Microbe-induced coordination of plant iron-sulfur metabolism enhances high light stress tolerance of Arabidopsis.

High light stress in subtropical and tropical regions strongly limits agricultural production due to photo-oxidative damage, decreased growth and yield. Here, we investigated whether beneficial microbes can protect plants under high light stress. We found that Enterobacter sp. SA187 (SA187) supports Arabidopsis thaliana growth under high light stress by reducing the accumulation of reactive oxygen species (ROS) and maintaining photosynthesis. When subjected to high light stress, SA187 triggers dynamic changes in Arabidopsis gene expression related to fortified iron metabolism and redox regulation thereby enhancing the plant anti-oxidative glutathione/glutaredoxin redox system. Genetic analysis shows that SA187-enhanced iron and sulfur metabolism are coordinated by ethylene signaling. In summary, beneficial microbes could be an effective and inexpensive means for enhancing high light stress tolerance in plants.

Factors Associated With Extrapulmonary Tuberculosis in Southeastern Mexico: A Case-Control Study.

INTRODUCTION: Extrapulmonary tuberculosis (EPTB) is a disease that can affect any organ or tissue. Due to its potential to cause more dangerous sequelae and the barriers to its timely diagnosis, greater clinical awareness of this disease is crucial. This study aimed to identify the factors associated with EPTB in the population of Oaxaca, Mexico. METHODS: This is an unpaired case-control study. The cases were patients with EPTB+ while the controls were patients with pulmonary tuberculosis (PTB+) registered in the Tuberculosis Epidemiological Surveillance System. Sociodemographic, clinical, and microbiological variables were recovered. Bivariate analyses were performed and logistic regression analyses were performed to calculate the odds ratio (OR). RESULTS: A total of 75 EPTB+ cases and 300 PTB+ controls were included. Of the total sample, 57.1% were men and 60.3% indigenous. The most frequent clinical presentations of EPTB+ were nodal (21.3%), miliary (21.3%), and breast (20.0%). According to logistic regression analysis, age <40 years (OR: 2.25 (95% CI: 1.13-4.49), female sex (OR: 1.92 (95% CI: 1.03-3.56)], urban residence (OR: 2.25 (95% CI: 1.11-4.55)), comorbidity with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (OR: 3.46 (95% CI: 1.31-9.10)), dyspnea (OR: 2.67 (1.22-5.82)), and adenopathy (OR: 3.38 (95% CI: 1.42-8.06)) were positively associated with EPTB+. CONCLUSION: These results can serve as a basis for screening EPTB+, thus improving the preventive and diagnostic capacity of local health services, taking as a starting point women under 40 years of age and patients with HIV/AIDS in urban areas, as well as the presence of adenopathy and dyspnea as clinical characteristics of the disease.

Update of the guidelines for the pharmacological treatment of rheumatoid arthritis by the Mexican College of Rheumatology 2023.

OBJECTIVE: To develop updated guidelines for the pharmacological management of rheumatoid arthritis (RA). METHODS: A group of experts representative of different geographical regions and various medical services catering to the Mexican population with RA was formed. Questions based on Population, Intervention, Comparison, and Outcome (PICO) were developed, deemed clinically relevant. These questions were answered based on the results of a recent systematic literature review (SLR), and the evidence's validity was assessed using the GRADE system, considered a standard for these purposes. Subsequently, the expert group reached consensus on the direction and strength of recommendations through a multi-stage voting process. RESULTS: The updated guidelines for RA treatment stratify various therapeutic options, including different classes of DMARDs (conventional, biologicals, and JAK inhibitors), as well as NSAIDs, glucocorticoids, and analgesics. By consensus, it establishes the use of these in different subpopulations of interest among RA patients and addresses aspects related to vaccination, COVID-19, surgery, pregnancy and lactation, and others. CONCLUSIONS: This update of the Mexican guidelines for the pharmacological treatment of RA provides reference points for evidence-based decision-making, recommending patient participation in joint decision-making to achieve the greatest benefit for our patients. It also establishes recommendations for managing a variety of relevant conditions affecting our patients.

Socioeconomic Status Correlates With Initial Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) Scores but Not the Likelihood of Spine Surgery.

