Barriers to Bariatric Surgery: a Mixed Methods Study Investigating Obstacles Between Clinic Contact and Surgery.

PURPOSE: Populations most affected by obesity are not reflected in the patients who undergo bariatric surgery. Gaps in the referral system have been studied, but there is a lack of literature investigating obstacles patients encounter after first contact with bariatric surgery clinics. We aim to identify patient populations at risk for attrition during bariatric surgery evaluation and determine patient reported barriers to bariatric surgical care. MATERIALS AND METHODS: This study was a single institution, retrospective, mixed methods study from 2012 to 2021 comparing patients who underwent bariatric surgery to those that withdrew. Surveys were performed of patients who withdrew, collecting information on patient knowledge, expectations, and barriers. RESULTS: This study included 5982 patients evaluated in bariatric surgery clinic. Those who attained bariatric surgery (38.8%) were more likely to be White (81.2 vs. 75.6%, p<0.001), married (48.5 vs. 44.1%, p=0.004), and employed full time (48.2 vs. 43.8%, p=0.01). They were less likely to live in an area with low income (37.1 vs. 40.7%, p=0.01) or poverty (poverty rate 15.8 vs. 17.4, p<0.001). Of the 280 survey respondents, fear of complications, length of insurance approval process, and wait time between evaluation and surgery were the most reported barriers. CONCLUSION: Patients who undergo bariatric surgery were more likely to be White, married, employed full time, and reside in more resourced environments which is not reflective of communities most affected by obesity. The complexity of insurance coverage requirements was a major barrier to bariatric surgery and should be a focus of future healthcare reform.

Clinical Outcomes and Hospital Utilization Among Patients Undergoing Bariatric Surgery With Telemedicine Preoperative Care.

Importance: Bariatric surgery is the mainstay of treatment for medically refractory obesity; however, it is underutilized. Telemedicine affords patient cost and time savings and may increase availability and accessibility of bariatric surgery. Objective: To determine clinical outcomes and postoperative hospital utilization for patients undergoing bariatric surgery who receive fully remote vs in-person preoperative care. Design, Setting, and Participants: This cohort study comparing postoperative clinical outcomes and hospital utilization after telemedicine or in-person preoperative surgical evaluation included patients treated at a US academic hospital. Participants underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy after telemedicine or in-person preoperative surgical evaluation between July 1, 2020, to December 22, 2021, or January 1, 2018, to December 31, 2019, respectively. Follow-up was 60 days from date of surgery. Exposures: Telemedicine-based preoperative care. Main Outcomes and Measures: Clinical outcomes, including operating room delay, procedure duration, length of hospital stay (LOS), and major adverse events (MAE), and postoperative hospital resource utilization, including emergency department (ED) visit or hospital readmission within 30 days of the surgical procedure. Results: A total of 1182 patients were included; patients in the telemedicine group were younger (mean [SD] age, 40.8 [12.5] years vs 43.0 [12.2] years; P = .01) and more likely to be female (230 of 257 [89.5%] vs 766 of 925 [82.8%]; P = .01) compared with the control group. The control group had a higher frequency of comorbidity (887 of 925 [95.9%] vs 208 of 257 [80.9%]; P < .001). The telemedicine group was found to be noninferior to the control group with respect to operating room delay (mean [SD] minutes, 7.8 [25.1]; 95% CI, 5.1-10.5 vs 4.2 [11.1]; 95% CI, 1.0-7.4; P = .002), procedure duration (mean [SD] minutes, 134.4 [52.8]; 95% CI, 130.9-137.8 vs 105.3 [41.5]; 95% CI, 100.2-110.4; P < .001), LOS (mean [SD] days, 1.9 [1.1]; 95% CI, 1.8-1.9 vs 2.1 [1.0]; 95% CI, 1.9-2.2; P < .001), MAE within 30 days (3.8%; 95% CI, 3.0%-5.7% vs 1.6%; 95% CI, 0.4%-3.9%; P = .001), MAE between 31 and 60 days (2.2%; 95% CI, 1.3%-3.3% vs 1.6%; 95% CI, 0.4%-3.9%; P < .001), frequency of ER visits (18.8%; 95% CI, 16.3%-21.4% vs 17.9%; 95% CI, 13.2%-22.6%; P = .03), and hospital readmission (10.1%; 95% CI, 8.1%-12.0% vs 6.6%; 95% CI, 3.9%-10.4%; P = .02). Conclusions and Relevance: In this cohort study, clinical outcomes in the telemedicine group were not inferior to the control group. This observation suggests that telemedicine can be used safely and effectively for bariatric surgical preoperative care.

Mandibular Measurements at the 20-Week Anatomy Ultrasound as a Prenatal Diagnostic Predictor of Pierre Robin Sequence.

