Citations

BACKGROUND: Free fibula flaps have been widely used for bony reconstruction in pediatric patients. While donor site complications have been well studied in adults, data in the pediatric population remains limited. This study exclusively reports donor-site morbidity following fibula flap harvests in the pediatric and adolescent population. METHODS: We reviewed all patients younger than 18 years with open physes who underwent fibula flap harvests at a single academic institution from 1997 to 2024. Demographics, clinical and surgical characteristics, and donor-site complications were recorded. RESULTS: Fifty-seven free fibula flaps were harvested from 55 pediatric patients (mean age 12 years; 29 female) with a mean follow-up of 6 years. Flaps were most commonly used for lower extremity reconstruction (52%) and following tumor resection (74%). Osteoarticular flaps (n=8) were associated with transient deep peroneal nerve palsy in four cases, all of which recovered antigravity dorsiflexion by 6 months. In standard segmental harvests (n=49), donor-site complications occurred in 38%, most frequently valgus ankle deformity (9%) and neuropathic pain (6%). Valgus deformity was more likely in patients with shorter distal residual fibula and an age–residual fibula index (A-RFI) <16. CONCLUSIONS: Vascularized fibula flaps are safe and versatile for pediatric skeletal reconstruction. Donor-site complications are common but generally manageable, with full recovery of nerve function. Osteoarticular harvests carry the highest risk of peroneal nerve injury, and valgus ankle deformity may occur, particularly with an age–residual fibula index <16. Careful planning and age-adjusted fibular preservation are essential to optimize outcomes.

Abstract Medial meniscus root tears are among the most painful and disabling injuries in knee preservation practice, frequently presenting with substantial functional decline, particularly in female patients. Recent research associates increased posterior tibial slope with both root tears and worse pain scores. Although biomechanically plausible, posterior tibial slope should be interpreted as an association rather than a primary causal driver, as small variations in slope alone are unlikely to fully account for symptom burden or structural progression. Pain and functional decline in this population more likely reflects a multifactorial mechanical environment, in which posterior tibial slope interacts with other determinants of joint loading, including meniscal extrusion, limb alignment, cartilage health, body mass index, subchondral bone response, and degenerative meniscal changes. In our view, posterior tibial slope is one contributor within a broader mechanical environment rather than the primary driver. However, the key clinical message is clear: root tears represent a critical joint‐failure event that demands early recognition and treatment.

BACKGROUND: Hemorrhagic risk in dural arteriovenous fistulas (dAVFs) is largely determined by venous anatomy, but the contribution of systemic cardiovascular factors and their medical therapy remains poorly defined. This study examined associations between cardiovascular risk factors and antithrombotic use and hemorrhagic presentation, angiographic obliteration, and early functional outcomes after treatment. METHODS: We analyzed 1350 adults with intracranial dAVFs from the international Consortium for Dural Arteriovenous Fistula Outcomes Research registry, which retrospectively accrued cases across 14 centers in 4 countries between 1990 and 2017. Demographics, cardiovascular comorbidities, antithrombotic use, angioarchitectural features, treatment strategies, and follow-up outcomes were collected from prospectively maintained databases. Primary end points were hemorrhagic presentation, angiographic obliteration, and 90-day functional status after treatment. Univariable and multivariable logistic regressions were performed with model-specific adjustments. RESULTS: Hemorrhage occurred in 375 patients (27.8%) and was most strongly associated with high-grade dAVF classification and male sex; antithrombotic therapy was associated with lower odds of hemorrhagic presentation. Other cardiovascular risk factors showed no independent relationship with bleeding. Angiographic obliteration was achieved in 621 of 845 patients (73.5%). Hemorrhagic onset, high dAVF grade, and surgical treatment were independently associated with angiographic obliteration, whereas smoking and embolization demonstrated only nonsignificant trends after adjustment. At 90 days, 934 patients (88.9%) were functionally independent. Baseline modified Rankin Scale score was the strongest factor associated with 90-day functional outcome, while neither cardiovascular comorbidities nor treatment modality independently influenced functional status. CONCLUSIONS: In this large multicenter dAVF cohort, hemorrhagic presentation was most strongly associated with venous angioarchitecture. Male sex and antithrombotic therapy were also independently associated with hemorrhagic presentation. Angiographic obliteration was common, particularly among surgically treated lesions, and 90-day functional outcome was most strongly associated with baseline functional status.