Objective To explore how socioeconomic status and patient characteristics may be associated with initial self-reports of pain and determine if there was an increased association with undergoing spine surgery. Methods Patients at an academic center between 2015 and 2021 who completed the Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) questionnaire were included. Multivariable linear regression models were used to determine the association between insurance type and patient factors with initial reports of pain. Multivariable logistic regression models were used to determine the association between PI and the likelihood of surgery in two time periods, three and 12 months. Results The study included 9,587 patients. The mean PROMIS-PI scores were 61.93 (SD 7.82) and 63.74 (SD 6.93) in the cervical and lumbar cohorts, respectively. Medicaid and Workers' Compensation insurance patients reported higher pain scores compared to those with private insurance: Medicaid (cervical: 2.77, CI (1.76-3.79), p<0.001; lumbar (2.05, CI (1.52-2.59), p<0.001); Workers' Compensation (cervical: 2.12, CI (0.96-3.27), p<0.001; lumbar: 1.51, CI (0.79-2.23), p<0.001). Black patients reported higher pain compared to White patients (cervical: 1.50, CI (0.44-2.55), p=0.01; lumbar: 1.51, CI (0.94-2.08), p<0.001). Higher PROMIS-PI scores were associated with a higher likelihood of surgery. There was no increased association of likelihood of surgery in Black, Medicaid, or Workers' Compensation patients when controlling for pain severity. Conclusion Black patients and patients with Medicaid and Workers' compensation insurance were likely to report higher pain scores. Higher initial pain scores were associated with an increased likelihood of surgery. However, despite increased pain scores, Black patients and those with Medicaid and Workers' Compensation insurance did not have a higher likelihood of undergoing surgery.

Assessment of Culture Systems to Produce Bacterial Cellulose with a Kombucha Consortium.

Bacterial cellulose (BC) is an emerging material for high-end applications due to its biocompatibility and physicochemical characteristics. However, the scale-up production of this material is still expensive, with the culture medium constituting one-third of the total cost. Herein, four different media (yeast nitrogen base, YNB; Murashige and Skoog, MSO; black tea; and NPK fertilizer solution) were compared while using sucrose as an additional carbon source. The yields of BC were best for YNB and fertilizer with 0.37 and 0.34 gBC/gC respectively. These two were then compared using glucose as a carbon source, with improvements in the production of 29% for the fertilizer, while only an 8% increase for YNB was seen; however, as the carbon concentration increased with a fixed N concentration, the yield was lower but the rate of production of BC increased. The obtained BC films were sanitized and showed low molecular weight and all the expected cellulose characteristic FT-IR bands while SEM showed nanofibers around 0.1 µm. Compared to traditional methods for lab-scale production, the use of the fertilizer and the consortium represent benefits compared to traditional lab-scale BC culture methods such as a competitive cost (two times lower) while posing resilience and tolerance to stress conditions given that it is produced by microbial communities and not with a single strain. Additionally, the low molecular weight of the films could be of interest for certain coating formulations.

The economic burden of systemic lupus erythematosus in Mexico.

AIMS: Our cost of illness study aimed to provide an estimate of the burden related to systemic lupus erythematosus (SLE) in the Mexican context. METHODS: Our model was used to simulate the resource utilization and economic consequences over a period of 5 years for patients with SLE in Mexico. The model simulated four health states-three phenotypes of SLE, including mild, moderate, and severe states, and death. Clinical parameters were retrieved from the literature. Resource utilization in our model represents the most common practice in the Mexican healthcare system. These include disease management, transient events (e.g. infections, flares, and complications due to SLE-related organ damage), and indirect costs. Direct non-medical costs were not considered. One-way sensitivity analysis was performed. RESULTS: The number of targeted Mexican SLE patients was 57,754. The numbers of SLE patients diagnosed with mild, moderate, and severe phenotypes were 8,230, 44,291, and 5,233, respectively. Disease management costs, including the treatment of each phenotype and disease follow-up, were MXN 4 billion ($ 415 million); the costs of transient events (infections, flares, and consequences of SLE-related organ damage) were MXN 5 billion ($ 478 million). Productivity loss costs among adult employed Mexican patients with SLE were estimated at MXN 17 billion ($ 1.6 billion). The total SLE cost in Mexico over 5 years from the payer and societal perspectives is estimated at MXN 9 billion ($ 893 million) and 26 billion ($ 2.5 billion), respectively. Over 5 years, the costs per patient per year from the payer and societal perspectives were MXN 32,131($ 3,095) and MXN 91,661($ 8,830), respectively. CONCLUSION: The findings pointed out the substantial economic burden associated with SLE, including the costs of disease progression and SLE transient events, such as flare-ups, infections, and organ damage, in addition to productivity loss due to work capacity impairment.