BACKGROUND: Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, and upper airway obstruction. Early recognition and appropriate perinatal management is crucial for optimizing outcomes. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific mandibular measurements could predict PRS diagnosis and disease severity. METHODS: A retrospective case-control study of 48 patients with PRS and gender-matched controls was performed. Medical records were reviewed for respiratory and surgical interventions. Three parameters to assess micrognathia were measured on mid-sagittal profile ultrasound images: frontal nasal-mental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. Student's t-test and univariate logistic regression was performed. P ≤ 0.05 was considered statistically significant. RESULTS: Patients with PRS demonstrated a significantly smaller mean FNMA compared to the control group, 129.3 ± 8.6° and 137.4 ± 3.2°, respectively (p < 0.0001), as well as significantly smaller mean FMA, 63.2 ± 9.2° and 74.8 ± 6.1°, respectively (p < 0.0001). The PRS group also demonstrated significantly larger mean alveolar overjet compared to the control group, 3.9 ± 1.4 mm and 2.1 ± 0.9 mm, respectively (p < 0.0001). The odds of respiratory intervention increased among cases when FMA was <68°. Additionally, there was a significant difference in median overjet between patients with PRS who did and did not require respiratory intervention. CONCLUSIONS: Mandibular features on the 20-week ultrasound can be measured to predict diagnosis and severity of PRS. This is an important first step to prepare for potential respiratory intervention at delivery to minimize perinatal hypoxia. Alveolar overjet, previously not described in prenatal ultrasound literature, is measurable and has utility in prenatal screening for PRS, as do FMA and FNMA.

Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals.

OBJECTIVE: To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications. SUMMARY BACKGROUND DATA: Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes. METHODS: A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population). RESULTS: A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02). CONCLUSIONS: A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.

Association between labor and delivery pain and postpartum pain with symptoms and clinical diagnosis of postpartum depression in patients with overweight and obesity.

PURPOSE: Childbirth pain has been associated with the risk for postpartum depression. However, existing studies have been limited by the use of depression screening tools as outcomes, and none to date have used a structured clinical interview for DSM-V (SCID), which is considered the gold standard for psychiatric diagnoses. This study aimed to quantify the relationships between labor and postpartum pain and postpartum depression diagnosis detected by SCID, as well as depression symptoms detected by the Center for Epidemiological Studies Depression Scale (CESD) screening tool, among a high-risk cohort. METHODS: The study was a secondary analysis of a prospective observational study of a cohort of women enriched for high risk for depression, i.e., pregnant women originally enrolled in a prospective study investigating factors leading to excessive gestational weight gain. Subjects were assessed prospectively for depression using both SCID and CESD at the third trimester and at 6 months postpartum. Overweight and obesity were defined as pre-gravid body mass index (BMI) ≥ 25 kg/m2. Both vaginal and cesarean deliveries were included in the cohort. Pain scores (0-10 numeric rating scale) during childbirth and after delivery were correlated with CESD and SCID. Propensity score matching was performed with propensity groups defined as those with low-moderate postpartum pain and those with high postpartum pain. The relationships between pain measures and 6-month postpartum depression diagnosis by SCID, and between pain measures and 6-month postpartum depression symptoms by CESD, were assessed by unweighted logistic regression and by logistic regression weighted by propensity score derived by average treatment effect (ATE) adjusted for baseline covariates. RESULTS: There were 237 subjects in the cohort for analysis. Labor and postpartum pain were not associated with depression diagnosis by SCID at 6 months postpartum. However, postpartum pain, but not labor pain, was associated with depressive symptoms on the CESD at 6 months postpartum. Women with higher maximum postpartum pain scores had significantly higher odds of developing clinically significant postpartum depressive symptoms at 6 months, compared to those with lower pain scores in the unweighted model (OR: 1.3, 95% CI 1.0, 1.5; P = 0.005) and ATE-weighted models (OR: 1.2, 95% CI 1.0, 1.5; P = 0.03). Consistent with prior work, SCID and CESD were strongly associated, and 92.9% (13/14) of participants with postpartum depression diagnosis by 6-month SCID also showed high CESD symptomology, P < 0.0001). CONCLUSIONS: Although labor and postpartum pain were not associated with clinical diagnosis of depression (SCID) at 6 months postpartum, postpartum pain was linked to 6-month postpartum depression symptoms. Depressive symptoms are more likely to be exhibited in women with higher postpartum pain, potentially reflecting poorer birth recovery. The contribution of postpartum pain and depressive symptoms to overall patterns of poor recovery after childbirth should be assessed further.

Longitudinal Assessment of Cardiac Function Following Multisystem Inflammatory Syndrome in Children Associated with COVID-19.

Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 is commonly associated with cardiac involvement. Studies found myocardial dysfunction, as measured by decreased ejection fraction and abnormal strain, to be common early in illness. However, there is limited data on longitudinal cardiac outcomes. We aim to describe the evolution of cardiac findings in pediatric MIS-C from acute illness through at least 2-month follow-up. A retrospective single-center review of 36 patients admitted with MIS-C from April 2020 through September 2021 was performed. Echocardiographic data including cardiac function and global longitudinal strain (GLS) were analyzed at initial presentation, discharge, 2-4-week follow-up, and at least 2-month follow-up. Patients with mild and severe disease, normal and abnormal left ventricular ejection fraction (LVEF), and normal and abnormal GLS at presentation were compared. On presentation, 42% of patients with MIS-C had decreased LVEF < 55%. In patients in whom GLS was obtained (N = 18), 44% were abnormal (GLS < |- 18|%). Of patients with normal LVEF, 22% had abnormal GLS. There were no significant differences in troponin or brain natriuretic peptide between those with normal and abnormal LVEF. In most MIS-C patients with initial LVEF < 55% (90%), LVEF normalized upon discharge. At 2-month follow-up, all patients had normal LVEF with 21% having persistently abnormal GLS. Myocardial systolic dysfunction and abnormal deformation were common findings in MIS-C at presentation. While EF often normalized by 2 months, persistently abnormal GLS was more common, suggesting ongoing subclinical dysfunction. Our study offers an optimistic outlook for recovery in patients with MIS-C and carditis, however ongoing investigation for longitudinal effects is warranted.

Associations between postpartum pain, mood, and maternal-infant attachment and parenting outcomes.

Pain and depression are interrelated, and worse postpartum pain has been associated with postpartum depression. It remains unclear whether improved pain and mood after delivery can also improve maternal parenting. Few studies have examined relationships between postpartum pain and negative mood (anxiety or depression) or their effects on parent-infant relationship outcomes. The purpose of this study was to explore the relationships between postpartum pain, mood, parent-infant attachment, parenting self-efficacy, and infant development. This was a prospective longitudinal observational pilot study of nulliparous women enrolled at the third trimester and presenting for labor and delivery at term gestation. Baseline third trimester assessments included validated inventories of pain (the brief pain inventory, BPI), depression (the Edinburgh postnatal depression screen, EPDS), anxiety (the state trait anxiety inventory, STAI), multidimensional scale of perceived social support (perceived social support scale, MSPSS) and perceived stress scale (PSS). Demographic and labor characteristics were recorded. At 6 weeks and 3 months postpartum, self-reported assessments included EPDS, STAI, BPI, maternal parent infant attachment scale (MPAS), and perceived maternal parenting self-efficacy (PMP-SE). Child development outcomes were assessed at 6 weeks and 3 months using the Ages and Stages Questionnaire (ASQ). Univariable linear regression assessed the relationships between pain and parenting outcomes (MPAS and PMP-SE), including potential interactions between pain and mood for parenting outcomes. Generalized linear modeling was used to explore the relationships between postpartum pain, parenting outcomes, and child development outcomes. Of 187 subjects, 87 had complete data on parent-infant attachment and parenting self-efficacy data at 3 months. Lower "pain right now" scores (BPI) on postpartum day 1 was associated with higher maternal-infant attachment (MPAS) at 6 weeks postpartum (Estimate - 1.8, 95% CI - 3.4 to - 0.2, P < 0.03) but not at 3 months (Estimate 0.23 95% CI - 1.1 to 1.6, P = 0.7). Higher depression (EPDS) scores at 6 weeks were also associated with lower MPAS scores at 6 weeks (Estimate - 1.24, 95% CI - 2.07 to - 0.40, P = 0.004). However, there was no evidence that the relationship between pain and MPAS varied by depression score at 6 weeks (P = 0.42). Pain scores at baseline, six weeks, or three months did not correlate with parenting outcomes (MPAS, PMP-SE) at six weeks or three months. Results of the generalized linear modeling revealed relationships between pain, age, anxiety (STAI), and depression (EPDS) predictors, and the outcomes of parenting (MPAS, PMP-SE) and gross motor and personal-social (ASQ) aspects of infant development. There is a pattern of association between worse postpartum pain, anxiety, and depression with worse parenting outcomes. Depression and pain may also affect infant development, but future work is required to replicate and characterize these potential relationships.

Intraoperative Hypoxia Independently Associated With the Development of Acute Kidney Injury Following Bilateral Orthotopic Lung Transplantation.

