Preoperative Symptoms of Depression are Associated With Worse Capability 6-weeks and 6-months After Total Hip Arthroplasty for Osteoarthritis.

BACKGROUND: Symptoms of depression have been associated with greater incapability following total hip arthroplasty (THA). A brief, 2-question, measure of symptoms of depression - the Patient Health Questionnaire-2 (PHQ-2) - may be sufficient to measure associations with the magnitude of incapability during recovery from THA. This study investigated whether preoperative symptoms of depression (measured with the PHQ-2) correlated with levels of incapability 6 weeks and 6 months after THA, accounting for demographic and clinical factors. METHODS: We performed a prospective cohort study across 5 centers and recruited 101 patients undergoing THA, of whom 90 (89%) completed follow-up. Patients completed demographics, a preoperative 2-item (PHQ-2) measure of symptoms of depression, and the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) at 6-weeks and 6-months postoperatively. Negative binomial regression models determined factors associated with HOOS JR at 6 weeks and 6 months, accounting for potential confounders. RESULTS: Accounting for potential confounding factors, we found that higher preoperative PHQ-2 scores (reflecting greater symptoms of depression) were associated with lower HOOS JR scores (reflecting a greater level of hip disability) at both 6 weeks (regression coefficient = -0.67, P < .001) and 6 months (regression coefficient = -1.9, P < .001) after THA. CONCLUSIONS: Symptoms of depression on a 2-question preoperative questionnaire are common, and greater symptoms of depression are associated with reduced capability within the first year following THA. These findings support the prioritization of routine mental health assessments before THA. Measuring mindset using relatively brief instruments will be important considering the current shift toward implementing self-reported measures of health status in clinical practice and incorporating them within alternative payment models.

Capability After Total Knee Arthroplasty for Osteoarthritis Is Strongly Associated With Preoperative Symptoms of Depression.

BACKGROUND: Primary total knee arthroplasty (TKA) aims to improve the level of capability (ability to perform valued life activities) associated with knee osteoarthritis (OA). However, some evidence suggests a substantial proportion of patients remain dissatisfied with their outcomes after this procedure. We sought to better understand the association between mental health, specifically symptoms of depression, with postoperative outcomes. Symptoms of depression are shown to be common among orthopaedic populations in general and can be briefly and conveniently evaluated using the Patient Health Questionnaire-2 (PHQ-2) in a less burdensome manner compared with longer mental health surveys. This study assesses the association between preoperative depressive symptoms (PHQ-2) and levels of capability at 6 weeks and 6 months after TKA. METHODS: We conducted a prospective cohort study involving 114 patients with knee OA across five clinics in California and Texas scheduled for TKA. Participants completed a preoperative PHQ-2 and Knee Injury and OA Outcome Score for Joint Replacement (KOOS JR) survey at 6 weeks and 6 months post-TKA. We analyzed these data using bivariate and multivariable regression. RESULTS: Preoperative PHQ-2 scores were significantly associated with lower KOOS JR scores at 6 weeks and 6 months post-TKA. Latino/Hispanic race was also associated with lower KOOS JR scores at 6 weeks. The association between preoperative depressive symptoms and level of capability after TKA were more pronounced at 6 months compared with 6 weeks. CONCLUSION: Preoperative symptoms of depression are strongly associated with reduced capability after TKA and can be screened for using the PHQ-2-a brief tool that can be feasibly incorporated into clinical workflows. User-friendly assessment of depressive symptoms can assist orthopaedic surgeons in identifying and addressing mental health at the outset during the management of knee OA.

Readability of Online Materials in Spanish and English for Breast Reduction Insurance Coverage.

INTRODUCTION: Breast reduction surgery aims to alleviate physical discomfort and improve the quality of life for individuals with macromastia. Insurance coverage plays a crucial role in making this surgery accessible, but navigating the complex approval process can be challenging. Online resources have become a primary information source, but limited research exists on the adequacy of online materials, particularly for Spanish-speaking patients. This study evaluates the readability, actionability, and understandability of online educational materials on breast reduction insurance coverage for Spanish- and English-speaking patients. METHODS: We conducted an online search using the phrase "breast reduction insurance" and selected the first eight institutional or organizational websites that provided information on breast reduction insurance in both English and Spanish. We evaluated online materials using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and Simplified Measure of Gobbledygook, Spanish (SOL). These tools were used to assess factors such as understandability and actionability, cultural sensitivity, and readability of the materials. RESULTS: Both English and Spanish materials scored high in understandability and actionability, with similar average scores between the languages. Cultural sensitivity scores indicated acceptable materials. However, Spanish materials had a higher reading grade level and more hard words compared to English materials. CONCLUSION: There is a need for accessible and understandable online resources on breast reduction insurance coverage, particularly for Spanish-speaking patients. While the assessed websites generally provided comprehensible information, improvements can be made to enhance visual aids and simplify language. These improvements can better educate patients, improve outcomes, and reduce healthcare costs. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Metagenome-Assembled Genomes from Photo-Oxidized and Nonoxidized Oil-Degrading Marine Microcosms.