Arthroscopic subacromial decompression improved outcomes in situationally depressed patients compared to clinically depressed or nondepressed patients.

Background: The purpose of this study is to evaluate patient reported outcomes after arthroscopic extensive débridement of the shoulder with subacromial decompression (SAD) for subacromial impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) system and evaluate if depression (Dep) (clinical or situational) impacts patients achieving a Minimal Clinically Important Difference (MCID). Methods: Preoperative PROMIS Physical function (PF), Mood, and Dep scores were obtained at the closest date prior to arthroscopic rotator cuff repair and postoperative scores were collected at every clinical visit thereafter. Final PROMIS score used for data analysis was determined by the patients final PROMIS value between 90 to 180 days. Clinical Dep was determined by patients having a formal diagnosis of "Depression or Major Depressive Disorder" at the time of their surgery. Situationally depressed patients, those without a formal diagnosis yet exhibited symptomatic depressive symptoms, were classified by having a PROMIS-Dep cutoff scores larger than 52.5. Results: A total of 136 patients were included for final statistical analysis. 13 patients had a clinical but not situational diagnosis of Dep, 86 patients were identified who had no instance of clinical or situational Dep (nondepressed). 35 patients were situationally depressed. All three cohorts demonstrated a significant improvement in postoperative PROMIS Dep, PI, and PF score relative to their preoperative value (P = .001). Situationally depressed patients achieved greater delta PROMIS-Dep compared to patients with major depressive disorder. Depressed patients had a higher chance of achieving MCID for PROMIS-Dep compared to nondepressed patients (P = .01). Logistic regression analysis demonstrated that underlying Dep did not alter the odds of obtaining MCID compared to nondepressed patients. Nonsmoking patients had significantly greater odds of achieving MCID for PF (P = .02). Discussion: Patients improved after undergoing SAD regardless of underlying Dep or depressive symptoms. Depressed patients exhibited greater change in PROMIS scores compared to nondepressed patients. Smoking remains a risk factor for postoperative outcomes in patients undergoing SAD for subacromial impingement. Identifying and counseling patients with underlying depressive symptoms without a formal major depressive disorder diagnosis may lead to improved outcomes. These findings may help guide clinicians in deciding who would benefit the most from this procedure.

Using PROMIS Scores to Provide Cost-Conscious Follow-up After Foot and Ankle Surgery.

BACKGROUND: National campaigns in the United States, such as Choosing Wisely, emphasize that decreasing low-value office visits maximizes health care value. Although patient-reported outcomes (PROs) are frequently used to quantify postoperative outcomes, they have not been assessed as a tool to help guide clinicians consider alternatives or discontinue in-person follow-up visits. The purpose of this study is to assess the frequency and cost of in-person follow-up visits after patients report substantial improvement defined as 2 consecutive improvements above preoperative Patient Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores. METHODS: Retrospective PROMIS PI data were obtained between 2015 and 2020 for common elective foot (n = 759) and ankle (n = 578) surgical procedures. Patients were divided into quartiles according to their preoperative PI score. Multivariable Cox proportional hazards models were used to investigate time to substantial improvement. Substantial improvement was defined as having 2 consecutive postoperative minimal clinically important differences (MCIDs) above preoperative PROMIS PI scores. MCID was measured using the distribution-based method. Multivariable negative binomial models were used to determine the number of visits and direct associated costs after substantial improvement. The cost to payors was estimated using reimbursement rates. RESULTS: Within 3 months, 12% to 46% of foot and 16% to 61% of ankle patients achieved substantial improvement. Results vary by preoperative pain quartile, with patients who report higher preoperative pain scores achieving earlier improvement. After achieving substantial improvement, foot and ankle patients averaged 3.60 and 4.01 follow-up visits during the remaining 9 months of the year. Visit costs averaged $266 and $322 per foot and ankle patient respectively. CONCLUSION: Postoperative follow-up visits are time-consuming and costly. Physicians might consider objective measures, such as PROMIS PI, to determine the need, timing, and alternatives for in-person follow-up visits for elective foot and ankle surgeries after patients demonstrate reliable clinical improvement. LEVEL OF EVIDENCE: Level III, retrospective cohort study at a single institution.

