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Background Accurate measurement of the cholesterol within lipoprotein(a) (Lp[a]-C) and its contribution to low-density lipoprotein cholesterol (LDL-C) has important implications for risk assessment, diagnosis, and treatment of atherosclerotic cardiovascular disease, as well as in familial hypercholesterolemia. A method for estimating Lp(a)-C from particle number using fixed conversion factors has been proposed (Lp[a]-C from particle number divided by 2.4 for Lp(a) mass, multiplied by 30% for Lp[a]-C). The accuracy of this method, which theoretically can isolate "Lp(a)-free LDL-C," has not been validated. Methods and Results In 177 875 patients from the VLDbL (Very Large Database of Lipids), we compared estimated Lp(a)-C and Lp(a)-free LDL-C with measured values and quantified absolute and percent error. We compared findings with an analogous data set from the Mayo Clinic Laboratory. Error in estimated Lp(a)-C and Lp(a)-free LDL-C increased with higher Lp(a)-C values. Median error for estimated Lp(a)-C <10 mg/dL was -1.9 mg/dL (interquartile range, -4.0 to 0.2); this error increased linearly, overestimating by +30.8 mg/dL (interquartile range, 26.1-36.5) for estimated Lp(a)-C ≥50 mg/dL. This error relationship persisted after stratification by overall high-density lipoprotein cholesterol and high-density lipoprotein cholesterol subtypes. Similar findings were observed in the Mayo cohort. Absolute error for Lp(a)-free LDL-C was +2.4 (interquartile range, -0.6 to 5.3) for Lp(a)-C<10 mg/dL and -31.8 (interquartile range, -37.8 to -26.5) mg/dL for Lp(a)-C≥50 mg/dL. Conclusions Lp(a)-C estimations using fixed conversion factors overestimated Lp(a)-C and subsequently underestimated Lp(a)-free LDL-C, especially at clinically relevant Lp(a) values. Application of inaccurate Lp(a)-C estimations to correct LDL-C may lead to undertreatment of high-risk patients.

Importance: The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of coronary artery calcium (CAC) scoring to guide the allocation of statin therapy among individuals with an intermediate risk of atherosclerotic cardiovascular disease (ASCVD)., Objective: To examine the association between risk-enhancing factors and incident ASCVD by CAC burden among those at intermediate risk of ASCVD., Design, Setting, and Participants: The Multi-Ethnic Study of Atherosclerosis is a multicenter population-based prospective cross-sectional study conducted in the US. Baseline data for the present study were collected between July 15, 2000, and July 14, 2002, and follow-up for incident ASCVD events was ascertained through August 20, 2015. Participants were aged 45 to 75 years with no clinical ASCVD or diabetes at baseline, were at intermediate risk of ASCVD (≥7.5% to <20.0%), and had a low-density lipoprotein cholesterol level of 70 to 189 mg/dL., Exposures: Family history of premature ASCVD, premature menopause, metabolic syndrome, chronic kidney disease, lipid and inflammatory biomarkers, and low ankle-brachial index., Main Outcomes and Measures: Incident ASCVD over a median follow-up of 12.0 years., Results: A total of 1688 participants (mean [SD] age, 65 [6] years; 976 men [57.8%]). Of those, 648 individuals (38.4%) were White, 562 (33.3%) were Black, 305 (18.1%) were Hispanic, and 173 (10.2%) were Chinese American. A total of 722 participants (42.8%) had a CAC score of 0. Among those with 1 to 2 risk-enhancing factors vs those with 3 or more risk-enhancing factors, the prevalence of a CAC score of 0 was 45.7% vs 40.3%, respectively. Over a median follow-up of 12.0 years (interquartile range [IQR], 11.5-12.6 years), the unadjusted incidence rate of ASCVD among those with a CAC score of 0 was less than 7.5 events per 1000 person-years for all individual risk-enhancing factors (with the exception of ankle-brachial index, for which the incidence rate was 10.4 events per 1000 person-years [95% CI, 1.5-73.5]) and combinations of risk-enhancing factors, including participants with 3 or more risk-enhancing factors. Although the individual and composite addition of risk-enhancing factors to the traditional risk factors was associated with improvement in the area under the receiver operating curve, the use of CAC scoring was associated with the greatest improvement in the C statistic (0.633 vs 0.678) for ASCVD events. For incident ASCVD, the net reclassification improvement for CAC was 0.067., Conclusions and Relevance: In this cross-sectional study, among participants with CAC scores of 0, the presence of risk-enhancing factors was generally not associated with an overall ASCVD risk that was higher than the recommended treatment threshold for the initiation of statin therapy. The use of CAC scoring was associated with significant improvements in the reclassification and discrimination of incident ASCVD. The results of this study support the utility of CAC scoring as an adjunct to risk-enhancing factor assessment to more accurately classify individuals with an intermediate risk of ASCVD who might benefit from statin therapy.

Importance: Low-density lipoprotein cholesterol (LDL-C) is typically estimated with the Friedewald or Martin/Hopkins equation; however, if triglyceride levels are 400 mg/dL or greater, laboratories reflexively perform direct LDL-C (dLDL-C) measurement. The use of direct chemical LDL-C assays and estimation of LDL-C via the National Institutes of Health Sampson equation are not well validated, and data on the accuracy of LDL-C estimation at higher triglyceride levels are limited., Objective: To compare an extended Martin/Hopkins equation for triglyceride values of 400 to 799 mg/dL with the Friedewald and Sampson equations., Design, Setting, and Participants: This cross-sectional study evaluated consecutive patients at clinical sites across the US with patient lipid distributions representative of the US population in the Very Large Database of Lipids from January 1, 2006, to December 31, 2015, with triglyceride levels of 400 to 799 mg/dL. Data analysis was performed from November 9, 2020, to March 23, 2021., Main Outcomes and Measures: Accuracy in LDL-C classification according to guideline-based categories and absolute errors between estimated LDL-C and dLDL-C levels. Patients were randomly assigned 2:1 to derivation and validation data sets. Levels of dLDL-C were measured by vertical spin-density gradient ultracentrifugation. The LDL-C levels were estimated using the Friedewald method, with a fixed ratio of triglycerides to very low-density lipoprotein cholesterol (VLDL-C ratio of 5:1), extended Martin/Hopkins equation with a flexible ratio, and Sampson equation with VLDL-C estimation by multiple least-squares regression., Results: A total of 111 939 patients (mean [SD] age, 52 [13] years; 65.0% male) with triglyceride levels of 400 to 799 mg/dL were included, representing 2.2% of 5 081 680 patients in the database. Across all individual guideline LDL-C classes (<40, 40-69, 70-99, 100-129, 130-159, 160-189, and ≥190), estimation of LDL-C by the extended Martin/Hopkins equation was most accurate (62.1%) compared with the Friedewald (19.3%) and Sampson (40.4%) equations. In classifying LDL-C levels less than 70 mg/dL across all triglyceride strata, the extended Martin/Hopkins equation was most accurate (67.3%) compared with Friedewald (5.1%) and Sampson (26.4%) equations. In addition, for classifying LDL-C levels less than 40 mg/dL across all triglyceride strata, the extended Martin/Hopkins equation was most accurate (57.2%) compared with the Friedewald (4.3%) and Sampson (14.4%) equations. However, considerable underclassification of LDL-C occurred. The magnitude of error between the Martin/Hopkins equation estimation and dLDL-C was also smaller: at LDL-C levels less than 40 mg/dL, 2.7% of patients had 30 mg/dL or greater differences between dLDL-C and estimated LDL-C using the Martin/Hopkins equation compared with the Friedewald (92.5%) and Sampson (38.7%) equations., Conclusions and Relevance: In this cross-sectional study, the extended Martin/Hopkins equation offered greater LDL-C accuracy compared with the Friedewald and Sampson equations in patients with triglyceride levels of 400 to 799 mg/dL. However, regardless of method used, caution is advised with LDL-C estimation in this triglyceride range.