We performed deep metagenomic sequencing on hydrocarbon-degrading marine microcosms designed to experimentally determine the effect of photo-oxidation on oil biodegradation dynamics. Assembly, binning, and dereplication yielded 73 unique metagenome-assembled genomes (MAGs) from 6 phyla, of which 61 are predicted to be over 90% complete.

Coverage, Apparent Consumption, and Monthly Use of Packaged Maize Flour in Morogoro Region, Tanzania.

INTRODUCTION: Tanzania aimed to reduce micronutrient deficiencies and neural tube defects by introducing mandatory fortification of large-scale packaged wheat and maize flour but not for small- and medium-scale mills. OBJECTIVES: Ascertain the proportion of the population in Morogoro region, Tanzania, that consumes packaged maize flour from small-, medium- and large-mills; and understand the impact of monthly apparent purchase and consumption of packaged flour. METHODS: In 2018, a regional, multistage cluster probability study was conducted among residents in Morogoro region living in households that reported consuming maize flour. Interviews collected information on sociodemographic factors and patterns of household flour consumption. Weighted medians estimated daily apparent flour consumption and the estimated average requirement (EAR), according to age. RESULTS: Information was collected on 711 households. Packaged maize flour was purchased 10-12 months of the year by 22.9% of households, 6-9 months by 17.6% of households, 1-5 months by 25.1% of households, and 34.4% did not purchased maize flour. Median apparent daily consumption of maize flour was 209.7 g/d/adult male equivalent (AME). Apparent median daily consumption of maize flour was 230.1 g/d/AME in rural areas and 176.2 g/d/AME in urban areas; 228.7 g/d/AME among males and 196.4 g/d/AME among females. If all packaged maize flour were fortified according to standards, those consuming packaged maize flour 10-12 months of the year would apparently consume 199.9 µg folic acid/d representing 49.7% of daily EAR requirements. CONCLUSIONS: Fortifying packaged maize flour at small-, medium- and large-mills is a promising strategy for increasing access to micronutrients, including folic acid.

Breast Paraffinoma: A Case Report of 20-Year-Old Mineral Oil Injection in a Male Patient.

Background: Mineral oil injection represents a dated practice of rapid and inexpensive breast augmentation. After a latency period, surrounding tissue becomes inflamed and fibrotic. Breast paraffinoma is well-documented in women; however, only 3 cases of such masses in male patients exist in the literature. Methods: We present a case of paraffinoma in a 63-year-old man from Puerto Rico who, desiring breasts, serially injected mineral oil into each breast daily for 13 years. Conservative management was initially attempted due to cardiac comorbidities and insurance authorization issues. The patient ultimately developed erosive wounds and therefore underwent excision of the bilateral breast masses as an en bloc specimen weighing 2.17 kg. Results: Pathology indicated sclerosing lipogranulomatosis (paraffinoma). The quality of the wounds remaining warranted negative pressure wound therapy with serial debridement. The patient went on to successful reconstruction with a reverse abdominoplasty preserving periumbilical and intercostal perforators. Conclusions: Plastic surgeons must educate patients against using exogenous injected materials for augmentation of the breasts, penis, or buttocks. Although uncommon in the US, certain populations like body builders and foreign immigrants are at higher risk for current or prior injection practices. Reverse abdominoplasty is a viable reconstructive modality for the large resulting defect.

Assessing the quality and reliability of patient information regarding aesthetic fat grafting on YouTube.

