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Consensus recommendations are lacking regarding appropriate timing of reimplantation following 2-stage resection arthroplasty for prosthetic joint infections (PJIs). We investigated whether the time from resection arthroplasty to reimplantation was associated with treatment outcome at 2 years.Retrospective cohort review was conducted for 101 patients undergoing resection arthroplasty with an antibiotic spacer for PJI at a single tertiary academic referral institution. Time from explantation and spacer placement to reimplantation was categorized into 3 groups:12, 12-18, and18 weeks. Baseline patient and treatment course characteristics across these groups were obtained. Multivariate binary logistic regression was used to characterize association between treatment failure and time to reimplantation, controlling for American Society of Anesthesiologists (ASA) score and prior revision surgery.Time to reimplantation (TTR)18 weeks demonstrated statistically significant increased odds of treatment failure, after controlling for ASA score and prior revision surgery (odds ratio 7.00, confidence interval 2.14-25.42, P = .002). After excluding patients requiring second spacer or Girdlestone prior to replant, this increased odds of failure remained (odds ratio 4.12, confidence interval 1.18-15.37, P = .029). TTR groups were similar with respect to demographics, except for ASA (2.96 for time to reimplantation18 weeks vs 2.55 for time to reimplantation12 weeks; P = .011). Patients with TTR18 weeks were more likely to have an unplanned readmission during the spacer period (48%, 19%, and 6% for time to reimplantation18, 12-18, and 0-12 weeks, respectively; P.002).Although decision regarding TTR is largely patient specific, surgeons should be aware that TTR18 weeks may be associated with higher rates of treatment failure at 2 years.

Web-based patient engagement portals are increasing in popularity after total hip and knee arthroplasty (THA and TKA). The literature is mixed regarding patient utilization of these modalities and potential clinical benefit. We sought to determine which demographic factors are associated with increased platform participation and to quantify the impact of a web-based patient portal on patient-reported outcome measures (PROMs).We performed a retrospective analysis of consecutive primary THA (n = 554) and TKA (n = 485) at a single academic institution with minimum follow-up of 12 months. Patients were divided into those who opted-in and those who opted-out of portal use. Global health and joint-specific PROMs were collected preoperatively and postoperatively. Linear mixed effects modeling, bivariate analysis, and logistic regression were utilized.Of the 1039 included patients, 60.6% (336) THA and 62.7% (304) TKA patients enrolled in the portal. Those who opted-in were younger (P.001, P.003), had higher body mass index (P = .024, P = .011), and had a higher household income (P.001, P.001) in THA and TKA cohorts, respectively. Portal participation in the TKA but not the THA cohort was associated with significant improvement in physical function (P = .017) and joint-specific function (P = .045). For THA patients who opted-in, increased portal logins were associated with more rapid improvement and higher functional scores (P = .013).There is an inherent difference between patients who opt-in to and those who opt-out of web-based portals. Added resources and support provided by portals may translate to improved PROMs for TKA patients but not THA patients.

Imaging-based navigation technologies require static referencing between the target anatomy and the optical sensors. Imaging-based navigation is therefore well suited to operations involving bony anatomy; however, these technologies have not translated to soft-tissue surgery. We sought to determine if fluorescence imaging complement conventional, radiological imaging-based navigation to guide the dissection of soft-tissue phantom tumors.Using a human tissue-simulating model, we created tumor phantoms with physiologically accurate optical density and contrast concentrations. Phantoms were dissected using all possible combinations of computed tomography (CT), magnetic resonance, and fluorescence imaging; controls were included. The data were margin accuracy, margin status, tumor spatial alignment, and dissection duration.Margin accuracy was higher for combined navigation modalities compared to individual navigation modalities, and accuracy was highest with combined CT and fluorescence navigation (p = 0.045). Margin status improved with combined CT and fluorescence imaging.At present, imaging-based navigation has limited application in guiding soft-tissue tumor operations due to its inability to compensate for positional changes during surgery. This study indicates that fluorescence guidance enhances the accuracy of imaging-based navigation and may be best viewed as a synergistic technology, rather than a competing one.

