Association Between Social Vulnerability and Streptococcus pneumoniae Antimicrobial Resistance in US Adults.

BACKGROUND: Growing evidence indicates antimicrobial resistance disproportionately affects individuals living in socially vulnerable areas. This study evaluated the association between the CDC/ATSDR Social Vulnerability Index (SVI) and Streptococcus pneumoniae (SP) antimicrobial resistance (AMR) in the United States. METHODS: Adult patients ≥18 years with 30-day nonduplicate SP isolates from ambulatory/hospital settings from January 2011 to December 2022 with zip codes of residence were evaluated across 177 facilities in the BD Insights Research Database. Isolates were identified as SP AMR if they were non-susceptible to ≥1 antibiotic class (macrolide, tetracycline, extended-spectrum cephalosporins, or penicillin). Associations between SP AMR and SVI score (overall and themes) were evaluated using generalized estimating equations with repeated measurements within county to account for within-cluster correlations. RESULTS: Of 8008 unique SP isolates from 574 US counties across 39 states, the overall proportion of AMR was 49.9%. A significant association between socioeconomic status (SES) theme and SP AMR was detected with higher SES theme SVI score (indicating greater social vulnerability) associated with greater risk of AMR. On average, a decile increase of SES, indicating greater vulnerability, was associated with a 1.28% increased risk of AMR (95% confidence interval [CI], .61%, 1.95%; P = .0002). A decile increase of household characteristic score was associated with a 0.81% increased risk in SP AMR (95% CI, .13%, 1.49%; P = .0197). There was no association between racial/ethnic minority status, housing type and transportation theme, or overall SVI score and SP AMR. CONCLUSIONS: SES and household characteristics were the SVI themes most associated with SP AMR.

Laminoplasty versus laminectomy with fusion for the treatment of spondylotic cervical myelopathy: short-term follow-up.

BACKGROUND CONTEXT: Laminoplasty and laminectomy with fusion are two common procedures for the treatment of cervical spondylotic myelopathy. Controversy remains regarding the superior surgical treatment. PURPOSE: To compare short-term follow-up of laminoplasty to laminectomy with fusion for the treatment of cervical spondylotic myelopathy. STUDY DESIGN/SETTING: Retrospective review comparing all patients undergoing surgical treatment for cervical spondylotic myelopathy by a single surgeon. PATIENT SAMPLE: All patients undergoing laminoplasty or laminectomy with fusion by a single surgeon over a 5-year period (2007-2011). OUTCOME MEASURES: Cervical alignment and range of motion on pre- and post-operative radiographs and clinical outcome measures including Japanese Orthopaedic Association (JOA) scores, neck disability index (NDI), short form-12 mental (SF-12M) and physical (SF-12P) composite scores and visual analog pain scores for neck (VAS-N) and arm (VAS-A). METHODS: Patients undergoing laminoplasty or laminectomy with fusion by a single surgeon were reviewed. Cohorts of 41 laminoplasty patients and 31 laminectomy with fusion patients were selected based on strict criteria. The cohorts were well matched based on pre-operative clinical scores, radiographic measurements, and demographics. The average follow-up was 19.2 months for laminoplasty and 18.2 months for laminectomy with fusion. Evaluated outcomes included Japanese Orthopaedic Association (JOA) score, neck disability index (NDI), short form-12 (SF-12), visual analog pain scores (VAS), cervical sagittal alignment, cervical range of motion, length of stay, cost and complications. RESULTS: The improvement in JOA, SF-12 and VAS scores was similar in the two cohorts after surgery. There was no significant change in cervical sagittal alignment in either cohort. Range-of-motion decreased in both cohorts, but to a greater degree after laminectomy with fusion. C5 nerve root palsy and infection were the most common complications in both cohorts. Laminectomy with fusion was associated with a higher rate of C5 nerve root palsy and overall complications. The average hospital length of stay and cost were significantly less with laminoplasty. CONCLUSIONS: This study provides evidence that laminoplasty may be superior to laminectomy with fusion in preserving cervical range of motion, reducing hospital stay and minimizing cost. However, the significance of these differences remains unclear, as laminoplasty clinical outcome scores were generally comparable to laminectomy with fusion.

