Testing a Behavioral Activation Gaming App for Depression During Pregnancy: Multimethod Pilot Study.

BACKGROUND: Depression during pregnancy is increasingly recognized as a worldwide public health problem. If untreated, there can be detrimental outcomes for the mother and child. Anxiety is also often comorbid with depression. Although effective treatments exist, most women do not receive treatment. Technology is a mechanism to increase access to and engagement in mental health services. OBJECTIVE: The Guardians is a mobile app, grounded in behavioral activation principles, which seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to assess app satisfaction and engagement and to explore changes in clinical symptoms of depression and anxiety among a sample of pregnant women with elevated depressive symptoms. METHODS: This multimethod pilot test consisted of a single-arm, proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a pregnant sample with depression (N=18). Participation included two web-based study visits: (1) a baseline assessment to collect demographic and obstetric information and to assess clinical symptoms and (2) an exit interview to administer follow-up measures and explore user experience. Participants completed biweekly questionnaires (ie, Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7) during the trial to assess depression and anxiety symptom severity. App satisfaction was measured using 2 self-report scales (ie, Mobile Application Rating Scale and Player Experience of Needs Satisfaction scale). Engagement with The Guardians was captured using game interaction metric data. We used backward-eliminated mixed effects longitudinal models to examine the effects of app engagement and satisfaction and length of time in the study on symptoms of depression and anxiety. Content analysis was conducted on qualitative data from exit interviews. RESULTS: The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively. Mixed effects models found significant negative main effects of week in study (ß=-.35; t61=-3.05; P=.003), number of activities completed (ß=-.12; t61=-2.05; P=.04), days played (ß=-.12; t58=-2.9; P=.005), and satisfaction, according to the Mobile Application Rating Scale (ß=-3.05; t45=-2.19; P=.03) on depressive symptoms. We have reported about similar analyses for anxiety. There is preliminary evidence suggesting harder activities are associated with greater mood improvement than easier activities. Qualitative content analysis resulted in feedback falling under the following themes: activities, app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications. CONCLUSIONS: Preliminary results from this multimethod study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double those of previous public mental health apps, and use of the app was associated with significant decrease in depressive symptom scores over the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression.

The lived experiences of individuals with postpartum psychosis: A qualitative analysis.

Postpartum psychosis (PP) is a severe psychiatric illness that occurs in about 1 to 2 per 1000 people in the perinatal period. To date, qualitative research investigating PP has focused on specific topics, such as treatment experiences or the impact of the illness on patients' lives and families. These studies have included small samples of women with histories of PP, often limited to certain geographical areas or treatment centers. Given the heterogeneity in presentations of PP and access to care, larger and geographically diverse samples are needed to broadly understand this complex illness. Initiated in 2018, the Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) consists of a large, international sample of those who have experienced PP. In addition to the specific aims of MGHP3, which include to better understand the phenomenology and potential genetic underpinnings of PP, this investigation invites participants to qualitatively describe their narratives of postpartum psychosis. This analysis included 130 participants who reported on 133 episodes of PP. Participants' responses to the PP narrative prompt fell under several overarching categories: 1) broad psychosocial experiences surrounding postpartum psychosis, 2) impact on the mother-baby dyad, 3) treatment experiences, and 4) recovery experiences. Our findings shed light on a range of ways in which individuals' lives are impacted by this illness, and point to areas for future research and clinical directions to improve the support and care for individuals with PP and their families.

Nitinol Staples for Olecranon Osteotomy Fixation, Juxtacortical Versus Inset, Effect on Biomechanical Stability.