Objective: Major guidelines recommend the use of secondary targets, such as non-HDL-C and apoB, to further reduce cardiovascular risk. We aimed to evaluate the proportion at which newer, more aggressive secondary lipid targets are exceeded in patients with LDL-C < 70 mg/dL estimated by Friedewald (LDLf-C) and Martin/Hopkins equations (LDLm-C)., Methods: We analyzed patients from the Very Large Database of Lipids with fasting lipids and estimated LDL-C <70 mg/dL by the Friedewald equation and Martin/Hopkins algorithm. Patients were categorized into three groups: LDL-C <40, 40-54 and 55-69 mg/dL. We calculated the proportion of patients with non-HDL-C and apoB above high-risk targets (non-HDL-C ≥ 100 and apoB ≥ 80mg/dL) for those with LDL-C 55-69 mg/dL and very high-risk targets (non-HDL-C ≥ 85 and apoB ≥ 65mg/dL) for those with LDL-C < 40 mg/dL and 40-54 mg/dL., Results: In patients with LDLf-C < 40 mg/dL, ~8 and ~4% did not meet high-risk secondary targets and ~21 and 25% did not meet very high-risk secondary targets for non-HDL-C and apoB, respectively. However, in patients with LDLm-C < 40 mg/dL <1% did not meet high-risk targets, while only 3% did not meet the very-high risk secondary target for apoB and none exceeded the very-high risk secondary target for non-HDL-C. Among individuals with LDL-C< 40 mg/dL, there were increasing proportions of individuals not meeting the very high-risk secondary apoB target at greater triglyceride levels, reaching up to ~19% using LDLm-C compared to ~60% using LDLf-C when triglyceride levels were 200-399 mg/dL. There were higher proportions of individuals not meeting high and very-high risk targets as triglyceride levels increased among those with LDL-C 40-54 and 55-69 mg/dL., Conclusion: In a large, US cross-sectional sample of individuals with LDL-C < 70 mg/dL, secondary non-HDL-C and apoB targets overall provide modest utility. However, attainment of very high-risk cutpoints for non-HDL-C and apoB is not achieved in a significant fraction of patients with triglycerides 200-399 mg/dL, even when using a more accurate calculation of LDL-C., Competing Interests: Drs. Martin and Jones are listed as coinventors on a pending patent filed by Johns Hopkins University for LDL‐C estimation using the method applied in this manuscript. Dr Jones has served as an advisor to Sanofi/Regeneron. Dr. Martin is supported by the American Heart Association (20SFRN35380046 and COVID19-811000), PCORI (ME-2019C1-15328), NIH (P01 HL108800), the David and June Trone Family Foundation, and the Pollin Digital Health Innovation Fund. He has served as a consultant in the past 24 months to AstraZeneca, Amgen, DalCor Pharmaceuticals, Esperion, Kaneka, Sanofi, and 89bio. He is a founder of and holds equity in Corrie Health, which intends to further develop the platform. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. The remaining authors have no disclosures to report., (© 2021 The Author(s). Published by Elsevier B.V.)

Background: Hyperlipoproteinemia Type III (HLP3), also known as dysbetalipoproteinemia, is defined by cholesterol and triglyceride (TG) enriched remnant lipoprotein particles (RLP). The gold standard for diagnosis requires demonstration of high remnant lipoprotein particle cholesterol (RLP-C) by serum ultracentrifugation (UC), which is not readily available in daily practice. The apoB algorithm can identify HLP3 using total cholesterol (TC), plasma triglyceride (TG), and apoB. However, the optimal TG cutoff is unknown., Objective: We analyzed apoB algorithm defined HLP3 at different TG levels to optimize the TG cutoff for the algorithm., Methods: 128,485 UC lipid profiles in the Very Large Database of Lipids (VLDbL) were analyzed. RLP-C was assessed at TG ≥ 133 mg/dL, ≥175 mg/dL, ≥200 mg/dL, and ≥ 250 mg/dL. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and prevalence adjusted and bias-adjusted kappa (PABAK) were calculated against UC Criterion (VLDL-C/TG ≥ 0.25) for HLP3., Results: The median age (IQR) was 57 years (46-68). 45% were men, 20.1% had diabetes, and 25.5% had hypertension. The median RLP-C level for the TG cutoffs (mg/dL) of ≥ 133, ≥ 175, ≥ 200, and ≥ 250 were 34, 43, 50, and 62 mg/dL, respectively, compared to 67 mg/dL in UC defined HLP3. TG ≥ 133 mg/dL yielded optimal results (Sn 29.5%, Sp 98.5%, PABAK 0.96, PPV 13.6%, NPV 99.4%)., Conclusion: TG ≥ 133 mg/dL allows for high sensitivity in screening for HLP3. Higher TG cutoffs may identify more severe HLP3 phenotypes, but with a large loss in sensitivity for HLP3., (Copyright © 2020 National Lipid Association. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Individuals with low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL are considered high-risk and current guidelines recommend initiating high-intensity statin therapy in this group. We sought to examine the predictive ability of zero CAC in this high-risk group., Methods: Multi-Ethnic Study of Atherosclerosis participants without clinical cardiovascular disease and baseline LDL-C ≥190 mg/dL were identified. Cardiovascular risk factors were compared between those with CAC = 0 and CAC >0. Multivariable Poisson regression was used to identify predictors of CAC = 0. Association of CAC = 0 with incident cardiovascular events over a median follow-up of 13.2 years was examined using multivariable-adjusted Cox regression., Results: 246 individuals (mean age = 63 ± 9.4 years; 42% male; 31% white; 37% CAC = 0) with LDL-C ≥190 mg/dL were identified (mean LDL-C = 215 ± 27 mg/dL). Age <65 years (RR = 2.17, 95%CI = 1.49-3.23), female sex (RR = 2.10, 95%CI = 1.42-3.10), and no diabetes (RR = 2.22, 95%CI = 1.18-4.17) were associated with CAC = 0. Individuals with CAC = 0 had a lower risk for future cardiovascular events (incidence rate per 1000 person-years = 4.7; 10-year risk = 3.7%; risk/year = 0.4%) than those with CAC >0 (incidence rate per 1000 person-years = 26.4; 10-year risk = 20%; risk/year = 2.0%), adjusted HR 0.25 (95%CI = 0.10-0.66)., Conclusions: Among persons with LDL-C ≥190 mg/dL, younger age, female sex, and the absence of diabetes were associated with CAC = 0. CAC = 0 was associated with a low risk of cardiovascular events, suggesting the utility of CAC assessment for stratifying risk in this high-risk group., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The Martin/Hopkins low-density lipoprotein cholesterol equation (LDL-C N ) was previously demonstrated as more accurate than Friedewald LDL-C estimation (LDL-C F ) in a North American database not able to take race into account., Objectives: We hypothesized that LDL-C N would be more accurate than LDL-C F and correlate better with LDL particle number (LDL-P) in a racially diverse Brazilian cohort., Methods: We performed a cross-sectional analysis of 4897 participants in the Brazilian Longitudinal Study of Adult Health, assessing LDL-C F and LDL-C N accuracy via overlap with ultracentrifugation-based measurement among clinical guideline LDL-C categories as well as mg/dL and percent error differences. We analyzed by triglyceride categories and correlated LDL-C estimation with LDL-P., Results: LDL-C N demonstrated improved accuracy at 70 to <100 and <70 mg/dL (P < .001), with large errors ≥20 mg/dL about 9 times more frequent in LDL-C F at LDL-C <70 mg/dL, mainly due to underestimation. Among individuals with LDL-C <70 mg/dL and triglycerides ≥150 mg/dL, 65% vs 100% of ultracentrifugation-based low-density lipoprotein cholesterol calculation fell within appropriate categories of estimated LDL-C F and LDL-C N , respectively (P < .001). Similar results were observed when analyzed for age, sex, and race. Participants at LDL-C <70 and 70 to <100 mg/dL with discordantly elevated LDL-C N vs LDL-C F had a 58.5% and 41.5% higher LDL-P than those with concordance (P < .0001), respectively., Conclusions: In a diverse Brazilian cohort, LDL-C N was more accurate than LDL-C F at low LDL-C and high triglycerides. LDL-C N may avoid underestimation of LDL-C and better reflect atherogenic lipid burden in low particle size, high particle count states., (Copyright © 2019 National Lipid Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Five decades ago, Fredrickson, Levy, and Lees (FLL) qualitatively characterized clinical dyslipidemias with specific implications for cardiovascular and non-cardiovascular morbidity and mortality. They separated disorders of elevated cholesterol and triglycerides into five phenotypes (types I-V) based on their lipoprotein profile. Although clinicians generally consider them rare entities, modern FLL prevalence may be greater than previously reported., Material and Methods: We performed a cross-sectional analysis in 5,272 participants from the 2011-2014 National Health and Nutrition Examination Survey and 128,506 participants from the Very Large Database of Lipids study with complete, fasting lipid profiles. We used a validated algorithm to define FLL phenotypes employing apolipoprotein B, total cholesterol, and triglycerides., Results: Overall prevalence of FLL phenotypes was 33.9%. FLL prevalence in the general population versus clinical lipid database was: type I (0.05 vs. 0.02%), type IIa (3.2 vs. 3.9%), type IIb (8.0 vs. 10.3%), type III (2.0 vs. 1.7%), type IV (20.5 vs. 24.1%), and type V (0.15 vs. 0.13%). Those aged 40-74 years had a higher overall prevalence compared to other age groups ( p < 0.001) and men had overall higher prevalence than women ( p < 0.001). Those with diabetes (51.6%) or obese BMI (49.0%) had higher prevalence of FLL phenotypes compared to those without diabetes (31.3%; p < 0.001) and normal BMI (18.3%; p < 0.001)., Conclusions: FLL phenotypes are likely far more prevalent than appreciated in clinical practice, in part due to diabetes and obesity epidemics. Given the prognostic and therapeutic importance of these phenotypes, their identification becomes increasingly important in the era of precision medicine., Competing Interests: VS, VAP, JP, RMV, MLE, RQ, EG, MB, and RSB have no relevant disclosures. PPT: Speakers Bureau; Amarin, Akcea, Amgen, Kowa, Merck, Nova Nordisk, Regeneron, Sanofi (Consultant/Advisory Board). SRJ: Co-inventor for a method to estimate LDL cholesterol levels, patent application pending; funding from the David and June Trone Family Foundation. SSM: Co-inventor for a method to estimate LDL cholesterol levels, patent application pending; Consultant/Advisory Board for Sanofi/Regeneron, Amgen, Quest Diagnostics, Akcea, Novo Nordisk, Esperion., (Copyright: © 2019 Termedia & Banach.)