Ankylosing Spondylitis Increases Perioperative and Postoperative Complications After Total Hip Arthroplasty.

BACKGROUND: Ankylosing spondylitis (AS) is a chronic autoimmune spondyloarthropathy that primarily affects the axial spine and hips. Progressive disease leads to pronounced spinal kyphosis, positive sagittal balance, and altered biomechanics. The purpose of this study is to determine the complication profile of patients with AS undergoing total hip arthroplasty (THA). METHODS: The Medicare sample was searched from 2005 to 2012 yielding 1006 patients with AS who subsequently underwent THA. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for 90-day, 2-year, and the final postoperative follow-up for complications including hip dislocation, periprosthetic fracture, wound complication, revision THA, and postoperative infection. RESULTS: Compared to controls, AS patients had an RR of 2.50 (CI, 1.04-5.99) of THA component breakage at 90-days post-operatively and 1.99 (CI, 1.10-3.59) at 2-years. The RR of periprosthetic hip dislocation was elevated at 90 days (1.44; CI, 0.93-2.22) and significantly increased at 2-years (1.67; CI, 1.25-2.23) and overall follow-up (1.49; CI, 1.14-1.93). Similarly, the RR for THA revision was elevated at 90-days (1.46; CI, 0.97-2.18) and significantly increased at 2-years (1.69; CI, 1.33-2.14) and overall follow-up (1.51; CI, 1.23-1.85). CONCLUSION: Patients with AS are at increased risk for complications after THA. Altered biomechanics from a rigid, kyphotic spine place increased demand on the hip joints. The elevated perioperative and postoperative risks should be discussed preoperatively, and these patients may require increased preoperative medical optimization as well as possible changes in component selection and position to compensate for altered spinopelvic biomechanics.

Cervical Myelopathy Doubles the Rate of Dislocation and Fracture After Total Hip Arthroplasty.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a common and underdiagnosed cause of gait dysfunction, rigidity, and falls in the elderly. Given the frequent concurrency of CSM and hip osteoarthritis, this study is designed to evaluate the relative risk of CSM on perioperative and short-term outcomes after total hip arthroplasty (THA). METHODS: The Medicare Standard Analytical Files were searched from 2005 to 2012 to identify all patients undergoing primary THA and the subset of patients with preexisting CSM. Risk ratios with 95% confidence intervals were calculated for 90-day, 1-year, and overall follow-up for common postoperative complications: periprosthetic dislocation, fracture, infection, revision THA, and wound complications. RESULTS: The risk ratios of all surgical complications, including dislocation, periprosthetic fractures, and prosthetic joint infection, were increased approximately 2-fold at all postoperative time points for patients. CONCLUSION: Preexisting CSM is a significant risk factor for primary THA complications including dislocation, periprosthetic fractures, and prosthetic joint infection.

Can we predict response to the McKenzie method in patients with acute low back pain? A secondary analysis of a randomized controlled trial.

PURPOSE: To evaluate whether patients' treatment preferences, characteristics, or symptomatic response to assessment moderated the effect of the McKenzie method for acute low back pain (LBP). METHODS: This study involved a secondary analysis of a previous RCT on the effect of adding the McKenzie method to the recommended first-line care for patients with acute non-specific LBP. 148 patients were randomized to the First-line Care Group (recommended first-line care alone) or the McKenzie Group (McKenzie method in addition to the first-line care) for a 3-week course of treatment. The primary outcome was pain intensity at 3 weeks. The ability of six patient characteristics to identify those who respond best to McKenzie method was assessed using interaction terms in linear regression models. RESULTS: The six investigated potential effect modifiers for response to the McKenzie method did not predict a more favorable response to this treatment. None of the point estimates for effect modification met our pre-specified criterion of clinical importance of a 1 point greater improvement in pain. For five of the six predictors, the 95% CI did not include our criterion for meaningful clinical improvement. CONCLUSION: We were unable to find any clinically useful effect modifiers for patients with acute LBP receiving the McKenzie method.

