Background
Acute hip fractures are a public health problem that affect primarily older adults. Given the subtleties in different patient indications and classifications such as fracture type, preoperative mobility/functional status, and presence or absence of preexisting/symptomatic arthritis, Chat Generative Pre-trained Transformer (ChatGPT) may be a helpful clinical decision-making tool in the treatment plan to optimize patient outcomes. The purpose of this study was to evaluate the accuracy of ChatGPT-4.0 by comparing its appropriateness scores for acute hip fractures with the American Academy of Orthopedic Surgeons (AAOS) Appropriate Use Criteria (AUC) given various patient scenarios. 

Methods
Using the AUC as the gold standard, a numerical scale was utilized to quantify the appropriateness of 6 different treatments. Quantitative scores ranging from 1-9 were assigned as follows: 7-9 signifies “Appropriate,” 4-6 signifies “May Be Appropriate,” and 1-3 signifies “Rarely Appropriate.” ChatGPT-4.0 was prompted separately and asked to assign an appropriate score for each treatment. To measure any notable errors, AAOS AUC scores were subtracted from the ChatGPT-4.0 scores, and the mean error, mean absolute error, and mean squared error were calculated. Spearman’s rank correlation coefficients and paired t-tests were used to determine statistical significance.

Results
30 patient scenarios were evaluated among 6 different treatment options for a total of 180 paired scores. Spearman’s rank correlation testing found that there was a very strong positive correlation between AAOS and ChatGPT-4.0 scores for Multiple Cannulated Screw Fixation, a strong positive correlation between scores for THA and for Hemiarthroplasty, and a moderate positive correlation for Long Cephalomedullary Nails. There was a non-significant weak positive correlation between scores for Short Cephalomedullary Nails and for Sliding Hip Screw ± Anti-Rotation Screw. Using a paired t-test, there were significant differences between scores for Long Cephalomedullary Nails.

Conclusion
The AAOS AUC is designed to optimize treatment outcomes for acute hip fractures in adults by improving the quality of care, and minimizing short- and long-term mortality. The appropriateness scores for THA, Hemiarthroplasty, Long Cephalomedullary Nails, and Multiple Cannulated Screw Fixation determined by ChatGPT-4.0 were positively correlated with the AUC scores. ChatGPT-4.0 overestimated the appropriateness of THA, Hemiarthroplasty, and Long Cephalomedullary Nails. The scores to treat with Long Cephalomedullary Nails were non-equivalent. Although it demonstrated some utility in recommending the appropriateness of treatment options for acute hip fractures in older adults, clinicians should refrain from fully relying on ChatGPT-4.0. The AI model needs improvement to assist physicians and must be further evaluated.

Can Large Language Models Recommend Treatment for Hip Fractures?

Background
Cutibacterium, as a ubiquitous, commensal gram-positive organism, represents a diagnostic challenge for arthroplasty surgeons. The characteristics of Cutibacterium culture positivity in THA and TKA are not well understood.

Methods
1: Retrospective chart review of patients with Cutibacterium culture following THA or TKA. 
2: Patient baseline characteristics and lab results were analyzed using T-test and chi-squared analysis. 
3: Those who underwent subsequent surgery were evaluated at one year using MSIS ORT.

Results
Of those with Cutibacterium-positive cultures, 10 of 21 THAs (47.6%) preoperatively met MSIS infection criteria, while 7 of 8 TKAs preoperatively met MSIS criteria (87.5%) (p= 0.13). Mean ESR was 36.4 mm/h for THA and 51.5 mm/h for TKA (p = 0.21), with mean CRP of 35.2 mg/dL for THA and 36.8 mg/dL for TKA (p = 0.95). Mean cell count and percent polymorphonuclear (PMNs) leukocytes from intra-articular aspiration was 27,055 with 68% PMNs for THA and 22,194 with 73.9% PMNs for TKA (p = 0.72 and p = 0.70, respectively). Mean cell count and percent PMNs was 24,143 (range of 95 to 128,205) with 58.9% PMNs for monomicrobial infections and 25,903 with 78.8% PMNs for polymicrobial infections. Of patients who underwent surgical intervention following positive periprosthetic Cutibacterium culture and had one-year follow-up (n =22), 16 (72%) had successful outcomes at one year. Only ASA was significantly different between the success and failure groups.

