure, which allows primary soft tissue closure, prevents the need for more proximal amputation, and allows for ease of prosthetic fitting and suspension. [ABSTRACT FROM AUTHOR]

Single series case reports have described bilateral traumatic patellar tendon ruptures, and less frequently, with little or no trauma. Patellar tendon rupture most often occurs in patients younger than 40 years old and is commonly precipitated by a sudden, significant eccentric contraction. Patellar tendon ruptures are uncommon in those older than 40 years of age, but when they occur, may indicate an underlying systemic disorder. Corticosteroid injections, rheumatic disease, metabolic disorders, and fluoroquinolone use have all been associated with increased risk of tendon rupture. While the Achilles tendon is the most commonly affected by fluoroquinolone use, cases involving the rotator cuff, biceps, wrist extensors, and quadriceps tendon among others, have been described. A case is presented of a 43-year-old man without pre-existing medical comorbidities who sustained atraumatic bilateral patellar tendon ruptures following a treatment course of fluoroquinolone medication. [ABSTRACT FROM AUTHOR]

Background: Although it is generally known that clavicle fractures represent a common injury of the shoulder girdle in the general population, the true incidence in the active duty military population is unknown. Given the implications for such injuries on the ability to perform occupation-specific tasks, determining the incidence in the U.S. military population is worthwhile. The purpose of this study was to determine the incidence of clavicle fractures in the U.S. military and to identify any demographic risk factors for injury.Methods: We performed a query of the Defense Medical Epidemiology Database with the code from the International Classification of Diseases, Ninth Revision, for clavicle fractures for the years 1999 through 2008. An overall injury incidence was calculated, in addition to multivariate analysis, to determine independent risk factors among the following demographic considerations: sex, race, branch of military service, rank, and age.Results: During the study period, a total of 12,514 clavicle fractures were documented among an at-risk population of 13,770,767 person-years for an incidence rate (IR) of 0.91 per 1,000 person-years in the U.S. Military. Males, when compared with females, were more than twice as likely to sustain a clavicle fracture (IR ratios [IRR], 2.30; 95% confidence intervals [CI], 2.12-2.49). The peak incidence of clavicle fractures occurred in the age groups of <20 and 20 to 24. Compared to black service members, the white service members were associated with significantly higher rate of clavicle fractures (IRR, 2.45; 95% CI, 2.28-2.63). The service members serving in the Marine Corps were associated with a higher IR of clavicle fractures when compared to those in the Navy (IRR, 1.44; 95% CI, 1.35-1.53). Junior enlisted service members were 34% as likely to sustain a clavicle fracture when compared to senior officers (IRR, 1.46; 95% CI, 1.34-1.60 and IRR, 1.12; 95% CI, 0.99-1.28, respectively).Conclusions: The incidence of clavicle fractures among U.S. military personnel (0.908 per 1,000 person-years) is higher than previous epidemiological reports. [ABSTRACT FROM AUTHOR]

Management of displaced midshaft clavicle fractures in the military, a largely shoulder-bearing population, is controversial. We aimed to report the military-relevant functional outcomes after plate fixation. We performed a nested cross-sectional analysis of active duty service members enrolled in an ongoing multicenter, randomized trial on clavicle plating. For this analysis, we included subjects with 26 months follow-up. Outcome measures included radiographic appearance, physical examination, a military-specific questionnaire, and validated shoulder surveys. Mean follow-up for 28 clavicle fractures was 13 months. Union rate by 12 weeks was 93% (26/28). There was one case of soft tissue irritation requiring hardware removal. At latest follow-up, 75% of patients were satisfied; 68% had mild/no pain; 79% had full range of motion; 75% could perform push-ups; and 21% have deployed. For the majority of active duty personnel, rapid healing, return to military-specific tasks, and satisfaction with outcome are possible after plate fixation of clavicle fractures. However, approximately 25% report some functional limitations at 1 year. [ABSTRACT FROM AUTHOR]

During the current conflicts, over 950 soldiers have sustained a combat-related amputation. The majority of these are acute, but an unknown number are performed months to years after the initial injury. The goal of this study is to determine the prevalence of late amputations in our combat wounded. Electronic medical records and radiographs of all soldiers who had a combat-related, lower extremity injury that resulted in amputation were reviewed to confirm demographic, injury, and amputation information. Time to amputation was defined as a late amputation when it occurred more than 12 weeks following the date of injury. There were 348 major limb amputees that met inclusion criteria. Fifty-three (15.2%) amputees had a late amputation (range = 12 wk-5.5 yr). While the majority of combat-related amputations occur acutely, more than 15% occur late. This study demonstrates that further research is needed to identify predictive factors and outcomes of the late amputation. [ABSTRACT FROM AUTHOR]

