Sex related difference in postoperative pain and opioid use following posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: This project aims to evaluate the relationship between biological sex and postoperative pain and in patients receiving posterior spinal fusion for adolescent idiopathic scoliosis. METHODS: This is a retrospective study of patients (n=137) aged 10-17 receiving posterior spinal fusion for adolescent idiopathic scoliosis between 01/2018 and 09/2022. Each patient received surgery by the same pediatric orthopedic surgeon with identical postoperative pain management regimen at a children's hospital or a tertiary referral center with a pediatric spine program. RESULTS: There were no significant differences in any background characteristics between the male and female patients, including age, BMI, number of levels fused, preoperative degree of scoliosis, and length of surgery and anesthesia (p>0.05). There were no differences in amount given of any intraoperative medications, nor in amount of postoperative scheduled analgesics (p>0.05). Female patients demonstrated higher average pain scores on Visual Analogue Scale evaluations during the first 24 hours postoperatively (5.0 vs 3.6, p<0.0001), 24-48 hours postoperatively (4.9 vs 4.0, p=0.03), and at the first physical therapy evaluation (5.3 vs 3.8, p<0.001). These patients received significantly greater amounts of morphine milligram equivalents in the first 24 hours postoperatively (42.2 vs 31.5, p=0.01) and for the hospitalization in total (63.8 vs 51.3, p=0.048). There was no difference in hours until hospital discharge (44.3 vs 42.6, p=0.62) nor until first ambulation (20.1 vs 21.3, p=0.24) between the female and male patients. CONCLUSION: The influence of biopsychosocial factors on postoperative pain in adolescents is complex. This study adds to the existing pool of literature suggesting differences in pain perception between adolescent female and male patients. Female patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may benefit from increased preoperative counseling and more aggressive intra- and postoperative pain management regimens.

Slimmer's Palsy Following Weight Loss Associated With Metastatic Breast Cancer: A Case Report.

Common peroneal neuropathy (CPN), also known as Slimmer's Palsy, is an isolated peripheral neuropathy typically associated with rapid weight loss resulting in loss of adipose tissue and subsequent nerve compression at the fibular head and is up to three times more common in individuals with malignancy. In this case report, we describe the diagnosis of CPN in a 54-year-old female with a 2.5-month history of atraumatic left foot drop and left ankle paresthesias, preceded by a 35-40 pound weight loss over the prior 3.5 month period in the setting of metastatic breast cancer.

Serotonin Syndrome Triggered by an Interaction Between Opioid Analgesics and Cobicistat: A Challenging Diagnostic Case Report.

Serotonin syndrome is a clinically diagnosed disorder that may occur secondary to medications that increase the release of endogenous serotonin, impair the reuptake of serotonin from the synaptic cleft, are direct serotonin receptor agonists, or increase the sensitivity of the postsynaptic serotonin receptor. In this case report, we describe the diagnosis of serotonin syndrome in a 60-year-old immunocompromised male. This case is unique, as many of the medications associated with the development of serotonin syndrome in this patient are not typically thought of as being associated with serotonin syndrome, though, in this clinical context, they combined to produce a profound pro-serotonergic effect.

Prevalence of allergic contact dermatitis in children with and without atopic dermatitis: A multicenter retrospective case-control study.

BACKGROUND: As both allergic contact dermatitis and atopic dermatitis (AD) have similar clinical presentations and are characterized by spongiotic dermatitis on skin biopsy, many children with AD are not referred for patch testing and allergic contact dermatitis is underdiagnosed. OBJECTIVE: To provide updated prevalence data of common contact allergens in children with and without AD. METHODS: This is a retrospective case-control study using the Pediatric Allergic Contact Dermatitis Registry from 2018 to 2022. RESULTS: A total of 912 children were included (615 with AD and 297 without AD). Children with AD were more likely to have a longer history of dermatitis (4.1 vs 1.6 years, P < .0001), have seen more providers (2.3 vs 2.1, P = .003), have greater than 1 positive patch test (PPT) result (P = .005), have a greater number of PPT results overall (2.3 vs 1.9, P = .012), and have a more generalized distribution of dermatitis (P = .001). PPT to bacitracin (P = .030), carba mix (P = .025), and cocamidopropyl betaine (P = .0007) were significantly increased in children with AD compared to those without AD. LIMITATIONS: Technical variation between providers and potential for misclassification, selection, and recall biases. CONCLUSION: Children with AD are significantly more likely to have PPT reactions and should be referred for evaluation of allergic contact dermatitis and obtain patch testing.