Introduction: Dysbetalipoproteinaemia (HLP3) is a disorder characterized by excess cholesterol-enriched, triglyceride-rich lipoprotein remnants in genetically predisposed individuals that powerfully promote premature cardiovascular disease if untreated. The current prevalence of HLP3 is largely unknown., Material and Methods: We performed cross-sectional analysis of 128,485 U.S. adults from the Very Large Database of Lipids (VLDbL), using four algorithms to diagnose HLP3 employing three Vertical Auto Profile ultracentrifugation (UC) criteria and a previously described apolipoprotein B (apoB) method. We evaluated 4,926 participants from the 2011-2014 National Health and Nutrition Examination Survey (NHANES) with the apoB method. We examined demographic and lipid characteristics stratified by presence of HLP3 and evaluated lipid characteristics in those with HLP3 phenotype discordance and concordance as determined by apoB and originally defined UC criteria 1., Results: In U.S. adults in VLDbL and NHANES, a 1.7-2.0% prevalence is observed for HLP3 with the novel apoB method as compared to 0.2-0.8% prevalence in VLDbL via UC criteria 1-3. Participants who were both apoB and UC criteria HLP3 positive had higher remnant particles as well as more elevated triglyceride/apoB and total cholesterol/apoB ratios (all p < 0.001) than those who were apoB method positive and UC criteria 1 negative., Conclusions: HLP3 may be more prevalent than historically and clinically appreciated. The apoB method increases HLP3 identification via inclusion of milder phenotypes. Further work should evaluate the clinical implications of HLP3 diagnosis at various lipid algorithm cut-points to evaluate the ideal standard in the modern era., Competing Interests: VAP, VS, JP, RMV, MLE, EB, RQ, EG, MB, RSB, DM and ADS have no relevant disclosures. PPT: Speakers Bureau; Amarin, Akcea, Amgen, Kowa, Merck, Nova Nordisk, Regeneron, Sanofi (Consultant/Advisory Board). SRJ: Co-inventor for a method to estimate LDL cholesterol levels, patent application pending; funding from the David and June Trone Family Foundation. DS: personal fees from Amgen Inc, Akcea Therapeutics, Medicure, Sanofi, Regeneron; personal fees from the National Lipid Association outside the submitted work. SSM: Co-inventor for a method to estimate LDL cholesterol levels, patent application pending; Consultant/Advisory Board for Sanofi/Regeneron, Amgen, Quest Diagnostics, Akcea, Novo Nordisk, Esperion., (Copyright: © 2019 Termedia & Banach.)