ABSTRACT Understanding how fish navigate complex natural environments requires bridging fine-scale biomechanics with ecological behavior. We investigated the volitional movement and energetics of wild red drum (Sciaenops ocellatus) across laboratory, mesocosm and field settings. Using flow-respirometry, we quantified metabolic costs and swimming kinematics under ecologically relevant flow conditions shaped by bluff bodies mimicking mangrove roots and oyster mounds. Fish swimming in turbulent wakes exhibited reduced oxygen consumption and altered tailbeat dynamics, especially at high flow speeds. In a large outdoor mesocosm, dual accelerometers revealed a rich behavioral repertoire, including maneuvering and rest, which is not easily observable in confined lab settings. Spectral analysis and clustering identified eight distinct locomotory states, highlighting the limitations of summed acceleration metrics. Field telemetry tracked wild red drum across a 54 km estuarine corridor for a 3 year period through an array of 36 acoustic receivers, revealing movement patterns shaped by tidal flow and physical habitats. Hydrodynamic modeling showed that although laboratory trials demonstrated substantial energetic savings at high flows (approaching 100 cm s−1), wild fish were detected predominantly in low-velocity microhabitats (&lt;30 cm s−1) near structurally complex features. This mismatch suggests that habitat selection is an adaptive strategy driven by ecological factors such as foraging opportunities, predation refuge and site fidelity, rather than hydrodynamic efficiency alone. Our multi-scalar approach demonstrates that whereas flow–structure interactions can reduce locomotor costs for fish, habitat use in the wild reflects broader ecological constraints, offering a framework for integrating biomechanics, physiology and ecology in conservation-relevant contexts.

Background: Managing heart failure (HF) can be challenging for rural dyads, potentially contributing to depressive symptoms. Coping resources may be important components for dyadic interventions targeting depressive symptoms. Purpose: To explore actor and partner effects of coping resources on depressive symptoms in rural HF dyads. Methods: Using a cross-sectional design, data were collected from 42 rural HF dyads using the Interpersonal Support Evaluation List-12, Social Problem-Solving Inventory Revised-Short, Global Family Function, Family APGAR, and the Center for Epidemiological Studies-Depression scales. Data were analyzed using the Actor-Partner Interdependence Model. Results: Patients were 66.42 and caregivers were 60.83 years old. No partner effects noted. Significant actor effects for patients and caregivers between their own social support and depressive symptoms and their own problem-solving and depressive symptoms were found. There was also a significant actor effect between the caregivers’ family satisfaction and depressive symptoms. Conclusions: Dyadic interventions that enhance coping resources are needed.

Abstract Objective To evaluate the feasibility of collecting Patient-Reported Outcomes Measurement Information System (PROMIS) data within an electronic health record (EHR) for patients undergoing basivertebral nerve ablation (BVNA). Design: Retrospective feasibility study. Setting: Academic community-based health system. Subjects: Seventy-one unique patients (73 procedures) treated with BVNA between 2022–2025. Methods PROMIS Pain Interference, Pain Intensity, and Physical Function surveys were administered at baseline and at 3-, 6-, and 12-month follow-up using EHR-embedded automated workflows. In parallel, a structured quality improvement intervention was implemented to improve survey completion via emphasis on baseline survey completion. The intervention included a standardized nursing rooming checkpoint to verify PROMIS completion prior to the procedure, staff education with scripted patient engagement language, real-time EHR visual prompts using dot phrases to identify incomplete surveys, and monthly site-level performance dashboards reviewed with clinical staff and leadership. Completion rates were extracted from institutional dashboards and workflow bottlenecks were identified through process mapping and staff feedback. A two-proportion test compared pre- and post-intervention baseline completion rates. Clinic visit duration was tracked as a balancing measure to evaluate potential workflow burden. Results Seventy-one patients underwent 73 BVNA procedures. Completion rates were 31.82% at baseline, 77.78% at 3 months, 40.00% at 6 months, and 100% at 12 months among patients reaching those timepoints. Longitudinal engagement was 56%, while longitudinal completeness was 33%. Baseline survey completion improved from 31.82% (21/66) before intervention to 100% (6/6) following implementation (z ≈ 3.0, p ≈ 0.003) durable through three months. Clinic workflow efficiency was not adversely affected, with 83% of visits remaining within the standard 30-minute time slot and no statistically significant increase in visit duration (p ≈ 0.36). Conclusions PROMIS data collection during interventional spine care is feasible and can be reliably integrated into routine clinical workflows when supported by targeted quality improvement interventions. Improving baseline survey capture substantially expands the denominator of patients eligible for longitudinal outcome measurement without increasing clinical workload. Hybrid implementation strategies combining automated EHR deployment with structured clinical oversight may enable reliable PROMIS integration in procedural spine practice.