Purpose: Hardware prominence is a concern in the fixation of olecranon osteotomies. Staple fixation has provided low-profile secure fixation in other areas of orthopedics. Without insetting, staples still have subcutaneous prominence. This study examines whether nitinol staples, when inset into bone via cortical notching, in an olecranon osteotomy can provide fixation strength sufficient for daily activities. Methods: Olecranon osteotomies were created in 8 cadaver arms and fixed with 2 nitinol staples. For inset and juxtacortical (noninset) staples, a micrometer measured the displacement between preplaced proximal and distal wires for 3 increasing loads: 0 N, 15 N, and 150 N. This measurement reflected the loss of osteotomy compression. We placed each arm in a pneumatic machine that flexed the elbow from 0° to 90° for 500 cycles at each load. We performed a 2-tailed t test (α value 0.05, ß value 0.2) to evaluate for differences in the loss of compression between inset and noninset nitinol staples. Results: We performed the displacement measurement procedure for both staple types at each of the 3 loads. At 0 N, the average displacement of inset was 0 mm and that of noninset was 0.02 mm. At 15 N, the average displacement of inset was 0.02 mm and that of noninset was 0.04 mm. At 150 N, the average displacement of inset was 0.05 mm and that of noninset was 0.09 mm. When comparing the displacement at the 3 force loads, there were no statistically significant differences between the staple types (P = .323). Conclusions: This study shows that inset staples do not considerably weaken osteotomy fixation with nitinol staples. Thus, nitinol staples may provide a low-profile, operatively-efficient fixation method compared with tension-band or screw-and-plate fixation methods for olecranon osteotomies. Future research can include comparing staples with plate constructs.Type of study/level of evidence: Therapeutic III.

The Effect of Intraoperative Glove Choice on Carpal Tunnel Pressure.

Introduction The aim of this study was to quantify the effect of surgical gown and glove wear on carpal tunnel pressure. The authors hypothesized that gowning and gloving is associated with an increase in carpal tunnel pressure in cadaveric specimens wearing appropriately sized gloves. Furthermore, they hypothesized that increased glove thickness, double gloving, and smaller-than-appropriately sized gloves would all serve to increase carpal tunnel pressure. Materials and Methods Baseline carpal tunnel pressure measurements were obtained in 11 cadaveric specimens. Each specimen was subsequently gowned and gloved. Carpal tunnel pressures were obtained for each specimen fitted with four different types of gloves in four scenarios: (1) appropriately sized gloves, (2) one full-size smaller, (3) one full-size larger, and (4) double gloved. Results Mean carpal tunnel baseline value was 3.5 mm Hg. Appropriately sized single-glove wear more than doubled baseline carpal tunnel pressure. Double gloving and smaller-than-appropriately sized glove wear more than tripled baseline values. Among the single-glove subgroup, the thickest gloves (ortho) were associated with the highest increase in pressure from baseline values. Conclusion Glove selection can have repercussions related to carpal tunnel pressure. Susceptible surgeons should consider these factors when making decisions regarding intraoperative glove wear.

Ulnar-Sided Wrist Pain in the Athlete.

Ulnar-sided wrist pain is a common problem in athletes that can be challenging owing to its frequent combination of overuse in conjunction with acute injury. Repetitive pronosupination, wrist flexion and extension, as well as radial and ulnar deviation can predispose the athlete to injury of ulnar structures. Careful understanding of the sport-specific injuries as well as the underlying biomechanics are key to understanding and treating the athlete. In this article, we discuss the most frequent causes of ulnar-sided wrist pain in the athlete and focus on anatomy and pathophysiology, presentation, and diagnosis, as well as nonoperative and operative treatment options.

The electric scooter: A surging new mode of transportation that comes with risk to riders.

Objective: The proliferation of electric scooter sharing companies has inundated many municipalities with electric scooters. The primary objective of this study is to characterize the epidemiology of injuries from this new mode of transportation in order to inform injury prevention efforts.Methods: A multicenter, retrospective study was conducted at two level 1 trauma centers in an urban setting. Patients seen in the emergency department from September 4, 2018 to November 4, 2018 were included if injury coding and chart review identified a scooter-related injury. Demographics, injury patterns, and other injury related factors were obtained via chart review.Results: Ninety-two patients were identified over the study period in 2018 with electric scooter-related injuries. Of the patients utilizing an electric scooter; none used protective gear and 33% used alcohol prior to presentation. More than 60% of patients required medical intervention including laceration repair (26%), fracture reduction (17%), operative fixation of a fracture (7%), or arterial embolization for an associated arterial injury (1%). Approximately 10% of patients required inpatient admission and one required an admission to the intensive care unit.Conclusion: We found a substantial increase in the number of scooter-related injuries during the first two months of electric scooter legalization. There was a lack of safety equipment utilization and concomitant alcohol utilization was common. These may offer areas of focus for injury prevention efforts. Additionally, standardization of injury coding for electric scooter related injury is critical to future studies and will help better understand the impact of this new mode of transportation.