Estado nutricional y medidas antropométricas en escolares Zapotecas y no Zapotecas de Oaxaca, México / Nutritional status and anthropometric measurements in Zapotec and non-Zapoteca schoolchildren from Oaxaca, Mexico

Introducción: Los grupos indígenas se enfrentan a la discriminación y exclusión, lo que genera inequidades en el ámbito de la salud. Además, son nutricionalmente vulnerables, lo que afecta su potencial de crecimiento y desarrollo en comparación con población no indígena. Objetivo: comparar el estado nutricional y medidas antropométricas entre escolares zapotecas y no zapotecas de una región de Oaxaca, México. Material y métodos: estudio descriptivo trasversal en una muestra representativa de 477 escolares de 8 a 11 años de un municipio de Oaxaca. Se dividió a la población en zapoteco (Zap+) y no zapoteco (Zap-). Se obtuvo el peso, talla, circunferencia de cintura, circunferencia de brazo y el pliegue tricipital. Se calculó el IMC para la edad, el índice cintura-talla e indicadores del componente graso y muscular del brazo. Se utilizó la prueba chi cuadrada y exacta de Fisher para diferencias proporcionales Resultados: El 51,5% de escolares fue Zap+ y se reportó una alta prevalencia de sobrepeso y obesidad de 33,7%. Las niñas Zap+ presentaron mayor prevalencia de desmedro (p=0,032) y los niños Zap+ presentaron menor % área grasa de brazo (0,004). Entre niños y niñas Zap-, los niños presentaron bajo peso (p=0,040) y musculatura reducida (p=0,003), mientras que las niñas presentaron mayor proporción grasa arriba del promedio (p=<0,001). Los niños Zap- presentaron mayor prevalencia de desmedro en comparación con los Zap+ (p=0,022). Esta diferencia se mantuvo hasta los 11 años (p=0,007). Se observó que las niñas Zap+ de 11 años presentaron una menor musculatura (p=0.001) y mayor riesgo cardiovascular (p=0,032) en comparación con las Zap-. Conclusiones: Se observaron cambios seculares positivos en niños Zap+ reflejados en una mayor talla que las niñas Zap+ y niños Zap-, y una tendencia al aumento del IMC y riesgo cardiovascular en las niñas Zap+ lo cual podría reflejar una posible transición nutricional.(AU)

Introduction: Indigenous groups face discrimination andexclusion, which generates inequities in the field of health. Inaddition, they are nutritionally vulnerable, which affects theirgrowth and development potential compared to the non-in-digenous population. Objective: to compare the nutritional status and anthro-pometric measurements between Zapotec and non-Zapotecschoolchildren from a region of Oaxaca, Mexico. Material and methods: cross-sectional descriptive studyin a sample of 477 schoolchildren aged 8 to 11 from a mu-nicipality in Oaxaca. The population was divided into Zapotec(Zap+) and non-Zapotec (Zap-). Weight, height, waist cir-cumference, arm circumference and triceps fold were meas-ured. Anthropometric indicators and the fatty and muscularcomponent of the arm were calculated. A comparative analy-sis of nutritional status and body composition was performedbetween Zap+ and Zap- using chi square and Fisher’s exacttest. A p value <0.05 was considered significant. Results: 51.5% of schoolchildren were Zap+ and a highprevalence of overweight and obesity of 33.7% was reported.Zap+ girls had a higher prevalence of wasting (p=0.032) andZap+ boys had a lower % arm fat area (0.004). Among Zap-boys and girls, boys had low weight (p=0.040) and reducedmusculature (p=0.003), while girls had a higher proportion offat above average (p=<0.001). Zap- children had a higherprevalence of stunting compared to Zap+ children (p=0.022).It was observed that 11-year-old Zap+ girls had less muscle(p=0.001) and a higher cardiovascular risk (p=0.032) com-pared to Zap- girls. Conclusions: Positive secular changes were observed inZap+ boys, reflected in greater height than Zap- boys, and atrend in increasing BMI and cardiovascular risk in Zap+ girls,which could reflect a possible nutritional transition.(AU)

Brain energetics and glucose transport in metabolic diseases: role in neurodegeneration.