Conclusion
1) Cutibacterium PJI could lead to more subtle clinical and laboratory changes compared to other microbial species.
2) Patients with Cutibacterium-positive cultures following TKA or THA may not meet MSIS infection criteria.
3) Inflammatory markers and fluid characteristics of Cutibacterium-positive THAs and TKAs were elevated but had more subtle changes compared to accepted values for more virulent microbial species.
4) Patients who undergo surgical intervention following a positive periprosthetic Cutibacterium culture often have successful outcomes at one year.


Patients with Positive Cutibacterium Culture Following Total Hip (THA) and Total Knee Arthroplasty (TKA) Often do not Meet MSIS Criteria for Infection

Background: Stress fractures are a type of bone injury resulting from repetitive microtrauma and abnormal bone stress. There are two main types of stress fractures: fatigue fractures (repetitive stress on normal bones) and insufficiency fractures (any injury to weakened bones). This case report highlights a rare and challenging diagnosis of bilateral synchronous fatigue fractures of the proximal tibial metaphysis, accompanied by sprains of the medial menisci and anterior cruciate ligaments.

Case presentation: A 36-year-old male with a BMI of 33 and a sedentary lifestyle for over a decade started jogging and playing cricket matches. He developed pain and swelling in both knees within a week of becoming physically active. There was no history of trauma. Weight-bearing increased the pain. Point tenderness was present along the medial side of the knee joint lines. Tibial traction tests, varus, and valgus stress tests were negative on both legs. McMurray test was negative on the left side and positive on valgus stress with external rotation on the right leg, suggesting a tear on the medial meniscus on the right side. 

He was clinically diagnosed as having a medial meniscal tear on the right knee and left infrapatellar bursitis on the left knee. X-rays of both knees were normal. Initial management with the RICE algorithm (Rest, Ice, Compression, and elevation) and NSAIDs did not improve clinical status. MRI taken after two weeks showed bilateral stress fractures of the proximal tibial metaphysis, bilateral partial tears of the medial menisci, and anterior cruciate ligaments. Lab tests showed elevated ESR, normal Vitamin D and calcium levels, and negative for autoantibodies. Bone densitometry was normal. With the new diagnosis, he was treated with partial immobilization by knee splints with bathroom privileges for three weeks and physiotherapy for 12 weeks. He started walking with support after three months and total weight bearing after six months of initial diagnosis.

Discussion: The diagnosis was initially missed, leading to mistreatment and significant physical, mental, and financial consequences to the patient. This case emphasizes the importance of considering stress fractures and ligament injuries in individuals with recent intense exercise history, particularly in obese patients and obtaining imaging studies earlier. It also underscores the need for evidence-based practices and encourages healthcare professionals to stay updated with current research to improve patient care.

Bilateral Synchronous Proximal Tibial Metaphyseal Stress Fractures with Sprains of Anterior Cruciate Ligaments and Medial Menisci – A Case Report