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in developed nations. Therapeutic modulation of dyslipidemia by inhibiting 3'-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase is standard practice throughout the world. However, based on findings from Mendelian studies and genetic sequencing in prospective longitudinal cohorts from around the world, novel therapeutic targets regulating lipid and lipoprotein metabolism, such as apoprotein C3, angiopoietin-like proteins 3 and 4, and lipoprotein(a), have been identified. These targets may provide additional avenues to prevent and treat atherosclerotic disease. We therefore review these novel molecular targets by addressing available Mendelian and observational data, therapeutic agents in development, and early outcomes results., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Selected dyslipidemia guidelines recommend non-high-density lipoprotein-cholesterol (non-HDL-C) and apolipoprotein B (apoB) as secondary targets to the primary target of low-density lipoprotein-cholesterol (LDL-C). After considering 2 LDL-C estimates that differ in accuracy, we examined: (1) how frequently non-HDL-C guideline targets could change management; and (2) the utility of apoB targets after meeting LDL-C and non-HDL-C targets., Methods: We analyzed 2518 adults representative of the US population from the 2011 to 2012 National Health and Nutrition Examination Survey and 126 092 patients from the Very Large Database of Lipids study with apoB. We identified all individuals as well as those with high-risk clinical features, including coronary artery disease, diabetes mellitus, and metabolic syndrome who met very high- and high-risk guideline targets of LDL-C <70 and <100 mg/dL using Friedewald estimation (LDL-C F ) and a novel, more accurate method (LDL-C N ). Next, we examined those not meeting non-HDL-C (<100, <130 mg/dL) and apoB (<80, <100 mg/dL) guideline targets. In those meeting dual LDL-C and non-HDL-C targets (<70 and <100 mg/dL, respectively, or <100 and <130 mg/dL, respectively), we determined the proportion of individuals who did not meet guideline apoB targets (<80 or <100 mg/dL)., Results: A total of 7% to 9% and 31% to 36% of individuals had LDL-C <70 and <100 mg/dL, respectively. Among those with LDL-C F <70 mg/dL, 14% to 15% had non-HDL-C ≥100 mg/dL, and 7% to 8% had apoB ≥80 mg/dL. Among those with LDL-C F <100 mg/dL, 8% to 10% had non-HDL-C ≥130 mg/dL and 2% to 3% had apoB ≥100 mg/dL. In comparison, among those with LDL-C N <70 or 100 mg/dL, only ≈2% and ≈1% of individuals, respectively, had non-HDL-C and apoB values above guideline targets. Similar trends were upheld among those with high-risk clinical features: ≈0% to 3% of individuals with LDL-C N <70 mg/dL had non-HDL-C ≥100 mg/dL or apoB ≥80 mg/dL compared with 13% to 38% and 9% to 25%, respectively, in those with LDL-C F <70 mg/dL. With LDL-C F or LDL-C N <70 mg/dL and non-HDL-C <100 mg/dL, 0% to 1% had apoB ≥80 mg/dL. Among all dual LDL-C F or LDL-C N <100 mg/dL and non-HDL-C <130 mg/dL individuals, 0% to 0.4% had apoB ≥100 mg/dL. These findings were robust to sex, fasting status, and lipid-lowering therapy status., Conclusions: After more accurately estimating LDL-C, guideline-suggested non-HDL-C targets could alter management in only a small fraction of individuals, including those with coronary artery disease and other high-risk clinical features. Furthermore, current guideline-suggested apoB targets provide modest utility after meeting cholesterol targets., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01698489., (© 2018 American Heart Association, Inc.)

Background: Recent recommendations favoring nonfasting lipid assessment may affect low-density lipoprotein cholesterol (LDL-C) estimation. The novel method of LDL-C estimation (LDL-C N ) uses a flexible approach to derive patient-specific ratios of triglycerides to very low-density lipoprotein cholesterol. This adaptability may confer an accuracy advantage in nonfasting patients over the fixed approach of the classic Friedewald method (LDL-C F )., Methods: We used a US cross-sectional sample of 1 545  634 patients (959 153 fasting ≥10-12 hours; 586 481 nonfasting) from the second harvest of the Very Large Database of Lipids study to assess for the first time the impact of fasting status on novel LDL-C accuracy. Rapid ultracentrifugation was used to directly measure LDL-C content (LDL-C D ). Accuracy was defined as the percentage of LDL-C D falling within an estimated LDL-C (LDL-C N or LDL-C F ) category by clinical cut points. For low estimated LDL-C (<70 mg/dL), we evaluated accuracy by triglyceride levels. The magnitude of absolute and percent differences between LDL-C D and estimated LDL-C (LDL-C N or LDL-C F ) was stratified by LDL-C and triglyceride categories., Results: In both fasting and nonfasting samples, accuracy was higher with the novel method across all clinical LDL-C categories (range, 87%-94%) compared with the Friedewald estimation (range, 71%-93%; P ≤0.001). With LDL-C <70 mg/dL, nonfasting LDL-C N accuracy (92%) was superior to LDL-C F accuracy (71%; P <0.001). In this LDL-C range, 19% of fasting and 30% of nonfasting patients had differences ≥10 mg/dL between LDL-C F and LDL-C D , whereas only 2% and 3% of patients, respectively, had similar differences with novel estimation. Accuracy of LDL-C <70 mg/dL further decreased as triglycerides increased, particularly for Friedewald estimation (range, 37%-96%) versus the novel method (range, 82%-94%). With triglycerides of 200 to 399 mg/dL in nonfasting patients, LDL-C N <70 mg/dL accuracy (82%) was superior to LDL-C F (37%; P <0.001). In this triglyceride range, 73% of fasting and 81% of nonfasting patients had ≥10 mg/dL differences between LDL-C F and LDL-C D compared with 25% and 20% of patients, respectively, with LDL-C N ., Conclusions: Novel adaptable LDL-C estimation performs better in nonfasting samples than the fixed Friedewald estimation, with a particular accuracy advantage in settings of low LDL-C and high triglycerides. In addition to stimulating further study, these results may have immediate relevance for guideline committees, laboratory leadership, clinicians, and patients., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01698489., (© 2017 American Heart Association, Inc.)

Background: Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery., Materials and Methods: 56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients., Results: There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016)., Conclusions: There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively. Level of evidence Level III.

The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was $1028, whereas mean EF construct cost was $4204. Therefore, DCP resulted in significant cost savings with no difference in complication rates, making it a valuable alternative to EF for the provisional stabilization of open tibial shaft fractures.

This study investigated whether current Medicare reimbursements for orthopaedic trauma procedures correlate with complications. A total of 18,510 patients representing 33 orthopaedic trauma procedures from 2005 to 2011 were studied. Adverse events and Medicare payments for each orthopaedic trauma procedure were collected. Linear regressions determined correlations between complications and Medicare payments for orthopaedic trauma procedures. A weak correlation between Medicare payments and complications was found for all procedures (r = .399, p = .021). A 1.0% increase in complications was associated with a payment increase of only $100. There were no correlations between complications and reimbursements for upper extremity (p = .878) and lower extremity (p = .713) procedures. A strong correlation (r = .808, p = .015) existed for hip and pelvic fractures, but a 1.1% increase in hip and pelvic complications correlated with only an increase of $100 in reimbursements. This study is the first to show that Medicare payments are not strongly correlated with complications, therefore demonstrating the potential risks of a bundled payment system for orthopaedic trauma surgeons.

Purpose of Review: Coronary artery calcium (CAC) has been proposed as an integrator of information from traditionally measured, non-traditionally measured, and unmeasured risk factors for coronary atherosclerosis. The 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk identified several knowledge gaps regarding CAC, including radiation risks, cost-effectiveness, and improving discrimination and reclassification of estimated risk over the Pooled Cohort Equations in the ACC/AHA Atherosclerotic Cardiovascular Disease Estimator. In this review, we focus on recent CAC literature addressing these knowledge gaps. We further highlight the potential for CAC to enrich future randomized controlled trials., Recent Findings: The use of CAC allows for personalization of cardiovascular risk despite the presence or absence of traditional risk factors across many demographics. Avenues to reduce radiation exposure associated with CAC scanning include increasing the interval between scans for those with CAC scores of zero and estimating CAC from non-cardiac gated CT scans. While limited studies have suggested cost-effectiveness in cardiac risk assessment with the incorporation of CAC in screening algorithms, several studies have demonstrated the ability of CAC to identify non-traditional risk factors that may be used to expand cardiovascular risk personalization in other high-risk populations. Literature from the past 2 years further supports CAC as a strong marker to personalize cardiac risk assessment. While multiple potential avenues to reduce radiation are available and cost-effectiveness analyses are encouraging, further studies are necessary to clarify patient selection for CAC scanning given the interplay between CAC and other imaging modalities in risk personalization algorithms.

