Functional Outcomes of Congenital Scoliosis at a Mean 35-Year Follow-up Post In Situ Fusion. Revisiting Patients From the 2002 Goldberg et al Study.

BACKGROUND: The management of congenital scoliosis poses a significant challenge for treating surgeons. The aim of our study was to provide insight into the long-term clinical results of spinal fusion in congenital scoliosis. METHODS: We performed a retrospective review of the scoliosis database in our institution for the period 1976 until 2002 identifying 43 patients with congenital scoliosis who underwent spinal fusion. Patient demographics, diagnosis, levels fused, and radiographs were evaluated. Patients were evaluated for unplanned return to the operating room (UPROR) via SRS 22, EQ5D-5L, and Oswestry Disability Index (ODI). RESULTS: Of the 43 patients who fulfilled the inclusion criteria, 22 patients agreed to participate, 3 patients were known to be deceased and 18 patients were lost to follow-up or declined to participate and were excluded. The mean age of the respondents was 40.7 years (range, 30 to 47 y) with a mean follow-up from index surgery of 35 years (range, 20 to 44 y). At most recent follow-up, 12 patients (54%) underwent UPROR. The mean age at diagnosis was 3.4 years (range, birth to 11.5 y), and the mean age for first surgery was 5.8 years (range, 1 to 13 y). As regards radiologic follow-up; the mean number of levels fused was 5.2 (range, 2 to 12). Thoracic fusion was performed in 17 patients (77%). The mean T1 to T12 height at index surgery and maturity was 166 mm (range, 130 to 240 mm) and 202 mm (range, 125 to 270 mm), respectively. The mean functional scores at follow-up were SRS 22: 4.5 (range, 2.4 to 5), cumulative EQ5D-5L score 7.2 (range, 5 to 15), and ODI: 8% (range, 2 to 30%). All respondents completed high school, 10 patients (45%) completed university, and 2 patients were awarded doctorates. Currently, 17 patients (77%) are in paid employment. CONCLUSIONS: This report constitutes the largest series of patients treated by spinal arthrodesis for congenital scoliosis followed into maturity. We demonstrate the thorax continues to grow after index fusion, patient-reported outcomes were satisfactory with superior educational and employment rates and unplanned return to theatre is rare in adult life. LEVEL OF EVIDENCE: Therapeutic Level IV.

Mandating reimbursement for non-FDA-regulated cannabis is bad public policy.

An influential cannabis lobby and its allies are engaged in an aggressive initiative to mandate health and worker's compensation insurance coverage for non-standardized, non-FDA-regulated cannabis products. If successful, mandated reimbursement would present a severe public health risk and force taxpayers to fund a risky and under-regulated industry. Leaders in psychiatry and other medical specialties have sounded the alarm about the marketing and sale of cannabis products for medical uses without prior review by the FDA. We echo their strong opposition to bills requiring workers' compensation carriers and health insurance plans to cover the cost of dispensary-purchased "medical" cannabis. Mandated insurance reimbursement of dispensary products is "a recipe for a public health disaster, as lowering or eliminating out-of-pocket costs will encourage more consumers to become certified under a state's medical cannabis program, and result in more frequent use of higher-potency cannabinoids (e.g., THC and CBD) that are associated with serious adverse events." Until there are thorough studies into these products, including adverse events, side effects and long-term concerns, these products should not be considered appropriate alternatives to FDA-approved medications. Their use should not be encouraged nor paid for through mandated reimbursement by public or private third-party payers.

Substance use and related disorders among persons exposed to the 9/11 terrorist attacks: Essentials for screening and intervention.

A growing body of research supports the association between direct exposure to the September 11, 2001, terrorist attacks, increased rates of alcohol and substance use and elevated risk of subsequent diagnosis with trauma-related and substance use disorders. Posttraumatic stress disorder (PTSD) is the most diagnosed psychiatric illness in individuals who witnessed the 9/11 attacks or participated in disaster response efforts, and substance use disorders (SUDs) are highly comorbid with PTSD. The presence of both conditions poses challenges for clinical management and highlights the importance of screening and offering intervention to this at-risk population. This paper provides background on substance use, SUDs, and co-occurring PTSD in trauma exposed populations, describes best practices for identifying harmful substance use, the role of psychotherapy and medication for addiction treatment (MAT), and recommendations for management of co-occurring SUD and PTSD.