Background
Patients who present with cervical dystonia may also present with cervical myelopathy. This presentation can be problematic because patients with cervical myelopathy need fusion surgery such as an anterior discectomy and fusion (ACDF) to stabilize the spine and prevent damage to the spinal cord. The involuntary tremor caused by cervical dystonia can result in problems with boney fusion in the post-operative period. Deep Brain Stimulation (DBS) provides a potential solution to this problem when more conservative treatments like medication, halo vests, and botulinum toxin fail to reduce tremor.
Case Presentation
A 46-year-old female presented to our center with a chief complaint of neck pain. The patient also presented with bilateral upper extremity radiculopathy, paresthesia, and a myelopathic gait. She had a 15-year history of cervical dystonia and had tried various medications and botulinum toxin injections without resolution of symptoms. In addition to this the patient had cervical myelopathy caused by disc herniation at the C5-C6 and C6-C7 level. Although the patient was a candidate for ACDF, she was advised to have her dystonic tremor treated before ACDF to prevent pseudoarthrosis and hardware failure because of the tremor. The patient underwent bilateral DBS in the Globus pallidus interna (GPi) utilizing an Abbott InfinityTM DBS system. After placement of the DBS-GPi leads, batteries were placed, and the system was turned on which was able to provide significant relief of the patient’s tremor. The patient was followed up at 3 months and had a >75% reduction in her tremors. After the significant reduction in tremor, the patient underwent C5-C6 and C6-C7 ACDF at 6 months post DBS-GPi. The patient reported that the paresthesia had improved significantly, and the weakness had gradually improved at 3 months post ACDF. There was no radiographic evidence of hardware loosening or malalignment.
Discussion
The presentation of both Cervical Dystonia and Cervical Myopathy concurrently is a challenging couple of pathologies to manage. Bilateral DBS-GPi prior to ACDF is a viable strategy for managing these pathologies surgically. 


DBS before ACDF for a patient with Cervical Dystonia and Cervical Myelopathy

Background 

Increased preoperative shoulder dislocations are associated with recurrent instability and greater glenoid bone loss. Initial instability events and subsequent episodes can result in 6.8% and 20% increased glenoid bone loss respectively. Glenoid bone loss increases the risk of instability recurrence and poor outcomes following shoulder stabilization surgery. Low socioeconomic status (SES) indicators, such as high Area Deprivation Index (ADI) and non-commercial insurance status, correlate with emergency room visits and delays to orthopaedic care. This study assesses the correlation between ADI, insurance status, and preoperative glenoid bone loss. We hypothesized higher national ADI and non-commercial insurance would correlate with greater levels of radiographic glenoid bone loss. 



Methods 

339 Bankart repair patients were identified. Data obtained included demographics, national ADI, insurance status, and glenoid bone loss. National ADI was obtained utilizing the Neighborhood Atlas Website and patients’ home addresses. Patients were excluded for prior ipsilateral shoulder surgery (N=16), lack of viewable imaging (N=97), and low-quality magnetic resonance imaging (MRI)(N=34). Glenoid bone loss was measured using the Best-fit circle method on high-quality MRIs (i.e., Fast imaging employing steady-state acquisition (FIESTA)). Three-dimensional alignment of images provided the best glenoid en face view. Researchers were blinded to ADI and insurance status during radiographic analysis and inter- and intra-observer reliability testing. Glenoid bone loss was compared between insurance types using one-way ANOVAs. Before evaluating the ADI and glenoid bone loss association, a scatterplot was generated to qualitatively assess the nature of the relationship. A curve fitting tool determined a quadratic non-linear regression best characterized the association between ADI and glenoid bone loss. 



Results 

192 patients (23% female; 23.9±7.5 years of age; national ADI=16.7%±16.0%) were included. Patients experienced 9.50±6.59% glenoid bone loss. A significant quadratic association between national ADI and glenoid bone loss (R2=0.483, p<0.001) was observed. Individuals with non-commercial insurance experienced greater glenoid bone loss compared to commercial insurance (commercial=8.80±6.46%, other=12.52±6.36%, p=0.003). Interobserver reliability was .910; intraobserver reliability was .948. 



Conclusion 

Our findings indicate a positive association between area deprivation and MRI-measured glenoid bone loss in patients with anterior shoulder instability. Patients with low SES indicators, such as high ADI and non-commercial insurance, are more likely to have greater glenoid bone loss and could be at risk for increased rates of pre- and postoperative instability. While a correlation between low SES indicators and glenoid bone loss has been demonstrated; the association of SES with surgical complexity and functional outcomes in this context should be explored.