Abstract Background Lung cancer is the leading cause of cancer-related death, and the most common cancer diagnosed globally. Approximately 85% of lung cancer cases are non-small cell lung cancer (NSCLC). After initial surgical treatment, adjuvant therapy with conventional or targeted chemotherapy can help optimize survival. These treatments, however, must be tailored to each patients’ problematic situation, including cancer characteristics and goals of care. Shared decision making (SDM) is a method of care by which patients and clinicians work together to form plans of care that advance the patient’s problematic human situation. This method often requires evaluating alternative options, “trying them on” for fit given their practical demands and favorable and unfavorable effects. Tools used within the encounter can facilitate and support SDM conversations, yet none exist for considering care post-surgical treatment of NSCLC. Therefore, we aimed to evaluate the effectiveness of a novel encounter tool for SDM, NSCLC Choice, compared to usual care at improving SDM and reducing decisional conflict for patients with resected early-stage NSCLC considering adjuvant treatment. Methods We will conduct a parallel, patient-level randomized trial comparing NSCLC Choice with usual care. Patients will be eligible if they are adults with stage >1B NSCLC eligible for postsurgical adjuvant chemotherapy. Allocation will be central and post-consent. Patients will be blinded to our trial hypothesis, instead of being invited to evaluate an educational intervention. Our primary outcome is SDM quality, which we will assess using participant reported measures (patient SDM-Q-9) obtained immediately post-encounter and an observer measure estimated from video recording of trial encounters in both arms (OPTION12). With resources to conduct a 100-patient trial, we will have >80% power to detect a 12-point medium difference between arms in patient-reported SDM-Q-9. We will also assess the secondary outcomes of knowledge about the disease and the features of treatment options using an ad hoc questionnaire, decisional conflict using the Decisional Conflict Scale, and patient and clinician satisfaction using the metrics used in prior SDM intervention trials. We will also determine encounter length using video recordings. Discussion In testing NSCLC Choice, we seek to determine the extent to which this intervention can improve care for patients with NSCLC considering adjuvant therapy after surgery. In addition, we expect to determine whether this intervention is satisfactory to participants and feasible in practice. If successful, this study will result in an evidence-based tool for promoting patient-centered conversations around NSCLC and cancer care those fits. Trial Registration: NCT06122064 ClinicalTrials.gov

Abstract Background The Global Bipolar Cohort (GBC) was established to identify existing bipolar disorder (BD) cohorts worldwide and foster collaborations focused on descriptive and analytic outcomes relevant to BD. A distributed analytic framework has been implemented to engage multiple sites without the need for central data pooling. This report describes the GBC endeavor and global functional impairment patterns. Cross-cohort comparisons of functional correlates are limited by heterogeneous measures and data-sharing constraints. Large, culturally diverse comparisons are needed to distinguish broadly reproducible correlates from cohort-specific effects. Participating sites completed a 28-item descriptive survey covering diagnostic methods, cognition, genetics, treatment, functioning, and follow-up strategies. We implemented a harmonized local logistic regression model of dichotomized functional outcome and shared summary statistics only. Results We identified 69 cohorts across five continents. Thirty-seven cohorts contributed functional outcome analyses from 17,130 participants. Outcome measures included clinician-rated disability scales and social indicators such as employment and marital status. The proportion classified with poor functioning ranged from 16% to 77% (mean 50%). In 32 of 37 cohorts, the overall regression model significantly explained variance in functioning. Current depressive symptoms were the most robust and reproducible correlate of poor functional outcome: they were assessed in 29 cohorts, significant in 22 (75.8%), ranked among the top three correlates in 22, and were the top-ranked correlates in 19. Associations between depressive burden and poor functioning were observed across clinician-rated disability scales and work or social indicators, and across geographically diverse cohorts. Comorbid substance use disorder and medication-related variables were associated with poorer functioning in subsets of cohorts, whereas sex, ancestry, bipolar subtype, psychosis history, and premorbid IQ showed weak or inconsistent associations. Cognitive measures, available in a minority of regression models, showed modest and non-uniform effects. Conclusions Across heterogeneous international cohorts, current depressive symptom burden emerged as the most consistent correlate of poor functioning in bipolar disorder. These findings replicate earlier multisite work at a larger scale, show that protocol-based distributed analyses can identify reproducible clinical signals without sharing individual-level data, and support prioritizing detection and treatment of depressive symptoms when aiming to improve real-world functioning. Future work should expand longitudinal harmonization and representation of under-studied populations.