The objective of this study was to determine the clinical factors that are predictors for intraoperative transfusion in orthopaedic trauma patients. A retrospective chart review of patients admitted to a level I trauma center with isolated fractures was conducted. Variables such as gender, height, weight, body mass index, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were assessed to determine likelihood of blood transfusion. A total of 1819 patients with isolated fractures were identified. ASA class was strongly associated with patients receiving intraoperative blood transfusion. For example, compared with patients with an ASA class I, patients with an ASA class IV were 14.71 times more likely to receive transfusion. Patients' ASA class is correlated with the need for intraoperative blood transfusion in patients undergoing orthopaedic surgery for isolated fractures. Institutional or departmental maximum surgical blood order schedule algorithms could use patients' preoperative ASA class to determine whether blood transfusion will be necessary during procedures.

Purpose: As US healthcare expenditures continue to rise, there is significant pressure to reduce the cost of inpatient medical services. Studies have estimated that over 70% of routine labs may not yield clinical benefits while adding over $300 in costs per day for every inpatient. Although orthopaedic trauma patients tend to have longer inpatient stays and hip fractures have been associated with significant morbidity, there is a dearth of data examining pre-operative labs in predicting post-operative adverse events in these populations. The purpose of this study was to assess whether pre-operative labs significantly predict post-operative cardiac and septic complications in orthopaedic trauma and hip fracture patients., Methods: Between 2006 and 2013, 56,336 (15.6%) orthopaedic trauma patients were identified and 27,441 patients (7.6%) were diagnosed with hip fractures. Pre-operative labs included sodium, BUN, creatinine, albumin, bilirubin, SGOT, alkaline phosphatase, white count, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. For each of these labs, patients were deemed to have normal or abnormal values. Patients were noted to have developed cardiac or septic complications if they sustained (1) myocardial infarction (MI), (2) cardiac arrest, or (3) septic shock within 30 days after surgery. Separate regressions incorporating over 40 patient characteristics including age, gender, pre-operative comorbidities, and labs were performed for orthopaedic trauma patients in order to determine whether pre-operative labs predicted adverse cardiac or septic outcomes., Results: 749 (1.3%) orthopaedic trauma patients developed cardiac complications and 311 (0.6%) developed septic shock. Multivariate regression demonstrated that abnormal pre-operative platelet values were significantly predictive of post-operative cardiac arrest (OR: 11.107, p=0.036), and abnormal bilirubin levels were predictive (OR: 8.487, p=0.008) of the development of septic shock in trauma patients. In the hip fracture cohort, abnormal partial thromboplastin time was significantly associated with post-operative myocardial infarction (OR: 15.083, p=0.046), and abnormal bilirubin (OR: 58.674, p=0.002) significantly predicted the onset of septic shock., Conclusions: This is the first study to demonstrate the utility of pre-operative labs in predicting perioperative cardiac and septic adverse events in orthopaedic trauma and hip fracture patients. Particular attention should be paid to haematologic/coagulation labs (platelets, PTT) and bilirubin values., Level of Evidence: Prognostic Level II., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The objective of this study was to compare complication rates and costs of staged columnar fixation (SCF) to external fixation for bicondylar tibial plateau fractures. Patients who received SCF or temporary external fixation across a 3-year period at a major level I trauma center underwent a retrospective chart review for associated complications. Fisher's exact analysis was used to determine any statistical difference in complication rates between both groups. However, there was no significant difference in complication rates between the SCF and external fixator groups. Average medial plate costs for SCF were $2131 compared with an average external fixator cost of $4070 (p < .0001). Given that all patients with external fixation undergo eventual medial and lateral plating, savings with SCF include $4070 plus operative costs for removing the fixator. As our health care system focuses on cost-cutting efforts, orthopaedic trauma surgeons must explore cheaper and equally effective treatment alternatives.

Purpose: Cardiovascular complications constitute morbidity and mortality for hip fracture patients. Relatively little data exist exploring risk factors for post-operative complications. Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database, we identified significant risk factors associated with adverse cardiac events in hip fracture patients and provide recommendations for practising orthopaedists., Methods: A cohort of 27,441 patients with hip fractures from 2006 to 2013 was identified using Current Procedural Terminology codes. Cardiac complications were defined as cardiac arrests or myocardial infarctions occurring within 30 days after surgery. Bivariate analysis was run on over 30 patient and surgical factors to determine significant associations with cardiac events. Multivariate logistical analysis was then performed to determine risk factors most predictive for cardiac events., Results: Of the 27,441 hip fracture patients, 594 (2.2%) had cardiac complications within 30 days post-operatively. There was no significant association with respect to type of hip fracture surgery and adverse cardiac event rates (p = 0.545). After multivariate analysis, dialysis use (OR: 2.22, p = 0.026), and histories of peripheral vascular disease (OR: 2.11, p = 0.016), stroke (OR: 1.83, p = 0.009), COPD (OR: 1.69, p = 0.014), and cardiac disease (OR: 1.55, p = 0.017) were significantly predictive of post-operative cardiac events in all hip fracture patients., Conclusion: Orthopaedic trauma surgeons should be aware of cardiac disease history and atherosclerotic conditions (PVD, stroke) in risk stratifying patients to prevent cardiac complications. Our recommendations to reduce cardiac events include simple pre-operative lab-work to full-fledged cardiac work-up and referrals to specific medicine disciplines based on the specific risk factors present.

The purpose of this study was to investigate operative costs and postoperative complication rates in relation to utilization of locking versus nonlocking implants in isolated, lower limb fractures. Seventy-seven patients underwent plate fixation of isolated bicondylar tibial plateau, bimalleolar ankle, and trimalleolar ankle fractures at a large tertiary care center. Fixation with locking versus nonlocking implants was compared to incidence of postsurgical complications. Costs of these implants were directly compared. No significant correlation was found between locking versus nonlocking implants and incidence of complications. However, the cost of fixation with locking implants was significantly greater than nonlocking for all fractures. Utilization of more costly locking implants was not associated with reduced postoperative complications compared with nonlocking implants. More attention must be dedicated toward maximizing cost efficiency, since uniform usage of nonlocking implants has the potential to reduce surgical costs without compromising patient outcomes in isolated lower extremity fractures.

Length of stay (LOS) drives costs for hip fracture patients. One factor that affects LOS is delayed transfer of patients to rehabilitation centers. It is therefore imperative that orthopedists have a mechanism for identifying which patients require rehabilitation services after surgery. We conducted a study to identify patient risk factors that are significantly associated with discharge to rehabilitation. Using 2011 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) data, we prospectively analyzed the cases of 4815 patients who underwent hip fracture surgery and had discharge information available. Discharge location, surgery type, patient demographics, 32 patient comorbidities, and 7 operative factors were identified in these patients. Fisher exact tests were used to determine which patient factors were significantly associated with discharge to rehabilitation. Of the 4815 patients, 80.3% were discharged to rehabilitation and 19.7% to home. After multivariable analysis, age over 65 years, female sex, dialysis, prior percutaneous coronary intervention, hypertension, general anesthesia, and ASA (American Society of Anesthesiologists) class higher than 2 had higher odds of discharge to rehabilitation, and DNR (do not resuscitate) status had higher odds of discharge to home. This study was the first to determine which factors predicted discharge to rehabilitation in hip fracture patients. Knowing these risk factors provides orthopedists with a mechanism that can be used to identify which patients require rehabilitation after surgery, thereby facilitating transfer and potentially decreasing LOS and associated costs.