INTRODUCTION Symptoms of stress, depression, and burnout are prevalent in medicine, adversely affecting physician performance. We investigated real-time measurements of physiological strain in orthopaedic resident and faculty surgeon volunteers and identified potential daily stressors. METHODS We performed a prospective blinded cohort pilot study in our academic orthopaedic department. Physicians used a wearable fitness device for 12 weeks to objectively measure heart rate variability (HRV), a documented parameter of overall well-being. Baseline burnout levels were assessed using the Maslach Burnout Inventory questionnaire. Daily surveys inquiring on work responsibilities (clinic, operating room [OR], or "other") were correlated with physiological parameters of strain. Descriptive statistics and linear mixed effects modeling were used to evaluate bivariate relationships. RESULTS Of the 21 participating surgeons, 9 faculty and 12 residents, there was a response rate of 95.2% for the initial burnout survey. Daily surveys were completed for 63.8% (54.9 ± 22.3 days) of the total collection window, and surgeons wore the device for 83.2% of the study (71.6 ± 25.0 days). Residents trended toward lower personal accomplishment and greater psychological detachment on the Maslach Burnout Inventory, with 5 surgeons including 1 faculty surgeon (11.1%) and 4 resident surgeons (33.3%) found to have negatively trending HRV throughout the study period demonstrating higher physiological strain. Time in the OR led to increased next-day HRV (y-intercept = 47.39; B = 4.90; 95% confidence interval, 2.14-7.66; P < 0.001), indicative of lower physiological strain. An increase in device-reported sleep from a surgeon's baseline resulted in a significant increase in next-day HRV (y-intercept = 50.46; B = 0.64; 95% confidence interval, 0.11-1.17; P = 0.02). DISCUSSION Orthopaedic residents, more than faculty, had physiologic findings suggestive of burnout. Time in the OR and increased sleep improved physiological strain parameters. Real-time biometric measurements can identify those at risk of burnout and in need of well-being interventions. LEVEL OF EVIDENCE Level III.

To investigate the functioning of the PROMIS-Global Health (PROMIS-GH) across clinical setting, patient age, and medical complexity by evaluating differential item functioning (DIF) within the Global Physical Health (GPH) and Global Mental Health (GMH) domains. To our knowledge, no study demonstrates lack of differential item functioning (DIF) for PROMIS-GH across these populations. We hypothesize that the PROMIS-GH domains of GMH and GPH will perform similarly when compared across these populations. Seven thousand nine hundred and seventy four complete PROMIS Global Health measures were retrospectively analyzed using the ‘Lordif’ package on the R platform. DIF was investigated for both GMH and GPH across clinical environment (Orthopedic Surgery, Family Medicine, & Internal Medicine), age group (≤ 53, > 53–66, > 66), and Charlson Comorbidity Index (CCI:0, CCI:1, CCI:2 +) using quasi Monte Carlo estimation. To assess the significance of DIF, Wald tests were used with the Benjamini & Hochberg procedure. No items contained in the GMH or GPH demonstrated DIF across age groups, medical complexity, or clinical environment. Items assessing the domains of GMH and GPH within the PROMIS–GH function comparably across treatment setting, age category, and medical comorbidities. The PROMIS–Global Health holds potential to facilitate interdisciplinary patient care and patient optimization prior to surgical intervention.