Low Socioeconomic Indicators Correlate with Greater Pre-Operative Glenoid Bone Loss

**Scoring is only possible in the semifinals hall**

**Abstract:**



Evaluation of Flow-Diversion Procedures Using Microangioscopy: Correlation with Histology and Digital Subtraction Angiography

Background
The biopsychosocial model suggests that health outcomes are determined by the interplay of biological, psychological, and social factors. Within this framework, health follows a social gradient, in which socioeconomic status has a direct impact on health outcomes. In the United States, each group on the social ladder has better health than the group below it. These patterns of inequity are manifested through differential access to resources, including housing, education, and healthcare. 

In order to reduce these health disparities, the Upstate Medical Legal Partnership (MLP) was developed as an integrated, upstream approach to improve health outcomes for marginalized populations throughout Upstate South Carolina. More specifically, through a collaboration between Furman University, Prisma Health Upstate, and South Carolina Legal Services, the Upstate MLP coordinates and streamlines access to non-medical assistance when a medical problem is caused or exacerbated by a social or legal problem. The objective of this study was to qualitatively explore the impact of the MLP on health and quality of life for pediatric clients and their families. 

Methods
This study utilized the WHO social determinants of health (SDoH) framework to develop an interview guide. The interview guide assessed the effect of the MLP on health status, health access, and other SDoH domains. The MLP team interviewed 18 caregivers of pediatric patients who were referred to the MLP for assistance. Data analysis was conducted using the qualitative coding software NVivo using a grounded theory approach to understand the impact of MLP intervention on the health and well-being of pediatric clients and their families. 

Results
Prior to receiving MLP assistance, the caretakers reported three main areas of stress: difficulty balancing work and childcare, challenges adhering to treatment programs, and inhibited overall family functioning. However, by securing additional financial resources (SSI, Medicaid, TANF), facilitating custody proceedings, and providing social support for these families, the MLP was able to reduce the amount of stress perceived by these caregivers. Several downstream effects of this reduced caregiver stress were identified. Caregivers reported improved treatment compliance for themselves and their children, improved ability to balance work and childcare, and improved overall family functioning. 

Conclusion
Medical Legal Partnerships have the potential to improve health outcomes for caregivers and their children by securing economic resources, finalizing custody arrangements, and providing social support. The study demonstrated that MLP intervention allowed caregivers to have increased treatment compliance and improved family functioning, which has positive health implications for the pediatric clients and their caregivers.


Downstream Impacts of the Upstate Medical Legal Partnership: How Embedding Lawyers in Hospitals Can Be Used to Tackle the Social Determinants of Health

The Impact of Insurance Status and Surgical Approach on Clinical Outcomes of Segmental Colectomy


Small-for-gestational-age (SGA) children may be at risk for earlier puberty and adverse long-term health sequalae. This study investigates associations between SGA and age at menarche using secondary data analysis of 992 female children in a U.S. birth cohort of primarily non-marital births. SGA was defined as <10th percentile of weight for gestational age within the sample. We estimated unadjusted and adjusted Ordinary Least Squares (OLS) models of associations between SGA and age at menarche in years, as well as unadjusted and adjusted logistic regression models of associations between SGA and menarche before age 11. SGA was associated with slightly earlier menarche, but the difference was not statistically significant even when adjusting for maternal sociodemographic characteristics and when further adjusting for prenatal smoking and maternal pre-pregnancy overweight and obesity. Similarly, SGA was not significantly associated with the odds of menarche before age 11 in unadjusted or adjusted models. Maternal non-Hispanic Black race-ethnicity, Hispanic ethnicity, and pre-pregnancy obesity all had independent associations with earlier age at menarche and menarche before age 11. Therefore, it appears that inherited maternal risk factors play more direct roles.