Hip Fracture in the Elderly Patients: A Sentinel Event.

IMPORTANCE: Hip fracture in the elderly patients is associated with increased morbidity and mortality. There is great need for advance care planning should a patient fail to rehabilitate or experience an adverse event during or after recovery. This study was performed to evaluate for palliative care consultation and changes in code status and/or advance directives in elderly patients with hip fracture. METHODS: We performed a retrospective review of 186 consecutive patients aged 65 years and older with a hip fracture due to a low-energy fall who underwent surgery at a large academic institution between August 1, 2013, and September 1, 2014. Risk factors assessed were patient demographics, home status, mobility, code status, comorbidities, medications, and hospitalizations prior to injury. Outcomes of interest included palliative care consultation, complications, mortality, and most recent code status, mobility, and home. RESULTS: About 186 patients with hip fractures were included. Three patients died, and 12 (6.5%) sustained major complications during admission. Nearly one-third (51 patients) died upon final follow-up approximately 1.5 years after surgery. Of the patients who died, palliative care consulted on 6 (11.8%) during initial admission. Eleven (21.6%) were full code at death. Three patients underwent cardiopulmonary resuscitation (CPR) and 1 underwent massive transfusion and extracorporeal membrane oxygenation prior to changing their code status to do not attempt resuscitation. CONCLUSION: Hip fracture in elderly patients is an important opportunity to reassess the patient's personal health-care priorities. Advance directives, goals of care, and code status documentation should be updated in all elderly patients with hip fracture, should the patient's health decompensate.

Treatment effectiveness and fidelity of manual therapy to the knee: A systematic review and meta-analysis.

Manual therapy (MT) is a commonly used treatment for knee osteoarthritis (OA) but to date only one systematic review has explored its effectiveness. The purpos e of the present study was to perform a systematic review and meta-analysis of the literature, to determine the effectiveness and fidelity of studies using MT techniques in individuals with knee OA. Relevant studies were assessed for inclusion. Effectiveness was measured using effect sizes, and methodological bias and treatment fidelity were both explored. Effect sizes were calculated using standardized mean differences (SMD) based on pooled data depending on statistical and clinical heterogeneity, as well as risk of bias. The search captured 2,969 studies; after screening, 12 were included. Four had a low risk of bias and high treatment fidelity. For self-reported function, comparing MT with no treatment resulted in a large effect size (standardized mean difference [SMD] 0.84), as did adding MT to a comparator treatment (SMD 0.78). A significant difference was found for pain when adding MT to a comparator treatment (SMD 0.73). The findings in the present meta-analytical review support the use of MT versus a number of different comparators for improvement in self-reported knee function. Lesser support is present for pain reduction, and no endorsement of functional performance can be made at this time.

SHOULDER EXTERNAL ROTATOR ECCENTRIC TRAINING VERSUS GENERAL SHOULDER EXERCISE FOR SUBACROMIAL PAIN SYNDROME: A RANDOMIZED CONTROLLED TRIAL.