Background We sought to evaluate whether tourniquet use, with the resultant ischemia and reperfusion, during surgical treatment of an open lower-extremity fracture was associated with an increased risk of complications. Methods This is a retrospective cohort study of 1,351 patients who had an open lower-extremity fracture at or distal to the proximal aspect of the tibia and who participated in the FLOW (Fluid Lavage of Open Wounds) trial. The independent variable was intraoperative tourniquet use, and the primary outcome measures were adjudicated unplanned reoperation within 1 year of the injury and adjudicated nonoperative wound complications. Results Unplanned reoperation and nonoperative wound complications were roughly even between the no-tourniquet (18.7% and 19.1%, respectively) and tourniquet groups (17.8% and 20.8%) (p = 0.78 and p = 0.52). Following matching, as determined by model interactions, tourniquet use was a significant predictor of unplanned reoperation in Gustilo Type-IIIA (odds ratio, 3.60; 95% confidence interval, 1.16 to 11.78) and IIIB fractures (odds ratio, 16.61; 95% confidence interval, 2.15 to 355.40). Conclusions The present study showed that tourniquet use did not influence the likelihood of complications following surgical treatment of an open lower-extremity fracture. However, in cases of severe open fractures, tourniquet use was associated with increased odds of unplanned reoperation; surgeons should be cautious with regard to tourniquet use in this setting. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Next-generation sequencing (NGS) offers improved sensitivity compared to culture-based methods for identifying organisms from synovial joints. It remains unclear whether native microorganisms exist in a joint, and positive NGS results may be interpreted as pathologic when in fact they may represent this native microbiome. The purpose of this study was to characterize the native knee microorganism profile in patients undergoing primary total knee arthroplasty (TKA). Methods Forty consecutive patients with osteoarthritis undergoing primary total knee arthroplasty were enrolled prospectively. During TKA surgery but prior to arthrotomy, the native knee was aspirated and the fluid was sent for NGS analysis. Immediately after arthrotomy, four separate tissue samples were also sent for NGS analysis. All microbes identified by NGS were recorded. Results Twelve out of forty patients (30%) had at least one positive organism identified by NGS from their native knee. Of those with positive NGS results, 9/12 (75%) had more than one organism identified (range two to 11). There were no significant differences in demographics, comorbidities, or incidence of prior knee injections between the two groups. There were 48 unique organisms identified from all patients, and the average number of organisms identified by NGS was 4.6 per patient. Four sterile water controls were all negative for organisms. Conclusion A proportion of patients with osteoarthritis undergoing primary total knee arthroplasty have organisms identified in their joint by NGS at the time of surgery. Organisms identified after TKA by NGS when concern for periprosthetic joint infection exists may represent the native microbiome rather than pathogenic microbes.

Several patient-reported outcome measures (PROMs) exist to measure outcomes after total hip arthroplasty (THA) but can be limited by patient-perceived burden and completion rates. We analyzed whether the modified single assessment numerical evaluation (M-SANE), a one-question PROM, would perform similarly to multiple-question PROMs among patients undergoing primary THA.Patients undergoing THA completed the Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10), the Hip Disability and Osteoarthritis Outcomes Score Junior (HOOS-Jr), and M-SANE questionnaires both preoperatively and postoperatively. The M-SANE assessment asked patients to assess their hip on a scale from 0 to 10, with 10 being the best possible score. Validity of M-SANE compared with other PROMs was determined by Spearman's correlation and floor and ceiling effects. Responsiveness was analyzed using standardized response mean (SRM).One hundred and thirty six patients with at least 1-year follow-up were reviewed. The average M-SANE score improved from 3.3 preoperatively to 7.1 at one year postoperatively. There was moderate to strong correlation at one-year follow-up between the M-SANE and HOOS-Jr (ρ = 0.75, P.001) and PROMIS-10 physical component summary (ρ = 0.63, P.001). Floor and ceiling effects of the M-SANE (floor 2.0%, ceiling 21.3%) were comparable to the HOOS-Jr (floor 0.0%, ceiling 20.8%). The responsiveness of the M-SANE after THA (SRM = 1.06, 95% CI: 0.79-1.33) was comparable to HOOS-Jr (SRM = 1.33, 95% CI: 1.08-1.59) and superior to PROMIS-10 physical component summary (SRM = 0.65, 95% CI: 0.55-0.74).The M-SANE has performed similarly across multiple psychometric properties compared with more burdensome PROMs in assessing longitudinal patient-reported outcomes after THA.

Curative surgery for other many cancers requires that the tumor be removed with a zone of normal tissue surrounding the tumor with ‘negative’ margins. Sarcomas, cancers of the bones, muscles, and fat, require WLE for cure. Unfortunately, ‘positive’ margins occur in 20–25% of sarcoma surgeries, associated with cancer recurrence and reduced survival. Our group successfully tested a small-molecule fluorophore (ABY-029) in sarcomas that targets the epidermal growth factor receptor. We sought to evaluate human sarcoma xenografts for epidermal growth factor receptor expression and binding of ABY-029 with and without exposure to standard presurgical chemotherapy and radiation. We inoculated groups of 24 NSG mice with five cell lines (120 mice total). Eight mice from each cell line received: 1) radiation alone; 2) chemotherapy alone; or 3) chemotherapy and radiation. We administered ABY-029 2–4 hours before surgery. Tumor and biopsy portions of background tissues were removed. All tissues were imaged on a LI-COR Odyssey and processed in pathology. There were no significant reductions in epidermal growth factor receptor expression or in ABY-029-mediated fluorescence in tumors exposed to chemotherapy, radiation, or both. fluorescence-guided surgery demonstrates strong promise to improve curative surgical cancer care, particularly for sarcomas where the positive margin rate is substantial. Fluorophore performance must be evaluated under circumstances that duplicate accurately the biological milieu relevant to a particular cancer. This work shows that human sarcoma xenografts subjected to standard therapies do not demonstrate a change in epidermal growth factor receptor expression or in epidermal growth factor receptor-targeted fluorescence, thereby indicating that epidermal growth factor receptor-targeted fluorescence-guided surgery should be feasible under normal therapeutic conditions in the clinic.