PURPOSE: Patients increasingly consult social media regarding aesthetic surgery. Given the popularity of fat transfer operations, this study assesses the quality and reliability of patient information available on YouTube regarding aesthetic fat grafting. METHODS: The terms "fat grafting" and "fat transfer" were searched on YouTube with respect to the terms "face", "breast", "buttock", and "Brazilian butt lift". Filtered by view count, the top 20 unique, English language, aesthetic surgery-related videos for each search combination were reviewed by three independent reviewers for demographic and descriptive characteristics. Videos were rated for information reliability and quality using the modified DISCERN (MD) tool (1 = low, 5 = high) and global quality scale (GQS) (1 = poor, 5 = excellent). RESULTS: Out of 80 total videos, 76% were authored by physicians and 24% by laypersons. The overall mean MD score was 1.5 and the mean GQS was 2.6. Videos authored by physicians outscored those by non-medical authors (MD: 1.6 vs. 1.3; GQS 2.7 vs. 2.2). Board-certified plastic surgeon videos (N = 30) scored higher on both the MD (1.7 vs 1.3) and GQS (3.1 vs 2.2) than those of non-medical authors. On the contrary, videos by laypersons and non-plastic surgeons had 40% more views, twice as many "likes" and nearly double as many subscribers. CONCLUSION: The overall quality of information presented in aesthetic fat grafting procedures videos on YouTube is low and from unreliable sources. Surgeons should educate patients regarding potentially inaccurate information, and professional societies should disseminate high-quality media.

Functional Outcomes of a Musculoskeletal Integrated Practice Providing Comprehensive Whole Person Care for Hip Osteoarthritis.

BACKGROUND: Outcomes of hip osteoarthritis (OA) management within integrated practice units (IPUs) are lacking. This study reports 6-month and 1-year patient-reported outcomes (PROs) of IPU care, the proportion of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) at 1 year, and baseline factors associated with the likelihood of achieving MCID and SCB. METHODS: We retrospectively evaluated 1009 new patients presenting to an IPU with hip OA between October 2017 and June 2020. Patients experienced multidisciplinary team-based management. Individuals with baseline and 6-month PROs or baseline and 1-year PROs (Hip Disability and Osteoarthritis Outcome Score Joint Replacement, HOOS JR) were included. We used anchor-based MCID and SCB thresholds and multivariable binary logistic regression models to identify baseline factors associated with achieving 1-year MCID and SCB. RESULTS: HOOS JR increased from baseline to 6 months (Δ = 19.1 ± 2.1, P = .065) and baseline to 1 year (Δ = 35.8 ± 2.9, P < .001). At 1 year, 72.7% (IPU only) and 88% (IPU-based total hip arthroplasty [THA]) achieved MCID (P < .001), and 62.3% (IPU only) and 88% (IPU-based THA) achieved SCB (P < .001). In multivariable regression, lower baseline HOOS JR scores (r = 0.96, P = .04), undergoing THA (r = 0.213, P < .001), and fewer symptoms of generalized anxiety (r = 0.932, P = .018) were independently associated with achieving MCID at 1 year. The same factors were independently associated with achieving SCB at 1 year. Lower baseline anxiety (Generalized Anxiety Disorder Questionnaire-7 item) and greater hip-related preoperative limitations result in greater likelihood of achieving MCID and SCB. CONCLUSION: Significant improvements in patient outcomes can be achieved by IPUs providing comprehensive care for hip OA including the management of psychological distress. Future prospective studies should compare the outcomes of IPUs with traditional care in managing diverse patient phenotypes.

Industry Payments to Plastic Surgeons, 2013 to 2018: Who's Getting Paid?

BACKGROUND: The Physician Payments Sunshine Act of 2010 mandated that all industry payments to physicians be publicly disclosed. To date, industry support of plastic surgeons has not been longitudinally characterized. The authors seek to evaluate payment trends from 2013 to 2018 and characteristics across plastic surgeon recipients of industry payments. METHODS: The authors cross-referenced those in the 2019 American Society of Plastic Surgeons member database with Centers for Medicare & Medicaid Services Open Payments database physician profile identification number indicating industry funds received within the study period. We categorized surgeons by years since American Board of Plastic Surgery certification, practice region, and academic affiliation. RESULTS: A sum of $89,436,100 (247,614 payments) was received by 3855 plastic surgeons. The top 1 percent of earners (n = 39) by dollar amount received 52 percent of industry dollars to plastic surgeons; of these, nine (23 percent) were academic. Overall, 428 surgeons (11 percent) were academic and received comparable dollar amounts from industry as their nonacademic counterparts. Neither geographic location nor years of experience were independent predictors of payments received. The majority of individual transactions were for food and beverage, whereas the majority of industry dollars were typically for royalties or license. CONCLUSIONS: Over half of all industry dollars transferred went to just 1 percent of American Society of Plastic Surgeons members receiving payments between 2013 and 2018. Considerable heterogeneity exists when accounting for payment subcategories.

