A clinical model to predict postoperative improvement in sub-domains of the modified Japanese Orthopedic Association score for degenerative cervical myelopathy.

PURPOSE: The modified Japanese Orthopedic Association (mJOA) score consists of six sub-domains and is used to quantify the severity of cervical myelopathy. The current study aimed to assess for predictors of postoperative mJOA sub-domains scores following elective surgical management for patients with cervical myelopathy and develop the first clinical prediction model for 12-month mJOA sub-domain scores.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Byron F.] Last name [Stephens], Author 2 Given name: [Lydia J.] Last name [McKeithan], Author 3 Given name: [W. Hunter] Last name [Waddell], Author 4 Given name: [Anthony M.] Last name [Steinle], Author 5 Given name: [Wilson E.] Last name [Vaughan], Author 6 Given name: [Jacquelyn S.] Last name [Pennings], Author 7 Given name: [Jacquelyn S.] Last name [Pennings], Author 8 Given name: [Scott L.] Last name [Zuckerman], Author 9 Given name: [Kristin R.] Last name [Archer], Author 10 Given name: [Amir M.] Last name [Abtahi] Also, kindly confirm the details in the metadata are correct.Last Author listed should be Kristin R. Archer METHODS: A multivariable proportional odds ordinal regression model was developed for patients with cervical myelopathy. The model included patient demographic, clinical, and surgery covariates along with baseline sub-domain scores. The model was internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients. RESULTS: The model identified mJOA baseline sub-domains to be the strongest predictors of 12-month scores, with numbness in legs and ability to walk predicting five of the six mJOA items. Additional covariates predicting three or more items included age, preoperative anxiety/depression, gender, race, employment status, duration of symptoms, smoking status, and radiographic presence of listhesis. Surgical approach, presence of motor deficits, number of surgical levels involved, history of diabetes mellitus, workers' compensation claim, and patient insurance had no impact on 12-month mJOA scores. CONCLUSION: Our study developed and validated a clinical prediction model for improvement in mJOA scores at 12 months following surgery. The results highlight the importance of assessing preoperative numbness, walking ability, modifiable variables of anxiety/depression, and smoking status. This model has the potential to assist surgeons, patients, and families when considering surgery for cervical myelopathy. LEVEL OF EVIDENCE: Level III.

Tailor Made: A Pilot Virtual Weight Loss Intervention Individually Tailored for African American Men.

This study tests the acceptability and feasibility of the first virtual weight loss study individually tailored for middle-aged African American men. Tailor Made is a 3-month randomized controlled pilot of a weight loss intervention that included 58 overweight or obese African American men (mean age of 50.4; SD = 7.9). Control group participants received a Fitbit activity tracker and Bluetooth-enabled scale and copies of the self-led Tailor Made curriculum. Intervention group participants received the same Fitbit, Bluetooth-enabled scale, and curriculum and also participated in weekly, 45-minute virtual small group, professional-led education sessions using the Tailor Made curriculum and received three SMS text messages weekly: (a) a message individually tailored on African American Manhood that links men's values, goals, and motivation to health-promoting behavior; (b) a goal-tracking message to monitor physical activity, healthier eating, and lifestyle changes; and (c) a reminder 24 hours before their session. Participation rates in weekly small group sessions, randomization, and attendance at the assessments suggest that Tailor Made was feasible and acceptable. Only among intervention group participants, we found a small and significant decrease in BMI between baseline and final. In addition, active minutes of physical activity decreased for the control group while active minutes for the intervention group remained steady throughout the intervention. In sum, we demonstrated that a virtual, individually tailored weight loss intervention is feasible and acceptable to African American men. Participants valued the convenience of a virtual intervention, but there were a number of ways we may be able to enhance the potential benefits of this approach.

Coordination and Pilot Implementation of a Standardized Data Collection for Touching Hands.

PURPOSE: Touching Hands is an American Society for Surgery of the Hand program that provides hand surgeries to the world's underserved communities. The purpose of this study was to develop and implement a systematic data collection method for Touching Hands to assess patient outcomes, volunteer impact, alleviated disease burden, and cost-effectiveness. METHODS: Research electronic data capture (REDCap) was used as the secure software platform to facilitate data collection. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire was used to assess pre-and postoperative patient-reported outcomes. The Maslach Burnout Inventory-Human Services (Medical Personnel) survey was administered to volunteers before and after the mission to measure impact on volunteers. Case information was collected to calculate disability-adjusted life years and cost-effectiveness. RESULTS: The data collection system was implemented in some capacity in 4 domestic and 3 international mission sites during 2020 and 2021. CONCLUSIONS: Substantial limitations exist for the implementation of a systematic data collection framework for Touching Hands and warrant further modification and optimization. CLINICAL RELEVANCE: A REDCap database can be used for standardized and centralized patient and volunteer data collection for Touching Hands missions.

Evaluation of a Vitamin D Screening and Treatment Protocol Using a Seasonal Calculator in Athletes.

ABSTRACT: Vitamin D is important in musculoskeletal health, and low serum vitamin D concentration is common in athletes. This study implemented a vitamin D screening and supplementation protocol in a cohort of National Collegiate Athletic Association Division I athletes using summer 25-hydroxyvitamin D concentration and a seasonal variation calculator to achieve sufficient vitamin D concentration year-round. After implementation of the Vitamin D Protocol, there was a nonsignificant difference in athletes with sufficient winter vitamin D concentrations (72.6%) compared with summer vitamin D concentrations (66.1%) (P = 0.40). The Seasonal Variation Calculator predicted winter vitamin D concentrations (8 ± 18 ng·mL-1) higher than actual winter vitamin D concentrations (P < 0.01). While most athletes (78%) believed vitamin D was important for athletic performance, athlete compliance to the Vitamin D Protocol was inconsistent. In the future, adjustment of vitamin D screening and supplementation protocols may help athletes achieve sufficient vitamin D status year-round.