BACKGROUND: Shoulder pain affects up to 67% of the population at some point in their lifetime with subacromial pain syndrome (SAPS) representing a common etiology. Despite a plethora of studies there remains conflicting evidence for appropriate management of SAPS. PURPOSE: To compare outcomes, for individuals diagnosed with SAPS, performing a 6-week protocol of eccentric training of the shoulder external rotators (ETER) compared to a general exercise (GE) protocol. STUDY DESIGN: Randomized controlled trial. METHODS: Forty-eight individuals (mean age 46.8 years + /-17.29) with chronic shoulder pain, and a clinical diagnosis of SAPS were randomized into either an experimental group performing ETER or a control group performing a GE program. The intervention lasted for six weeks, and outcomes were measured after three weeks, six weeks, and again at six months post intervention. RESULTS: The primary outcome of function, measured by the Western Ontario Rotator Cuff Index, demonstrated a significant interaction effect derived from a multilevel hierarchical model accounting for repeated measures favoring the experimental group at week 3: 14.65 (p=.003), Week 6: 17.04 (p<.001) and six months: 15.12 (p=.007). After six months, secondary outcome measures were improved for Numeric Pain Rating Scale levels representing pain at worst (p=.006) and pain on average (p=0.02), external rotator (p<.001), internal rotator (p=0.02), and abductor strength (p<.001). There were no statistically significant differences in secondary outcome measures of Global Rating of Change, Active Range of Motion, the Upper Quarter Y Balance Test and strength ratios after six months. CONCLUSION: An eccentric program targeting the external rotators was superior to a general exercise program for strength, pain, and function after six months. The findings suggest eccentric training may be efficacious to improve self-report function and strength for those with SAPS. LEVEL OF EVIDENCE: 2b.

The Impact of Lumbar Spine Disease and Deformity on Total Hip Arthroplasty Outcomes.

Concomitant spine and hip disease in patients undergoing total hip arthroplasty (THA) presents a management challenge. Degenerative lumbar spine conditions are known to decrease lumbar lordosis and limit lumbar flexion and extension, leading to altered pelvic mechanics and increased demand for hip motion. In this study, the effect of lumbar spine disease on complications after primary THA was assessed. The Medicare database was searched from 2005 to 2012 using International Classification of Diseases, Ninth Revision, procedure codes for primary THA and diagnosis codes for preoperative diagnoses of lumbosacral spondylosis, lumbar disk herniation, acquired spondylolisthesis, and degenerative disk disease. The control group consisted of all patients without a lumbar spine diagnosis who underwent THA. The risk ratios for prosthetic hip dislocation, revision THA, periprosthetic fracture, and infection were significantly higher for all 4 lumbar diseases at all time points relative to controls. The average complication risk ratios at 90 days were 1.59 for lumbosacral spondylosis, 1.62 for disk herniation, 1.65 for spondylolisthesis, and 1.53 for degenerative disk disease. The average complication risk ratios at 2 years were 1.66 for lumbosacral spondylosis, 1.73 for disk herniation, 1.65 for spondylolisthesis, and 1.59 for degenerative disk disease. Prosthetic hip dislocation was the most common complication at 2 years in all 4 spinal disease cohorts, with risk ratios ranging from 1.76 to 2.00. This study shows a significant increase in the risk of complications following THA in patients with lumbar spine disease. [Orthopedics. 2017; 40(3):e520-e525.].

Cauda Equina Compression in the Absence of Neurologic Signs.

The patient was a 45-year-old man with a 4-year history of chronic low back pain, intensifying insidiously over the previous 8 months. On physical examination, generalized, severe low back pain was increased with all motions, with no abnormal neurologic signs. The initial physical therapy diagnosis was nonspecific low back pain; however, when the patient reported worsening symptoms at 2-week follow-up, he was advised to complete his previously scheduled magnetic resonance imaging and physician follow-up before further physical therapy. Magnetic resonance imaging revealed a mass at L5 consistent with benign nerve sheath tumor.

Sagittal Balance Correction in Lateral Interbody Fusion for Degenerative Scoliosis.

