Return to Sporting Activities Following Long Fusions to the Pelvis in Adult Spinal Deformity.

BACKGROUND CONTEXT: Returning to recreational sporting activities after adult spinal deformity (ASD) correction may significantly impact the patient's perceived quality of life. PURPOSE: This study sought to characterize participation in sporting activities before and after ASD surgery, and to identify factors associated with impaired return to sports. STUDY DESIGN: Cross-sectional survey and retrospective review of prospectively collected data. PATIENT SAMPLE: Patients who underwent posterior-only thoracolumbar ASD surgery between 2016-2021 with ≥1 year follow-up and ≥3 levels of fusion to the pelvis were included. OUTCOME MEASURES: Preoperative and postoperative participation in sports, timing of return to these activities, and reasons for limited sports participation postoperatively were assessed. METHODS: A survey was used to evaluate outcome measures. Differences in demographic, surgical, and perioperative variables between patients who reported improved, unchanged, or worsened activity tolerance were evaluated. RESULTS: Ninety-five patients were included (mean age: 64.3±10.1 years; BMI: 27.3±6.1 kg/m2; median levels fused: 7). The survey was completed at an average of 43.5 ± 15.9 months after surgery. Sixty-eight (72%) patients participated in sports preoperatively. The most common sports were swimming (n=33, 34.7%), yoga (n=23, 24.2%), weightlifting (n=20, 21.1%), elliptical (n=19, 20.0%), and golf (n=11, 11.6%). Fifty-seven (83.8%) returned to at least one sport postoperatively, most commonly 6-12 months after surgery (45%). Elliptical had the highest rate of equal or improved participation (53%). Patients generally returned below their preoperative level to all other sports. Reasons for reduced sporting activities included physical limitation (51.4%), fear (20.0%), pain (17.1%), and surgeon advice (8.6%). There were no differences in the demographic, surgical, or perioperative characteristics between those who returned to sports at the same or better level compared with those who returned at a lower level. CONCLUSIONS: 84% of patients successfully resumed sporting activities after undergoing fusion to the sacrum/pelvis for ASD. However, this return is typically at a lower level of participation than their preoperative participation, particularly in higher demand sports. Understanding trends in sporting activity may be valuable for counseling patients and setting expectations.

Factors associated with successful electrolarynx use after total laryngectomy, a multi-institutional study.

Objective: To identify characteristics associated with successful electrolarynx (EL) use after total laryngectomy (TL). Methods: Records of 196 adults who underwent TL from 03/15/2012 to 03/15/2022 at the University of Washington and Puget Sound Veterans Affairs were reviewed. Characteristics included age, Charlson Comorbidity Index, social support, pre-operative radiation (RT) and chemoradiation (CRT), and 6-month post-TL swallow status. EL success was evaluated using pre-defined criteria of intelligibility, reliability, and independence with use. Poisson regressions and robust standard error estimates were used to estimate unadjusted risk ratios for each characteristic. Statistically significant characteristics were included in multivariate analysis (MVA) to estimate adjusted risk ratios. Results: Median age was 64, median Charlson Comorbidity Index was 5, 170 (87%) were male, 159 (81%) had high social support, and 159 (81%) attained post-TL full-oral diet. Pre-operatively, 110 (56%) had RT, including 55 (28%) with CRT. Ninety-three (47%) met our criteria for EL success. Characteristics significantly associated with EL success included social support (p = .037) and post-TL full-oral diet (p = .037); both approached significance on MVA. EL success varied by pre-operative treatment on univariate (p = .005) and MVA (p = .014). Compared to no prior RT or CRT, the probability of EL success was 29% higher with prior RT and 29% lower with prior CRT in MVA, although these associations did not reach significance. Conclusions: In this retrospective review, EL success correlated with high social support, post-TL full-oral diet, and pre-operative treatment history. These results warrant validation in a larger prospective study to help guide the choice of voice rehabilitation modalities or intensified speech therapy. Level of Evidence: 4.

The association between arterial compliance, as assessed by PTC1 and PTC2 from radial artery waveforms, and age, sex, and race/ethnicity.