Prevalence and predictors of depression, a debilitating medical illness, are unknown among officers working in jails. We conducted a cross-sectional survey with jail officers at four facilities, utilizing age, ethnicity, gender, musculoskeletal back disorder, global physical health and mental health, and psychological well-being as predictor variables. Descriptive analyses detailed prevalence, and hierarchical regression models identified depression predictors. The prevalence of depression among jail officers was high and strongly influenced by job burnout over and above other health indicators. Mitigation of workplace stressors and identification of targeted interventions are needed to reduce risks for depression among jail officers.

Patient-reported outcome measures (PROMs) are important for tracking outcomes following total knee arthroplasty (TKA) but can be limited by time constraints and patient compliance. We sought to evaluate the utility of the one-question, modified single assessment numerical evaluation (M-SANE) score in TKA patients compared to legacy PROMs.Patients undergoing TKA completed the Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10), the Knee Disability and Osteoarthritis Outcomes Score Junior (KOOS Jr), and M-SANE (modified-SANE) assessments both preoperatively and postoperatively. The M-SANE score asked patients to rate their native or prosthetic knee on a scale from 0 to 10, with 10 being the best function. M-SANE validity was determined by the Spearman's correlation between the collected PROMs and the Bland-Altman plots. PROM responsiveness was assessed using the standardized response mean.In total, 217 patients completed PROMs preoperatively and at 1 year postoperatively. Floor and ceiling effects of the M-SANE were higher than other PROMs but still relatively low (4%-11%). There was a moderate to strong correlation at nearly all time points between the M-SANE and KOOS Jr (ρ = 0.44-0.78, P.001). There was a weak correlation between the M-SANE and PROMIS physical component summary at the preoperative evaluation (ρ = 0.28) but a strong correlation at 1-year follow up (0.65, P.001). The long-term responsiveness of the M-SANE to TKA (standardized response mean [SRM] = 0.98, 95% confidence interval [CI] 0.80-1.17) was comparable to both the KOOS Jr (SRM = 1.19, 95% CI 1.00-1.38) and PROMIS physical component summary (SRM = 0.82, 95% CI 0.74-0.91). Bland-Altman plots demonstrated that the M-SANE and KOOS Jr capture combined knee pain and functionality differently.The M-SANE score was comparable to validated multiple-question PROMs in TKA patients. The demonstrated validity of the M-SANE, as well as its comparable responsiveness to more lengthy PROMs, highlights its use as a one-question PROM for assessment of patient undergoing TKA.

Total knee arthroplasty (TKA) is 1 of the top 2 most common and expensive surgical procedures among Medicare beneficiaries. Due to the procedure's high annual cost, overdiagnosis and subsequent overutilization of TKA has substantial health-policy implications. Concerns regarding the overexaggeration of radiographic findings and overutilization of TKA have been expressed by medical insurers. Currently, the standard of care for assessing potential knee arthroplasty candidates includes assigning a Kellgren-Lawrence (KL) radiographic score. Our study investigated the accuracy of reported preoperative KL scores in patients undergoing TKA.Records of 277 patients who had underwent TKA at our institution for knee osteoarthritis were randomly selected from a large patient data registry and retrospectively reviewed. Two blinded raters assigned KL scores to the radiographs obtained during the preoperative assessment, which were compared to the scores reported by the operative surgeon. An intraclass correlation coefficient (ICC) was calculated to determine inter-rater reliability.Between blinded raters, ICCReporting of KL score is consistent between operative surgeons and independent reviewers. In cases of disagreement between reviewers, the operative surgeon was generally more conservative in their estimation of the extent of osteoarthritis present radiographically. Concerns regarding inflation of radiographic findings to support surgical preauthorization are unwarranted.