Objectives: To identify risk factors for developing a fracture-related infection in operatively treated ballistic tibia fractures and to report the microbiologic results of intraoperative cultures., Design: Retrospective review., Setting: Level 1 trauma center., Patients/participants: One hundred thirty-three adults with operatively treated low-velocity ballistic tibia fractures, from 2011 to 2021., Intervention: One dose of prophylactic cefazolin or equivalent as well as perioperative prophylaxis., Main Outcome Measurements: Deep infection rate., Results: The deep infection rate was 12% (16/134) with no significant difference in injury characteristics, index surgical characteristics, or time to antibiotics between the groups ( P > 0.05). Patients who were slightly older (35.5 vs. 27 median years, P = 0.005) and with higher median body mass indexes (BMIs) (30.09 vs. 24.51, P = 0.021) developed a deep infection. 56.3% of patients presented with signs of infection within the first 100 days after injury. Nine patients had polymicrobial infections. There were 29 isolated organisms, 69% were uncovered by first-generation cephalosporin prophylaxis (anaerobes, gram-negative rods, Enterococcus, methicillin resistant Staphylococcus Aureus [MRSA] ), and 50% of patients developed recalcitrant infection and required a second reoperation where 6 organisms were isolated, half of which were not covered by first-generation prophylaxis ( Enterococcus, Staphylococcus Aureus MRSA )., Conclusions: We found a deep infection rate of 12% among ballistic tibia fractures receiving standard-of-care antibiotic prophylaxis. Increased age and body mass index were associated with deep infections. Half became recalcitrant requiring a second reoperation. 66.7% of isolated organisms were not covered by first-generation cephalosporin prophylaxis. Consideration should be given to treatment options such as broader prophylaxis or local antibiotic treatment., Level of Evidence: IV., Competing Interests: Dr. Brianna R. Fram reports paid consulting for Synthes. Dr. Joseph R. Hsu reports consultancy and speaker fees for Stryker, consultancy for Globus Medical, speaker fees from Smith & Nephew speakers' bureau, speaker fees from Integra Lifesciences, and speaker fees from Depuy/Synthes. The remaining authors declare no conflict of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent metabolic disorder characterized by hepatic steatosis associated with metabolic abnormalities. Recent research has shed light on the intricate interplay among interleukin-1 receptor 1 (IL1R1), gut microbiota, and bile acids in the pathogenesis of MASLD. This review aims to provide a comprehensive overview of the current understanding of the role of IL1R1, gut microbiota, and bile acids in MASLD, exploring their interrelationships and potential mechanisms. We summarize the evidence supporting the involvement of IL1R1 in inflammation, discuss the influence of gut microbiota on bile acid metabolism and its influence on liver health, and elucidate the bidirectional interactions among IL1R1 signaling, gut microbiota composition, and bile acid homeostasis in MASLD. Furthermore, we highlight emerging therapeutic strategies targeting these interrelated pathways for the management of MASLD., (© 2024 The Author(s). Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Competing Interests: Potential Conflicts of Interest and Funding Sources: This study did not receive any funding. The authors do not have any conflicts of interest to declare.

Competing Interests: Potential Conflicts of Interest and Funding Sources: This manuscript did not receive any funding. Dr. Hsu reports consultancy for Globus Medical and personal fees from Smith & Nephew speakers’ bureau

Displaced intra-articular calcaneus fractures (DIACFs) are difficult injuries to treat and are often encountered by orthopedic surgeons. For DIACFs treated nonoperatively or with open reduction internal fixation (ORIF), a common complication is painful subtalar arthritis and the need for a secondary subtalar fusion, which prolongs the overall recovery time. One treatment option to address this sequela involves ORIF with subtalar fusion as the primary treatment. We describe a reproducible, minimally invasive surgical technique for primary ORIF with subtalar fusion when the calcaneal tuberosity is amendable to cannulated screw fixation to treat these complex calcaneal fractures. Our technique offers advantages compared to other techniques in that it avoids screw traffic, allows easy bony compression of the subtalar joint, and minimizes soft tissue damage via percutaneous screw fixation. Fourteen fractured calcanei in 12 patients underwent our technique and all achieved bony union with a median time to fusion of 107.5 days (range, 54-530 days). Eight patients returned to work with the remaining 4 patients having an unknown work status at last follow-up, although 2 of these 4 patients resumed normal activities. Only 1 patient experienced a complication, which was an infection after achieving bony union, and was treated with successful hardware removal and our infection protocol. Overall, we conclude our surgical technique offers a successful option in the treatment of DIACFs when the calcaneal tuberosity is amendable to cannulated screw fixation., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