BACKGROUND: There is limited literature on differences in arterial compliance, as assessed from arterial pressure waveforms, with age, sex, and race/ethnicity. PTC1 and PTC2 are indices of arterial compliance, which are derived from a Windkessel model of the waveform, relatively easy to obtain, and associated with cardiovascular disease. METHOD: PTC1 and PTC2 were computed from radial artery waveforms from participants of the Multi-Ethnic Study of Atherosclerosis at baseline and again 10 years later. We evaluated the association of PTC1, PTC2, and 10-year change in PTC1 and PTC2 with age, sex, and race/ethnicity. RESULTS: Among 6245 participants in 2000-2002 (mean ±â€ŠSD of age was 62 ±â€Š10 years; 52% female; 38% White, 12% Chinese, 27% Black, and 23% Hispanic/Latino), means ±â€ŠSDs for PTC1 and PTC2 were 394 ±â€Š334 and 94 ±â€Š46 ms. After adjustment for cardiovascular disease risk factors, mean PTC2 was 1.1 ms (95% confidence interval: 1.0, 1.2) lower (arterial stiffness was greater) per year older age, was 22 ms (19, 24) lower for females, and varied by race/ethnicity ( P  < 0.001; e.g., 5 ms lower for Blacks compared with Whites), although the differences were smaller at older ages ( P  < 0.001 for age-sex, P  < 0.001 for age-race/ethnicity interactions). Among 3701 participants with repeat measurements in 2010-2012, arteries had stiffened (mean ±â€ŠSD 10-year decrease in PTC2: 13 ±â€Š46 ms) consistent with cross-sectional age-trend and tended to stiffen less for females and Blacks consistent with cross-sectional age-interactions. CONCLUSION: Differences in arterial compliance by age, sex, and race/ethnicity lend support to identify and act on societal factors that may drive health disparities.

Inter-arm systolic blood pressure difference: non-persistence and association with incident cardiovascular disease in the Multi-ethnic Study of Atherosclerosis.

We investigated inter-arm systolic blood pressure (sIAD) difference, reproducibility, and incident cardiovascular disease (CVD). We hypothesized that higher sIAD values have low prevalence and nonpersistence over years, but that CVD risk is higher starting from the time of first high absolute sIAD. In Multi-Ethnic Study of Atherosclerosis participants (n = 6725, 53% female, 45-84 years old), Doppler systolic blood pressure (SBP) measurements were made in both arms (10-minute interval) thrice over 9.5 years. Proportional hazards for CVD (coronary heart disease, heart failure, stroke, peripheral arterial disease (PAD)) over 16.4 years were tested according to time-varying absolute inter-arm difference with covariates: (1) age, gender, race, and clinic; (2) model 1 plus height, heart rate, BP, antihypertensives, BMI, smoking status, lipids, lipid lowering medication, and diabetes. High sIAD was not persistent across exams. Maximum absolute sIAD ≥ 15 mmHg was found at least once in 815 persons. Maximum absolute sIAD had a graded relationship with incident stroke or PAD: 6.2% events; model 2 hazard ratio per 10 mmHg 1.34 (95% CI, 1.15-1.56) and this risk was approximately doubled for maximum absolute sIAD ≥ 15 mmHg vs 0-4 mmHg. Total CVD risk (18.4% events) was increased only for maximum absolute sIAD ≥25 mmHg. Associations with incident CVD did not differ for higher SBP in left vs right arm. A higher maximum absolute sIAD at any exam was associated with greater risk for stroke and PAD especially for values ≥ 15 mmHg, and ≥25 mmHg for other CVD. Measuring SBP between arms may help identify individuals at risk for CVD.

Modeling the Potential of Treg-Based Therapies for Transplant Rejection: Effect of Dose, Timing, and Accumulation Site.

Introduction: The adoptive transfer of regulatory T cells (Tregs) has emerged as a method to promote graft tolerance. Clinical trials have demonstrated the safety of adoptive transfer and are now assessing their therapeutic efficacy. Strategies that generate large numbers of antigen specific Tregs are even more efficacious. However, the combinations of factors that influence the outcome of adoptive transfer are too numerous to be tested experimentally. Here, mathematical modeling is used to predict the most impactful treatment scenarios. Methods: We adapted our mathematical model of murine heart transplant rejection to simulate Treg adoptive transfer and to correlate therapeutic efficacy with Treg dose and timing, frequency of administration, and distribution of injected cells. Results: The model predicts that Tregs directly accumulating to the graft are more protective than Tregs localizing to draining lymph nodes. Inhibiting antigen-presenting cell maturation and effector functions at the graft site was more effective at modulating rejection than inhibition of T cell activation in lymphoid tissues. These complex dynamics define non-intuitive relationships between graft survival and timing and frequency of adoptive transfer. Conclusion: This work provides the framework for better understanding the impact of Treg adoptive transfer and will guide experimental design to improve interventions.