Evidence for a Multimodal Pain Management Regimen in Reduction of Postoperative Opioid Use in Pediatric Patients Receiving Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This project aims to evaluate the relationship between increased use of intraoperative nonopioid analgesics, muscle relaxers, and anesthetics and postoperative outcomes, including opioid utilization, time until ambulation, and hospital length of stay. SUMMARY OF BACKGROUND DATA: Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine that occurs in otherwise healthy adolescents, occurring with a frequency of 1% to 3%. Up to 60% of patients receiving spinal surgeries, particularly posterior spinal fusion (PSF), experience at least 1 day of moderate-to-severe pain after surgery. PATIENTS AND METHODS: This is a retrospective chart review of pediatric patients aged 10 to 17 having received PSF with >5 levels fused for AIS at a dedicated children's hospital and a regional tertiary referral center with a dedicated pediatric spine program between January 2018 and September 2022. A linear regression model was used to evaluate the influence of baseline characteristics and intraoperative medications on the total amount of postoperative morphine milligram equivalents received. RESULTS: There were no significant differences in the background characteristics of the two patient populations. Patients receiving PSF at the tertiary referral center received equivalent or greater amounts of all nonopioid pain medications and demonstrated decreased time until ambulation (19.3 vs . 22.3 h), postoperative opioid use (56.1 vs . 70.1 MME), and postoperative hospital length of stay (35.9 vs . 58.3 h). Hospital location was not individually associated with a difference in postoperative opioid use. There was not a significant difference in postoperative pain ratings. When accounting for all other variables, liposomal bupivacaine had the greatest contribution to the decrease in postoperative opioid use. CONCLUSION: Patients receiving greater amounts of nonopioid intraoperative medications utilized 20% fewer postoperative morphine milligram equivalents, were discharged 22.3 hours earlier and had earlier recorded evidence of mobility. Postoperatively, nonopioid analgesics were as effective as opioids in the reduction of subjective pain ratings. This study further demonstrates the efficacy of multimodal pain management regimens in pediatric patients receiving PSF for AIS.

Changes in Product Use and Quality of Life After Patch Testing in Children With Allergic Contact Dermatitis: A Follow-up Survey.

BACKGROUND: Patch testing is the standard to diagnose allergic contact dermatitis (ACD). OBJECTIVE: This study assessed the value of patch testing for product changes and quality of life in children with ACD. METHODS: In this cross-sectional survey, we used a questionnaire to follow up with families of ACD patients about changes since patch testing and counseling preferences. Eligible participants were 18 years or younger during expanded series or personalized patch tests at the Washington University School of Medicine from 2007 to 2020. RESULTS: Of the 43 enrolled participants, most were positive for multiple allergens (63%) and changed personal products after patch testing (71%). Only 26% of the families consistently read product labels before patch testing, compared with 66% after. Patients saw a mean relative reduction of 49% in severity of rash (8.2-4.2 of 10), 46% in interference with activities (5.7-3.1), and 51% in self-consciousness (7.0-3.4) since patch testing. Families gave favorable feedback for counseling on products to avoid (9.4 of 10 average rating of usefulness), product recommendations (8.5 of 10), and chemical names (7.9 of 10). CONCLUSIONS: Patch testing can lead to meaningful improvements in quality of life for most children with ACD. Counseling related to positive patch test results should include discussion of specific products to use and avoid.

Rate of continued conservative management versus progression to surgery at minimum 1-year follow-up in patients with pre-arthritic hip pain.

BACKGROUND: Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. OBJECTIVE: To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum 1-year follow-up. DESIGN: Retrospective cohort study. SETTING: Single tertiary care academic medical center. PATIENTS: Patients ages 13 to 40 years who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n = 713 patients, 830 hips). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The primary outcome was the rate of progression to surgery at minimum 1-year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. RESULTS: In a cohort with a mean age of 25.4 (SD 8.1) years, 72.7% female, and mean follow-up of 2.6 (range 1.0-4.8) years, 429 of 830 hips (51.7%, 95% confidence interval [CI] 48.2% to 55.1%) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year, 95% CI 0.93 to 0.98), pain duration longer than 6 months (ORs 1.87-2.03, p ≤ .027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System [PROMIS] point, 0.92 to 0.99), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47, 2.05 to 5.89), acetabular dysplasia (OR 2.75, 1.73 to 4.35), and/or labral tear (OR 10.71, 6.98 to 16.47). Radiographic dysplasia (lateral center edge angle <20 degrees) increased the likelihood of surgery in all subgroups (ORs 2.05-8.47, p ≤ .008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α > 63 degrees) (OR 1.03/degree, 1.00 to 1.06). CONCLUSION: Almost half of patients with pre-arthritic hip pain did not progress to surgery at a minimum 1-year follow-up. A trial of conservative management is likely worthwhile in most patients.

