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AimsThe aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures.Patients and MethodsThe Kids’ Inpatient Database (KID) was used to evaluate children between birth and 17 years of age, from 1997 and 2012, who had undergone open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. Demographics, hospital charges, lengths of stay (LOS), and complications were analyzed.ResultsObesity was significantly associated with increased rates of open reduction and internal fixation (ORIF) for: distal humeral (odds ratio (OR) = 2.139, 95% confidence interval (CI) 1.92 to 3.44; p < 0.001); distal radius and ulna fractures (OR = 1.436, 95% CI 1.14 to 2.16; p < 0.05); distal femoral (OR = 2.051, 95% CI 1.69 to 3.60; p < 0.05); tibial and fibula shaft (OR = 2.101, 95% CI 2.10 to 3.50; p < 0.001); and ankle (OR = 1.733, 95% CI 1.70 to 2.39; p < 0.001). Older age was significantly associated with ORIF for all fractures (p < 0.05). LOS, hospital charges, and complications were significantly increased in obese patients following ORIF for upper and lower limb fractures (p < 0.05).ConclusionObese paediatric patients are more likely to undergo ORIF in both upper and lower limb fractures and have more inpatient complications. These findings may assist in informing obese paediatric fracture patients and their families regarding the increased risk for open operative fixation and associated outcomes. Cite this article: Bone Joint J 2019;101-B:491–496.

Study Design: Retrospective cohort study. Objective: To determine the effects of operative time on postoperative complications in patients age 65 and older undergoing posterior lumbar fusion. Methods: All patients age 65 and older undergoing posterior lumbar fusion were identified in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome measures were complications occurring up to 30 days postoperatively, including death, any complication, and complication subtypes. The primary independent variable was operative duration. Both bivariate and multivariate analyses utilized logistic regression and analyzed operative duration as a continuous variable. Statistical significance was considered P < .05. Results: A total of 4947 patients age 65 and older undergoing posterior lumbar fusion were identified. The mean operative time was 3.3 hours (SD 1.7). The overall complication rate was 13.4% (n = 665). In multivariate analysis, each incremental hour of operative time was associated with increased risk of postoperative thromboembolism (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.10-1.37), transfusion (OR= 1.25; 95% CI = 1.18-1.32), urinary tract infection (OR = 1.21; 95% CI = 1.10-1.32), and total postoperative complications (OR = 1.22; 95% CI = 1.16-1.27). Conclusion: For patients age 65 and older undergoing posterior lumbar fusion, longer operative time is associated with greater risk for thromboembolism, transfusion, intubation, kidney injury, urinary tract infection, surgical site infection, and overall postoperative complications. This data highlights several specific complications that are influenced by operative time in older patients, and further supports the need for future protocols that seek to safely minimize operative time for posterior lumbar fusion.

About 6% of women in the world live in countries that ban all abortions, and 34% in countries that only allow abortion to preserve maternal life or health. In the USA, over the last decades—even before Dobbs v. Jackson Women’s Health Organization overturned the federal right to abortion—various states have sought to restrict abortion access. Often times, this legislation has been advanced based on legislators’ personal moral values. At the bedside, in contrast, provision of abortion care should adhere to the normative principles of medical ethics and reproductive justice, centreing patients and their individual reproductive intentions and desires. Abortion regulations, through their influence on patients and providers, may facilitate or impede such ethical care at the bedside. In this paper, we present a framework to model how abortion legislation should fit into the patient–provider relationship and to clarify the dynamics by which legislation may affect healthcare encounters. Our proposed framework serves as a tool to analyse the ethical impact of abortion regulations. We propose a model for assessing abortion policies based not on legislators’ or advocates’ individual moral claims, but on the shared, normative framework of clinical medical ethics. Through contrasting case studies, we demonstrate how a robust normative ethical framework can recentre patients and their reproductive needs. Our model is one way to account for—and safeguard—patients’ diverse viewpoints and needs in the development of abortion policy, and it can serve to ground narratives for advocacy by healthcare workers and their professional organisations.

Aim: Create a Language ENvironment Analysis (LENA)-based intervention to increase adolescent and infant speech and improve 12-month language outcomes. Methods: Randomised control trial of adolescent (15-19 years) mother-infant pairs comparing language-motor (intervention) and motor (control) groups. Intervention included reviewing language-motor curriculums, formative feedback on 4 LENA recordings (baseline, post-curriculum, 4 and 12-months) and 16-weekly language-motor texts. Controls reviewed a motor curriculum, summative feedback of four recordings after study completion and 4-monthly motor texts. Primary outcome was 12-month MacArthur scores. Secondary outcomes were LENA counts and social impacts to language outcomes. Results: A total of 108 infants were randomised. Groups had similar baseline characteristics and LENA counts. Both groups had low maternal Peabody Picture Vocabulary age-equivalents (14.2 years). On post-curriculum recording, intervention infants had higher vocalisations (188 vs 109, P = .02) and conversations (49 vs 30, P = .005) than controls. Group 4-month and 12-month LENA counts and 12-month MacArthur scores were similar. In regression analyses, more people in the home and cohabiting with the infant's father were associated with higher MacArthur scores. Conclusions: Linguistic feedback and a simple curriculum resulted in short-term increased vocalisations and conversational turns for infants of adolescent mothers that were not sustained over time. Household characteristics provided protective effects on outcomes.