Assessment of Discordance Between Physicians and Family Members Regarding Prognosis in Patients With Severe Acute Brain Injury.

Importance: Shared decision-making requires key stakeholders to align in perceptions of prognosis and likely treatment outcomes. Objective: For patients with severe acute brain injury, the objective of this study was to better understand prognosis discordance between physicians and families by determining prevalence and associated factors. Design, Setting, and Participants: This mixed-methods cross-sectional study analyzed a cohort collected from January 4, 2018, to July 22, 2020. This study was conducted in the medical and cardiac intensive care units of a single neuroscience center. Participants included families, physicians, and nurses of patients admitted with severe acute brain injury. Exposures: Severe acute brain injury was defined as stroke, traumatic brain injury, or hypoxic ischemic encephalopathy with a Glasgow Coma Scale score less than or equal to 12 points after hospital day 2. Main Outcomes and Measures: Prognosis discordance was defined as a 20% or greater difference between family and physician prognosis predictions; misunderstanding was defined as a 20% or greater difference between physician prediction and the family's estimate of physician prediction; and optimistic belief difference was defined as any difference (>0%) between family prediction and their estimate of physician prediction. Logistic regression was used to identify associations with discordance. Optimistic belief differences were analyzed as a subgroup of prognosis discordance. Results: Among 222 enrolled patients, prognostic predictions were available for 193 patients (mean [SD] age, 57 [19] years; 106 men [55%]). Prognosis discordance occurred for 118 patients (61%) and was significantly more common among families who identified with minoritized racial groups compared with White families (odds ratio [OR], 3.14; CI, 1.40-7.07, P = .006); among siblings (OR, 4.93; 95% CI, 1.35-17.93, P = .02) and adult children (OR, 2.43; 95% CI, 1.10-5.37; P = .03) compared with spouses; and when nurses perceived family understanding as poor compared with good (OR, 3.73; 95% CI, 1.88-7.40; P < .001). Misunderstanding was present for 80 of 173 patients (46%) evaluated for this type of prognosis discordance, and optimistic belief difference was present for 94 of 173 patients (54%). In qualitative analysis, faith and uncertainty emerged as themes underlying belief differences. Nurse perception of poor family understanding was significantly associated with misunderstanding (OR, 2.06; 95% CI, 1.07-3.94; P = .03), and physician perception with optimistic belief differences (OR, 2.32; 95% CI, 1.10-4.88; P = .03). Conclusions and Relevance: Results of this cross-sectional study suggest that for patients with severe acute brain injury, prognosis discordance between physicians and families was common. Efforts to improve communication and decision-making should aim to reduce this discordance and find ways to target both misunderstanding and optimistic belief differences.

The association between indices of blood pressure waveforms (PTC1 and PTC2) and incident heart failure.

OBJECTIVES: The radial artery pulse waveform is a continuous measure of pressure throughout the cardiac cycle, and thus can provide more information than just systolic and diastolic blood pressures. New indices based on a Windkessel model of the waveform, PTC1 and PTC2, are related to arterial compliance and add information for prediction of incident cardiovascular disease (coronary heart disease, stroke, myocardial infarction) but their association with heart failure is unknown. METHODS: Among 6229 adults (mean age 62 years) from four race/ethnic groups who were initially free of clinical cardiovascular disease and heart failure in 2000-2002, we evaluated the associations of baseline PTC1 and PTC2 with incident heart failure. RESULTS: Mean ±â€Šstandard deviation PTC1 and PTC2 were 394 ±â€Š334 and 94 ±â€Š46 ms, respectively. During a median of 15.7 years follow-up, there were 357 heart failure events (148 with reduced, 150 with preserved, and 59 with unknown ejection fraction). After adjustment for traditional risk factors, the hazard ratio for heart failure per 1 standard deviation higher PTC2 was 0.73 (95% confidence interval: 0.63--0.85). Higher PTC2 was also significantly associated with lower risk of heart failure with reduced ejection fraction (hazard ratio = 0.67; 95% confidence interval: 0.56--0.80). There was no evidence of a significant association between PTC2 and heart failure with preserved ejection fraction or between PTC1 and heart failure. CONCLUSION: The PTC2 measure of the radial artery pulse waveform may represent a novel phenotype related to heart failure, especially heart failure with reduced ejection fraction.