Peri-operative Anticoagulation Strategies, Bleeding and Thrombotic Complications in Pediatric Patients Undergoing Intervention for Congenital Portosystemic Shunts.

BACKGROUND: Congenital portosystemic shunts (CPSS) are rare congenital abnormalities causing abnormal blood flow between the portal vein and systemic circulation. This study reports on the peri-operative anticoagulation management of CPSS patients post closure, focusing on the incidence of thrombotic and bleeding complications. METHODS: This is a single-center retrospective analysis of CPSS patients who underwent surgery or endovascular intervention between 2005 and 2021. The protocol included unfractionated heparin (UFH) during and immediately after surgery, followed by either warfarin or low molecular weight heparin (LMWH) postoperatively. Outcomes assessed included postoperative thrombotic and bleeding complications. RESULTS: A total of 44 patients were included. Postoperatively, 89% received treatment-dose UFH, transitioning to warfarin or LMWH at discharge. Thrombotic complications occurred in 16% of patients, predominantly in the superior mesenteric vein. Surgical interventions and continuous infusion of tissue plasminogen activator (tPA) were used for clot resolution. Bleeding complications were observed in 64% of patients, primarily managed with transfusions and temporary UFH interruption. No deaths related to thrombotic, or bleeding events were reported. CONCLUSIONS: Our findings underscore the delicate balance required in anticoagulation management for CPSS patients, revealing an occurrence of both thrombotic and bleeding complications postoperatively. LEVELS OF EVIDENCE: Level II, retrospective study.

Trace metals in coastal marine sediments: Natural and anthropogenic sources, correlation matrices, and proxy potentials.

Rapidly spreading industrialization since the 19th century has led to a drastic increase in trace metal deposition in coastal sediments. Provided that these trace metals have remained relatively immobile after deposition, their sedimentary enrichments can serve as records of local-regional pollution histories. Factors controlling this proxy potential include trace metal geochemistry (carrier-, and host phase affinity), and depositional environmental factors (redox variability, particulate shuttling, organic matter loading, bathymetry). Yet, the relative importance and interactions between these controls are still poorly understood, hampering the reliable use of trace metal-based environmental proxies. By summarizing nine site-specific correlation matrices of 16 metal (loid) s (Pb, Cd, Cu, Zn, Sb, Sn, Ni, As, Tl, V, Mo, U, Re, Fe, Mn, Al), total organic C, and S contents in short sediment cores into a single meta-matrix, we test a novel approach for quickly detecting common and contrasting trace metal enrichment patterns across different study locations. Our meta-matrix shows two trace metal groups, within which positive correlations of e.g., Pb, Cd, Zn, Cu, Sb suggest a primary "anthropogenically sourced" (group I) control, whereas known "redox-sensitive" (group II) trace metals (Mo, U, Re) are characterized by fewer positive correlations. However, some group I metals (Cd, Zn, Cu, Sb) also covary with group II metals, inferring that redox variability may obscure primary anthropogenic signals; Sb even shows advantages over Mo and U under oxic conditions. As a more robust pollution indicator we identified Pb; yet for reconstructing historical Pb atmospheric pollution signals (1970s Pb peak), it is crucial to consider the distance from shore. In near-shore environments, local (fluvial) pollution signals may overprint large-scale (atmospheric) signals. Our findings demonstrate that combining site-specific sedimentary correlation and distribution patterns with a meta-matrix considerably aids the understanding of trace metal sequestration in different coastal sedimentary environments, which thereby improves trace metal proxy reliability.

The association between maternal sleep and circadian rhythms during pregnancy and infant sleep and socioemotional outcomes.

Studies have established that maternal sleep and circadian rhythm disturbances during pregnancy are associated with poor prenatal and perinatal outcomes for mothers and offspring. However, little work has explored its effects on infant sleep or socioemotional outcomes. The current study examined the relationship between maternal sleep and circadian rhythm disturbances during pregnancy and infant sleep and socioemotional outcomes in a diverse sample of N = 193 mothers and their infants (51% White; 52% Female; Mage = 11.95 months). Maternal sleep and circadian rhythms during pregnancy were assessed using self-reports and actigraphy. Mothers reported on infants' sleep and socioemotional outcomes when infants were one year old. When controlling for infant sex, age, gestational age at birth, family income-to-needs ratios, and maternal depression, mothers who reported more sleep problems during pregnancy had infants with more sleep disturbances when they were one year old. Moreover, mothers who had later sleep timing (i.e., went to bed and woke up later, measured via actigraphy) during pregnancy had infants with more dysregulation (e.g., increased feeding difficulties, sensory sensitivities) and externalizing problems, and mothers with increased intra-daily variability in rest-activity rhythms (as measured via actigraphy) had infants with more externalizing problems. Findings suggest that maternal sleep and circadian rhythm disturbances during pregnancy may be a risk factor for infant sleep problems and socioemotional difficulties.

