Secondary Surgery Following Lapidus Bunionectomy.

While the Lapidus bunionectomy is a common procedure utilized to address hallux valgus, the incidence of secondary surgery is not well established. Our primary goal was to determine the incidence of revision surgery and hardware removal following the Lapidus bunionectomy in addition to the risk factors associated with each. A retrospective nested case-control study of adult patients who underwent a Lapidus bunionectomy for symptomatic hallux valgus over a 9-year period was performed. The incidence rates and 95% confidence intervals (CI) of secondary surgery in the 3 years following the procedure along with the estimated independent associations and odds ratios between baseline demographic, clinical, and radiographic characteristics were calculated. Of the original cohort of 2540 patients, 127 were identified (5.0%; CI: 4.1%, 5.8%) who underwent revision surgery and 165 (6.5%; CI: 5.5%, 7.5%) who underwent hardware removal following Lapidus bunionectomy. Initially, the hallux valgus angle, intermetatarsal angle, and tibial sesamoid position were risk factors for revision surgery. However, in adjusted analyses for revision surgery, using a screw for third point of fixation emerged as the only independent risk factor (odds ratio [OR] = 3.01; CI: 1.59, 5.69). In adjusted analyses for hardware removal, female sex (OR = 2.33; CI: 1.08, 5.00) and third point of fixation (OR = 2.92; CI: 1.82, 4.69) emerged as independent risk factors. While the overall risks associated with Lapidus bunionectomy are low and the need for revision surgery are low, this study helps to identify specific risk factors for secondary surgery and hardware removal to help in evaluation and discussion with patients.

Prophylactic transdermal scopolamine for the reduction of postoperative length of stay after uterine aspiration at Kaiser Permanente Northern California from 2017-2018.

OBJECTIVE: To determine if transdermal scopolamine is associated with decreased postoperative nausea and vomiting and shorter length of stay in the postoperative care unit among patients undergoing uterine aspiration for abortion or early pregnancy loss. STUDY DESIGN: We conducted a retrospective cohort study at an integrated medical center that initiated a protocol to prescribe transdermal scopolamine to patients undergoing uterine aspiration under moderate sedation. We compared outcomes among patients who underwent uterine aspiration in 2017, before the institution enacted the protocol, with their counterparts in 2018, immediately after the institution instated the protocol. We reviewed patient charts for data on the postoperative length of stay, use of additional antiemetics, and a standardized clinician designated postoperative nausea and vomiting score. We analyzed outcomes by relevant demographic and clinical characteristics using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables. RESULTS: The final sample included 386 patients; 228 who did not receive scopolamine and 158 who did. The cohorts were comparable in terms of demographic and clinical characteristics. The cohort that received transdermal scopolamine had a similar mean postoperative length of stay (75.4 ± 54.1 vs 71.1 ± 50.8 minutes; p = 0.43). There were no differences in the proportions of patients who were provided additional antiemetics (26 ± 11.4 vs 17 ± 10.8; p = 0.84) or had transient vomiting and retching (3 ± 1.9 vs 3 ± 1.3; p = 0.69) between the cohorts. CONCLUSION: We found no evidence that prophylactic transdermal scopolamine reduces postoperative nausea, vomiting, or length of stay among patients undergoing uterine aspiration. IMPLICATIONS: Among patients who underwent uterine aspiration under moderate sedation, use of prophylactic transdermal scopolamine was not associated with shorter postoperative length of stay or lesser use of antiemetics. Prophylactic transdermal scopolamine is not likely to be useful for patients undergoing uterine aspiration and could be an unnecessary cost.

Association of Adult Depression With Educational Attainment, Aspirations, and Expectations.