OBJECTIVE: Research on employee opinions of workplace wellness programs is limited. METHODS: At a large academic medical center in Boston, we conducted 12 focus groups on employee perceptions of wellness programs. We analyzed data using the immersion-crystallization approach. Participant mean age (N=109) was 41 years; 89% were female; 54% were White. RESULTS: Employees cited prominent barriers to program participation: limited availability; time and marketing; disparities in access; and workplace culture. Encouraging supportive, interpersonal relationships among employees and perceived institutional support for wellness may improve workplace culture and improve participation. Employees suggested changes to physical space, including onsite showers and recommended that a centralized wellness program could create and market initiatives such as competitions and incentives. CONCLUSIONS: Employees sought measures to address serious constraints on time and space, sometimes toxic interpersonal relationships, and poor communication, aspects of workplaces not typically addressed by wellness efforts.

OBJECTIVE The aim of this study was to explore posttraumatic stress disorder (PTSD) symptom prevalence and health characteristics among jail correctional officers, a generally understudied population of public safety workers. METHOD A Conservation of Resources (COR)-inspired framework explored relationships to PTSD symptoms among jail officers (N = 320) employed in Midwest US jails. RESULTS More than half (53.4%) of jail officers screened positively for PTSD. Hierarchical regression analysis indicates that burnout was a significant predictor of symptoms of PTSD (B = 0.25, P

Patient-reported outcomes (PROs) provide data on the effect of conditions and treatments on patients' lives without third party interpretation. Mounting evidence suggests that PROs may be useful in elective procedure decision making, but its utility in trauma remains unclear. Longitudinally collected PROs may prove effective in identifying patients recovering below the norm. We sought to document recovery trajectory in patients with and without complication and to evaluate the sources of variability in functional recovery after injury.This retrospective study included 831 patients with trauma, identified via Current Procedural Terminology (CPT) codes for surgical extremity and/or pelvic/acetabular fracture management between 2014 and 2018. Global Physical Health (GPH) scores collected via the PROMIS Global Health in a 14-month window after injury were analyzed using mixed-effects modeling.A curvilinear GPH recovery trajectory was observed where patients demonstrated an initial positive recovery trajectory (B = 1.28, P0.001) gradually decelerating over time (B = -0.07, P0.001). Patients who experienced complications requiring revision surgery demonstrated markedly lower GPH scores. Several notable predictors of postoperative physical health recovery were identified, including both between-person (B = 0.52, 95% CI, 0.48 to 0.56) and within-person (B = 0.41, 95% CI, 0.36 to 0.46) Global Mental Health (GMH) score, Body Mass Index (BMI) (B = -0.07, 95% CI, -0.12 to -0.02), two or more psychiatric diagnoses (B = -0.97, 95% CI, -1.84 to 0.09), Injury Severity Score 10 to 15 and 16+ (B = -2.62, 95% CI, -4.81 to 0.42 and B = -2.17, 95% CI, -3.60 to 0.74, respectively), readmission for complication (B = -2.64, 95% CI, -3.60 to 1.68), and lower extremity or multiextremity fracture (relative to upper extremity) (B = -3.61, 95% CI, 4.45 to 2.78, B = -4.11, 95% CI, -5.77 to 2.44, respectively). Additional analysis suggests that GMH scores are related to the presence of psychiatric diagnoses.This study establishes a normal course of recovery as reflected by PROMIS GPH score to serve as an index for monitoring individual postoperative course. Patients who experienced a complication demonstrated markedly lower GPH across all time points, potentially allowing earlier identification of at-risk patients. Furthermore, GMH may represent a modifiable risk factor that could profoundly affect physical recovery.Level III (Prognostic Study = Retrospective Cohort).