Purpose: Deep venous thrombi (DVT) and pulmonary emboli (PE) are common complications in hip fracture patients. It is imperative that orthopaedists know the patient risk factors for DVT and PE, including if type of surgery plays a role. To this end, we used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify significant risk factors., Methods: From the 2006-2011 ACS NSQIP database, 27,441 patients with hip fractures were identified using a Current Procedural Terminology (CPT) code search. DVT and PE complications, type of surgery based on CPT code, patient demographics, medical comorbidities and operative factors were identified for each patient. Fisher's exact tests were used to (1) determine if rates of DVT and PE significantly differed based on type of surgery and (2) identify significant associations between patient factors and development of DVT/PE. These significant factors were then used as covariates in multivariable analysis to determine which risk factors predicted postoperative DVT/PE., Results: Of the 27,441 hip fracture patients, 449 (1.6 %) developed DVT/PE. There was a significant difference in rates of DVT/PE based on surgery (p = 0.015): patients undergoing intramedullary nailing of inter-/peri-/subtrochanteric femoral fractures had the highest rates of DVT/PE (2.06 %). After multivariate analysis, renal failure and recent surgery were significant risk factors for DVT/PE., Conclusions: This study was the first to show through large, multicentre, prospective data that type of hip fracture surgery impacts rates of DVT/PE. We further identified two additional risk factors orthopaedists should be aware of. Knowing these risk factors will help in peri-operative planning to reduce complications.

Aim: To investigate inpatient length of stay (LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach., Methods: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach (open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists' score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher's exact and non-parametric t-tests (Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches., Results: Ninety-four patients with isolated sacral fractures were identified: 31 (30.4%) who underwent open reduction and internal fixation (ORIF) vs 63 (67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients (P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups (19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups (9.5% percutaneous vs 6.5% ORIF)., Conclusion: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.

The use of antibiotic prophylaxis and debridement is controversial when treating low- and high-velocity gunshot-induced fractures, and established treatment guidelines are currently unavailable. The purpose of this review was to evaluate the literature for the prophylactic antibiotic and debridement policies for (1) low-velocity gunshot fractures of the extremities, joints, and pelvis and (2) high-velocity gunshot fractures of the extremities. Low-velocity gunshot fractures of the extremities were subcategorized into operative and non-operative cases, whereas low-velocity gunshot fractures of the joints and pelvis were evaluated based on the presence or absence of concomitant bowel injury. In the absence of surgical necessity for fracture care such as concomitant absence of gross wound contamination, vascular injury, large soft-tissue defect, or associated compartment syndrome, the literature suggests that superficial debridement for low-velocity ballistic fractures with administration of antibiotics is a satisfactory alternative to extensive operative irrigation and debridement. In operative cases or those involving bowel injuries secondary to pelvic fractures, the literature provides support for and against extensive debridement but does suggest the use of intravenous antibiotics. For high-velocity ballistic injuries, the literature points towards the practice of extensive immediate debridement with prophylactic intravenous antibiotics. Our systematic review demonstrates weak evidence for superficial debridement of low-velocity ballistic fractures, extensive debridement for high-velocity ballistic injuries, and antibiotic use for both types of injury. Intra-articular fractures seem to warrant debridement, while pelvic fractures with bowel injury have conflicting evidence for debridement but stronger evidence for antibiotic use. Given a relatively low number of studies on this subject, we recommend that further high-quality research on the debridement and antibiotic use for gunshot-induced fractures of the extremities should be conducted before definitive recommendations and guidelines are developed.

In an era of concern over the rising cost of health care, cost-effectiveness of auxiliary services merits careful evaluation. We compared costs and benefits of Helicopter Emergency Medical Service (HEMS) with Ground Emergency Medical Service (GEMS) in patients with an isolated ankle fracture. A medical record review was conducted for patients with an isolated ankle fracture who had been transported to a level 1 trauma center by either HEMS or GEMS from January 1, 2000 to December 31, 2010. We abstracted demographic data, fracture grade, complications, and transportation mode. Transportation costs were obtained by examining medical center financial records. A total of 303 patients was included in the analysis. Of 87 (28.71%) HEMS patients, 53 (60.92%) had sustained closed injuries and 34 (39.08%) had open injuries. Of the 216 (71.29%) GEMS patients, 156 (72.22%) had closed injuries and 60 (27.78%) had open injuries. No significant difference was seen between the groups regarding the percentage of patients with open fractures or the grade of the open fracture (p = .07). No significant difference in the rate of complications was found between the 2 groups (p = 18). The mean baseline cost to transport a patient via HEMS was $10,220 + a $108/mile surcharge, whereas the mean transport cost using GEMS was $976 per patient + $16/mile. Because the HEMS mode of emergency transport did not significantly improve patient outcomes, health systems should reconsider the use of HEMS for patients with isolated ankle fractures., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study is to investigate how the Charlson Comorbidity Index (CCI) scores contribute to increased length of stay (LOS) and healthcare costs in hip fracture patients., Materials and Methods: Through retrospective analysis at an Urban level I trauma center, charts for all patients over the age of 60 years who presented with low-energy hip fracture were evaluated. 615 patients who underwent operative fixation of hip fracture or hemiarthroplasty secondary to hip fracture were identified using Current Procedural Terminology (CPT) codes search and included in the study. Data was collected on patient demographics, medical comorbidities, and hospitalization length; from this, the CCI score and the cost to the institution (with an average cost/day of inpatient stay of $4,530) were calculated., Results: Multivariate linear regression analysis modeled the length of stay as a function of CCI score. Each unit increase in the CCI score corresponded to an increase in length of hospital stay and hospital costs incurred [effect size = 0.21; (0.0434-0.381); p = 0.014]. Patients with a CCI score of 2 (compared to a baseline CCI score of 0), on average, stayed 1.92 extra days in the hospital, and incurred $8,697.60 extra costs., Conclusions: The CCI score is associated with length of stay and hospital costs incurred following treatment for hip fracture. The CCI score may be a useful tool for risk assessment in bundled payment plans., Level of Evidence: Level III.

Objectives: As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. We therefore sought to determine financial risks under bundled payments by identifying adverse event rates for (1) orthopaedic trauma patients compared with general orthopaedic patients and (2) based on anatomic region and (3) to identify patient factors associated with complications., Design: Prospective., Setting: Multicenter., Patients/participants: A total of 146,773 orthopaedic patients (22,361 trauma) from 2005 to 2011 NSQIP data were identified., Interventions: Minor and major adverse events, demographics, surgical variables, and patient comorbidities were collected., Main Outcome Measurements: Multivariate regressions determined significant risk factors for the development of complications., Results: The complication rate in the trauma group was 11.4% (2554/22,361) versus 4.1% (5137/124,412) in the general orthopaedic group (P = 0.001). When controlling for all variables, trauma was a risk factor for developing complications [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.57-1.81]. After controlling for several patient factors, hip and pelvis patients were 4 times more likely to develop any perioperative complication than upper extremity patients (OR: 3.79, 95% CI: 3.01-4.79, P = 0.01). Lower extremity patients are 3 times more likely to develop any complication versus upper extremity patients (OR: 2.82, 95% CI: 2.30-3.46, P = 0.01)., Conclusions: Our study is the first to show that orthopaedic trauma patients are 2 times more likely than general orthopaedic patients to sustain complications, despite controlling for identical risk factors. There is also an alarming difference in complication rates among anatomic regions. Orthopaedic trauma surgeons will face increased financial risk with bundled payments., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Violence has recently been reported among a primarily young, minority population in Nashville, Tennessee. School-based programs have been proven as effective methods of reducing violent behavior, beliefs, and actions that lead to violence among adolescents., Methods: Investigators implemented a rigorous search for an appropriate school-based violence prevention program for Metropolitan Nashville middle school students utilizing a systematic review and discussion group with victims of violence. 27 programs nation-wide were reviewed and 2 discussion groups with African American males under the age of 25 admitted to a level 1 trauma center for assault-related injuries were conducted. Our findings led to a single, evidence-based conflict resolution program. In conjunction with educators, we evaluated the program's effectiveness in a pilot study in a Nashville middle school with high rates of violence., Results: 122 students completed the conflict resolution program and described their behavior and experiences with violence in a pre-test/post-test self-rate questionnaire. Results showed a significant decrease in violent behavior and an increase in students' competencies to deal with violence (p less than 0.05)., Conclusions: This study shows that a reduction in violent behavior and beliefs among middle school students can be achieved through the implementation of a targeted violence intervention program. A larger-scale intervention is needed to develop more conclusive evidence of effectiveness., (© 2015 KUMS, All rights reserved.)