BACKGROUND: Acute kidney injury (AKI) is a common postoperative complication in bilateral orthotopic lung transplant (BOLTx) recipients, but the contribution of intraoperative variables is not well defined. The authors hypothesized that intraoperative hypotension as well as hypoxia and vasopressor use would be associated with the development of postoperative AKI after BOLTx in patients without pre-existing renal dysfunction. METHODS: The authors performed a retrospective analysis of patients undergoing BOLTx at a single center between 2013 and 2017. Intraoperative variables of hemodynamics included duration of mean arterial pressure <55, <60, and <65 mm Hg; duration of oxygen saturation <90%; and vasoactive-inotropic score (VIS). Associations between the occurrence of AKI and intraoperative hypotension, hypoxemia, and VIS were evaluated while controlling for significant confounding variables. RESULTS: AKI occurred in 177 (72%) of 245 patients in postoperative days 1-7. Notable significant differences in univariate analyses included cumulative mechanical support time, maximum VIS, peripheral oxygen saturation <90% for >15 min, total minutes oxygen saturation <90%, and surgery duration in minutes. There was no significant difference in intraoperative hypotension measured as a duration >15 min for mean arterial pressure <55, <60, or <65 mm Hg. Multivariate logistic regression revealed preoperative creatinine (Odds ratio [OR], 7.77; confidence interval [CI], 1.96-30.83; P = 0.004), surgery duration (OR, 1.004; CI, 1.002-1.007; P = 0.002), and oxygen saturation (OR, 2.06; CI, 1.01-4.24; P = 0.049) <90% for >15 min to be independently associated with AKI. CONCLUSIONS: This study revealed that >15 min of intraoperative hypoxia was independently associated with postoperative AKI after BOLTx.

Pregnant Victims of Intimate Partner Homicide in the National Violent Death Reporting System Database, 2003-2014: A Descriptive Analysis.

Intimate partner homicide (IPH) is a leading cause of maternal mortality in the United States. However, very little information exists as to the circumstantial factors associated with IPH during pregnancy. We conducted a descriptive study of the demographic characteristics, psychosocial service engagement, and crises experiences (i.e., life and relationship stressors) among pregnant and nonpregnant victims to understand what differences, if any, exist in their risk profile for IPH. Data from the Centers for Disease Control and Prevention's National Violent Death Reporting System (NVDRS) were used for this study. The NVDRS is a national opt-in tracking system of all violent deaths in the United States. Pregnant victims (N = 293) were significantly more likely to be 5 years younger than nonpregnant victims, African American, and never married. Pregnant victims were more likely to be seen in the emergency room following the fatal incident. Nonpregnant victims (N = 2,089) were significantly more likely to have suspected alcohol use at the time of their death. In strictly proportional terms, we also observed higher rates of mental health problems, a history of mental health treatment, and a reported history of intimate partner violence (IPV), crisis, or family problems among nonpregnant victims. A wider range of IPH-related risk factors (e.g. substance abuse) need to be included IPV assessments. Future studies should seek to develop effective interventions to prevent IPH, particularly among reproductive aged women.

Omitting the Early Postoperative Follow-up in Uncomplicated Operative Supracondylar Humerus Fractures in Children Does Not Negatively Affect Outcomes.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common surgically treated elbow injuries in children. There have been debates regarding if an early postoperative follow-up before pin removal is necessary to decrease the complications related to surgical fixation. To date, studies examining this topic have included smaller sample sizes, limiting the generalizability of their findings. METHODS: A retrospective chart review of outcomes after operative management of Gartland type II and III SCH fractures at a single level 1 pediatric trauma center between 2005 and 2015 was performed. Patient demographics, fracture characteristics, pin number and configuration, timing of initial follow-up, change in treatment plan after initial follow-up, time to pin removal, initial and final fracture radiographic parameters, and complications were observed via chart review. RESULTS: A total of 1518 SCH fractures underwent operative fixation: 755 Gartland type II and 765 type III. Of the 1518 SCH fractures identified, 1370 met inclusion criteria and were included for analysis. Of these, 1196 patients returned for initial follow-up within 1 to 2 weeks of surgery, and 174 patients had their initial follow-up 3 to 4 weeks postoperatively. There were 8 incidences where initial early follow-up resulted in a change of management; however, change in management was limited to cast alteration in 7 of these cases. CONCLUSIONS: Closed reduction and percutaneous pin fixation of otherwise uncomplicated closed SCH fractures have good outcomes and a very low complication rate at a level 1 pediatric trauma center. Early postoperative follow-up before the pin removal visit provides minimal utility in decreasing complications and may be safely omitted as long as the initial fracture fixation is deemed to be stable. LEVEL OF EVIDENCE: Level III.

Targets for Intervention? Preoperative Predictors of Postoperative Ileus After Colorectal Surgery in an Enhanced Recovery Protocol.