Objectives: Developmental Dysplasia of the Hip (DDH) is a common congenital anomaly requiring early diagnosis to minimize invasive treatments. This study evaluates Lebanese pediatricians’ knowledge of DDH risk factors, screening methods, and treatment strategies, comparing their practices to American and European guidelines to propose screening recommendations. Methods: A cross-sectional descriptive study was conducted using a confidential questionnaire to assess Lebanese pediatricians’ knowledge and practices regarding DDH. Contact information for pediatricians was obtained from the Lebanese Order of Physicians. Out of 600 emailed and 100 distributed questionnaires, 263 responses were received, and data were analyzed using proportion tests. Results: Of the 263 respondents (19.9% response rate), 84% routinely ordered radiographs at 4 months, while only 0.4% followed recommended guidelines. About 50% performed hip stability tests (Barlow and Ortolani) at 6 months, and 78.32% recommended the Pavlik harness for post-6-month treatment. Additionally, 97% valued periodic reminders about DDH. Significant gaps were identified in training on risk factor identification, physical examination procedures, imaging indications, management of abnormal findings, and treatment choices. Conclusions: The study highlights a critical training gap in DDH screening among Lebanese pediatricians. Implementing routine neonatal screening aligned with international recommendations is essential to reduce delayed diagnosis and its associated economic burden. Improved education and training on DDH screening and treatment are crucial for early detection and better patient outcomes.

Background The diagnosis of periprosthetic joint infection (PJI) is facilitated by consensus identification of synovial biomarkers, which may be aided by targeted microbial next generation sequencing (NGS) of synovial fluid. The primary objective of the study was to evaluate NGS performance across 3 years to ICM 2018 minor criteria for PJI. Methods Synovial fluid specimens submitted from 2020–2022 by outpatient surgical clinics to MicroGenDX for matched synovial biomarker and NGS analysis were selected for retrospective analysis. Synovial biomarkers tested included C-reactive protein (CRP), white blood cell (WBC) count, and polymorphonuclear (PMN) leukocyte percentage. Synovial fluid analysis compared NGS microbial positivity with positive incidence of PJI determined by scoring of synovial biomarkers using ICM 2018 minor criteria for infection. Results The overall sensitivity, specificity, and accuracy of NGS to ICM diagnosed PJI across 2,011 specimens was 76.4% [95% CI, 0.723–0.801], 92.3% [0.91–0.94], and 88.7% [0.87–0.90], respectively. When comparing the diagnostic performance of NGS and individual biomarkers to infection, NGS was more specific to PJI than synovial CRP (specificity = 0.894, 95% CI: 0.88–0.91), but not PMN or WBC. NGS was positive in 7.7% of ICM negative samples. NGS positive: ICM negative samples were associated with significantly elevated synovial PMN ( p = 0.001) and WBC ( p &lt; 0.0001) compared to NGS negative: ICM negative samples. Across all samples, NGS positivity was associated with significantly elevated results for all tested biomarkers ( p &lt; 0.0001). Eight bacterial species dominated the composition in 68% of samples, whereas 46 different microbes were dominant in the remaining third. Conclusion Microbial targeted NGS positivity was concordant with ICM minor criteria for PJI and should be considered a useful tool for diagnosis. There is a low risk of false positive detections comparable to ICM biomarkers. Elevated biomarkers in NGS positive: ICM negative samples may indicate infection occurring that is poorly captured by the three measured synovial biomarkers. Uncommon species are collectively common to PJI and NGS is uniquely positioned to detect such species as they are frequently missed by conventional microbiological testing, including culture and quantitative PCR. These results suggest formal diagnostic schemes would benefit from the addition of NGS as a diagnostic criterion.