Gender Preferences of Patients When Selecting Orthopaedic Providers.

Background: Orthopaedic surgery is a male-dominated specialty associated with many stereotypes, despite the increased representation of females compared to 30 years ago. Numerous studies have examined medical student and resident perceptions regarding females in orthopaedic surgery to explain the disparity, but there are few studies that analyze whether patients have a gender preference in their orthopaedic surgeon. Our study sought to determine whether patients have a preference for the gender of their orthopaedic surgeon, and what traits in orthopaedic surgeons are important to their patients. Methods: A total of 191 new patients seen in the emergency department and orthopaedic urgent care clinic were administered a 22-question survey regarding preferences in their orthopaedic provider. Patients were asked questions regarding preferred gender of their provider, as well as preferences in characteristics exhibited. Results: The majority of patients did not have a preference for the gender of their orthopaedist (83.9%); however, 14.5% of patients preferred a female surgeon and 1.6% of patients preferred a male surgeon. Female patients had a preference for the same gender compared to male patients and preferred females (p=0.04). Of the patients that had a preference, 90% preferred a female provider. There were trends towards preference for gender that varied depending on subspecialty. There was a statistically insignificant trend towards preference for male providers in total joint replacements and spine surgery, and conversely a preference for female providers in hand surgery and pediatric orthopaedics. 48.6% of patients cited the single most important trait to be board certification, followed by years in practice (27.1%), then reputation or prestige (16.7%). Over one-third of patients found physical appearance, gender, racial background and age to be important traits. Conclusions: The majority of patients did not have a preference for the gender of their orthopaedic surgeon. 16.1% of patients had a preference, and the majority of these patients preferred female surgeons. Preferences for a specific gender were seen that varied based on the subspecialty. Efforts at increasing gender diversity in orthopaedics should continue to be a major goal.Level of Evidence: III.

Closed Reduction Percutaneous Pinning of a Pediatric Supracondylar Distal Humerus Fracture.

Pediatric supracondylar humerus fractures are the most common type of fracture of the elbow in children. Treatment options for these fractures depend on the fracture type as well as the severity of the fracture; however, the standard of care is closed reduction and percutaneous pin fixation for Gartland type 2 and 3 fractures. Controversy exists regarding the ideal pin configuration, size, and number of pins for best stabilization. We present a technique video illustrating our method of lateral entry-pinning of a type 3 supracondylar humerus fracture using three 2.0-mm smooth pins.

Functional Outcomes for Nonoperatively Treated Proximal Fifth Metatarsal Fractures.

Fractures of the proximal fifth metatarsal are relatively common and can be treated with a variety of treatment modalities. The goals of the current study were to answer the following questions: (1) Is there a difference in functional outcomes with different nonoperative treatment modalities for avulsion and Jones fractures? (2) What is the long-term functional impairment? This study included 53 patients who were treated for proximal fifth metatarsal fracture at 1 university health care system between 2004 and 2013. Treatment methods included shoe modification, cast, and boot. Patients completed a telephone questionnaire that included selected questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). Treatment groups were stratified as shoe modification or immobilization, and the results of the MODEMS survey were compared. At most recent follow-up, no significant difference was found between the 2 patient groups (P=.062) for self-reported effects of the injury on work and quality of life. No significant difference was found for frequency of use of pain medication (P=.157), patient satisfaction with current symptoms (P=.633), ambulatory status (P=.281), or pain level with strenuous activity (P=.772). Obese patients were more likely to have severe pain with strenuous activity (P=.015). Most (87%) patients were able to ambulate without the need for assistive devices. Of the study patients, 79% could wear dress shoes, excluding high heels, comfortably. The findings showed that patients who were treated with a variety of nonoperative methods for closed proximal fifth metatarsal fracture had acceptable functional outcomes, regardless of treatment method. [Orthopedics. 2017; 40(6):e1030-e1035.].