BACKGROUND: Postoperative ileus occurs in up to 30% of colorectal surgery patients and is associated with increased length of stay, costs, and morbidity. While Enhanced Recovery Protocols seek to accelerate postoperative recovery, data on modifiable preoperative factors associated with postoperative ileus in this setting are limited. We aimed to identify preoperative predictors of postoperative ileus following colorectal surgery in Enhanced Recovery Protocols, to determine new intervention targets. METHODS: We performed a retrospective single-center cohort study of patients ≥ 18 years old who underwent colorectal surgery via Enhanced Recovery Protocols (7/2015-7/2017). Postoperative ileus was defined as nasogastric tube insertion postoperatively or nil-per-os by postoperative day 4. Preoperative risk factors including comorbidities and medication use were identified using multivariable stepwise logistic regression. RESULTS: Of 530 patients, 14.9% developed postoperative ileus. On univariate analysis of perioperative and postoperative factors, postoperative ileus patients had increased psychiatric illness, antidepressant and antipsychotic use, American Society of Anesthesiologists classification, ileostomy creation, postoperative opioid use, complications, surgery duration, and length of stay (p < 0.05). Multivariable logistic regression model for preoperative factors identified psychiatric illness, preoperative antipsychotic use, and American Society of Anesthesiologists classification ≥ 3 as significant predictors of postoperative ileus (p < 0.05). DISCUSSION: Postoperative ileus remains a common complication following colorectal surgery under Enhanced Recovery Protocols. Patients with pre-existing psychiatric comorbidities and preoperative antipsychotic use may be a previously overlooked cohort at increased risk for postoperative ileus. Additional research and preoperative interventions within Enhanced Recovery Protocols to reduce postoperative ileus for this higher-risk population are needed.

Epiphyseal Translation as a Predictor of Avascular Necrosis in Unstable Slipped Capital Femoral Epiphysis.

BACKGROUND: Physeal instability has been shown to be associated with a higher risk of avascular necrosis (AVN) in patients with slipped capital femoral epiphysis (SCFE). The purpose of this study was to identify additional preoperative factors associated with AVN in patients with unstable SCFE. METHODS: Basic demographic information, chronicity of symptoms, and estimated duration of nonambulatory status were noted. Preoperative radiographs were used to measure the Southwick slip angle, slip severity by Wilson criteria, and epiphyseal translation. Translation was measured by 3 distinct radiographic parameters in the position demonstrating maximal displacement. Postoperative radiographs at the time of most recent follow-up were assessed for the presence of AVN. Translation measurements were tested for inter-rater reliability. Patients who developed AVN were compared with those that did not by Fisher exact test and Wilcoxon tests. Logistic regression assessed the effect of translation on the odds of developing AVN. Receiver operating characteristic curve was plotted to assess any threshold effect. RESULTS: Fifty-one patients (55 hips) out of 310 patients (16%) treated for SCFE were considered unstable. Seventeen hips' unstable SCFE (31%) showed radiographic evidence of AVN. Slip severity by Wilson grade (P=0.009) and epiphyseal translation by all measurements (P< 0.05) were statistically significantly greater among patients who developed AVN. Superior translation had the best inter-rater reliability (intraclass correlation coefficient=0.84). Average superior translation in hips that developed AVN was 17.2 mm compared with 12.9 mm in those that did not (P<0.02). Although the receiver operating characteristic curve did not demonstrate a threshold effect for AVN, it did effectively rule out AVN in cases with <1 cm of superior translation. Age, sex, laterality, chronicity of prodromal symptoms or inability to bear weight, Southwick slip angle, and method of treatment did not vary with the occurrence of AVN. CONCLUSIONS: Epiphyseal translation, either by Wilson Grade or measured directly, is associated with AVN in patients with an unstable SCFE. LEVEL OF EVIDENCE: Level II-development of diagnostic criteria.

Intermediate-term annualized curve progression of adolescent idiopathic scoliosis curves measuring 40° or greater.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: The objective of this study was to examine intermediate-term progression for a large series of patients with adolescent idiopathic scoliosis (AIS) with curves 40° or greater. BACKGROUND: Curve progression in AIS has been well documented for smaller curves in adolescence up to skeletal maturity; however, the data on curve progression past 40° or into adulthood are limited. With many surgeons recommending surgical correction when patients reach this threshold, it is important to understand the radiographic progression of curves into adulthood. METHODS: A database of all patients seen by a single surgeon from 1984 through 2018 with AIS curves progressing to at least 40° entered prospectively was utilized for this study. This included a total of 738 patients. Curve progression was analyzed overall and stratified by length of follow-up, curve location, and Risser stage at the time of presentation among other variables. Curve magnitude and Risser stage designations in this study were validated by performing a separate inter- and intrarater agreement study using four independent reviewers reading 50 patients' Cobb angle and Risser stage blinded in triplicate to examine the reliability of the study measurements. RESULTS: Annualized curve progression (ACP) averaged 6.3 ± 10.4°. ACP varied with length of follow-up: patients with up to 1 year of follow-up had an average ACP of 11.5 ± 17.0°, while those with 1-2 years had 8.2 ± 8.8°, and 2-5 years had 3.7 ± 4.1°, tapering off further from there. Risser stage 0 or 1 was associated with the highest ACP as compared to Risser stage 2-3 or 4-5. Intraclass correlation (ICC) values for Cobb angle measurement and Risser stage designations from four raters measuring 50 patients' measures, blinded and in triplicate, were all > 0.80, signifying a high degree of reliability within and between readers. CONCLUSIONS: Annualized curve progression for 40° and greater curves was not linear over time; it was greatest immediately after a curve reaches 40° and tapered off over the next decade. Immature Risser stage at presentation was strongly associated with increasing ACP at all time frames. LEVEL OF EVIDENCE: Prognostic Level I.