OBJECTIVES: Neurons and glial cells are the main functional and structural elements of the brain, and the former depends on the latter for their nutritional, functional and structural organization, as well as for their energy maintenance. METHODS: Glucose is the main metabolic source that fulfills energetic demands, either by direct anaplerosis or through its conversion to metabolic intermediates. Development of some neurodegenerative diseases have been related with modifications in the expression and/or function of glial glucose transporters, which might cause physiological and/or pathological disturbances of brain metabolism. In the present contribution, we summarized the experimental findings that describe the exquisite adjustment in expression and function of glial glucose transporters from physiologic to pathologic metabolism, and its relevance to neurodegenerative diseases. RESULTS: A exhaustive literature review was done in order to gain insight into the role of brain energetics in neurodegenerative disease. This study made evident a critical involvement of glucose transporters and thus brain energetics in the development of neurodegenerative diseases. DISCUSSION: An exquisite adjustment in the expression and function of glial glucose transporters from physiologic to pathologic metabolism is a biochemical signature of neurodegenerative diseases.

Interrupción del embarazo en nefritis lúpica: un análisis bioético desde el método integral / Termination of pregnancy in lupus nephritis: A bioethical analysis with the integrative method

Antecedentes y objetivo: La interrupción del embarazo en pacientes con enfermedades reumatológicas es controvertida y pocas veces se realiza un análisis bioético. En este estudio analizamos el caso de una paciente embarazada con nefritis lúpica sin respuesta a tratamiento a quien se le planteó la interrupción del embarazo. Métodos: Se aplicó el modelo integral, incluyendo distintos sistemas normativos para el análisis del dilema. Resultados: Desde el utilitarismo es justificable la interrupción del embarazo, buscando el mayor beneficio para la mayoría de las partes. La deontología justifica tanto continuar como interrumpir el embarazo, centrando la importancia en la acción misma y en la autonomía. Para la ética de la virtud, la importancia de las decisiones recae en la persona que realiza la acción buscando el florecimiento: la interrupción del embarazo sería justificable. Discusión y conclusiones: La interrupción del embarazo sería una solución adecuada según el modelo integral. El análisis bioético de casos paradigmáticos es fundamental para asegurar el mejor actuar posible en casos similares en reumatología.(AU)

Background and objective: Termination of pregnancy in patients with rheumatic diseases is controversial and a bioethical analysis is rarely performed. In this study we analysed the case of a pregnant patient with lupus nephritis unresponsive to treatment, for whom termination of pregnancy is considered. Methods: The integrative model was applied combining different normative ethical theories. Results: From a utilitarian perspective, termination of pregnancy is justifiable, seeking the greatest benefit for the greatest number of stakeholders. Deontology justifies both terminating and continuing the pregnancy, focusing on the action itself and on autonomy. In virtue ethics the importance of decisions rests with the person who performs the action seeking flourishing; termination of pregnancy would be justifiable. Discussion and conclusions: Interruption of pregnancy is a justifiable solution following the integrative model. Bioethical analysis of paradigmatic cases is essential to ensure the best possible action and as a precedent for future similar situations in rheumatology.(AU)

Termination of pregnancy in lupus nephritis: A bioethical analysis with the integrative method.

BACKGROUND AND OBJECTIVE: Termination of pregnancy in patients with rheumatic diseases is controversial and a bioethical analysis is rarely performed. In this study we analysed the case of a pregnant patient with lupus nephritis unresponsive to treatment, for whom termination of pregnancy is considered. METHODS: The integrative model was applied combining different normative ethical theories. RESULTS: From a utilitarian perspective, termination of pregnancy is justifiable, seeking the greatest benefit for the greatest number of stakeholders. Deontology justifies both terminating and continuing the pregnancy, focusing on the action itself and on autonomy. In virtue ethics the importance of decisions rests with the person who performs the action seeking flourishing; termination of pregnancy would be justifiable. DISCUSSION AND CONCLUSIONS: Interruption of pregnancy is a justifiable solution following the integrative model. Bioethical analysis of paradigmatic cases is essential to ensure the best possible action and as a precedent for future similar situations in rheumatology.

Evaluating medical students' knowledge of patient-reported outcomes and the impact of curriculum intervention in consecutive cohorts.