Physician Burnout and Barriers to Care on Professional Applications.

We surveyed New York physicians to study their perceptions of reporting requirements related to their own mental health care on professional applications, including whether they were experiencing symptoms of burnout. Over half of the responding physicians reported experiencing symptoms of burnout and these physicians were at increased odds of perceiving a barrier to seeking mental health care if they had to report such care on professional applications and renewals for medical licensure, malpractice, and hospital privileges and credentialing compared to physicians not experiencing symptoms of burnout. As state medical boards, hospitals, and insurers seek information to help assess risks posed by physicians, it is essential to strike an appropriate balance between their duty to protect the public and the physician's right to confidentiality. This balance can be assessed based on the questions that are asked on various professional applications and how information gleaned through physician responses is used. Overly intrusive questions, though well intentioned to protect the public, may run counter to current interpretations of federal law and may inhibit care-seeking among physicians, which is critical to both patient safety and physician health.

Social problem solving and depressive symptoms over time: a randomized clinical trial of cognitive-behavioral analysis system of psychotherapy, brief supportive psychotherapy, and pharmacotherapy.

OBJECTIVE: Depression is associated with poor social problem solving, and psychotherapies that focus on problem-solving skills are efficacious in treating depression. We examined the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy (Kocsis et al., 2009). METHOD: Participants with chronic depression (n = 491) received cognitive-behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), which emphasizes interpersonal problem solving, plus medication; brief supportive psychotherapy (BSP) plus medication; or medication alone for 12 weeks. RESULTS: CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions. CONCLUSIONS: It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches.

Early adversity in chronic depression: clinical correlates and response to pharmacotherapy.

BACKGROUND: There is growing evidence suggesting that early adversity may be a marker for a distinct pathway to major depressive disorder (MDD). We examined associations between childhood adversity and a broad variety of clinical characteristics and response to pharmacotherapy in a large sample of patients with chronic forms of MDD. METHODS: Subjects included 808 patients with chronic forms of MDD (chronic MDD, double depression, or recurrent MDD with incomplete recovery between episodes and a total continuous duration of >2 years) who were enrolled in a 12-week open-label trial of algorithm-guided pharmacotherapy. Baseline assessments included a semi-structured diagnostic interview, and clinician- and self-rated measures of depressive symptoms, social functioning, depressotypic cognitions, and personality traits, and childhood adversity. Patients were re-evaluated every 2 weeks. RESULTS: A longer duration of illness; earlier onset; greater number of episodes, symptom severity, self-rated functional impairment, suicidality, and comorbid anxiety disorder; and higher levels of dysfunctional attitudes and self-criticism were each associated with multiple forms of childhood adversity. A history of maternal overcontrol, paternal abuse, paternal indifference, sexual abuse, and an index of clinically significant abuse each predicted a lower probability of remission. Among patients completing the 12-week trial, 32% with a history of clinically significant abuse, compared to 44% without such a history, achieved remission. CONCLUSIONS: These findings indicate that a history of childhood adversity is associated with an especially chronic form of MDD that is less responsive to antidepressant pharmacotherapy.

Mobility in Hurler syndrome.

Hurler syndrome is an autosomal recessive metabolic storage disease. Hematopoietic stem cell transplant increases life expectancy, but the effects on associated musculoskeletal abnormalities remains unclear, and long-term data are limited. We detail the follow-up of 23 patients at a mean of 8.5 years after successful hematopoietic stem cell transplant. All patients underwent clinical examination at an annual multidisciplinary clinic. Serial radiological studies were reviewed to assess development and management of hip dysplasia and genu valgum. All patients demonstrated characteristic acetabular dysplasia and failure of ossification of the superolateral femoral head. Eight patients underwent bilateral pelvic and femoral derotation (mean age at surgery, 4.4 years); 4 patients had pelvic osteotomy only. Mean preoperative acetabular angle was 34 degrees. Genu valgum of variable severity due to failure of ossification of the lateral aspect of the proximal tibial metaphysis was observed early, and 6 patients underwent medial epiphyseal stapling, decreasing tibiofemoral angle by a mean of 8 degrees. Clinically, all patients were independently mobile, with restriction of internal hip rotation being the most significant clinical finding. Valgus knees and pronated feet were a typical finding. This cohort represents one of the largest available for study, and ongoing review will clarify the progression of musculoskeletal problems and determine the effectiveness of orthopaedic intervention.