INTRODUCTION: Social factors across one's lifespan may contribute to the relationship between low educational attainment and depression, but this relationship has been understudied. Previous studies assessing the association between educational attainment and depression did not fully account for prior common determinants across the life course and possible interactions by sex or race/ethnicity. It is also unclear whether the link between educational attainment and depression is independent of the role of aspired educational attainment or expected educational attainment. METHODS: We used generalized linear log link models to examine the association between educational attainment at age 25 and depression at age 40 in the National Longitudinal Survey of Youth 1979 cohort, adjusting for confounders and mediators from childhood, adolescence, and adulthood. RESULTS: Members of each educational attainment group were less likely to be depressed at age 40 than those with less education. After adjusting for educational aspirations and educational expectations, the risk ratios became closer to the null. Neither sex nor race/ethnicity interacted with educational attainment. Additionally, low educational expectations in adolescence, but not low educational aspirations, was associated with a higher risk of depression at age 40. CONCLUSION: Our study provides a nuanced understanding of the role of education, educational expectations, and educational aspirations as part of education's effect on risk of depression after controlling for a thorough set of confounders and mediators. Our findings may help advance the study of social determinants of depression.

Minimally Invasive Intermetatarsal Nerve Decompression for Morton's Neuroma: A Review of 27 Cases.

Minimally invasive nerve decompression for operative management of Morton's neuroma has been shown to be an effective alternative to neurectomy; however, little is known about postoperative outcomes. In this retrospective case series, we reviewed 27 procedures in 25 patients who underwent minimally invasive nerve decompression as primary surgical management for Morton's neuroma. Most subjects (22, or 88%) had 12 or more months of health plan enrollment postoperatively; 3 (12%) had 4 to 7 months of enrollment after the procedure. Postoperative patient satisfaction, complications and the need for a follow-up neurectomy were ascertained from medical record review. Additionally, demographic and clinical data were extracted from electronic sources. Patient satisfaction was unknown for 5 (18.5%) of the 27 procedures. Among the 22 (81.5%) procedures for which there were valid patient satisfaction data, patient satisfaction was excellent for 11 (50%); good for 2 (9.1%), and poor for 9 (40.9%). During the follow-up period, 5 (18.5%) patients required an open neurectomy. Among the 6 (22.2%) patients who presented without a Mulder's sign on physical exam preoperatively, 83% reported excellent results. Minimally invasive nerve decompression may not be as effective as previously seen; however, it may be indicated in patients presenting with absence of a Mulder's sign, a physically small or nascent neuroma.

Osseous and Soft Tissue Complications Associated With Foot and Ankle Surgery in Patients With Rheumatoid Arthritis Taking a Variety of Antirheumatic Medications.

There are multiple antirheumatic drug modalities available to patients with symptomatic rheumatoid arthritis (RA) that function to suppress the overactive immune system, but the inflammatory and immune suppression may contribute to postoperative complications. The purpose of this study was to determine if antirheumatic medications increased the risk of both soft tissue and osseous postoperative complications in patients with RA who underwent foot and ankle surgery. We reviewed patients with RA, aged 18years and older, who underwent either an elective or a nonelective foot or ankle surgery involving an osseous procedure between 2009 and 2014. Chart review was conducted to document procedure type, active medications, and postoperative complications. Of the final 110 subjects meeting inclusion criteria, 31 (28%) patients had a postoperative complication (13 soft tissue, 9 osseous, and 9 both soft tissue and osseous). There was no statistically significant association between taking antirheumatic medications in the perioperative period and postoperative complications. Increased surgery duration and peripheral neuropathy were associated with a statistically significant increase in postoperative complications. Every 15 minutes of increased surgery time led to a 1.2-fold increase in complication risk. Nonelective procedures had a higher risk of soft tissue complications than did elective procedures (odds ratio 4.2, 95% confidence interval 1.1 to 16.0). Although there was no statistically significant association between the specific medication and complications, some medications trended toward statistical significance. When working with patients with RA, our findings suggest the importance of considering the risk of surgery duration and the potential risk of antirheumatic medications in the perioperative period.

Diagnostic Pathway of Oral Cavity Cancer in an Integrated Health Care System.