Physical and Cognitive Function Trends in Post-acute Care After Total Joint Arthroplasty in Medicare Beneficiaries: 2013-2018.

OBJECTIVES: Physical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018. DESIGN: Observational study using Medicare enrollment, claims, and assessment data from 2013-2018. SETTING AND PARTICIPANTS: 1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018. METHODS: Medicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013-2018) by estimating multivariable models that controlled for patient- and hospital-level covariates. RESULTS: Multivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)-21.57% (2018), P < .001], HHA increased (46.72%-72.47%, P < .001), and IRF decreased (9.13%-5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)-14.23 (2018), P < .001] and cognitive impairment (13.25%-12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09-3.94, P < .001) and cognitive impairment (13.95%-16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81-37.78, P < .001) and cognitive dependence increased (39.08%-46.36%, P < .001), indicating greater dependence. CONCLUSIONS AND IMPLICATIONS: From 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

Effects of clinically relevant radionuclides on the activation of a type I interferon response by radiopharmaceuticals in syngeneic murine tumor models.

Radiopharmaceutical therapies (RPT) activate a type I interferon (IFN1) response in tumor cells. We hypothesized that the timing and amplitude of this response varies by isotope. We compared equal doses delivered by 90 Y, 177 Lu, and 225 Ac in vitro as unbound radionuclides and in vivo when chelated to NM600, a tumor-selective alkylphosphocholine. Response in murine MOC2 head and neck carcinoma and B78 melanoma was evaluated by qPCR and flow cytometry. Therapeutic response to 225 Ac-NM600+anti-CTLA4+anti-PD-L1 immune checkpoint inhibition (ICI) was evaluated in wild-type and stimulator of interferon genes knockout (STING KO) B78. The timing and magnitude of IFN1 response correlated with radionuclide half-life and linear energy transfer. CD8 + /Treg ratios increased in tumors 7 days after 90 Y- and 177 Lu-NM600 and day 21 after 225 Ac-NM600. 225 Ac-NM600+ICI improved survival in mice with WT but not with STING KO tumors, relative to monotherapies. Immunomodulatory effects of RPT vary with radioisotope and promote STING-dependent enhanced response to ICIs in murine models. Teaser: This study describes the time course and nature of tumor immunomodulation by radiopharmaceuticals with differing physical properties.

Prison food and the carceral experience: a systematic review.

PURPOSE: This study aims to focus on studies that qualitatively explore prison food experience. The goal is to elaborate a framework to better understand how prison food shapes the worldwide carceral experience. DESIGN/METHODOLOGY/APPROACH: This systematic literature review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. It consists of four phases: identifying the studies, screening the studies, evaluating the eligibility of screened studies and inclusion of studies. After the four phases, ten studies (nine qualitative studies and one with mixed methods) were included in the review. FINDINGS: There is a consensus among the researchers in the reviewed literature that prison food shapes the carceral experience. More specifically, four themes that encompass the experience of people with prison food emerged from the reviewed literature: food appreciation (taste of the prison food and perceived nutritional value), food logistics (preparation, distribution and consumption), food variety (institutional menu and commissary store) and food relationships (symbol of caring or power or punishment). ORIGINALITY/VALUE: The literature reviewed demonstrated that when incarcerated individuals have a negative view of prison food, the carceral experience is negatively impacted. This systematic review identified four dimensions that encompass the food experience within the prison environment, providing a framework for navigating this subject.

Sirtuin E deacetylase is required for full virulence of Aspergillus fumigatus.