Scoliosis: a review.

Scoliosis, lateral curvature of the spine, has been studied since Hippocrates' time, but remains a disputed subject in orthopaedic surgery, because of its several varieties, unknown cause and unpredictable course. A review of 30 years' experience in a paediatric orthopaedic unit was undertaken to clarify the problem. Patient records, collected prospectively, were examined to demonstrate the incidence, prevalence, extent, course and outcome of the commonest variety, adolescent idiopathic scoliosis. Reference was made to the results of previously published studies. Records from a school screening programme showed that, while slight degrees of spinal curvature were widely prevalent in the community, these were of no clinical significance and major cosmetic deformity was rare: only 8 in 10,000 adolescent girls had Cobb angles of 40 degrees or more and only half of these underwent surgical correction. Evidence to support non-operative treatment could not be demonstrated and it did not reduce the incidence of surgical intervention. Because the course of scoliosis did not seem to correspond with much published work, or with current hypotheses of aetiology, a rethinking of the whole subject is advocated. An alternative model of pathogenesis deriving from developmental biology was proposed. While advances in surgical methods have been significant, the core problems of aetiology and natural history remain. Until they are resolved, all conclusions on management must be provisional. This is where innovative thinking needs to be directed.

A randomized trial of 'soft cast' for distal radius buckle fractures in children.

A buckle fracture is a stable fracture where there is a dorsal cortex compression of the distal radius. A total of 117 children with buckle fracture treated at our institution were randomised prospectively into two treatment groups: soft cast or rigid cast. The rigid cast group attended clinic after three weeks for removal of the cast. In the soft cast group, the cast was removed by parents at home after three weeks. Telephone follow-up was carried out after 4 to 5 weeks post fracture. Both groups had full recovery as compared to the uninjured side and parents were satisfied with the treatment. Only one patient in the soft cast group had a problem as compared to 5 in the rigid cast group (p = 0.035, using chi square test). When given a choice, parents of children in both groups opted for future treatment with a soft cast (p < 0.01 using chi square test). Our study showed that buckle fractures of the distal radius can safely be treated with a soft cast without the need for more than one fracture clinic appointment.

Treatment of femoral shaft fractures in children using the "Tobruk" method.

The "Tobruk" technique of plaster augmentation of a Thomas' splint can be used for the treatment of femoral shaft fractures in children. The radiological and clinical data of 118 patients treated using this method were reviewed over a consecutive 3-year period. The mean age of the patients was 4.25 years. Mean hospital stay was 14.11 days. Mean time spent in the "Tobruk" splint was 44.77 days. Loss of reduction during splintage occurred in 9.32% of patients. Skin complications occurred in 5 patients (4.2%), and cast repairs were necessary in 3 patients. "Tobruk" splinting is a relatively safe and effective way of treating femoral shaft fractures in children. Although its use is not widespread, especially in the United States, until better results are achieved with spica casting and elastic stable intramedullary nails, it does provide a valid option in the treatment of these fractures. A controlled randomized prospective trial with long-term follow-up is needed to fully elucidate its value.

A peer-based assistance program for officers with the New York City Police Department: report of the effects of Sept. 11, 2001.

Few data on stress symptoms related to the World Trade Center disaster in law enforcement personnel have been reported. Most New York City Police Department (NYPD) officers had significant exposure to the events of Sept. 11, 2001. Approximately 5,000 officers responded within the first 2 days, and more than 25,000 officers worked at ground zero, the morgues, or the Staten Island landfill. Because the police are the first line of defense against terrorist attacks, it is imperative that they maintain optimal health and functioning. Concern for the long-term effects from traumatic exposure is warranted. In partnership with Project Liberty, peer officers and clinicians from the Police Organization Providing Peer Assistance performed outreach, support work, and screening for stress symptoms related to the disaster in the NYPD from December 2002 until December 2003. Psychological issues in law enforcement personnel, a description of the outreach program, and data from these screenings are presented.