SGA and age at menarche in a diverse population-based U.S. sample

Uncovering Patterns between Obstructive Sleep Apnea and Disease Comorbidities: An Exploration of Patient Demographics

Background : Worldwide studies show an increasing trend of sleep disorders in recent times. We aimed to assess the association of epidemiology and socio-demographic disparities of organic sleep disorders (OSDs) using the National Inpatient Sample Database in the US population.

Methods : A retrospective study of the NIS (2016-2018) using the ICD-10-CM codes was performed. Hospitalizations with the diagnosis of OSDs (REM sleep behavior disorder, parasomnia, circadian rhythm, insomnia, hypersomnia, and narcolepsy) were identified. Weighted analysis was performed using an unpaired t-test & chi-square test. Mix effect multivariate regression analysis was performed to evaluate epidemiology & demographic disparities associated with OSDs.

Results : Out of 87,761,798 hospitalizations, 2,128,329 (2.43%) had organic sleep disorders. Amongst OSDs, prevalence of insomnia-2.32%, REM sleep behavior disorder-0.1%, parasomnia-0.1%, circadian rhythm-0.1%, hypersomnia-0.04%, and narcolepsy-0.06%. Population with OSDs was older (60 vs 58 years) and OSDs were higher in the age group 50-75 years (2.8% vs >75 years: 2.38% vs 18-50 years: 1.98%), male (2.53% vs female: 2.35%), White race (2.74% vs Native American: 2.06% vs Black: 1.83% vs Hispanic: 1.69%) and median household income of 76-100th percentile (2.61% vs 0-25th: 2.26%). Prevalence of hypertension (61.48% vs 55.58%), obesity (17.00% vs 15.77%), drug abuse (13.80% vs 6.70%), alcohol dependence (10.50% vs 5.81%), smoking (22.57% vs 16.10%) and AIDS (10.79% vs 6.03%) was higher amongst OSDs than no OSDs (p<.0001). In regression analysis, we found patients with age 50-75 years (aOR 1.08, 95%CI 1.06-1.10), female (1.05, 1.04-1.05), median income 76-100 percentile (1.10, 1.09-1.11), hypertension (1.18, 1.17-1.19), dyslipidemia (1.27, 1.26-1.28), obesity (1.09, 1.08-1.1) and AIDS (1.88, 1.86-1.9) had significantly higher odds of OSDs.

Conclusion : We identified a higher prevalence of OSD in the male, white, and high socioeconomic status population with insomnia being the most common type. Early identification and risk mitigation are essential to reduce the burden of ODSs. Our study is confounded by the absence of severity, outcomes of disease, causality, and long term follow up of patients


Epidemiology And Socio-demographic Disparities Associated With Organic Sleep Disorders Among USA Hospitalizations - A National Estimate

Background: Bariatric surgery (BS) has proved to reduce comorbidity burden among patients with established cardiovascular diseases (CVD). However, its impact on mortality and hospital outcomes remains to be investigated among this population of patients.
Methods: National Inpatient Sample (NIS) database was queried to identify admission cases with CVD during 2019. Mortality rate and hospital outcomes were compared according to the types of CVD and history of BS.
Results: Out of 7,803,805 hospitalizations during 2019, data of 38,354 patients with a history of BS was stratified according to the types of CVD (Table1). History of BS was associated with lower mortality among all CVD subtypes. However, its impact on reducing the length of stay was only statistically significant among established cases of heart failure, atrial fibrillation, peripheral vascular diseases, and aortic dissection/aneurysm. Regardless, previous BS was not associated with lower cost of hospitalization among patients admitted with CVD. Among BS procedures, sleeve gastrectomy played a more beneficial role than gastric bypass among CVD patients.
Conclusion: Bariatric surgery is associated with reduced mortality and length of hospitalization among patients with established CVD with sleeve gastrectomy having a more desirable outcome. However, its impact on acute cases of CVD such as myocardial infarction and cerebrovascular accident remains unclear. 


Bariatric Surgery is Associated with Better Outcomes Among Hospitalized Patients with Established Cardiovascular Diseases in the United States: An Insight from the National Inpatient Sample Data 2019

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