BACKGROUND: Patient-reported outcomes (PROs) collection and utilization improves patient-provider communication, symptom reporting, and patient satisfaction. Despite their significance, the science and utility of PROs are not part of required curriculum in medical education. The authors describe the results of a survey distributed to medical students evaluating their experience, knowledge, and perceptions of PROs, report on outcomes of the impact of formal PRO education on medical student knowledge, and describe strategies to foster the spread of PRO education into other programs. METHODS: The authors developed and distributed a 20-question web-based survey distributed to medical students at two U.S. medical schools to evaluate students' experience, knowledge, and perceptions of PROs. To compare medical students' knowledge in their pre-clinical years (M1-M2) to those in their clinical years (M3-M4), the authors calculated odds ratios and determined significance determined using chi-squared tests. To determine the utility of formal education on medical students' knowledge of PROs, the authors invited 4th year medical students at a single institution to participate in a survey before and two weeks after receiving formal PRO education as part of the medical school curriculum, spanning three years. RESULTS: 137 (15%) medical students responded to the initial survey. Respondents' knowledge of PROs was low and did not differ when comparing pre-clinical to clinical years in school. Less than 10% had received education on PROs and only 16% felt prepared to use PROs in patient care. Respondents demonstrated positive attitudes towards PROs, with 84% expressing interest in learning about PROs. In the second phase education cohort of 231 (77% response rate) 4th -year medical students over three years, formal education improved correct response rates to PRO questions. After education, 90% (121/134) agreed PROs are an important component of high-quality care. CONCLUSIONS: This study identifies a gap in knowledge about PROs among medical students irrespective of year in training. It also shows that structured education may help fill the PRO knowledge gap, potentially providing future clinicians with the skills to implement PROs into clinical practice, aligning with the broader shift towards patient-centric evidence-based healthcare practices.

CYP2D6 genotyping and the clinical impact on outcomes in breast cancer tamoxifen-treated patients.

Aims: To report the distribution of allele frequencies of CYP2D6 gene and to evaluate their influence on the clinical outcomes of a group of breast cancer patients receiving adjuvant tamoxifen treatment from Uruguay. Patients & methods: 199 samples were genotyped through real-time polymerase chain reaction assays. Metabolization profiles were inferred from the genotypes. Correlations were evaluated using Pearson's χ2 test. Results: Phenotype frequencies were 0.65 normal (NM), 0.30 intermediate (IM) and 0.05 poor metabolizers (PM). Similar clinical outcomes between NM and (PM + IM) patient groups (odds ratio = 1.011, 95% CI = 0.2703-3.7826; p = 0.987) were found. Conclusion: CYP2D6 allele frequencies were analyzed for the first time in a cohort from Uruguay. Results did not support any impact of CYP2D6 gene polymorphisms on clinical outcomes.

Comparable performance of machine learning algorithms in predicting readmission and complications following total joint arthroplasty with external validation.

BACKGROUND: The purpose of the study was to use Machine Learning (ML) to construct a risk calculator for patients who undergo Total Joint Arthroplasty (TJA) on the basis of New York State Statewide Planning and Research Cooperative System (SPARCS) data and externally validate the calculator on a single TJA center. METHODS: Seven ML algorithms, i.e., logistic regression, adaptive boosting, gradient boosting (Xg Boost), random forest (RF) classifier, support vector machine, and single and a five-layered neural network were trained on the derivation cohort. Models were trained on 68% of data, validated on 15%, tested on 15%, and externally validated on 2% of the data from a single arthroplasty center. RESULTS: Validation of the models showed that the RF classifier performed best in terms of 30-d mortality AUROC (Area Under the Receiver Operating Characteristic) 0.78, 30-d readmission (AUROC 0.61) and 90-d composite complications (AUROC 0.73) amongst the test set. Additionally, Xg Boost was found to be the best predicting model for 90-d readmission and 90-d composite complications (AUC 0.73). External validation demonstrated that models achieved similar AUROCs to the test set although variation occurred in top model performance for 90-d composite complications and readmissions between our test and external validation set. CONCLUSION: This was the first study to investigate the use of ML to create a predictive risk calculator from state-wide data and then externally validate it with data from a single arthroplasty center. Discrimination between best performing ML models and between the test set and the external validation set are comparable. LEVEL OF EVIDENCE: III.

The effect of a workplace wellness program on disability, function and pain in healthcare providers workers with low back pain-outcomes of 3040 academic health center employees.

