The Impact of the COVID-19 Pandemic on Racial Disparities in Patients Undergoing Total Shoulder Arthroplasty in the United States

INTRODUCTION: The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the US and to determine whether these disparities were affected by the COVID-19 pandemic. METHODS: Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April-December from 2019-2020. Utilization was assessed for White/Black/Hispanic/Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age/sex/CMS-Hierarchical Condition Categories (HCC) score, dual enrollment (proxy for socioeconomic status), time fixed effects, and Core-based Statistical Area (CBSA) fixed effects was used to study difference across groups. RESULTS: In 2019, TSA volume/1000 beneficiaries was 1.51 for White and 0.57 for non-White, a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P\u3c0.01). There was an overall 14% decrease in TSA volume/1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference;8.7%,p = 0.02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%,p = 0.05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture. CONCLUSIONS: During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA while disparities were less apparent for proximal humerus fracture

Differentiating Between Simple And Complex Pediatric Musculoskeletal Extremity Infections: Identifying Predictors Early In The Hospital Course

Complex musculoskeletal infections, defined as subfascial reaching infections involving muscle, and/or bone, occur more frequently in our age of increasing antibiotic resistance and bacterial virulence. These infections correlate with longer hospital stays, increased surgical need, and poorer outcomes compared to simple superficial soft tissue infections. Pediatric musculoskeletal infections often have an ambiguous presentation, however, complicating diagnosis and appropriate treatment. The goal of this study is to identify predictors of complicated infections to allow for quick differentiation between simple and complex pediatric extremity infections. By identifying these factors, aggressive treatment of the potentially more serious infections early in the hospital course may improve outcomes. Children with complex musculoskeletal infections present with higher laboratory values, heart rate, and pain scores compared to simple infections. It is our belief, these values may help stratify patients into “simple” or “complex” infection groups. Early identification of patients with parameters correlated with “complex” infections may prevent delays of treatment and potentially decrease length of stay and complications for those with these high-virulence infections

Characteristics of antimicrobial resistance in Escherichia coli isolated from retail meat products in North Carolina.

BackgroundEscherichia coli is commonly used as an indicator for antimicrobial resistance (AMR) in food, animal, environment, and human surveillance systems. Our study aimed to characterize AMR in E. coli isolated from retail meat purchased from grocery stores in North Carolina, USA as part of the National Antimicrobial Resistance Monitoring System (NARMS).Materials and methodsRetail chicken (breast, n = 96; giblets, n = 24), turkey (n = 96), and pork (n = 96) products were purchased monthly from different counties in North Carolina during 2022. Label claims on packages regarding antibiotic use were recorded at collection. E. coli was isolated from meat samples using culture-based methods and isolates were characterized for antimicrobial resistance using whole genome sequencing. Multi-locus sequence typing, phylogroups, and a single nucleotide polymorphism (SNP)-based maximum-likelihood phylogenic tree was generated. Data were analyzed statistically to determine differences between antibiotic use claims and meat type.ResultsOf 312 retail meat samples, 138 (44.2%) were positive for E. coli, with turkey (78/138; 56.5%) demonstrating the highest prevalence. Prevalence was lower in chicken (41/138; 29.7%) and pork (19/138;13.8%). Quality sequence data was available from 84.8% (117/138) of the E. coli isolates, which included 72 (61.5%) from turkey, 27 (23.1%) from chicken breast, and 18 (15.4%) from pork. Genes associated with AMR were detected in 77.8% (91/117) of the isolates and 35.9% (42/117) were defined as multidrug resistant (MDR: being resistant to ≥3 distinct classes of antimicrobials). Commonly observed AMR genes included tetB (35%), tetA (24.8%), aph(3'')-lb (24.8%), and blaTEM-1 (20.5%), the majority of which originated from turkey isolates. Antibiotics use claims had no statistical effect on MDR E. coli isolates from the different meat types (X2 = 2.21, p = 0.33). MDR was observed in isolates from meat products with labels indicating "no claims" (n = 29; 69%), "no antibiotics ever" (n = 9; 21.4%), and "organic" (n = 4; 9.5%). Thirty-four different replicon types were observed. AMR genes were carried on plasmids in 17 E. coli isolates, of which 15 (88.2%) were from turkey and two (11.8%) from chicken. Known sequence types (STs) were described for 81 E. coli isolates, with ST117 (8.5%), ST297 (5.1%), and ST58 (3.4%) being the most prevalent across retail meat types. The most prevalent phylogroups were B1 (29.1%) and A (28.2%). Five clonal patterns were detected among isolates.ConclusionsE. coli prevalence and the presence of AMR and MDR were highest in turkey retail meat. The lack of an association between MDR E. coli in retail meat and antibiotic use claim, including those with no indication of antimicrobial use, suggests that additional research is required to understand the origin of resistance. The presence of ST117, an emerging human pathogen, warrants further surveillance. The isolates were distinctly diverse suggesting an instability in population dynamics

Impact of the COVID-19 Pandemic on Shoulder Arthroplasty: Surgical Trends and Post-Operative Care Pathway Analysis

INTRODUCTION: COVID-19 triggered disruption in the conventional care pathways for many orthopedic procedures. The current study aims to quantify the impact of the COVID-19 pandemic on shoulder arthroplasty hospital surgical volume, trends in surgical case distribution, length of hospitalization, post-hospital disposition, and 30-day readmission rates. METHODS: This study queried all Medicare (100% sample) fee-for-service beneficiaries who underwent a shoulder arthroplasty procedure (DRG 483, CPT 23472) from January 1, 2019 to December 18, 2020. Fracture cases were separated from non-fracture cases, which were further subdivided into anatomic or reverse arthroplasty. Volume per 1000 Medicare beneficiaries was calculated from April to December 2020 and compared to the same months in 2019. Length of stay (LOS), discharged-home rate, and 30-day readmission for the same period were obtained. The yearly difference adjusted for age, sex, race (white vs. non-white), CMS-Hierarchical Condition Categories (HCC) risk score, month fixed effects, and Core-based Statistical Area (CBSA) fixed effects, with standard errors clustered at the provider level was calculated using a multivariate analysis (p \u3c 0.05). RESULTS: 49,412 and 41,554 TSA cases were observed April through December for 2019 and 2020, respectively. There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% (19% reduction in anatomic TSA, 13% reduction in RTSA, and 3% reduction in fracture cases). LOS for all shoulder arthroplasty cases decreased by 16% (-0.27 days, p\u3c 0.001) when adjusted for confounders. There was a 5% increase in the discharge-home rate (88.0% to 92.7%, p\u3c0.001); most prominent in fracture cases with a 20% increase in discharged-home cases (65.0% to 73.4%, p\u3c0.001). There was no significant change in 30-day hospital readmission rates overall (p = 0.20) or when broken down by individual procedures. CONCLUSIONS: There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% during the COVID-19 pandemic. A decrease in LOS and increase in the discharged-home rates was also observed with no significant change in 30-day hospital readmission, indicating that a shift towards an outpatient surgical model can be performed safely, efficiently and has potential to provide value