Background There are a variety of criteria for defining successful treatment after two-stage exchange arthroplasty for prosthetic joint infection (PJI). To accurately assess current practices and improve techniques, it is important to first establish reliable, clinically relevant, reproducible criteria for defining persistent infection and "successful" outcomes. Question/purpose Is the proportion of patients considered to have successful management of PJI after two-stage resection arthroplasty smaller using 2019 Musculoskeletal Infection Society Outcome Reporting Tool (MSIS ORT) criteria than when using a Delphi-based criterion? Methods Patients were retrospectively identified by Current Procedural Technology codes for resection arthroplasty with placement of an antibiotic spacer for infected THA or TKA between April 1, 2011 and January 1, 2018 at a tertiary academic institution. The initial review identified 180 procedures during this time period. Nine patients had documented transition of care outside the system, 16 did not meet the MSIS criteria for chronic PJI, and 34 patients were excluded for lack of documented 2-year follow-up. The mean follow-up duration of the final cohort of 121 procedures in 120 patients was approximately 3.7 ± 1.7 years. Forty percent (49 of 121) of the procedures were performed on the hip and 60% (72 of 121) were performed on the knee. The mean time from primary THA or TKA to explantation was 4.6 years. The mean age of the patients at the time of explantation was 66 years. The mean time from spacer placement to replantation was 119 days. The final 121 patient records were reviewed by a single reviewer and outcomes were subsequently assigned to "successful" and "unsuccessful" outcomes based on the MSIS ORT and Delphi-based consensus criterion, two previously published and validated multidimensional definition schemes. Chi-squared and t-test analyses were performed to identify differences between "successful" and "unsuccessful" outcomes with respect to patient baseline characteristics using each outcome-reporting criterion. Results Overall, the MSIS ORT classified a smaller proportion of patients as having a "successful" treatment outcome after two-stage exchange arthroplasty for PJI than the Delphi-based consensus method did (MSIS: 55% [63 of 114], Delphi: 70% [71 of 102]; relative risk 0.79 [0.65-0.98]; p = 0.03). However, there were no differences when stratified by hips (MSIS: 55% [26 of 47], Delphi: 74% [29 of 39]; relative risk 0.74 [0.54-1.02]; p = 0.07) and knees (MSIS: 55% [37 of 67], Delphi: 67% [42 of 63]; relative risk 0.83 [0.63-1.09]; p = 0.19). Notably, the disease of 16% of the patients (19 of 121) was not classifiable per the Delphi method because these patients never underwent reimplantation. Conclusion The present study demonstrated that the MSIS criteria detect fewer instances of "successful" infection management after two-stage resection arthroplasty for PJI than the Delphi method in this cohort. Based on these findings, researchers and surgeons should aim for standardized reporting after intervention for PJI to allow for a better comparison of outcomes across different studies and ultimately allow for improved techniques and approaches to the treatment of PJI. Level of evidence Level III, diagnostic study.

Background Value-based health-care delivery is a framework for restructuring our health-care systems with the goal of providing better outcomes for patients at lower cost. Value is determined by patient health outcomes per dollar spent on health services. We sought to develop a value dashboard that could be used to easily track and improve the value of total hip and knee arthroplasty (THA and TKA). Methods We created a value dashboard for TKAs and THAs at our institution. Value was defined as quality of outcomes per dollar spent. The dashboard for each procedure displayed the average value by surgeon, compared with institutional averages for physical function scores and cost. Quality metrics were determined by weighted surgeon ranking using a modified Delphi process and included both clinical and patient-reported outcomes, as measured by the mean change in the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) physical function score, mean change in the Hip disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR) or the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), mean change in the modified Single Assessment Numeric Evaluation (SANE) score, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. Average direct costs per surgeon were used. Data from January 2017 through April 2018 were included to ensure 1-year follow-up. Results Six surgeons were included in the value dashboard for TKA, and 5 were included in the THA dashboard. The value for TKA by surgeon ranged from 7% below to 12% above the institutional benchmark. The value for THA by surgeon ranged from 12% below to 7% above the institutional benchmark. Conclusions The proposed dashboard utilizes value in a health-care framework and could be used for comparing and improving value for THA and TKA. This dashboard successfully combined patient outcome metrics and direct costs of surgical procedures. Future studies should focus on involving patients in this process and using national data to create benchmarks, which could provide a more accurate representation of value than using institutional averages.

Objective : Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. Methods All patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. Results 108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management. Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. Conclusions 21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.