PURPOSE: (1) Identification of musculoskeletal risk factors for healthcare providers suffering low back pain (LBP) and the creation of risk profiles for those individuals and (2) analyze the impact of a workplace wellness program on healthcare providers who suffer from low back pain. METHODS: A total of 3040 employees at an academic healthcare center underwent a computer-adaptive survey of health-related quality of life (HRQOL), biometric tests, and a disability and functional movement assessment as part of the workplace wellness program (WWP). Clinical interventions with a rehabilitation specialist were offered to employees identified as at risk for low back pain. Data collected were analyzed using descriptive methods and multivariable regressions to address the study objectives. RESULTS: Of the 3040 healthcare providers enrolled in this study, 77% identified with non-specific LBP with greater weakness, numbness, reduced flexibility, and physical activity. The major predictive risk factors for LBP were Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference score, PROMIS fatigue, previous work injury, flexibility, numbness, PROMIS social function, level of education, and BMI. Healthcare providers with LBP who completed the WWP improved in most dimensions of HRQOL and disability and functional outcomes. CONCLUSIONS: A high proportion of healthcare providers suffer from LBP as a result of the nature of their work. Disability and functional outcomes measurements and PROMIS results quantitatively assess healthcare providers with LBP. Organizations can develop injury mitigation programs to target employees at high risk of LBP using the risk factors we identify. Completion of the WWP was associated with improvements in disability, HRQOL and functional measures.

Racial/ethnic and income-based differences in the use of surgery for cervical and lumbar disorders in New York State: a retrospective analysis.

BACKGROUND CONTEXT: The extent to which use of spine surgeries for patients with cervical and lumbar disorders varies by their race/ethnicity and income is currently unknown. PURPOSE: To assess racial/ethnic and income-based differences in use of spine surgery in New York State (NYS) from 2016 to 2019. STUDY DESIGN: Retrospective observational analysis using 2016 to 2019 New York Statewide Planning and Research Cooperative System (SPARCS) data, direct standardization, and multivariable mixed-effects linear regression models. METHODS: A dataset of patients who underwent surgery for cervical and spinal disorders in NYS in the period 2016 to 2019 was used to determine county-level age- and sex-standardized annual cervical and lumbar surgery rates expressed as number of surgeries per 10,000 individuals. Further sub-analysis was performed with the key independent variables being the combination of individual-level race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic individuals) and income (low-/high-income residing in zip codes below/above state median income); and year. We estimated multivariable mixed-effects linear regression models which controlled county-level variables to determine the adjusted rates of spine surgeries for patients belonging to various race/ethnicity and income group combinations. RESULTS: The study included 29,650 and 42,498 patients in the cervical and lumbar cohorts, respectively. In 2019, the county-level mean cervical and lumbar surgery rates were 3.88 and 5.19 surgeries per 10,000 individuals, respectively. There was a five-fold rate variation across NYS. In 2019, the adjusted cervical rates were 4.59 (White low-income), 4.96 (White high-income), 7.20 (Black low-income), 3.01 (Black high-income), 4.37 (Hispanic low-income), and 1.17 (Hispanic high-income). The adjusted lumbar rates were 5.49 (White low-income), 6.31 (White high-income), 9.43 (Black low-income), 2.47 (Black high-income), 4.22 (Hispanic low-income), and 2.02 (Hispanic high-income). The rates for low-income Black or Hispanic patients were significantly higher than their high-income counterparts. Low-income Black patients had the highest rates. Over the study period, the gap/difference increased significantly between high-income Hispanic and White individuals by 2.19 (95% confidence interval [CI]: -4.27, -0.10, p=.04) for cervical surgery; and between low-income Black and White individuals by 2.82 (2.82, 95% CI: 0.59, 5.06, p=.01) for lumbar surgery. CONCLUSION: There are differences in the rates of spine surgery in New York State, among identifiable groups. Black individuals from poorer zip codes experience relatively higher spine surgery rates. Understanding the drivers of surgical rate variation is key to improving the equitable delivery of spine care. A better understanding of such rate variations could inform health policy.