BACKGROUND: Sagittal balance restoration has been shown to be an important determinant of outcomes in corrective surgery for degenerative scoliosis. Lateral interbody fusion (LIF) is a less-invasive technique which permits the placement of a high lordosis interbody cage without risks associated with traditional anterior or transforaminal interbody techniques. Studies have shown improvement in lumbar lordosis following LIF, but only one other study has assessed sagittal balance in this population. The objective of this study is to evaluate the ability of LIF to restore sagittal balance in degenerative lumbar scoliosis. METHODS: Thirty-five patients who underwent LIF for degenerative thoracolumbar scoliosis from July 2013 to March 2014 by a single surgeon were included. Outcome measures included sagittal balance, lumbar lordosis, Cobb Angle, and segmental lordosis. Measures were evaluated pre-operative, immediately post-operatively, and at their last clinical follow-up. Repeated measures ANOVAs were used to assess the differences between pre-operative, first postoperative, and a follow-up visit. RESULTS: The average sagittal balance correction was not significantly different: 1.06cm from 5.79cm to 4.74cm forward. The average Cobb angle correction was 14.1 degrees from 21.6 to 5.5 degrees. The average change in global lumbar lordosis was found to be significantly different: 6.3 degrees from 28.9 to 35.2 degrees. CONCLUSIONS: This study demonstrates that LIF reliably restores lordosis, but does not significantly improve sagittal balance. Despite this, patients had reliable improvement in pain and functionality suggesting that sagittal balance correction may not be as critical in scoliosis correction as previous studies have indicated. CLINICAL RELEVANCE: LIF does not significantly change sagittal balance; however, clinical improvement does not seem to be contingent upon sagittal balance correction in the degenerative scoliosis population. The DUHS IRB has determined this study meets criteria for an IRB waiver.

The role of iatrogenic foraminal stenosis from lordotic correction in the development of C5 palsy after posterior laminectomy and fusion.

BACKGROUND: Post-operative C5 nerve root palsy is a known complication following cervical spine surgery. Although several theories have been proposed, there remains no consensus as to the etiology of the palsies. Multiple pre-operative radiographic measures have been assessed for utility in predicting palsy. The purpose of this study is to evaluate published radiographic parameters as well as specifically evaluate the effect of cervical lordosis in the development of C5 palsy to establish thresholds that reliably predict the incidence. METHODS: This study is a retrospective review of 54 consecutive multilevel cervical laminectomy and fusion surgeries performed by a single spine surgeon between June 2007 and February 2014. Pre-operative MRI and pre- and post-operative plain films were assessed to measure anteroposterior diameter (APD) of the spinal cord, cervical laminar angles, anteroposterior foraminal diameters (FD), cervical curvature index (Ishihara), cervical spine angle (C2-7), and C4-5 angle. Univariate analysis through independent t tests was used to compare differences between groups. Stepwise logistic regression was performed to identify pre-operative variables associated with C5 palsy. Receiver operating characteristic curves were created for significant variables to assess predictive accuracy through determining the area under the curve. RESULTS: There were 13 (24%) palsies in the 54 patients in the study. All palsies completely resolved within 6 months. Among pre-operative measures, FD and APD were significantly different between the palsy and non-palsy groups. The average post-operative C4-5 angle was significantly different between the groups, though the cervical spine angle and curvature index, as well as the change in these measures from pre-operative measurements, did not differ significantly between groups. CONCLUSIONS: Post-operative palsy is likely a result of iatrogenic nerve root compression from a decreased in cross-sectional area of the neuroforamen in a patient with pre-operative narrowing of the foramen. However, spinal cord drift back may also play a role from the combined effect of posterior decompression from laminectomy and relative slack afforded by increased lordosis. Accordingly, increased post-operative lordosis would increase the likelihood of effect from both of these mechanisms. We recommended limited conservative lordotic correction in patients with pre-operative foraminal narrowing.

Injuries presenting to a walk-in clinic at a summer dance intensive program: a three-year retrospective data analysis.