Effect of a Question-Building Intervention on Patient Activation in Integrated Musculoskeletal Care.

Patient activation, the propensity for patients to engage in adaptive health behaviors, is a modifiable factor associated with health outcomes and treatment compliance. The authors evaluated the effect of a question-building intervention (QBI) on patient activation among patients with musculoskeletal symptoms and a low baseline level of activation. Patients seeking treatment for musculoskeletal pain were recruited at the beginning of their outpatient clinic appointment, and they completed the Patient Activation Measure 10-item version (PAM-10) and a demographic questionnaire. Those identified as low activating, based on the initial PAM-10 scores, completed a QBI protocol before their consultation with their provider. A follow-up PAM-10 survey was administered at the end of the visit. A paired sample Student's t test was used to evaluate preintervention and postintervention PAM-10 scores. Fisher's exact test and an unpaired t test were used to assess the association between demographic variables and achievement of minimal clinically important difference (MCID) for PAM-10. Of 194 patients who consented to participate, 60 were identified as low activating and completed the QBI. A paired Student's t test showed a statistically significant increase in mean PAM-10 scores from preintervention (47.3±7.4) to postintervention (54.8±16.8; P<.001). No statistically significant differences were shown in the likelihood of achieving MCID for PAM-10 scores for the sociodemographic variables that were tested. Low-activating patients may benefit from a simple question-formulating intervention before consultation with an orthopedic provider. [Orthopedics. 2021;44(5):e661-e667.].

Systematic Process Framework for Conducting Implementation Science Research in Food Fortification Programs.

Food fortification has proven to be an effective approach for preventing micronutrient deficiencies in many settings. Factors that lead to successful fortification programs are well established. However, due to the multisectoral nature of fortification and the added complexities present in many settings, the barriers to success are not always evident and the strategies to address them are not always obvious. We developed a systematic process for identifying and addressing gaps in the implementation of a food fortification program. The framework is composed of 4 phases: (1) connect program theory of change to program implementation; (2) develop an implementation research agenda; (3) conduct implementation research; and (4) analyze findings and develop/disseminate recommendations for next steps. We detail steps in each phase to help guide teams through the process. To our knowledge, this is the first attempt to outline a systematic process for applying implementation science research to food fortification. The development of this framework is intended to promote implementation research in the field of food fortification, thus improving access to and effectiveness of this key public health intervention.

Clinician Facial Expression of Emotion Corresponds with Patient Mindset.