This study investigates sex-specific effects in a gain-of-function model to evaluate Nfil3 function in relation to high-fat diet (HFD)-induced metabolic dysfunction-associated steatotic liver disease (MASLD) and gut microbiota (GM)-induced alterations in the bile acid (BA) profile. MASLD is induced in both wild type and Nfil3-deficient (NKO) C57BL/6 J mice through an HFD. The hepatic immune response is evaluated using flow cytometry, revealing that NKO mice exhibit lower body weight, serum triglyceride (TG) levels, tissue injury, inflammation, and fat accumulation. The Nfil3 deletion reduces macrophage counts in fibrotic liver tissues, decreases proinflammatory gene and protein expression, and diminishes gut barrier function. Alpha and beta diversity analysis reveal increased GM alpha diversity across different sexes. The Nfil3 gene deletion modifies the BA profile, suggesting that negative feedback through the Nfil3-FXR-FGF15 axis facilitates BA recycling from the liver via enterohepatic circulation. Therefore, inhibiting Nfil3 in the liver offers a viable treatment approach for MASLD., (© 2024. The Author(s).)

Objectives: Malnutrition has been shown to increase complications and leads to poor outcomes in surgical patients, but it has not been studied extensively in orthopedic trauma. This study's purpose is to determine the perspective and assessment of nutrition by orthopedic traumatologists., Methods: A survey was created and distributed via REDCap to orthopedic traumatologists at 60 U.S. trauma centers. Out of 183 distributed surveys, 130 surgeons completed the survey (71%). The survey focused on the importance of nutrition and practice patterns in orthopedic trauma., Results: Seventy-five percent of surgeons thought that nutritional status was "very important" to the final outcome of patients with orthopedic trauma injuries, 24% responded "somewhat important" and 1% responded "not important." Furthermore, 88% perform nutritional assessments; most surgeons (77%) utilize nutritional laboratory markers, with the most common markers being albumin, pre-albumin, transferrin and CRP. Additionally, 42% think trending the laboratory markers is important, and 50% are not sure if nutrition markers should be tested at multiple time points. Despite 75% of surgeons believing that nutrition is very important, only 8% discuss it with patients routinely. When asked what is more important for outcomes, nutrition or Vitamin D, almost three times as many surgeons thought nutrition was more important (29% vs 11%, respectively)., Conclusions: While orthopedic traumatologists believe nutrition is an important determinant of patient outcomes, this study shows a clear lack of consensus and variability in practice regarding nutrition among surgeons. Orthopedic trauma surgeons need specific guidelines on how to assess and treat malnutrition in trauma patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Opioids are commonly prescribed for the management of acute orthopedic trauma pain, including nonoperative distal radius fractures., Objectives: This prospective study aimed to determine if a clinical decision support intervention influenced prescribing decisions for patients with known risk factors. We sought to quantify frequency of opioid prescriptions for acute nonoperative distal radius fractures treated., Methods: We performed a prospective study at one large health care system. Utilizing umbrella code S52.5, we identified all distal radius fractures treated nonoperatively, and the encounters were merged with the Prescription Reporting with Immediate Medication Mapping (PRIMUM) database to identify encounters with opioid prescriptions and patients with risk factors for opioid use disorder. We used multivariable logistic regression to determine patient characteristics associated with the prescription of an opioid. Among encounters that triggered the PRIMUM alert, we calculated the percentage of encounters where the PRIMUM alert influenced the prescribing decision., Results: Of 2984 encounters, 1244 (41.7%) included an opioid prescription. Age increment is a significant factor to more likely receive opioid prescriptions (p < 0.0001) after adjusting for other factors. Among encounters where the physician received an alert, those that triggered the alert for early refill were more likely to influence physicians' opioid prescribing when compared with other risk factors (p = 0.0088)., Conclusion: Over 90% of patients (106/118) continued to receive an opioid medication despite having a known risk factor for abuse. Additionally, we found older patients were more likely to be prescribed opioids for nonoperatively managed distal radius fractures., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aims: Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient's quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients., Methods: Lifetime Markov models were developed evaluating active healthy middle-aged male amputees. Costs of the prostheses, associated complications, use/non-use, and annual costs of arthroplasty parts and service for both a socket and osseointegrated (OPRA) prosthesis were included. Effectiveness was evaluated using the questionnaire for persons with a transfemoral amputation (Q-TFA) until death. All costs and Q-TFA were discounted at 3% annually. Sensitivity analyses on those cost variables which affected a change in treatment (OPRA to socket, or socket to OPRA) were evaluated to determine threshold values. Incremental cost-effectiveness ratios (ICERs) were calculated., Results: For treatment-naïve patients, the lifetime ICER for OPRA was $279/quality-adjusted life-year (QALY). For treatment-refractory patients the ICER was $273/QALY. In sensitivity analysis, the variable thresholds that would affect a change in the course of treatment based on cost (from socket to OPRA), included the following for the treatment-naïve group: yearly replacement components for socket > $8,511; cost yearly replacement parts OPRA < $1,758; and for treatment-refractory group: yearly replacement component for socket of > $12,467., Conclusion: The use of the OPRA prosthesis in physically active transfemoral amputees should be considered as a cost-effective alternative in both treatment-naïve and treatment-refractory socket prosthesis patients. Disease-specific quality of life assessments such as Q-TFA are more sensitive when evaluating cost-effectiveness., Competing Interests: J. Voigt reports payment from Integrum for analysis and writing of this article. J. A. Forsberg reports an institutional grant from the US Navy Bureau of Medicine and Surgery, institutional funding for two osseointegration clinical trials from the US Army, and institutional research support from Zimmer Biomet, consulting fees and payment for expert testimony from The Solsidan Group, payment or honoraria for lectures, presentations, speakers bureuas, manuscript writing or educational events from the Canadian Orthopaedic Society and Japanese Orthopaedic Society, stock or stock options in Prognostix AB, and a US patent (10,952,774), all of which are unrelated to this study. D. H. Melton reports consulting fees from Paradigm Corp unrelated to this study, and sits on the External Advisory Panel of the Limb Loss Preservation Registry, funded by the National Institutes of Health/Department of Defence funded grant. B. K. Potter reports research funding from the US Navy BUMED, CDMRP, DHA, and the National Institutes of Health, unrelated to this study. J. M. Souza reports consulting fees from Checkpoint, Integrum, and Balmoral, and travel expenses from Integrum, Hanger, and Balmoral, all of which are unrelated to this study. B. Wilke reports research support from Avanos and Summit Medical, unrelated to this study., (© 2024 Voigt et al.)