Aspergillus fumigatus represents a public health problem due to the high mortality rate in immunosuppressed patients and the emergence of antifungal-resistant isolates. Protein acetylation is a crucial post-translational modification that controls gene expression and biological processes. The strategic manipulation of enzymes involved in protein acetylation has emerged as a promising therapeutic approach for addressing fungal infections. Sirtuins, NAD+-dependent lysine deacetylases, regulate protein acetylation and gene expression in eukaryotes. However, their role in the human pathogenic fungus A. fumigatus remains unclear. This study constructs six single knockout strains of A. fumigatus and a strain lacking all predicted sirtuins (SIRTKO). The mutant strains are viable under laboratory conditions, indicating that sirtuins are not essential genes. Phenotypic assays suggest sirtuins' involvement in cell wall integrity, secondary metabolite production, thermotolerance, and virulence. Deletion of sirE attenuates virulence in murine and Galleria mellonella infection models. The absence of SirE alters the acetylation status of proteins, including histones and non-histones, and triggers significant changes in the expression of genes associated with secondary metabolism, cell wall biosynthesis, and virulence factors. These findings encourage testing sirtuin inhibitors as potential therapeutic strategies to combat A. fumigatus infections or in combination therapy with available antifungals.

Eutrophication and Deoxygenation Drive High Methane Emissions from a Brackish Coastal System.

Coastal environments are a major source of marine methane in the atmosphere. Eutrophication and deoxygenation have the potential to amplify the coastal methane emissions. Here, we investigate methane dynamics in the eutrophic Stockholm Archipelago. We cover a range of sites with contrasting water column redox conditions and rates of organic matter degradation, with the latter reflected by the depth of the sulfate-methane transition zone (SMTZ) in the sediment. We find the highest benthic release of methane (2.2-8.6 mmol m-2 d-1) at sites where the SMTZ is located close to the sediment-water interface (2-10 cm). A large proportion of methane is removed in the water column via aerobic or anaerobic microbial pathways. At many locations, water column methane is highly depleted in 13C, pointing toward substantial bubble dissolution. Calculated and measured rates of methane release to the atmosphere range from 0.03 to 0.4 mmol m-2 d-1 and from 0.1 to 1.7 mmol m-2 d-1, respectively, with the highest fluxes at locations with a shallow SMTZ and anoxic and sulfidic bottom waters. Taken together, our results show that sites suffering most from both eutrophication and deoxygenation are hotspots of coastal marine methane emissions.

Equine Endothelial Cells Show Pro-Angiogenic Behaviours in Response to Fibroblast Growth Factor 2 but Not Vascular Endothelial Growth Factor A.

Understanding the factors which control endothelial cell (EC) function and angiogenesis is crucial for developing the horse as a disease model, but equine ECs remain poorly studied. In this study, we have optimised methods for the isolation and culture of equine aortic endothelial cells (EAoECs) and characterised their angiogenic functions in vitro. Mechanical dissociation, followed by magnetic purification using an anti-VE-cadherin antibody, resulted in EC-enriched cultures suitable for further study. Fibroblast growth factor 2 (FGF2) increased the EAoEC proliferation rate and stimulated scratch wound closure and tube formation by EAoECs on the extracellular matrix. Pharmacological inhibitors of FGF receptor 1 (FGFR1) (SU5402) or mitogen-activated protein kinase (MEK) (PD184352) blocked FGF2-induced extracellular signal-regulated kinase 1/2 (ERK1/2) phosphorylation and functional responses, suggesting that these are dependent on FGFR1/MEK-ERK signalling. In marked contrast, vascular endothelial growth factor-A (VEGF-A) had no effect on EAoEC proliferation, migration, or tubulogenesis and did not promote ERK1/2 phosphorylation, indicating a lack of sensitivity to this classical pro-angiogenic growth factor. Gene expression analysis showed that unlike human ECs, FGFR1 is expressed by EAoECs at a much higher level than both VEGF receptor (VEGFR)1 and VEGFR2. These results suggest a predominant role for FGF2 versus VEGF-A in controlling the angiogenic functions of equine ECs. Collectively, our novel data provide a sound basis for studying angiogenic processes in horses and lay the foundations for comparative studies of EC biology in horses versus humans.

Sulfide Toxicity as Key Control on Anaerobic Oxidation of Methane in Eutrophic Coastal Sediments.