BACKGROUND: Mental health has a notable and perhaps underappreciated relationship with symptom intensity related to musculoskeletal pathophysiology. Tools for increasing awareness of mental health opportunities may help musculoskeletal specialists identify and address psychological distress and unhealthy misconceptions with greater confidence. One such type of technology-software that identifies emotions by analyzing facial expressions-could be developed as a clinician-awareness tool. A first step in this endeavor is to conduct a pilot study to assess the ability to measure patient mental health through specialist facial expressions. QUESTIONS/PURPOSES: (1) Does quantification of clinician emotion using facial recognition software correlate with patient psychological distress and unhealthy misconceptions? (2) Is there a correlation between clinician facial expressions of emotions and a validated measure of the quality of the patient-clinician relationship? METHODS: In a cross-sectional pilot study, between April 2019 and July 2019, we made video recordings of the clinician's face during 34 initial musculoskeletal specialist outpatient evaluations. There were 16 men and 18 women, all fluent and literate in English, with a mean age of 43 ± 15 years. Enrollment was performed according to available personnel, equipment, and room availability. We did not track declines, but there were only a few. Video recordings were analyzed using facial-emotional recognition software, measuring the proportion of time spent by clinicians expressing measured emotions during a consultation. After the visit, patients completed a demographic questionnaire and measures of health anxiety (the Short Health Anxiety Inventory), fear of painful movement (the Tampa Scale for Kinesiophobia), catastrophic or worst-case thinking about pain (the Pain Catastrophizing Scale), symptoms of depression (the Patient Health Questionnaire), and the patient's perception of the quality of their relationship with the clinician (Patient-Doctor Relationship Questionnaire). RESULTS: Clinician facial expressions consistent with happiness were associated with less patient health anxiety (r = -0.59; p < 0.001) and less catastrophic thinking (r = -0.37; p = 0.03). Lower levels of clinician expressions consistent with sadness were associated with less health anxiety (r = 0.36; p = 0.04), fewer symptoms of generalized anxiety (r = 0.36; p = 0.03), and less catastrophic thinking (r = 0.33; p = 0.05). Less time expressing anger was associated with greater health anxiety (r = -0.37; p = 0.03), greater symptoms of anxiety (r = -0.46; p < 0.01), more catastrophic thinking (r = -0.38; p = 0.03), and greater symptoms of depression (r = -0.42; p = 0.01). More time expressing surprise was associated with less health anxiety (r = -0.44; p < 0.01) and symptoms of depression (r = -0.52; p < 0.01). More time expressing fear was associated with less kinesiophobia (r = -0.35; p = 0.04). More time expressing disgust was associated with less catastrophic thinking (r = -0.37; p = 0.03) and less health anxiety (GAD-2; r = -0.42; p = 0.02) and symptoms of depression (r = -0.44; p < 0.01). There was no association between a clinicians' facial expression of emotions and patient experience with patient-clinician interactions. CONCLUSION: The ability to measure a patient's mindset on the clinician's face confirms that clinicians are registering the psychological aspects of illness, whether they are consciously aware of them or not. Future research involving larger cohorts of patients, mapping clinician-patient interactions during consultation, and more sophisticated capture of nonverbal and verbal cues, including a broader range of emotional expressions, may help translate this innovation from the research setting to clinical practice. CLINICAL RELEVANCE: Tools for measuring emotion through facial recognition could be used to train clinicians to become aware of the psychological aspects of health and to coach clinicians on effective communication strategies both for gentle reorientation of common misconceptions as well as for appropriate and timely diagnosis and treatment of psychological distress.

Comparison of an Artificial Intelligence-Enabled Patient Decision Aid vs Educational Material on Decision Quality, Shared Decision-Making, Patient Experience, and Functional Outcomes in Adults With Knee Osteoarthritis: A Randomized Clinical Trial.

Importance: Decision aids can help inform appropriate selection of total knee replacement (TKR) for advanced knee osteoarthritis (OA). However, few decision aids combine patient education, preference assessment, and artificial intelligence (AI) using patient-reported outcome measurement data to generate personalized estimations of outcomes to augment shared decision-making (SDM). Objective: To assess the effect of an AI-enabled patient decision aid that includes education, preference assessment, and personalized outcome estimations (using patient-reported outcome measurements) on decision quality, patient experience, functional outcomes, and process-level outcomes among individuals with advanced knee OA considering TKR in comparison with education only. Design, Setting, and Participants: This randomized clinical trial at a single US academic orthopedic practice included 129 new adult patients presenting for OA-related knee pain from March 2019 to January 2020. Data were analyzed from April to May 2020. Intervention: Patients were randomized into a group that received a decision aid including patient education, preference assessment, and personalized outcome estimations (intervention group) or a group receiving educational material only (control group) alongside usual care. Main Outcomes and Measures: The primary outcome was decision quality, measured using the Knee OA Decision Quality Instrument (K-DQI). Secondary outcomes were collaborative decision-making (assessed using the CollaboRATE survey), patient satisfaction with consultation (using a numerical rating scale), Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) score, consultation time, TKR rate, and treatment concordance. Results: A total of 69 patients in the intervention group (46 [67%] women) and 60 patients in the control group (37 [62%] women) were included in the analysis. The intervention group showed better decisional quality (K-DQI mean difference, 20.0%; SE, 3.02; 95% CI, 14.2%-26.1%; P < .001), collaborative decision-making (CollaboRATE, 8 of 69 [12%] vs 28 of 60 [47%] patients below median; P < .001), satisfaction (numerical rating scale, 9 of 65 [14%] vs 19 of 58 [33%] patients below median; P = .01), and improved functional outcomes at 4 to 6 months (mean [SE] KOOS JR, 4.9 [2.24] points higher in intervention group; 95% CI, 0.8-9.0 points; P = .02). The intervention did not significantly affect consultation time (mean [SE] difference, 2.23 [2.18] minutes; P = .31), TKR rates (16 of 69 [23%] vs 7 of 60 [12%] patients; P = .11), or treatment concordance (58 of 69 [84%] vs 44 of 60 [73%] patients; P = .19). Conclusions and Relevance: In this randomized clinical trial, an AI-enabled decision aid significantly improved decision quality, level of SDM, satisfaction, and physical limitations without significantly impacting consultation times, TKR rates, or treatment concordance in patients with knee OA considering TKR. Decision aids using a personalized, data-driven approach can enhance SDM in the management of knee OA. Trial Registration: ClinicalTrials.gov Identifier: NCT03956004.