Objectives: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population., Design: Retrospective case series., Setting: Eight, academic, level 1 trauma centers., Patients Selection Criteria: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019., Outcome Measures and Comparisons: Success rate of nonunion surgery., Results: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate., Conclusions: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Dr. J.R. Hsu reports consultancy for Globus Medical and personal fees from Smith & Nephew speakers' bureau. The remaining authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures., Design: Retrospective., Setting: Level 1 academic center., Patient Selection Criteria: Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021., Outcome Measures and Comparisons: Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature., Results: The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively., Conclusions: The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns., Design: A prospective observational study., Setting: One large healthcare system., Patients and Participants: Adult patients presenting with shoulder osteoarthritis., Interventions: A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder., Main Outcome Measure: The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures., Results: A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription., Conclusion: Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.

Background: Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines., Methods: This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts., Results: An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility., Conclusion: The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objectives: This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices., Methods: We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing., Results: This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients ( n  = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing., Conclusion: A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines., Competing Interests: Dr. Hsu reports consultancy for Globus Medical and Stryker, consultancy and speaker fees from Smith & Nephew speakers' bureau, speaker fees from Integra Lifesciences, and speaker fees from Depuy/Synthes. Dr. Bosse reports stock ownership in an orthopaedic implant company and grant funding from the Department of Defense. Dr. Griggs reports board membership for the American College of Emergency Physicians and payment from Boston University for preparation of pain management and opioid prescribing educational materials. Dr. Leas reports consulting for Restor3d. Dr. Runyon reports research grant funding from Abbot Laboratories and Bristol-Myers Squibb., (Thieme. All rights reserved.)