Evidence-Based Medicine Curriculum Improves Pediatric Emergency Fellows' Scores on In-Training Examinations.

OBJECTIVES: The aim of this study was to determine if implementation of our evidence-based medicine (EBM) curriculum had an effect on pediatric emergency medicine fellows' scores on the relevant section of the in-training examination (ITE). METHODS: We obtained deidentified subscores for 22 fellows over 6 academic years for the Core Knowledge in Scholarly Activities (SA) and, as a balance measure, Emergencies Treated Medically sections. We divided the subscores into the following 3 instruction periods: "baseline" for academic years before our current EBM curriculum, "transition" for academic years with use of a research method curriculum with some overlapping EBM content, and "EBM" for academic years with our current EBM curriculum. We analyzed data using the Kruskal-Wallis test, the Mann-Whitney U test, and multivariate mixed-effects linear models. RESULTS: The SA subscore median was higher during the EBM period in comparison with the baseline and transition periods. In contrast, the Emergencies Treated Medically subscore median was similar across instruction periods. Multivariate modeling demonstrated that our EBM curriculum had the following independent effects on the fellows' SA subscore: (1) in comparison with the transition period, the fellows' SA subscore was 21 percentage points higher (P = 0.005); and (2) in comparison to the baseline period, the fellows' SA subscore was 28 percentage points higher during the EBM curriculum instruction period (P < 0.001). CONCLUSIONS: Our EBM curriculum was associated with significantly higher scores on the SA section of the ITE. Pediatric emergency medicine educators could consider using fellows' scores on this section of the ITE to assess the effect of their EBM curricula.

Comparison of the Coagulation Profile of Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion With and Without Tranexamic Acid.

STUDY DESIGN: Prospective, observational cohort study. OBJECTIVE: To improve the understanding of coagulation and bleeding mechanisms during spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Fibrinolysis is the mechanism of bleeding for adolescent idiopathic scoliosis undergoing posterior spinal fusion. Antifibrinolytics have become popular; however, literature to support their use remains mixed. The mechanism of action has not been demonstrated. METHODS: The coagulation profile of 88 adolescent idiopathic scoliosis patients undergoing posterior spinal fusion was analyzed. Standard coagulation laboratory investigations and thromboelastograms were drawn hourly through the case. Fifty-eight patients received no antifibrinolytic, whereas 30 patients received tranexamic acid by standardized protocol. The coagulation parameters, estimated blood loss, and transfusion requirements were compared in the two groups. RESULTS: The two cohorts had no differences in demographic or surgical characteristics. Mean age was 13.6 years, 83% were female, a mean of 11.1 levels were fused, and the mean duration of surgery was 209 minutes. The tranexamic acid cohort did not demonstrate a decrease in blood loss. The transfusion rate, however, dropped from 47% in the non-tranexamic acid cohort to 23% in the tranexamic acid cohort (p = .03). Standard coagulation parameters did not differ between the groups. Fibrinolysis was diminished in the tranexamic acid cohort as measured by a Fibrinolysis score (mean maximum value 2.0 without tranexamic acid vs. 0.7 with tranexamic acid, p < .0001) and the lysis percent at 30 minutes by thromboelastogram (elevated to 3.9% without tranexamic acid vs. 1.2% with tranexamic acid at the 3-hour mark, p = .05). CONCLUSIONS: This study provides confirmation of antifibrinolytic activity during posterior spinal fusion for adolescent idiopathic scoliosis. The presented data of fibrinolysis are proposed as standard measurements for future work on controlling blood loss during scoliosis surgery. LEVEL OF EVIDENCE: Level 2, prospective comparative study.

Truncal blocks and teenager postoperative pain perception after laparoscopic surgical procedures.