Background We evaluate whether patient exposures such as tobacco use are associated with high systemic or local in vivo oxidative state and with increased in vivo polyethylene oxidation. Methods We performed a case-control study which evaluated clinical factors associated with high systemic or local in vivo oxidative state among patients whose implants have been identified as demonstrating either extreme or minimal oxidation by our implant retrieval laboratory. Analysis of more than 2500 tibial inserts from explanted total knee arthroplasty demonstrated a wide spectrum of polyethylene oxidation. Components from some patients exhibited extremely high oxidation rates (super-oxidizers), and components from other patients demonstrated negligible oxidation (nonoxidizers). Patients’ clinical data were retrospectively investigated from a prospectively collected institutional database. Results Eighteen patients met criteria as either super-oxidizers (9) or nonoxidizers (9). Average time in vivo was 6.6 (±4.4) years. Reasons for removal were aseptic loosening (10), instability (3), infection (2), component malposition (1), massive osteolysis (1), and other (1). Chi-square for categorical predictors demonstrated that nonoxidizer patients were significantly more likely to be current smokers than super-oxidizers (6 vs 0, P = .012). No other free radical–associated variables were significantly different across oxidation groups. Conclusion There was a significant association between extremely low ultra-high-molecular-weight polyethylene oxidation and current smoking.

Background Correctional officers (COs) experience elevated rates of mental and physical ill-health as compared with other general industry and public safety occupations. The purpose of this study was to investigate demographic, mental health, job tenure, and work-family characteristics and their prospective association to burnout within and between jail officers during one year of new employment. Methods In 2016, newly hired jail officers (N = 144) completed self-reported surveys across four time points in a one-year prospective study at a Midwestern United States urban jail. Linear mixed-effects and growth modeling examined how work-family conflict (W-FC) and depressive symptoms relate to perceptions of burnout over time. Results Jail officer burnout increased and was related to rises in W-FC and depression symptoms. Within-person variance for W-FC (B pooled = .52, p

In 2011, a National Academy of Medicine report recommended that packaged food in the U.S. display a uniform front-of-package nutrition label, using a system such as a 0-3 star ranking. Few studies have directly compared this to other labels to determine which best informs consumers and encourages healthier purchases. In 2013, we randomized adult participants (N=1,247) in an Internet-based survey to one of six conditions: no label control; single traffic light; multiple traffic light; Facts Up Front; NuVal; or 0-3 star ranking. We compared groups on purchase intentions and accuracy of participants' interpretation of food labels. There were no differences in the nutritional quality of hypothetical shopping baskets across conditions (p=0.845). All labels improved consumers' abilities to judge the nutritional quality of foods relative to no label, but the best designs varied by outcomes. NuVal and multiple traffic light labels led to the greatest accuracy identifying the healthier of two products (p

Key Points Question Were resource constraints due to the COVID-19 pandemic associated with a delay in urgent fracture surgery beyond national time-to-surgery benchmarks? Findings In this cohort pre-post study that included 3589 patients, there was no association between time to surgery and COVID-19 in either open fracture or closed femur/hip fracture cohorts. Meaning Despite concerns that the unprecedented challenges associated with the COVID-19 pandemic would delay acute management of urgent surgery, many hospital systems within the US were able to implement strategies in keeping with time-to-surgery standards for orthopedic trauma., This cohort study evaluates whether the COVID-19 pandemic is associated with delays in urgent fracture surgery beyond national time-to-surgery benchmarks., Importance In response to the COVID-19 pandemic, many hospital systems were forced to reduce operating room capacity and reallocate resources. The outcomes of these policies on the care of injured patients and the maintenance of emergency services have not been adequately reported. Objective To evaluate whether the COVID-19 pandemic was associated with delays in urgent fracture surgery beyond national time-to-surgery benchmarks. Design, Setting, and Participants This retrospective cohort study used data collected in the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma among at 20 sites throughout the US and Canada and included patients who sustained open fractures or closed femur or hip fractures. Exposure COVID-19–era operating room restrictions were compared with pre–COVID-19 data. Main Outcomes and Measures Surgery within 24 hours after injury. Results A total of 3589 patients (mean [SD] age, 55 [25.4] years; 1913 [53.3%] male) were included in this study, 2175 pre–COVID-19 and 1414 during COVID-19. A total of 54 patients (3.1%) in the open fracture cohort and 407 patients (21.8%) in the closed hip/femur fracture cohort did not meet 24-hour time-to-surgery benchmarks. We were unable to detect any association between time to operating room and COVID-19 era in either open fracture (odds ratio [OR], 1.40; 95% CI, 0.77-2.55; P = .28) or closed femur/hip fracture (OR, 1.01; 95% CI, 0.74-1.37; P = .97) cohorts. In the closed femur/hip fracture cohort, there was no association between time to operating room and regional COVID-19 prevalence (OR, 1.07; 95% CI, 0.70-1.64; P = .76). Conclusions and Relevance In this cohort study, there was no association between meeting time-to-surgery benchmarks in either open fracture or closed femur/hip fracture during the COVID-19 pandemic compared with before the pandemic. This is counter to concerns that the unprecedented challenges associated with managing the COVID-19 pandemic would be associated with clinically significant delays in acute management of urgent surgical cases and suggests that many hospital systems within the US were able to effectively implement policies consistent with time-to-surgery standards for orthopedic trauma in the context of COVID-19–related resource constraints.