Objectives: Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We evaluated persistent opioid and benzodiazepine use after radical cystectomy and assessed the impact of their preoperative use on this outcome. We also explored associations between preoperative use and perioperative outcomes., Methods and Materials: We used prospectively maintained data from our enhanced recovery after surgery (ERAS) cystectomy database and the Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) database to identify controlled substance prescriptions for radical cystectomy patients. We separated patients by frequency of preoperative opioid and/or benzodiazepine prescriptions (0, 1, 2+) and used these cohorts to explore persistent use (prescription 3-12 months after surgery) alongside perioperative outcomes., Results: Our cohort included 257 patients undergoing cystectomy at a single institution from 2017 to 2021. Preoperative opioid and benzodiazepine prescriptions were documented for 120 (46.7%) and 26 (10.1%) patients, respectively. Persistent opioid use was observed in 20 (14.6%) of opioid-naive patients (no prescriptions in 9 months prior to surgery) while 13 (19.7%) patients with 1 preoperative prescription and 28 (51.9%) patients with 2 or more preoperative prescriptions demonstrated persistent use. New persistent benzodiazepine use occurred in 6 (2.6%) patients. Overall persistent benzodiazepine use was present in 11 (4.3%) patients. In a multivariable model, preoperative opioid and benzodiazepine prescriptions were associated with persistent opioid use (P < 0.001; P = 0.027 respectively). No association was identified between preoperative opioid or benzodiazepine usage and perioperative outcomes including length of stay, return of bowel function, inpatient opioid usage, inpatient or discharge complications, readmissions, or emergency department visits. Inpatient pain scores were noted to be higher in patients with ≥ 2 preoperative opioid prescriptions (P = 0.037)., Conclusions: Persistent opioid use was present in 23.7% of patients, with a new persistent use rate of 14.6%. Benzodiazepine use was less frequent than opioids, with a small number demonstrating new persistent use. Preoperative opioid and benzodiazepine use is associated with persistent opioid use postoperatively. Preoperative opioid and benzodiazepine use did not affect perioperative outcomes in our cohort., Competing Interests: Declaration of Competing Interest The authors have no relevent disclosures or competing interests. Previously presented as a poster at the Southeastern Section of the American Urological Association Annual Meeting in March 2022., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: To determine if the use of Peripheral Nerve Block (PNB) versus Local Infiltration Analgesia (LIA) for hip fracture patients, affected opioid consumption in the early post-operative period., Design: Retrospective cohort study SETTING: Two level 1 trauma centers PATIENTS/INTERVENTION: 588 patients with surgically treated AO/OTA 31A and 31B fractures between February 2016-October 2017 were included. 415 (70.6%) received general anesthesia (GA) alone, 152 received GA plus perioperative PNB (25.9%), and 21 had GA plus LIA intra-operatively (3.6%). Median age was 82 years; predominantly female (67%) and AO/OTA 31A fractures (55.37%)., Main Outcome Measures: Morphine Milligram Equivalents (MME) at 24 and 48 hours postoperatively, length of stay (LOS) and the occurrence of any complication after surgery RESULTS: The PNB cohort was less likely to use any opioid than the GA group at 24 and 48 hours postoperatively (OR: 0.36, 95% CI: 0.22-0.61 and OR: 0.56, 95% CI: 0.35-0.89 respectively). LOS ≥ 10 days had 3.24 times the odds of 24- and 48-hour opioid administration compared to LOS ≤ 10 days (OR: 3.24, 95% CI 1.11-9.42; OR: 2.98, 95% CI 1.38-6.41, respectively). The most common complication was post-operative delirium, with PNB more likely to present with any complication compared to GA (OR= 1.88, 95% CI 1.09-3.26). There was no difference when comparing LIA to general anesthesia., Conclusions: Our findings suggest PNB for hip fracture can help limit the use of post-operative opioids with adequate pain relief. Regional analgesia does not seem to avoid complications such as delirium., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Hsu reports consultancy and speaker fees for Stryker, consultancy and speaker fees from Smith & Nephew speakers’ bureau, soeaker fees from Integra Lifesciences, and speaker fees from Depuy/Synthes., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: To assess whether implementation of the Strengthen Opioid Misuse Prevention (STOP) Act was associated with an increase in the percentage of opioid prescriptions written for 7 days or fewer among patients with acute or postsurgical musculoskeletal conditions., Design: An interrupted time-series study was conducted to determine the change in duration of opioid prescriptions associated with the STOP Act., Setting: Data were extracted from the electronic health record of a large health care system in North Carolina., Subjects: Patients presenting from 2016 to 2020 with an acute musculoskeletal injury and the clinicians treating them were included in an interrupted time-series study (n = 12 839)., Methods: Trends were assessed over time, including the change in trend associated with implementation of the STOP Act, for the percentage of prescriptions written for ≤7 days., Results: Among patients with acute musculoskeletal injury, less than 30% of prescriptions were written for ≤7 days in January of 2016; by December of 2020, almost 90% of prescriptions were written for ≤7 days. Prescriptions written for ≤7 days increased 17.7% after the STOP Act was implemented (P < .001), after adjustment for the existing trend., Conclusions: These results demonstrate significant potential for legislation to influence opioid prescribing behavior., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)