INTRODUCTION: The prevalence of moderate to severe pain is high in hospitalized teenage patients admitted to surgical services. OBJECTIVES: The aims of this study were to determine (1) the preoperative and postoperative factors influencing teenager postoperative pain perception; and (2) suffering, defined as the patient's anxiety, pain catastrophizing thoughts, and mood. METHODS: Data were collected from medical records and from 2 medical interviews at the time of enrollment and postoperative day 1. Stepwise linear regression was conducted to assess variables that predicted teenagers' pain scores and suffering. RESULTS: Two hundred two patients (mean age = 13.8 years, SD = 1.9), 56.4% females, scheduled for laparoscopic surgical procedures completed the study. The variables found to be significant predictors of pain response in teenagers were pain on the day of surgery (6.81, 95% confidence interval [CI] = 0.08-13.55, P = 0.05) and use of regional anesthesia (single-injection rectus sheath, transversus abdominis plane, and paravertebral nerve blocks) (-6.58, 95% CI = -12.87 to -0.30, P = 0.04). The use of regional anesthesia was found to predict mood responses (all patients: 2.60, 95% CI = 0.68-4.52, P = 0.01; girls: 3.45, 95% CI = 0.96-5.93, P = 0.01; 14-17-year-old teens: 2.77, 95% CI = 0.44-5.10, P = 0.02) and to negatively predict catastrophic thoughts among all patients as a group (-4.35, 95% CI = -7.51 to -1.19, P = 0.01) and among 14- to 17-year-old teens (-5.17, 95% CI = -9.44 to -0.90, P = 0.02). CONCLUSION: A comprehensive pain approach that includes truncal blocks may improve teenagers' postoperative pain control after laparoscopic surgeries.

Ten-Year Mortality in the WISE Study (Women's Ischemia Syndrome Evaluation).

BACKGROUND: The WISE study (Women's Ischemia Syndrome Evaluation) was a prospective cohort study of 936 clinically stable symptomatic women who underwent coronary angiography to evaluate symptoms and signs of ischemia. Long-term mortality data for such women are limited. METHODS AND RESULTS: Obstructive coronary artery disease (CAD) was defined as ≥50% stenosis on angiography by core laboratory. We conducted a National Death Index search to assess the mortality of women who were alive at their final WISE contact date. Death certificates were obtained. All deaths were adjudicated as cardiovascular or noncardiovascular by a panel of WISE cardiologists masked to angiographic data. Multivariate Cox proportional hazards regression was used to identify significant independent predictors of mortality. At baseline, mean age was 58±12 years; 176 (19%) were non-white, primarily black; 25% had a history of diabetes mellitus, 59% hypertension, 55% dyslipidemia, and 59% had a body mass index ≥30. During a median follow-up of 9.5 years (range, 0.2-11.5 years), a total of 184 (20%) died. Of these, 115 (62%) were cardiovascular deaths; 31% of all cardiovascular deaths occurred in women without obstructive CAD (<50% stenosis). Independent predictors of mortality were obstructive CAD, age, baseline systolic blood pressure, history of diabetes mellitus, history of smoking, elevated triglycerides, and estimated glomerular filtration rate. CONCLUSIONS: Among women referred for coronary angiography for signs and symptoms of ischemia, 1 in 5 died from predominantly cardiac pathogeneses within 9 years of angiographic evaluation. A majority of the factors contributing to the risk of death seem to be modifiable by existing therapies. Of note, 1 in 3 of the deaths in this cohort occurred in women without obstructive CAD, a condition often considered benign and without guideline-recommended treatments. Clinical trials are needed to provide treatment guidance for the group without obstructive CAD.

Sudden Cardiac Death in Women With Suspected Ischemic Heart Disease, Preserved Ejection Fraction, and No Obstructive Coronary Artery Disease: A Report From the Women's Ischemia Syndrome Evaluation Study.

BACKGROUND: Sudden cardiac death (SCD) is often the first presentation of ischemic heart disease; however, there is limited information on SCD among women with and without obstructive coronary artery disease (CAD). We evaluated SCD incidence in the WISE (Women's Ischemia Syndrome Evaluation) study. METHODS AND RESULTS: Overall, 904 women with suspected ischemic heart disease with preserved ejection fraction and core laboratory coronary angiography were followed for outcomes. In case of death, a death certificate and/or a physician or family narrative of the circumstances of death was obtained. A clinical events committee rated all deaths as cardiovascular or noncardiovascular and as SCD or non-SCD. In total, 96 women (11%) died over a median of 6 years (maximum: 8 years). Among 65 cardiovascular deaths, 42% were SCD. Mortality per 1000 person-hours increased linearly with CAD severity (no CAD: 5.8; minimal: 15.9; obstructive: 38.6; P<0.0001). However, the proportion of SCD was similar across CAD severity: 40%, 58%, and 38% for no, minimal, and obstructive CAD subgroups, respectively (P value not significant). In addition to traditional risk factors (age, diabetes mellitus, smoking), a history of depression (P=0.018) and longer corrected QT interval (P=0.023) were independent SCD predictors in the entire cohort. Corrected QT interval was an independent predictor of SCD in women without obstructive CAD (P=0.033). CONCLUSIONS: SCD contributes substantially to mortality in women with and without obstructive CAD. Corrected QT interval is the single independent SCD risk factor in women without obstructive CAD. In addition to management of traditional risk factors, these data indicate that further investigation should address mechanistic understanding and interventions targeting depression and corrected QT interval in women.