CONTEXT: Survival for patients with oral cavity squamous cell carcinoma (OCSCC) has remained relatively stagnant despite advances in treatment. Few studies have examined why advanced-stage disease is diagnosed in 40% of patients with OCSCC nationally. OBJECTIVE: To characterize the diagnostic pathway of OCSCC in an integrated health care system. DESIGN: Retrospective study of patients with OCSCC (2007-2010). MAIN OUTCOME MEASURES: Referral patterns and demographic, clinical, and tumor characteristics associated with time to diagnosis (diagnostic interval). RESULTS: Of 247 patients, 167 (68%) had early-stage (I/II) disease, 86 (35%) were referred by dentists, and 70 (28%) had a history of premalignancy. The median time (interquartile range) from symptom onset to care sought from a primary care physician (patient interval), from primary care physician to otolaryngologist, and from otolaryngologist to diagnosis was 8.6 (4.0-25.8), 1.0 (0.6-3.1), 0.0 (0.0-3.0) weeks, respectively. These intervals did not differ by demographic characteristics, clinical factors, or tumor stage. Prolonged diagnostic intervals were observed among patients with premalignant lesions. CONCLUSION: The patient interval was the largest component of the total diagnostic interval. The subsequent professional workup proceeded relatively efficiently. Prolonged diagnostic interval in patients with premalignant lesions may reflect the natural history of malignant transformation rather than a delay in diagnosis. However, nearly one-fourth of these cases were diagnosed at an advanced stage; closer surveillance may represent an opportunity for diagnosis at an earlier stage. Surveillance for premalignant lesions and facilitating referrals from dentists may expedite the diagnosis and treatment of OCSCC. Further investigation is warranted.

Parent Involvement in the Pediatric Resident Applicant Interview.

BACKGROUND: Parents and patients are actively involved in the clinical learning environment, yet scant literature exists about their involvement in the residency interview process. We aimed to pilot a process of including parents in resident interviews and to determine its value. METHODS: During the 2016-17 residency interview cycle, 22 parent volunteers, blinded to applicant credentials, conducted brief structured interviews with 118 applicants. We then surveyed all parents and applicants with the use of mixed methods: descriptive statistics to analyze 5-point Likert-type-scale responses, and content analysis to identify themes from open-ended questions. Although parent interviews were not used in ranking, we later compared final composite parent interview scores (1-10, with 10 being high) among the final rank and match list candidates. RESULTS: Response rates were high for both groups (parents 100%; resident applicants 98.3%). Parents felt strongly positive about meeting applicants (mean ± SD, 5.00 ± 0.00), the value of parent participation (4.90 ± 0.30), and their own experience (4.95 ± 0.22). Applicants felt positive about meeting parents (4.45 ± 0.70), the value of parent participation (3.92 ± 0.84), and their own experience (4.51 ± 0.67). Several themes emerged from both groups, with the most salient parent themes including the value of patient-centered perspectives and appreciation and joy of meeting applicants. Parent interview scores correlated with the final match list, with matched applicants scoring higher (9.08 vs 8.51; P = .05). CONCLUSIONS: Involvement of parents in the pediatric residency interview process is achievable, is perceived positively by parents and applicants, and may provide valuable perspectives for consideration in residency selection.

Evaluating the Effectiveness of One-on-One Conversations to Increase Colorectal Cancer Screening in a Community-Based Clinical Setting.

CONTEXT: The American Cancer Society's 80% by 2018 initiative aims to increase at-home colorectal cancer (CRC) screening. OBJECTIVE: To assess the effectiveness of one-on-one conversations with patients about CRC screening on compliance with at-home fecal immunochemical tests (FITs). SETTING: Federally funded health care center serving a largely minority, urban, underserved population in Vallejo, California. METHODS: Patients aged 50 to 75 years were divided into 3 main intervention arms: (1) patients who received a one-on-one in-person consultation to discuss the need for CRC screening and the screening process, as well as a FIT; (2) patients who received a telephone call to discuss the need for CRC screening and the screening process before receiving a FIT in the mail; and (3) patients who were mailed a FIT with a letter explaining the importance of completing the FIT and instructions. The FITs were tracked to see if they were returned to the laboratory for processing, and the rates of return were compared in bivariate analyses using t and χ2 tests and in adjusted analyses using logistic regression with bootstrapping. RESULTS: A total of 3415 patients were included in the study. One-on-one conversations either in person (OR, 24.63; 95% CI, 19.28-31.46) or via telephone (OR, 14.74; 95% CI, 10.96-19.82) were more effective at getting patients to complete the at-home CRC screening than not having one-on-one conversations before receiving the FIT. CONCLUSION: Patients may be more likely to complete at-home FITs to screen for CRC if they are first able to discuss the need for screening and the screening process with a health care professional.