Objective To compare effects of a language intervention on Cuddler and parent adult word counts (AWC), and to compare Cuddler versus parent and nurse-care times. Design Prospective pilot cohort intervention study. Twelve Cuddler-low-visit (≤2/week) infant pairs and 17 high-visit (≥3/week) parent-infant pairs were enrolled. Each had a 16-hour baseline recording (R1) followed by a language curriculum with linguistic feedback and an outcome recording (R2) 1 week later. Bivariate group analyses and longitudinal negative binomial regressions were run. Results After the intervention, there were non-significant increases in AWC/h for Cuddlers and high-visit parents. Cuddler AWCs were similar to high-visit parents and significantly higher than nurse-care times on both recordings. Within the lowvisit group, hourly AWCs were higher when Cuddlers were present versus absent (R1 = 1779 versus 552, R2 = 2530 versus 534, p < 0.0001). Conclusions NICU language environments are different for low-visit and high-visit infants and Cuddlers can increase infant language exposure in the NICU.

protocol reduces inpatient outpatient opioid use in patients with MDD. STUDY DESIGN: This is a prospective cohort study of all patients older than 18 undergoing an uncomplicated CD at the University of Maryland Medical Center. We evaluated inpatient morphine milligram equivalents (MME) use pre-and post-implementation of an ERAC. We excluded CD done under general anesthesia, those complicated by massive transfusion events, bowel injury, requiring recovery in the intensive care unit, skin incision other than Pfannenstiel. Additionally, we excluded the patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Baseline demographics and outcomes were compared between pre-ERAC and post-ERAC cohorts using c2 test or Fisher's exact test for categorical variables and the Wilcoxon rank-sum test or Student's t-test for continuous variables. The associations between ERAC implementation and inpatient MME use for each postoperative day and stratified by the presence of MDD. RESULTS: Of 308 patients undergoing CD from October 2019 to September 2020, we identified 48 (24%) patients with MDD in the pre-ERAC cohort and 21 (18%) in the post-ERAC cohort (Table 1). Overall, patients with MDD had a higher inpatient MME use compared to those without MDD [18(5, 39.4) vs. 11.3(0, 26.3), p¼0.02]. They also reported higher pain scores [3.5 (2.4,5) vs. 2.9 (1.7,4.2)]. Patients in post-ERAC cohort were less likely to require opioids in the postoperative period (23.8% vs. 12.5%, p¼0.01) (Table 2). A similar relative reduction between pre-ERAC and post-ERAC cohorts was seen in patients with no MDD (35.7% vs. 18.4%, p<0.001). CONCLUSION: A mature ERAC protocol can result in the same relative reduction in inpatient opioids in patients with MDD compared with those without MDD.

Background or Objectives: HIV-positive women have higher rates of unmet need for contraception and unintended pregnancy and face unique obstacles in accessing family planning services, such as healthcare- related stigma and disclosing HIV status to partners. This study characterizes factors that influence the reproductive decision-making of women living with HIV and identifies areas for improvement in reproductive counseling in Kumasi. Methods: In this cross-sectional study, HIV-positive women, ages 18 to 45 years, presenting for care at Komfo Anokye Teaching Hospital between June and August 2017 were interviewed using structured surveys. Information gathered included demographics, method of contraceptive use, initiation of anti- retroviral therapy (ART), knowledge and use of contraception, and future reproductive plans. The primary outcome was current family planning use and future reproductive desire. Univariate analysis was used to characterize the demographics of the study group. Bivariate analysis including Chi-squared test was employed to assess the association between use of family planning between women with an HIV-positive and HIV-negative partner, with significance set at p < 0.05. Results: A total of 88 women were interviewed. The unmet need for contraception was 10%. Among all sexually active women, 26% did not use contraception. Fewer women with HIV-negative or untested partners were using contraception (65% and 67%, respectively), compared to women with HIV-positive partners (93%). Partner preference was the most common reason cited for not using a method of contraceptive (46%). Similar trends were found in future reproductive desires based on age cohorts, partner status, and use of family planning. Conclusion and Global Health Implications: Significant barriers to family planning use among HIV- positive women remain, especially those with a serodiscordant partner. Most partners were aware of their partner’s HIV status. This highlights an important opportunity to include partners in HIV and contraceptive counseling. Key words: • HIV • Family planning • Contraception • LARC • Serodiscordant • Ghana • Africa   Copyright © 2019 Hersey et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.