SRS-22r Scores in Nonoperated Adolescent Idiopathic Scoliosis Patients With Curves Greater Than Forty Degrees.

STUDY DESIGN: Case control comparative series. OBJECTIVE: Describe surgical range adolescent idiopathic scoliosis (AIS) patients electing to forgo surgery and compare health-related quality-of-life outcomes to a similar cohort of operated AIS patients by the same single surgeon. SUMMARY OF BACKGROUND DATA: No data have been published either documenting SRS-22r scores of nonoperated patients with curves ≥40° or comparing these scores to a demographically similar operated cohort. METHODS: Individuals with curves ≥40°, age ≥18 years, and electing to forgo surgery were identified. All patients completed an SRS-22r questionnaire. This nonoperated cohort's SRS-22r scores were compared to those of a large demographically similar cohort operated by the same surgeon. Group differences between the SRS-22r scores were evaluated by comparing these to published Minimal Clinically Important Differences (MCID) for the SRS-22r. RESULTS: One hundred ninety subjects with nonoperated curves were compared to 166 individuals who underwent surgery. The nonoperated cohort averaged 23.5 years of age, averaged 7.7 years since curve reached 40°, and had an average 50° Cobb angle at last follow-up. No statistical significant differences were found between the groups on the Pain, Function, or Mental Health domains of the SRS-22r. Statistically significant differences in favor of the operative cohort were found for self-image, satisfaction, and total score. The observed group differences did not meet the established thresholds for minimal clinically important differences in any of the domain scores, the average total score, or raw scores. CONCLUSION: There are no meaningful clinically significant differences in SRS-22r scores at average 8-year follow-up between AIS patients with curves ≥40° treated with or without surgery. These data in conjunction with an absence of long-term evidence of serious medical consequences with nonsurgical management of curves ≥40° should encourage surgeons to reevaluate the benefits of routine surgical care. LEVEL OF EVIDENCE: 3.

Does a Weekly Didactic Conference Improve Resident Performance on the Pediatric Domain of the Orthopaedic In-Training Examination?

BACKGROUND: Performance on the Orthopaedic In-training Examination (OITE) has been correlated with performance on the written portion of the American Board of Orthopaedic Surgery examination. Herein we sought to discover whether adding a regular pediatric didactic lecture improved residents' performance on the OITE's pediatric domain. METHODS: In 2012, a didactic lecture series was started in the University of Pittsburgh Medical Center (UPMC) Hamot Orthopaedic Residency Program (Hamot). This includes all topics in pediatric orthopaedic surgery and has teaching faculty present, and occurs weekly with all residents attending. A neighboring program [UMPC Pittsburgh (Pitt)] shares in these conferences, but only during their pediatric rotation. We sought to determine the effectiveness of the conference by comparing the historic scores from each program on the pediatric domain of the OITE examination to scores after the institution of the conference, and by comparing the 2 programs' scores. RESULTS: Both programs demonstrated improvement in OITE scores. In 2008, the mean examination score was 19.6±4.3 (11.0 to 30.0), and the mean percentile was 57.7±12.6 (32.0 to 88.0); in 2014, the mean examination score was 23.5±4.2 (14.0 to 33.0) and the mean percentile was 67.1±12.1 (40.0 to 94.0). OITE scores and percentiles improved with post graduate year (P<0.0001). Compared with the preconference years, Hamot residents answered 3.99 more questions correctly (P<0.0001) and Pitt residents answered 2.93 more questions correctly (P<0.0001). Before the conference, site was not a predictor of OITE score (P=0.06) or percentile (P=0.08); there was no significant difference found between the mean scores per program. However, in the postconference years, site did predict OITE scores. Controlling for year in training, Hamot residents scored higher on the OITE (2.3 points higher, P=0.003) and had higher percentiles (0.07 higher, P=0.004) than Pitt residents during the postconference years. CONCLUSIONS: This study suggests that adding a didactic pediatric lecture improved residents' scores on the OITE and indirectly suggests that more frequent attendance is associated with better scores. LEVEL OF EVIDENCE: Level III-retrospective case-control study.