Gender Disparity in 2013-2018 Industry Payments to Plastic Surgeons.

BACKGROUND: The gender pay gap in medicine has been under intense scrutiny in recent years; female plastic surgeons reportedly earn 11% less than their male peers. "Hidden" pay in the form of industry-based transfers exposes compensation disparity not captured by traditional wage-gap estimations. OBJECTIVES: The aim of this study was to reveal the sex distribution of industry payments to board-certified plastic surgeons across all years covered by the Center for Medicare and Medicaid Services Open Payment Database (CMS OPD). METHODS: We obtained the National Provider Identifier (NPI) for each surgeon in the American Society of Plastic Surgeons (ASPS) member directory to record gender. Next, "General Payments" data points from annual files for all years present in the CMS OPD, 2013 to 2018, were aggregated and joined to provider details by Physician Profile ID before quantitative analysis was performed. RESULTS: Of 4840 ASPS surgeons, 3864 (79.8%) reporting ≥1 industry payment were included with 3220 male (83.3%) and 644 female (16.7%). Over 2013 to 2018, females received mean [standard deviation] 56.01 [2.51] payments totaling $11,530.67 [$1461.45] each vs 65.70 [1.80] payments totaling $25,469.05 [$5412.60] for males. The yearly ratio of male-to-female payments in dollars was 2.36 in 2013, 2.69 in 2014, 2.53 in 2015, 2.31 in 2016, 1.72 in 2017, and most recently 1.96 in 2018. CONCLUSIONS: Individual male plastic surgeons received over twice the payment dollars given to their female counterparts, accepting both more frequent and higher-value transfers from industry partners. Payment inequity slightly declined in recent years, which may indicate shifting industry engagement gender preferences.

Influenza Vaccination Is Not Associated with Increased Number of Visits for Shoulder Pain.

BACKGROUND: Shoulder injury from vaccination was approved for automatic compensation from the Vaccine Injury Compensation Program (VICP)-a federal government program started in 1988 to shield the manufacturers of childhood vaccines from liability. The approval was made on the basis of case reports rather than experimental evidence. This, combined with the addition of influenza vaccination to the VICP in 2005 (which broadened coverage to include adults) and other social factors, was associated with a rapid rise in the number of claims of shoulder injury from vaccination over the last decade, which now account for more than half of all claims to the VICP. Given the high prevalence of newly symptomatic sources of shoulder pain such as rotator cuff tendinopathy, combined with the high prevalence of annual influenza vaccinations, there is a substantial risk of overlap leading to the post hoc ergo propter hoc fallacy ("after this, therefore because of this") contributing to misdiagnosis and inappropriate management of patients that perceive injury from vaccination. Records of medical care after a large number of vaccinations have a good chance of detecting serious shoulder pathology, even it is uncommon, which would result in an increased prevalence of visits for shoulder problems and specific types of shoulder pathology. QUESTIONS/PURPOSES: Is there a difference in the proportion of visits for shoulder pain within 3 months before and after vaccination among students and faculty receiving an influenza vaccination in the shoulder? METHODS: We studied people who were vaccinated for influenza between 2009 and 2018 at a university health service. During the study period, a comprehensive billing database identified 24,206 influenza vaccinations administered to 12,870 people (median age 20 years, range 16-77; 57% women). We had 80% power to detect a 0.1% increase in the proportion of shoulder problems after vaccination compared with before vaccination. Visits with coded ICD-9 shoulder diagnoses were identified from the electronic medical record. We compared the proportion of shoulder evaluations within 3 months before and 3 months after vaccination. RESULTS: With the numbers available, the proportion of visits for shoulder problems were not different before (1.1% [52 of 4801]) and after vaccination (1% [40 of 3977], risk ratio 1.1 [95% CI 0.8 to 1.5]; p = 0.72). Among all vaccinations, 49% (11,834 of 24,206) were preceded or followed by an appointment within 3 months before (20% [4801 of 24,206]), after (16% [3977]), or both before and after (13% [3056]) vaccine administration, and 1.4% (170) of these visits were related to a shoulder issue. The most common reason for shoulder-related appointments was atraumatic shoulder pain (79% [134 of 170]). CONCLUSIONS: Shoulder symptoms sufficient to seek care are notably common, even among relatively young adults, and are not more common after vaccination. Although this does not rule out an important rare pathology specific to vaccination, it seems important to consider the potential harms of assuming, based largely on chronology, that persistent shoulder pain after vaccination-something expected to be common based merely on the anticipated frequency of overlap of vaccination and common shoulder problems-represents harm from vaccine. LEVEL OF EVIDENCE: Level III, therapeutic study.