Coastal zones account for 75% of marine methane emissions, despite covering only 15% of the ocean surface area. In these ecosystems, the tight balance between methane production and oxidation in sediments prevents most methane from escaping into seawater. However, anthropogenic activities could disrupt this balance, leading to an increased methane escape from coastal sediments. To quantify and unravel potential mechanisms underlying this disruption, we used a suite of biogeochemical and microbiological analyses to investigate the impact of anthropogenically induced redox shifts on methane cycling in sediments from three sites with contrasting bottom water redox conditions (oxic-hypoxic-euxinic) in the eutrophic Stockholm Archipelago. Our results indicate that the methane production potential increased under hypoxia and euxinia, while anaerobic oxidation of methane was disrupted under euxinia. Experimental, genomic, and biogeochemical data suggest that the virtual disappearance of methane-oxidizing archaea at the euxinic site occurred due to sulfide toxicity. This could explain a near 7-fold increase in the extent of escape of benthic methane at the euxinic site relative to the hypoxic one. In conclusion, these insights reveal how the development of euxinia could disrupt the coastal methane biofilter, potentially leading to increased methane emissions from coastal zones.

Solid phase speciation controls copper mobilisation from marine sediments by methanobactin.

Although marine environments represent huge reservoirs of the potent greenhouse gas methane, they currently contribute little to global net methane emissions. Most of the methane is oxidized by methanotrophs, minimizing escape to the atmosphere. Aerobic methanotrophs oxidize methane mostly via the copper (Cu)-bearing enzyme particulate methane monooxygenase (pMMO). Therefore, aerobic methane oxidation depends on sufficient Cu acquisition by methanotrophs. Because they require both oxygen and methane, aerobic methanotrophs reside at oxic-anoxic interfaces, often close to sulphidic zones where Cu bioavailability can be limited by poorly soluble Cu sulphide mineral phases. Under Cu-limiting conditions, certain aerobic methanotrophs exude Cu-binding ligands termed chalkophores, such as methanobactin (mb) exuded by Methylosinus trichosporium OB3b. Our main objective was to establish whether chalkophores can mobilise Cu from Cu sulphide-bearing marine sediments to enhance Cu bioavailability. Through a series of kinetic batch experiments, we investigated Cu mobilisation by mb from a set of well-characterized sulphidic marine sediments differing in sediment properties, including Cu content and phase distribution. Characterization of solid-phase Cu speciation included X-ray absorption spectroscopy and a targeted sequential extraction. Furthermore, in batch experiments, we investigated to what extent adsorption of metal-free mb and Cu-mb complexes to marine sediments constrains Cu mobilisation. Our results are the first to show that both solid phase Cu speciation and chalkophore adsorption can constrain methanotrophic Cu acquisition from marine sediments. Only for certain sediments did mb addition enhance dissolved Cu concentrations. Cu mobilisation by mb was not correlated to the total Cu content of the sediment, but was controlled by solid-phase Cu speciation. Cu was only mobilised from sediments containing a mono-Cu-sulphide (CuSx) phase. We also show that mb adsorption to sediments limits Cu acquisition by mb to less compact (surface) sediments. Therefore, in sulphidic sediments, mb-mediated Cu acquisition is presumably constrained to surface-sediment interfaces containing mono-Cu-sulphide phases.

Endothelial dysfunction in neurodegenerative disease: Is endothelial inflammation an overlooked druggable target?

Neurological diseases with a neurodegenerative component have been associated with alterations in the cerebrovasculature. At the anatomical level, these are centred around changes in cerebral blood flow and vessel organisation. At the molecular level, there is extensive expression of cellular adhesion molecules and increased release of pro-inflammatory mediators. Together, these has been found to negatively impact blood-brain barrier integrity. Systemic inflammation has been found to accelerate and exacerbate endothelial dysfunction, neuroinflammation and degeneration. Here, we review the role of cerebrovasculature dysfunction in neurodegenerative disease and discuss the potential contribution of intermittent pro-inflammatory systemic disease in causing endothelial pathology, highlighting a possible mechanism that may allow broad-spectrum therapeutic targeting in the future.

Preadolescent Suicidal Thoughts and Behaviors: An Intensive Longitudinal Study of Risk Factors.