Hip fractures are the most costly fall-related fractures. Differences in hospital length of stay (LOS) based on type of surgery could have major financial implications in a potential bundled payment system in which all hip fractures are reimbursed a standard amount. We conducted a study to analyze differences in hospital LOS and costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing, open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP). Through retrospective chart review, 615 patients over age 60 years across a 9-year period at an urban level I trauma center were identified. Mean LOS and costs for hip fracture repair were 6.91 days and $30,011.25, respectively. HA/THA was associated with the longest mean LOS (7.43 days) and highest costs ($33,657.90). After several patient factors were adjusted for, ORIF was associated with 0.84 fewer in-patient days and $3805.20 less in hospitalization costs compared with HA/THA (P=.042). CRPP was associated with 1.63 fewer days and $7383.90 less in costs than HA/THA (P=.0076). Our results provide insight into the financial implications of hip fracture fixation and identify targets for quality improvement initiatives to improve efficiency of resource utilization.

Objectives: Although recent literature has demonstrated the utility of the ASA score in predicting postoperative length of stay, complication risk and potential utilization of other hospital resources, the ASA score has been inconsistently assigned by anaesthesia providers. This study tested the reliability of assignment of the ASA score classification by both attending anaesthesiologists and anaesthesia residents specifically among the orthopaedic trauma patient population., Methods: Nine case-based scenarios were created involving preoperative patients with isolated operative orthopaedic trauma injuries. The cases were created and assigned a reference score by both an attending anaesthesiologist and orthopaedic trauma surgeon. Attending and resident anaesthesiologists were asked to assign an ASA score for each case. Rater versus reference and inter-rater agreement amongst respondents was then analyzed utilizing Fleiss's Kappa and weighted and unweighted Cohen's Kappa., Results: Thirty three individuals provided ASA scores for each of the scenarios. The average rater versus reference reliability was substantial (Kw=0.78, SD=0.131, 95% CI=0.73-0.83). The average rater versus reference Kuw was also substantial (Kuw=0.64, SD=0.21, 95% CI=0.56-0.71). The inter-rater reliability as evaluated by Fleiss's Kappa was moderate (K=0.51, p<.001). An inter-rater comparison within the group of attendings (K=0.50, p<.001) and within the group of residents were both moderate (K=0.55, p<.001). There was a significant increase in the level of inter-rater reliability from the self-reported 'very uncomfortable' participants to the 'very comfortable' participants (uncomfortable K=0.43, comfortable K=0.59, p<.001)., Conclusions: This study shows substantial agreement strength for reliability of the ASA score among anaesthesiologists when evaluating orthopaedic trauma patients. The significant increase in inter-rater reliability based on anaesthesiologists' comfort with the ASA scoring method implies a need for further evaluation of ASA assessment training and routine use on the ground. These findings support the use of the ASA score as a statistically reliable tool in orthopaedic trauma., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: Hip fractures are one of the most common types of orthopaedic injury with high rates of morbidity. Currently, no study has compared risk factors and adverse events following the different types of hip fracture surgeries. The purpose of this paper is to investigate the major and minor adverse events and risk factors for complication development associated with five common surgeries for the treatment of hip fractures using the NSQIP database., Methods: Using the ACS-NSQIP database, complications for five forms of hip surgeries were selected and categorized into major and minor adverse events. Demographics and clinical variables were collected and an unadjusted bivariate logistic regression analyses was performed to determine significant risk factors for adverse events. Five multivariate regressions were run for each surgery as well as a combined regression analysis., Results: A total of 9640 patients undergoing surgery for hip fracture were identified with an adverse events rate of 25.2% (n=2433). Open reduction and internal fixation of a femoral neck fracture had the greatest percentage of all major events (16.6%) and total adverse events (27.4%), whereas partial hip hemiarthroplasty had the greatest percentage of all minor events (11.6%). Mortality was the most common major adverse event (44.9-50.6%). For minor complications, urinary tract infections were the most common minor adverse event (52.7-62.6%). Significant risk factors for development of any adverse event included age, BMI, gender, race, active smoking status, history of COPD, history of CHF, ASA score, dyspnoea, and functional status, with various combinations of these factors significantly affecting complication development for the individual surgeries., Conclusions: Hip fractures are associated with significantly high numbers of adverse events. The type of surgery affects the type of complications developed and also has an effect on what risk factors significantly predict the development of a complication. Concerted efforts from orthopaedists should be made to identify higher risk patients and prevent the most common adverse events that occur postoperatively., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objectives: To compare patient satisfaction between telemedicine and in-person follow-up appointments for orthopedic trauma., Design: Prospective randomized controlled trial (pilot study)., Setting: Level I trauma center., Patients/participants: Twenty-four patients were enrolled and randomized into 2 groups. Eight patients who had telemedicine follow-up appointments and 9 who had in-person follow-up visits were included in a per-protocol analysis. In the telemedicine group, 2 patients left the study because of nonadherence, 1 patient withdrew because of a weak Internet connection, and 1 patient sustained an open fracture. Three control patients left the study because of nonadherence., Intervention: The patients had 4 follow-up appointments during a 6-month period. Patients either had their 6-week and 6-month follow-ups through video calls or in the clinic., Main Outcome Measurements: After 6-week and 6-month follow-up appointments, the patients were given survey questions that were developed using literature-supported methods to compare follow-up experiences. The patients were monitored for complications., Results: There was no significant difference in patient satisfaction between telemedicine and in-person clinic visits (telemedicine: 89% satisfied; control: 100% satisfied; P = 0.74). Zero percent of patients in the telemedicine group took time off their work for their appointment compared with 55.6% in the control (P = 0.03). Telemedicine patients spent significantly less time on their visits (P = 0.01). The majority of the patients in the telemedicine group reported clear visual (87.5%) and sound quality (100%) through and agreed to future follow-up visits through telemedicine (75.0%). One patient in each group developed complications., Conclusions: Telemedicine may be a viable alternative to some in-person clinic visits because of similar measures of patient satisfaction but with significantly less time and distance traveled., Level of Evidence: Therapeutic level II. See Instructions for authors for a complete description of levels of evidence.