PROMIS PF correlates with HOOS, JR in patients with hip pain.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly integrated into reporting requirements tied to reimbursement. There may be advantages to computer adaptive tests that apply to many different anatomical regions and diseases, provided that important information is not lost. QUESTIONS: 1) Does the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computer adaptive test correlate with the Hip injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR: a hip-specific PROM); 2) Is there any difference in the amount of variation explained by various factors (e.g. age, BMI, presence of concomitant knee pain) for both measures? METHODS: In this prospective, cross-sectional study of 213 patients, we assessed the Pearson correlation of PROMIS PF and HOOS, JR. To investigate the variation explained by various patient-level factors, we constructed two multivariable linear regression models. RESULTS: We found a large correlation between PROMIS PF and HOOS, JR (r 0.58, P < 0.001). Disabled or unemployed status was independently associated with both lower PROMIS PF and HOOS, JR scores (regression coefficient [ß] -3.4; 95% confidence interval [CI] -5.8 to -1.0; P = 0.006 and ß -11; 95% CI -17 to -5.0; P < 0.001, respectively). Private rather than public insurance was associated with both higher PROMIS PF and HOOS, JR scores (ß 4.5; 95% CI 2.2 to 6.8; P < 0.001 and ß 6.4; 95% CI 0.49 to 12; P = 0.034, respectively). No floor or ceiling effects were observed for PROMIS PF. HOOS, JR scores showed 4.2% floor and 0.5% ceiling effect. CONCLUSIONS: This study adds to the evidence that general measures of physical limitations may provide similar information as joint- or region-specific measures. LEVEL OF EVIDENCE: Level III.

Pyriform Costal Cartilage Graft Improves Cleft-Side Alar Asymmetry in Secondary Cleft Rhinoplasty.

OBJECTIVE: The asymmetry of a retrusive cleft-side ala positioned posterior, lateral, and inferior relative to the noncleft ala is exacerbated by ipsilateral deficiency of the pyriform aperture. We describe use of pyriform costal cartilage grafts for enhanced structural foundation and alar symmetry in secondary cleft rhinoplasty. DESIGN: Retrospective case series. PATIENTS: All pyriform aperture paranasal augmentation secondary cleft rhinoplasty cases performed between May 2013 and February 2018 were included. Clinical photos were analyzed, and these results are provided in addition to a detailed description of the augmentation technique. RESULTS: Twelve total cleft patients, 10 (83.3%) unilateral cleft lip and palate, 1 (8.3%) unilateral cleft lip, and 1 cleft palate (8.3%) were included. Age averaged 18.6 ± 6.0 years with 3 (25.0%) males and 9 (75.0%) females. Costal cartilage grafting to the pyriform aperture through the gingivobuccal sulcus was used to reposition the alar base and nasal sill to a more anatomic anterior position, thereby enhancing symmetry in secondary cleft rhinoplasty. Average rib graft donor site incision was 2.5 cm. Follow-up ranged from 3.2 to 48.2 months, average 15.3 ± 14.4 months. No complications related to the pyriform cartilage graft were observed, other than one minor intraoperative breach of parietal pleura. CONCLUSIONS: We observed improvement in the anatomic contour of the cleft-side ala with costal cartilage grafting to the pyriform rim. This resulted in improved cleft-side alar form and thus overall alar symmetry. These results were obtained consistently, without significant complications. This technique is safe and provides a powerful tool to reposition the ala in secondary cleft rhinoplasty. Further studies will quantify the enhancement in nasal base symmetry.