Is high level of disability an indication for spinal fusion? Analysis of long-term outcome after posterior lumbar interbody fusion using carbon fiber cages.

OBJECTIVE: Posterior lumbar interbody fusion is a recognized procedure for the treatment of back pain associated with degenerative disc disease and segmental instability. It allows decompression of the spinal canal and circumferential fusion through a single posterior incision. METHODS: Sixty-five consecutive patients who underwent posterior lumbar interbody fusion using carbon cages and pedicle fixation between 1993 and 2000 were recruited and contacted with a postal survey. Clinical outcome was assessed by the postoperative clinical findings and complications and the fusion rate, which was assessed using the scoring system described by Brantigan and Steffee. Functional outcome was measured by using improvement in the Oswestry Disability Index, return to work, and satisfaction with the surgical outcome. The determinants of functional relief were analyzed against the improvement in disability using multiple regression analysis. RESULTS: The mean postoperative duration at the time of the study was 4.4 years. Overall radiologic fusion rate was 98%. There was a significant improvement in Oswestry Disability Index (P < 0.01). There was 84% satisfaction with the surgical procedure and 61% return to predisease activity level and full employment. We found preoperative level of disability to be the best determinant of functional recovery irrespective of age or the degree of psychological morbidity and litigation (P < 0.01). CONCLUSION: The combination of posterior lumbar interbody fusion and posterior instrumented fusion is a safe and effective method of achieving circumferential segmental fusion. A direct relationship between preoperative level of disability and functional recovery suggests that disability should be measured preoperatively and spinal fusion should be performed to alleviate disability caused by degenerative spine.

Assessing insomnia severity in depression: comparison of depression rating scales and sleep diaries.

Depression and sleep researchers typically assess insomnia severity differently. Whereas depression researchers usually assess insomnia with items on depression symptom inventories, sleep researchers usually assess the subjective experience of insomnia with sleep diaries. The present manuscript utilizes baseline data from 397 participants in a large multi-site chronic depression study to assess agreement between these two methodologies. The results indicate that the early, middle, and late insomnia items of the Hamilton Rating Scale for Depression (HRSD(24)) and the Inventory of Depression Symptoms - Self Report (IDS-SR(30)) are highly correlated with the weekly mean values of time to sleep onset, time awake after sleep onset, and time awake prior to the planned wake-up obtained from prospective sleep diaries. Results also reveal significant correspondence between the weekly-mean of daily sleep efficiency, an accepted measure of sleep continuity (the ratio between reported time asleep and time in bed), and the insomnia scale scores of the HRSD(24) and the IDS-SR(30) (the mean score on the three insomnia items of each depression measure). Unit increments in HRSD(24) scores for early, middle and late insomnia were associated with significant increases in unwanted minutes awake for corresponding periods on sleep diaries. Similar relationships were found for early insomnia on the IDS-SR(30) but not for middle and late insomnia. Overall, with few exceptions, findings revealed substantial agreement between the HRSD(24), IDS-SR(30) and prospective sleep diary data. The study supports the validity of the sleep items and sleep subscales of the HRSD(24) and the IDS-SR(30) as global measures of insomnia severity in depression. Conventional sleep assessment procedures can complement depression scales by providing additional information about specific aspects of sleep in depression.

Atypical distal radial fractures in children.

In a prospective study of paediatric injuries secondary to the use of the non-motorized microscooter, we found a high rate of upper limb trauma, and a distinct injury associated with the scooter. The most common single injury was a fracture of the distal third of radius and ulna, characterized by volar angulation of the distal fragment. This injury, akin to the Smiths fracture in adults, was predictive of scooter use in all cases. This pattern of injury was not repeated by any another mechanism of injury during the course of the study period. The mechanism of injury, seemingly specific to the scooter, is produced by a fall while continuing to clutch the handlebars, leading to palmar flexion and pronation of the wrist as they strike the ground. Fourteen children required admission and manipulation under anaesthesia. Four of these patients subsequently needed remanipulation under anaesthesia. This study suggests that the scooter is associated with a forearm fracture which is both distinctive and unstable.