Rate of Surgery and Baseline Characteristics Associated With Surgery Progression in Young Athletes With Prearthritic Hip Disorders.

BACKGROUND: Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetabular dysplasia, and acetabular labral tears, are a common cause of pain and dysfunction in adolescent and young adult athletes, and optimal patient-specific treatment has not been defined. Operative management is often recommended, but conservative management may be a reasonable approach for some athletes. PURPOSE: To identify (1) the relative rate of progression to surgery in self-reported competitive athletes versus nonathletes with PAHD and (2) baseline demographic, pain, and functional differences between athletes who proceeded versus those who did not proceed to surgery within 1 year of evaluation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: An electronic medical record review was performed of middle school, high school, and college patients who were evaluated for PAHD at a single tertiary-care academic medical center between June 22, 2015, and May 1, 2018. Extracted variables included patients' self-reported athlete status, decision to choose surgery within 1 year of evaluation, and baseline self-reported pain and functional scores on Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Hip disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score. RESULTS: Of 260 eligible patients (289 hips), 203 patients (78%; 227 hips) were athletes. Athletes were no more likely to choose surgery than nonathletes (130/227 hips [57%] vs 36/62 hips [58%]; relative risk [RR], 0.99 [95% CI, 0.78-1.25]). Among athletes, those who proceeded to surgery over conservative care were more likely to be female (81% vs 69%; RR, 1.34 [95% CI, 0.98-1.83]) and had more known imaging abnormalities (FAI: 82% vs 69%, RR, 1.47 [95% CI, 1.09-1.99]; dysplasia: 48% vs 27%, RR, 1.44 [95% CI, 1.16-1.79]; mixed deformity: 30% vs 10%, RR, 2.91 [95% CI, 1.53-5.54]; known labral tear: 84% vs 40%, RR, 2.79 [95% CI, 2.06-3.76]). Athletes who chose surgery also reported worse baseline hip-specific symptoms on all HOOS subscales (mean difference, 10.8-17.7; P < .01 for all). CONCLUSION: Similar to nonathletes, just over half of athletes with PAHD chose surgical management within 1 year of evaluation. Many competitive athletes with PAHD continued with conservative management and deferred surgery, but more structural hip pathology and worse hip-related baseline physical impairment were associated with the choice to pursue surgery.

Expanded Series and Personalized Patch Tests for Children: A Retrospective Cohort Study.

BACKGROUND: Epicutaneous patch testing was developed as a simple and effective method for diagnosing allergic contact dermatitis (ACD). Despite its proven value in ACD diagnoses, there is no defined standard for patch testing in children. OBJECTIVE: The aims of this study were to assess patch test positivity in pediatric patients with and without a history of atopic dermatitis suspected to have ACD, to compare these results with what the Thin-Layer Rapid Use Epicutaneous (T.R.U.E.) Test would have captured, and to evaluate likely exposures. METHODS: Pediatric patients receiving a North American 80 Comprehensive Series patch test or a personalized patch test were analyzed for allergen sensitization 48 to 72 hours after patch removal. These data were analyzed for allergen inclusion in the North American 80 Comprehensive Series patch test compared with the T.R.U.E. Test, as well as compared with patients with and without a history of atopic dermatitis. RESULTS: Of the 29 patients (mean ± SD age = 10.9 ± 5.1 years), 25 children demonstrated at least 1 positive reaction, with a total of 81 reactions overall. 40 (49.4%) of the reactions came from allergens outside of the T.R.U.E. Test, including cocamidopropyl betaine, which was frequent in patients with atopic dermatitis. CONCLUSIONS: Expanded and personalized patch tests provide a more comprehensive allergen inventory than the traditional T.R.U.E. Test. Pediatric patients frequently have reactions to allergens not included in the T.R.U.E. Test, and these allergens are commonly found in household products. Cocamidopropyl betaine was a particularly relevant allergen in our population. Expanded series patch testing and appropriate counseling should be provided to pediatric patients with ACD.