Summer dance intensive programs are an integral part of many serious dancers' training. The risk and rate of injury in this setting have not been well studied. The goal of this data analysis is to detail the epidemiology of dance injuries reported during a summer dance intensive over a consecutive 3 year period. Data collection included information regarding the number of evaluation and treatment sessions conducted at the program's walk-in clinic, body regions injured, whether the injuries were recurrences of pre-existing conditions or newly sustained during the intensive, and at what point in the program they were recorded. Overall, more of the clinic's clientele presented with multiple injuries than with single discrete injuries. The anatomic distribution of injuries appears to be consistent with previously reported data, with the four most commonly injured body regions being ankle, pelvis and hip, knee, and lumbar spine. Injuries sustained during the intensive (IR) occurred at a 2:1 ratio to pre-intensive injuries (PR). Relative to those with PR injuries, dancers with IR injuries were far more likely to present during the first half of the program. This study is a first step toward filling a gap in the literature by describing injury incidence in a specific population within the dance community.

Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials.

Clinical and personal equipoise exists when a clinician has no good basis for a choice between two or more care options or when one is truly uncertain about the overall benefit or harm offered by the treatment to his/her patient. For most manual therapy trials, equipoise does not likely exist. Because of the nature of the intervention a lack of equipoise can lead to bias and may account for a portion of the 'effect' that has traditionally been assigned to the intervention. Although there are methodological mechanisms to reduce the risk of bias associated with a lack of equipoise, most of the manual therapy trials to date are likely guilty of this form of bias.

Spondyloarthritis in a patient with unilateral buttock pain and history of Crohn disease.

BACKGROUND AND PURPOSE: Patients with inflammatory spinal conditions related to spondyloarthritis are rarely seen by primary care practitioners. However, patients with a history of inflammatory bowel disease and chronic low back or buttock pain should be examined carefully for the presence of spondyloarthritis, as proper management may include referral to a rheumatologist and appropriate medical intervention. CASE DESCRIPTION: A 27-year-old woman with a 6-month history of posterior buttock pain was referred for physical therapy with a diagnosis of piriformis syndrome. During the second physical therapy visit, a nonmechanical source of lumbopelvic pain was suspected, and the patient was referred for medical consultation. The patient underwent evaluation by a rheumatologist and was eventually diagnosed with spondyloarthritis associated with inflammatory bowel disease. OUTCOMES: The patient initiated treatment with anti-tumor necrosis factor medication to address the spondyloarthritis. Medical management resulted in significant improvement in all outcome measures. DISCUSSION: Clinical suspicion of spondyloarthritis is raised when specific historical, examination, and imaging findings are present. The posttest probability of spondyloarthritis is increased with the presence of inflammatory back pain and specific spondyloarthritic features, such as a positive history of inflammatory bowel disease, radiographic evidence of sacroiliitis, and improvement with anti-inflammatory medication. Referral of patients with these findings for a rheumatological evaluation is warranted, as these diseases are managed effectively with specific treatment.

Correlation of magnetic resonance imaging findings and reported symptoms in patients with chronic cervical dysfunction.

Information gathered from the patient history, physical examination, and advanced testing augments the decision-making process and is proposed to improve the probability of diagnostic and prognostic accuracy. However, these findings may provide inconsistent results and can lead to errors in decision-making. The purpose of this study was to examine the relationship between common clinical complaints and specific findings on magnetic resonance imaging (MRI) in patients with chronic neck dysfunction. Forty-five English-speaking participants (25 female), with mean age of 52 (SD = 13.4), were evaluated by a neurosurgeon for complaints of symptoms related to the cervical spine. All participants answered a subjective questionnaire and received an MRI of the cervical spine. Cramer's V nominal correlation was performed to explore the relationship between the targeted variables. The correlation matrix calculations captured three significant findings. Evidence of spinal cord compression was significantly correlated to 1) anteroposterior canal diameter of less than or equal to 9 mm (r = .31; p<0.05) and 2) diminished subarachnoid fluid around the cord (r = .48; p<0.01). Report of loss of dexterity was significantly correlated with 3) report of lower extremity clumsiness (r = .33; p<0.05). In this study, no definitive relationships were found between the clinical complaints of neck pain, hand function, or clumsiness and specific MRI findings of spinal cord compression. Further research is needed to investigate the diagnostic utility of subjective complaints and their association with advanced testing.