OBJECTIVE: Dramatic increases in rates of suicidal thoughts and behaviors (STBs) among youth highlight the need to pinpoint early risk factors. This study used intensive longitudinal sampling to assess what the concurrent associations were between risk factors and STB status, how proximal changes in risk factors were related to STB status, and how risk factors prospectively predicted changes in STB status in a preadolescent sample enriched for early childhood psychopathology. METHOD: A total of 192 participants were included from the Parent-Child Interaction Therapy-Emotional Development (PCIT-ED) Study, a longitudinal study of children with and without preschool depression. Participants 7 to 12 years of age completed a diagnostic interview, followed by 12 months of intensive longitudinal sampling, assessing experiences of suicidal ideation and 11 psychosocial variables with known links to STBs in adolescents and adults. Preadolescents with STB history (high-risk) received surveys weekly, and those without STB history (lower-risk) received surveys monthly. RESULTS: Female sex, elevated depressive symptoms, greater use of expressive suppression and rumination, emotional clarity, and perceived burdensomeness were uniquely concurrently associated with the likelihood of STB endorsement. Within the high-risk group, (1) increases in depression, expressive suppression, rumination, and perceived burdensomeness, and decreases in positive affect from weekt to weekt+1 were associated with a higher likelihood of a positive STB status at weekt+1; and (2) higher expressive suppression, perceived burdensomeness, and caregiver criticism and conflict at weekt compared to participants' mean levels prospectively predicted increases in the likelihood of a positive STB report from weekt to weekt+1. CONCLUSION: Psychosocial factors influencing STBs in adolescents and adults also affect preadolescents in day-to-day life. Expressive suppression and perceived burdensomeness consistently emerged as novel risk indicators and potential targets for treatment. In addition, increases in depression, rumination, and caregiver criticism and conflict, as well as decreases in positive affect, might prompt heightened STB screening and assessments for preadolescents with a history of STBs.

Factors Associated With Early Palliative Care Among Patients With Heart Failure.

Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.

Evaluation and post-transplant management of children after multi-organ-with-kidney transplantation.

Multi-organ transplantation involves the transplant of two or more organs from a single donor into a single recipient; in most cases, one of these organs is a kidney. Multi-organ transplantation is uncommon in pediatric transplantation but can be life-saving or significantly life-improving for children with rare diseases, including primary heart, liver, pancreas, or intestinal failure with secondary kidney failure, metabolic disorders, and genetic conditions causing multi-organ dysfunction. This manuscript reviews the current state of pediatric multi-organ transplantation that includes a kidney, with a focus on indications, evaluation, and key differences in management compared to kidney-alone transplantation. Guidelines and consensus statements for pediatric multi-organ transplantation are nonexistent; this review condenses reported statistics and peer-reviewed expert opinion while highlighting areas in need of further research.

Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?