Surgeon compensation models could potentially influence the utilization of elective procedures. We assessed whether transitioning from salaried to a relative value unit (RVU) productivity-based physician compensation model changed the surgical rate and patient selection in elective total hip and knee arthroplasty (THA and TKA) procedures.Our institution transitioned from salaried to RVU productivity-based reimbursement in July 2016. We performed a retrospective analysis on patients undergoing primary THA and TKA from July 2014 to July 2018 before and after the transition (salary period n = 820; RVU period n = 1188). Beta regression was used to determine the reimbursement structure as a predictor of surgery. The surgical rate was defined as the number of primary THA and TKA procedures per reimbursement period divided by all arthroplasty and osteoarthritis outpatient clinic encounters.There was a surgical rate of 15.8% (95% confidence interval [CI] 13.8%-17.8%) THA and 16.7% (95% CI 15.1%-18.1%) TKA procedures during RVU reimbursement compared to 11.1% (95% CI 9.8%-12.8%) THA and 11.7% (95% CI 10.5%-12.8%) TKA procedures during the salaried period (P.001). The adjusted odds of undergoing a THA or TKA procedure increased in the RVU compared to the salaried model (THA odds ratio 1.48, 95% CI 1.43-1.53; TKA odds ratio 1.50, 95% CI 1.46-1.55; P.001). There were no significant differences in patient age, gender, race, body mass index, or Charlson Comorbidity Index in salaried vs RVU productivity periods (P.05 for all covariates).Productivity-based physician compensation may encourage higher rates of elective arthroplasty procedures without broadening patient selection.

During the fall 2015 semester, I (i.e., the last author of this response) taught a doctoral seminar on performance appraisal. Although this course was a general survey of research and theory regarding work performance and performance appraisal processes and methods, we also talked extensively about the value of performance ratings to organizations, raters, and ratees. It was indeed serendipitous that this focal article came out when it did. As part of the final examination requirements (and, admittedly, as a pedagogical experiment), I asked the six PhD students in this course (i.e., the first six authors of this response) to read and respond to the Adler et al. (2016) debate regarding the relative merits of performance ratings. To highlight the perspectives of this next generation of industrial and organizational psychologists, I have collected here various representative comments offered by each of these emerging scholars on this issue.

Information and communication technologies (ICTs) are rapidly becoming indispensable organizational tools. Though the benefits of such technologies have been trumpeted, recent research has examined the unique pressures that may be introduced through the lens of a construct called workplace telepressure, defined as an urge for and preoccupation with quickly responding to ICTs (e.g., email). The current study further explores the workplace telepressure construct as a unique contributor to measures of workplace well-being over and above perceived workplace demands and individual differences, introducing new constructs into the study of workplace telepressure. Furthermore, the study critically evaluates the term "telepressure" as applied to the underlying construct, as "pressure" may connote a perception of external force being placed on an individual, whereas the definition offered by past research identifies a preoccupation and urge to respond immediately to ICT messages, which may be internally generated. Finally, the ability of workplace telepressure to account for unique variance in workplace subjective well-being measures is investigated.

Several aspects of diversity impact career transitions and trajectories. Whereas traditional conceptualizations of careers emphasize a clear path for the majority of people, modern careers are better characterized by a multitude and variety of potential mobility paths. Modern career trajectories have been linked to early developmental activities, which are similarly related to increased diversity and societal changes. This chapter discusses the impact of different forms of diversity on career transitions from lifespan and life course perspectives, as well from a dynamic perspective where one's career transitions are dictated by lesser-planned socio-contextual and personal circumstances. Special attention is given to contemporary research and unique issues related to women and older workers. Within this discussion is a review of work arrangements for adapting and capitalizing on the needs of this changing workforce. We conclude by outlining trends likely to influence career development in the future, including suggestions for future research.