Slipped upper femoral epiphysis. A retrospective, clinical and radiological study of fixation with a single screw.

We conducted a retrospective, clinical and radiological study of fixation with a single screw in slipped upper femoral epiphysis. Forty children (53 hips) who had a slipped upper femoral epiphysis were managed by in-situ pinning with a single cannulated screw. The average age of these patients was 12.7 years and their average weight was above the 50th centile at the time of diagnosis. There were three acute slips, eight acute-on-chronic slips and 35 chronic slips. They were followed for an average of 2 years. Fifty-eight percent of patients had an excellent clinical result, 36% a good result, 4% a fair result and 2% a poor result. The complication rate was 5.3%. Our experience with single cannulated screw fixation of slipped upper femoral epiphysis is encouraging. No complications resulted from the choice of the fixation device.

Spontaneous production of monocyte chemoattractant protein-1 and interleukin-8 by the human lumbar intervertebral disc.

STUDY DESIGN: Scoliotic and herniated human intervertebral disc tissue obtained intraoperatively was cultured, and the medium was analyzed for the production of monocyte chemoattractant protein-1 and interleukin-8. OBJECTIVES: This study was conducted to determine whether the human intervertebral disc is capable of spontaneous production of the chemokines monocyte chemoattractant protein-1 and interleukin-8. SUMMARY OF BACKGROUND DATA: Lumbar disc herniations undergo spontaneous regression with time. This is believed to occur via macrophage-mediated phagocytosis of herniated disc material. Monocyte chemoattractant protein-1, a chemotactic agent for macrophages, has recently been identified in rat intervertebral disc tissue. METHODS: Disc material obtained from patients undergoing surgery for scoliosis and sciatica was cultured using a serumless technique, and the medium was subsequently analyzed for levels of monocyte chemoattractant protein-1 and interleukin-8. RESULTS: Monocyte chemoattractant protein-1 and IL-8 were detected in both control and herniated disc specimens. Noncontained herniations produced higher levels of chemokines than those with an intact anulus. CONCLUSIONS: Human intervertebral disc tissue is capable of spontaneously producing the proinflammatory chemokines monocyte chemoattractant protein-1 and interleukin-8. These are chemotactic for macrophages and capillaries and may explain the ingrowth of granulation tissue seen in spontaneous disc herniation resorption.

Growth patterns in children with congenital vertebral anomaly.

STUDY DESIGN: Height and weight data in children with congenital vertebral anomaly, recorded routinely during clinical follow-up, were analyzed. OBJECTIVES: To determine whether these children are significantly deficient in growth or show an abnormality of maturation. SUMMARY OF BACKGROUND DATA: Structural abnormalities in the vertebral column, and surgery to prevent or correct deformity secondary to this, clearly have the potential to affect the individual's final height. It is not clear, however, whether this is the whole problem, or whether there are other factors to be considered. METHODS: The height and weight of patients with all forms of spinal deformity are routinely recorded at outpatient visits. Data from patients with congenital vertebral abnormalities were analyzed and compared with the national standards. To test the possibility that the observed short stature might be familial, family groups (parents and siblings of patients) were invited to be measured. RESULTS: At the end of growth, patients with congenital vertebral anomalies were smaller than average and also smaller than their parents and siblings. This was more marked in girls and in the presence of associated anomalies, especially when multiple, as in VACTERL association (vertebral, anal, cardiac, tracheal, esophageal, renal, and limb anomalies). It was also exacerbated by surgery, which had a demonstrable stunting effect on the spine. DISCUSSION: Although shortening of the spine was demonstrated in patients with prior spinal surgery, the contributions of the fact of surgery and the presumed severity of anatomic abnormality could not be differentiated. The observations that, even without surgery, girls were generally on a lower percentile than boys and that both have a tendency to lose height at growth spurt invite further investigation. CONCLUSIONS: The shortening of the spine by surgery is not a contraindication to treatment, because a straight, balanced spine must always be preferable to a longer, crooked and unbalanced one. However, it is another facet to be remembered when considering the management plan of the whole child.