BACKGROUND: The Medicare Merit-based Incentive Payment System (MIPS) ties reimbursement incentives to clinician performance to improve healthcare quality. It is unclear whether the MIPS quality score can accurately distinguish between high-performing and low-performing clinicians. QUESTIONS/PURPOSES: (1) What were the rates of unplanned hospital visits (emergency department visits, observation stays, or unplanned admissions) within 7, 30, and 90 days of outpatient orthopaedic surgery among Medicare beneficiaries? (2) Was there any association of MIPS quality scores with the risk of an unplanned hospital visit (emergency department visits, observation stays, or unplanned admissions)? METHODS: Between January 2018 and December 2019, a total of 605,946 outpatient orthopaedic surgeries were performed in New York State according to the New York Statewide Planning and Research Cooperative System database. Of those, 56,772 patients were identified as Medicare beneficiaries and were therefore potentially eligible. A further 34% (19,037) were excluded because of missing surgeon identifier, age younger than 65 years, residency outside New York State, emergency department visit on the same day as outpatient surgery, observation stay on the same claim as outpatient surgery, and concomitant high-risk or eye procedures, leaving 37,735 patients for analysis. The database does not include a list of all state residents and thus does not allow for censoring of patients who move out of state. We chose this dataset because it includes nearly all hospitals and ambulatory surgery centers in a large geographic area (New York State) and hence is not limited by sampling bias. We included 37,735 outpatient orthopaedic surgical encounters among Medicare beneficiaries in New York State from 2018 to 2019. For the 37,735 outpatient orthopaedic surgical procedures included in our study, the mean ± standard deviation age of patients was 73 ± 7 years, 84% (31,550) were White, and 59% (22,071) were women. Our key independent variable was the MIPS quality score percentile (0 to 19th, 20th to 39th, 40th to 59th, or 60th to 100th) for orthopaedic surgeons. Clinicians in the MIPS program may receive a bonus or penalty based on the overall MIPS score, which ranges from 0 to 100 and is a weighted score based on four subscores: quality, promoting interoperability, improvement activities, and cost. The MIPS quality score, which attempts to reward clinicians providing superior quality of care, accounted for 50% and 45% of the overall MIPS score in 2018 and 2019, respectively. Our main outcome measures were 7-day, 30-day, and 90-day unplanned hospital visits after outpatient orthopaedic surgery. To determine the association between MIPS quality scores and unplanned hospital visits, we estimated multivariable hierarchical logistic regression models controlling for MIPS quality scores; patient-level (age, race and ethnicity, gender, and comorbidities), facility-level (such as bed size and teaching status), surgery and surgeon-level (such as surgical procedure and surgeon volume) covariates; and facility-level random effects. We then used these models to estimate the adjusted rates of unplanned hospital visits across MIPS quality score percentiles after adjusting for covariates in the multivariable models. RESULTS: In total, 2% (606 of 37,735), 2% (783 of 37,735), and 3% (1013 of 37,735) of encounters had an unplanned hospital visit within 7, 30, or 90 days of outpatient orthopaedic surgery, respectively. Most hospital visits within 7 days (95% [576 of 606]), 30 days (94% [733 of 783]), or 90 days (91% [924 of 1013]) were because of emergency department visits. We found very small differences in unplanned hospital visits by MIPS quality scores, with the 20th to 39th percentile of MIPS quality scores having 0.71% points (95% CI -1.19% to -0.22%; p = 0.004), 0.68% points (95% CI -1.26% to -0.11%; p = 0.02), and 0.75% points (95% CI -1.42% to -0.08%; p = 0.03) lower than the 0 to 19th percentile at 7, 30, and 90 days, respectively. There was no difference in adjusted rates of unplanned hospital visits between patients undergoing surgery with a surgeon in the 0 to 19th, 40th to 59th, or 60th to 100th percentiles at 7, 30, or 90 days. CONCLUSION: We found that the rates of unplanned hospital visits after outpatient orthopaedic surgery among Medicare beneficiaries were low and primarily driven by emergency department visits. We additionally found only a small association between MIPS quality scores for individual physicians and the risk of an unplanned hospital visit after outpatient orthopaedic surgery. These findings suggest that policies aimed at reducing postoperative emergency department visits may be the best target to reduce overall postoperative unplanned hospital visits and that the MIPS program should be eliminated or modified to more strongly link reimbursement to risk-adjusted patient outcomes, thereby better aligning incentives among patients, surgeons, and the Centers for Medicare ad Medicaid Services. Future work could seek to evaluate the association between MIPS scores and other surgical outcomes and evaluate whether annual changes in MIPS score weighting are independently associated with clinician performance in the MIPS and regarding clinical outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Short-Term (6 Months or Less) Pain in Cemented versus Cementless Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Cementless total knee arthroplasty (TKA) has increased in popularity to potentially improve survivorship. Radiostereometric studies demonstrate increased component migration during the first 3 to 6 months in cementless constructs, generating concern for increased postoperative pain during early osseointegration. The purpose of this study was to evaluate short-term (≤ 6 months) pain and function in cemented versus cementless TKA. We hypothesized that cementless TKA patients report increased pain during the short-term (≤ 6 months) postoperative period. METHODS: The MEDLINE, EMBASE, CINAHL, and Cochrane Libraries were searched for studies evaluating short-term (≤ 6 months) outcomes of cemented versus cementless primary TKA. Studies involving hybrid fixation were excluded. A meta-analysis was performed using standardized mean difference for primary outcomes (early postoperative pain) and weighted mean difference (WMD) for secondary outcomes (early postoperative function). RESULTS: There were eleven studies included. There was no significant difference in acute postoperative pain between cemented and cementless TKA within 6 months of index TKA (standardized mean difference 0.08 in favor of cemented TKA; P = .10). Early postoperative forgotten joint scores (WMD 0.81; P = .81) and knee injury and osteoarthritis outcome scores for joint replacement (WMD 0.80 in favor of cemented TKA; P = .14) were also similar between groups. CONCLUSIONS: There is no difference in short-term (≤ 6 months) pain or early function between patients receiving cemented and cementless TKA. This suggests that surgeons may utilize cementless TKA without fear of increased pain due to micromotion within 6 months of index arthroplasty. However, additional studies with uniform assessment methods are needed to further inform differences in short-term pain and early functional outcomes between cemented and cementless TKA.