Patient experience measures such as satisfaction are increasingly tracked and incentivized. Satisfaction questionnaires have notable ceiling effects that may limit learning and improvement. This study tested a Guttman-type (iterative) Satisfaction Scale (GSS) after a musculoskeletal specialty care visit in the hope that it might reduce the ceiling effect. We measured floor effects, ceiling effects, skewness, and kurtosis of GSS. We also assessed factors independently associated with GSS and the top 2 possible scores. In this cross-sectional study, 164 patients seeing an orthopedic surgeon completed questionnaires measuring (1) a demographics, (2) symptoms of depression, (3) catastrophic thinking in response to nociception, (4) heightened illness concerns, and (5) satisfaction with the visit (GSS). Bivariate and multivariable analyses sought associations of the explanatory variable with total GSS and top 2 scores of GSS. Accounting for potential confounding using multivariable analysis, lower satisfaction was independently associated with greater symptoms of depression (β: −0.03; 95% CI: −0.05 to −0.00; P = .047). The top 2 scores of the GSS were independently associated with women (compared to men: odds ratio [OR]: 2.12, 99% CI: 1.01-4.45, P = .046) and lower level of education (masters’ degree compared to high school; OR: 0.16, 95% CI: 004-0.61, P = .007). The GSS had no floor effect, a ceiling effect of 38%, a skewness of −0.08, and a kurtosis of 1.3. The 38% ceiling effect of the iterative (Guttman-style) satisfaction measure is lower than ordinal satisfaction scales, but still undesirably high. Alternative approaches for reducing the ceiling effect of patient experience measures are needed.

Maternal-fetal stressors during the gestational period, such as psychosocial stress, disease burden, and medication use, have been shown to significantly affect the neurological and biological development of the fetus. To our knowledge, no previous study in the literature has synthesized the role of these various stressors in neurodevelopment into a single concise review article. Maternal psychosocial stress has been shown to raise levels of stress hormones, such as corticotropin-releasing hormone and adrenocorticotropic hormone, which in turn signal the release of glucocorticoids (eg, cortisol) along with catecholamines in the mother and fetus. These cascades could potentially have significant effects on fetal neurodevelopment. Further, this article highlights that certain maternal infectious disease states, such as influenza and Toxoplasma gondii, are associated with increased risk of psychiatric disorders among offspring, including schizophrenia and neurocognitive delay. Investigators have also found that antibodies from autoimmune disease have direct neurotoxic effects on neural cell receptors, manifesting in future cognitive performance deficits. Additionally, we note that the effects of opioid analgesics on fetal neurodevelopment are not well elucidated but some existing literature has found increased rates of neural tube defects and delays in central nervous system development. In summary, there is a need for increased prenatal screening for a wide breadth of maternal stressors to mitigate negative effects on fetal neurodevelopment.

The first concrete description of acupuncture can be found in the Yellow Emperor's Classic of Internal Medicine dated around 100BCE. 1 The text is a dialogue between the Yellow Emperor and his minister, as the basis of modernday acupuncture. 1 Based on Taoist philosophy, the dialogue within the text explains that health is attained by following Tao, and illness is the result of imbalance in yin and yang, influenced by the elements on the body. 2

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TikTok took the world by storm at the start of the COVID-19 pandemic and is now one of the largest social media apps, with more than 2 billion mobile downloads. 1 The app tailors a feed of videos to users' preferences based on engagements and interactions that fit each user's interests. Content generated by TikTok's artificial intelligence has been noted to be eerily specific, targeting viewers to niche interests, such as knitting, gardening, and even witchcraft. TikTok has helped launch businesses and create viral trends, in which users around the world participate. The app is also responsible for putting forward a new set of social media stars with large platforms and followings. The impact of this app has been astronomical as it weaved itself into the fabric of our society.