Objective: Our purpose was to identify the impact of the physical status of the American Society of Anesthesiologists (ASA) on the 30-day readmission of patients receiving operative management of orthopaedic fractures using the National Surgical Quality Improvement Program (NSQIP) database., Methods: We analyzed all patients with orthopaedic trauma injuries in the American College of Surgeons NSQIP database from 2005 to 2011. A total of 8761 patients representing 91 orthopaedic trauma procedures were identified and included in analysis after selection. Logistic regressions were conducted to identify the predictive ability of ASA on the likelihood of readmission for patients in each anatomic category (upper extremity, pelvis/acetabulum, lower extremity) and the combined study population., Results: The ASA physical status proved the strongest predictor of 30-day readmission for the selected orthopaedic trauma procedures. After controlling for age, gender, race, and medical comorbidities that were shown to be significant independent risk factors for readmission, ASA score continued to have a significant association on 30-day readmissions in the combined population (odds ratio = 1.45, 95% confidence interval = 1.13-1.88, P = 0.001). For the combined analysis, compared with patients with an ASA score of 1, patients with an ASA score of 2 were 1.04 times as likely to have a readmission (P = 0.001), patients with an ASA score of 3 were 3.77 times as likely to have a readmission (P = 0.001), and patients with an ASA score of 4 were 13.7 times as likely to have a readmission (P = 0.001)., Conclusions: ASA classification is an indicator for variance in readmission for patients receiving operative treatment of orthopaedic fractures. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. This model may be used to more accurately predict a patient's postoperative course and the expected risk for readmission, such that hospitals can target these "at-risk" individuals and reduce 30-day readmissions., Level of Evidence: Prognostic level II. See Instructions for authors for a complete description of levels of evidence.

We evaluated the operative notes for justification on the use of the 22-modifier in ankle fracture cases and compared the differences in physician billing and reimbursement. A total of 265 patients who had undergone operative management of isolated ankle fractures across a 10-year period were identified at a level I trauma center through a retrospective chart review. Of the 265 patients, 61 (23.0%) had been billed with the 22-modifier. The radiographs were reviewed by 3 surgeons to determine the complexity of the case. The amount of the professional fees and payments was obtained from the financial services department. Operative reports were reviewed for inclusion of eight 22-modifier criteria and word count. Mann-Whitney U tests of means were used to compare cases with and without the 22-modifier. From our analysis of preoperative radiographs, 37 (60%) showed evidence of a significantly complex fracture that justified the use of the 22-modifier. A review of the operative reports showed that 42 (68%) did not identify 2 or more reasons for requesting the 22-modifier in the report. Overall, the 22-modifier cases were not always reimbursed significantly greater amounts than the nonmodifier cases. No significant difference in the average word count of the operative notes was found. We have concluded that orthopedic trauma surgeons do not appropriately justify the use of the 22-modifier within their operative report. Further education on modifiers and the use of the operative report as billing documentation is required to ensure surgeons are adequately reimbursed for difficult trauma cases., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Heterotopic ossification (HO) about the hip after total hip arthroplasty and internal fixation of the hip, pelvis, and acetabulum has been linked to surgical approach. However, no study has investigated surgical approach and HO in patients undergoing hemiarthroplasty. We therefore aimed to explore the influence of operative approach in patients undergoing hemiarthroplasty., Methods: Through a retrospective case series at an Urban level I trauma center, we found 80 patients over the age of 60 undergoing hemiarthroplasty for femoral neck fractures from 2000 to 2009. Patient charts, operative notes, and radiographs were reviewed for demographics, operative approach (anterior: A, anterior-lateral: AL, posterior: P), and any development of HO. Fisher's exact test compared rates of HO among the three approaches. Student's t-tests compared Brooker Classification levels of HO among the approaches., Results: 82 hemiarthroplasties (26 A, 32 AL, 24 P) were included for analysis. 22 patients (27%) had HO. There was no significant difference in the development of HO based upon surgical approach: A: 19% (n = 5); AL: 34% (n = 11); P: 25% (n = 6). There was a significant difference in the grade of HO based on Brooker Classification (BC) with the posterior approach resulting in significantly lower grade of HO: A (BC: 2.60); AL (BC: 2.64); P (BC: 1.50) (p = 0.012)., Conclusions: Our data is the first to evaluate surgical approach and HO in patients with hemiarthroplasty. Patients have a significant risk of developing higher grade HO based on surgical approach (A or AL). Orthopedists should be mindful of these risks when considering A or AL approaches.

Objectives: Healthcare reimbursement models are changing. Fee-for-service may be replaced by pay-for-performance or capitated care. The purpose of this study was to examine the potential changes in orthopaedic trauma surgery patient management based on potential shifts in policy surrounding readmission and reimbursement., Methods: An e-mail survey consisting of 3 case-based scenarios was delivered to 375 orthopaedic surgeons. Five options for management of each case were provided. Each of the 3 cases was presented in 3 different healthcare settings: scenario A, our current healthcare setting; scenario B, in which 90-day reoperation or readmission would not be reimbursed; and scenario C, in which a capitated healthcare structure paid a fixed amount per patient., Results: The response rate was 40.3% with 151 surgeons completing the survey. A 71.1% of the respondents were in private practice settings, whereas 28.3% were in academic centers. In each case, there was significant increase in the respondents' choice to transfer patients to tertiary care centers under both the capitated and penalization systems as compared with the current fee-for-service model., Conclusions: This survey is the first of its kind to demonstrate through case-based scenarios that a healthcare system with readmission penalties and capitated reimbursement models may lead to a significant increase in transfer of complex orthopaedic trauma patients to tertiary care centers. Physicians should be encouraged to continue evidence-based medicine instead of making decisions due to finances, and other avenues of healthcare savings should be explored to decrease patient transfer rates with healthcare changes.

Purpose: Ankle fractures, one of the most common types of orthopaedic injury, have been associated with reduced functional outcome and significant changes in long-term employment. Although information on unemployment following ankle fractures can be important in cases of financial compensation, no studies have investigated rates of short-term disability and employment status among patients who have suffered isolated ankle fractures in the US., Method: We retrospectively reviewed 573 medical charts for patients who were treated for ankle fractures in the last 3 years at a level I trauma center. A total of 83 non-elderly patients that had isolated ankle fractures were contacted and surveyed over the phone. Patients were asked about employment history and current status, disability, type of fracture, and demographic information., Results: Fifty-three (62%) patients contacted were employed at the time of injury. In all, 34% (n = 18) of patients lost their job because of their injury, of which only 8 (44%) received new employment. A total of 15% (n = 8) of patients that were previously employed decided to no longer return to work. Ten patients (56%) received disability status., Conclusions: Ankle fracture patients are likely to suffer high rates of unemployment or disability shortly after their injury. Further investigations with a larger-scale, randomized patient population can provide important information on employment status following ankle fractures.

As the American healthcare system shifts towards bundled payments, readmissions will become a measure of healthcare quality. The purpose of this study was to characterize readmission trends and factors influencing readmission in patients with diaphyseal femur and tibia fractures. Through a retrospective chart review, all patients who presented to a level 1 trauma center from 2004 to 2006 were evaluated. By using current procedural terminology codes, 1,040 patients with diaphyseal tibia or femur fractures fixed by IMN were identified. 645 patients were included for analysis. 30-day, 60-day, and 90-day readmission rates were compared with fracture type, reason for readmission, and basic demographic information. The 60-day readmission rate for open tibia fractures (14.8%) was significantly higher than the 60-day readmission rate for closed tibia fractures (8.0%) (p = 0.037). When comparing reasons for 60-day readmissions, 50% of closed fractures were readmitted due to infection, while the other 50% needed additional surgery. 91.7% of open fractures readmitted in 60 days were due to infection. In a bundled payment system, orthopedic trauma must gain insight into drivers of readmission to identify those at risk for readmission and design effective healthcare plans for these patients.