Use of Area Deprivation Index to Predict Minimal Clinically Important Difference for Patient Reported Outcomes Measurement Information System After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Socioeconomic disparities correlate with worse outcomes after arthroscopic rotator cuff repair. However, use of a surrogate to describe socioeconomic disadvantage has been a challenge. The Area Deprivation Index (ADI) is a tool that encompasses 17 socioeconomic variables into a single metric based on census location. HYPOTHESIS: Higher ADI would result in a worse minimal clinically important difference (MCID) for the Patient Reported Outcomes Measurement Information System (PROMIS) and have less improvement in range of motion (ROM) following arthroscopic rotator cuff repair (ARCR). STUDY DESIGN: Cohort study; Level of evidence, 3. METHOD: A retrospective review was performed for patients who underwent arthroscopic rotator cuff repair. Patients in the most socioeconomically disadvantaged quartile (ADIHigh) were compared with the least disadvantaged quartile (ADILow) in the ability to reach MCID. Demographic and surgical features were assessed for attainment of MCID. RESULTS: In total 1382 patients were identified who underwent ARCR, of which a total of 306 patients met final inclusion criteria. A higher percentage of patients within the ADIHigh cohort identified as "Black" or "other" race and had government-issued insurance compared with the ADILow cohort (P < .05). The ADIHigh cohort had significantly worse postoperative forward flexion compared with the ADILow cohort (145.0°± 32.5° vs 156.3°± 23.4°; P = .001) despite starting with comparable preoperative ROM (P = .17). Logistic regression showed that ADI was the only variable significant for predicting achievement of MCID for all 3 PROMIS domains, with the ADIHigh cohort having significantly worse odds of achieving MCID Physical Function (odds ratio [OR], 0.31; P = .001), Pain Interference (OR, 0.21; P = .001), and Depression (OR, 0.28; P = .001). Meanwhile, age, sex, body mass index, and smoking history were nonsignificant. Moreover, "other" for race and Medicare insurance were significant for achievement of MCID Depression but not Physical Function or Pain Interference. Finally, ADI was the main feature for predictive logistic regression modeling. CONCLUSION: ADI served as the only significant predictor for achieving MCID for all 3 PROMIS domains after arthroscopic rotator cuff repair. Patients who face high levels of socioeconomic disadvantage have lower rates of achieving MCID. In addition, patients with greater neighborhood disadvantage demonstrated significantly worse improvement in active forward flexion. Further investigation is required to understand the role of ADI on physical therapy compliance and to identify the barriers that prevent equitable postoperative care.

Effect of Insurance Reimbursement Status on Pre- and Postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Scores After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Previous studies reported inferior patient-reported outcomes (PROs) after arthroscopic rotator cuff repair for patients receiving workers' compensation (WC) relative to patients with commercial insurance. The extent to which alternative insurance reimbursement, including Medicaid and Medicare, influences outcomes after arthroscopic rotator cuff repair remains understudied. HYPOTHESIS: Compared with patients with commercial insurance reimbursement, patients with WC or government-issued reimbursement would report lower pre- and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scores, report higher pre- and postoperative PROMIS Depression (D) and Pain Interference (PI) scores, and experience smaller levels of improvement in all PROMIS domains with surgical intervention. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Demographic and surgical data were extracted from the medical record, and PROMIS domains were prospectively collected. Patients were divided into cohorts based on insurance reimbursement status. Differences between insurance-based cohorts for baseline variables, pre- and postoperative PROMIS scores, and change from baseline to final follow-up (delta) for PROMIS scores were evaluated using Kruskal-Wallis or chi-square tests. Mixed-effects linear regression models were performed to assess the influence of insurance while controlling for other variables. Survival analysis was performed to determine time to achieve minimal clinically important difference (MCID) for each PROMIS domain per cohort. RESULTS: 1252 patients underwent arthroscopic rotator cuff repair, met inclusion criteria, and completed PROMIS questionnaires. Statistically significant differences were noted in demographic variables including age (P < .001), sex (P < .001), ethnicity (P < .001), and body mass index (P < .001) between insurance-based cohorts. Unadjusted analysis revealed significantly higher PF scores and lower PI and D scores for the group with commercial insurance relative to those with Medicare, Medicaid, and WC at 6- and 12-month follow-up (P < .01 all comparisons), except for the Medicare versus commercial subcohort analysis for PI at 6 months (P = .28). These differences persisted for the Medicare, Medicaid, and WC groups (P < .03 all comparisons) after adjustment for confounding variables in linear regression. CONCLUSIONS: The baseline characteristics of patients undergoing arthroscopic rotator cuff repair differed based on insurance reimbursement. Patients with commercial insurance reported improved physical function, decreased pain interference, and improved mood (less depression) relative to patients with government-issued and WC insurance, with maximum improvement 6 to 12 months postoperatively. There were few significant differences between insurance groups in change of PROMIS scores from preoperative to postoperative intervals, indicating that differences in the baseline demographic and surgical characteristics of these groups accounted for differences in response to surgery.