Reliability and Validity Evidence of the STarT-Lower Extremity Screening Tool for Patients With Lower Extremity Fracture: A Prospective Study.

OBJECTIVES: To determine whether a modified version of the STarT Back Screening Tool in its current structure has adequate properties for use in patients with lower extremity fracture. DESIGN: Single-center, prospective study. SETTING: Level I trauma center. PARTICIPANTS: Patients with lower extremity fracture without a history of chronic pain (N=114), with 93% follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six weeks after surgical fixation, individuals completed the Subgroups for Targeted Treatment of Lower Extremity Screening Tool (STarT-LE). A subsample completed the STarT-LE again 1 week later. The following questionnaires were completed at 6 weeks and 6 months: Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Brief Pain Inventory pain intensity subscale, and PROMIS Depression and Pain Interference computer adaptive testing modules. Reliability was evaluated using intraclass correlation coefficients (ICC) and Cronbach's alpha (α). Convergent validity evidence was measured concurrently using the Spearman ρ correlation between the 6-week STarT-LE and established questionnaires. Predictive validity evidence was evaluated by area under the curve analysis (AUC) using the 6-week STarT-LE total and psychosocial scores and 6-month criterion physical and psychosocial reference standards. RESULTS: The STarT-LE has good test-retest reliability (ICC, 0.85; 95% confidence interval, 0.78-0.91) and acceptable internal consistency (α=0.74). The convergent validity evidence was fair to moderate (ρ, 0.53-0.68; P<.001) and the predictive validity evidence was acceptable to excellent (AUC, 0.73-0.84). CONCLUSIONS: The STarT-LE has adequate properties for use in patients with lower extremity fracture. Future larger scale studies are needed to validate risk cutoffs.

How Many Steps Per Day During the Early Postoperative Period are Associated With Patient-Reported Outcomes of Disability, Pain, and Opioid Use After Lumbar Spine Surgery?

OBJECTIVE: To investigate whether early postoperative walking is associated with "best outcome" and no opioid use at 1 year after lumbar spine surgery and establish a threshold for steps/day to inform clinical practice. DESIGN: Secondary analysis from randomized controlled trial. SETTING: Two academic medical centers in the United States. PARTICIPANTS: We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition (N=248). A total of 212 participants (mean age, 62.8±11.4y, 53.3% female) had valid walking data at baseline. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability (Oswestry Disability Index), back and leg pain (Brief Pain Inventory), and opioid use (yes vs no) were assessed at baseline and 1 year after surgery. "Best outcome" was defined as Oswestry Disability Index ≤20, back pain ≤2, and leg pain ≤2. Steps/day (walking) was assessed with an accelerometer worn for at least 3 days and 10 h/d at 6 weeks after spine surgery, which was considered as study baseline. Separate multivariable logistic regression analyses were conducted to determine the association between steps/day at 6 weeks and "best outcome" and no opioid use at 1-year. Receiver operating characteristic curves identified a steps/day threshold for achieving outcomes. RESULTS: Each additional 1000 steps/d at 6 weeks after spine surgery was associated with 41% higher odds of achieving "best outcome" (95% confidence interval [CI], 1.15-1.74) and 38% higher odds of no opioid use (95% CI, 1.09-1.76) at 1 year. Walking ≥3500 steps/d was associated with 3.75 times the odds (95% CI, 1.56-9.02) of achieving "best outcome" and 2.37 times the odds (95% CI, 1.07-5.24) of not using opioids. CONCLUSIONS: Walking early after surgery may optimize patient-reported outcomes after lumbar spine surgery. A 3500 steps/d threshold may serve as an initial recommendation during early postoperative counseling.

Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels.

BACKGROUND: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables. QUESTIONS/PURPOSES: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians? METHODS: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized ß coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics. RESULTS: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did. CONCLUSION: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases. CLINICAL RELEVANCE: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.

Role of psychosocial factors on the effect of physical activity on physical function in patients after lumbar spine surgery.

BACKGROUND: The purpose of this study was to investigate the longitudinal postoperative relationship between physical activity, psychosocial factors, and physical function in patients undergoing lumbar spine surgery. METHODS: We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition. Physical activity was measured using a triaxial accelerometer (Actigraph GT3X) at 6-weeks (6wk), 6-months (6M), 12-months (12M) and 24-months (24M) following spine surgery. Physical function (computerized adaptive test domain version of Patient-Reported Outcomes Measurement Information System) and psychosocial factors (pain self-efficacy, depression and fear of movement) were assessed at preoperative visit and 6wk, 6M, 12M and 24M after surgery. Structural equation modeling (SEM) techniques were utilized to analyze data, and results are represented as standardized regression weights (SRW). Overall SRW were computed across five imputed datasets to account for missing data. The mediation effect of each psychosocial factor on the effect of physical activity on physical function were computed [(SRW for effect of activity on psychosocial factor X SRW for effect of psychosocial factor on function) ÷ SRW for effect of activity on function]. Each SEM model was tested for model fit by assessing established fit indexes. RESULTS: The overall effect of steps per day on physical function (SRW ranged from 0.08 to 0.19, p<0.05) was stronger compared to the overall effect of physical function on steps per day (SRW ranged from non-existent to 0.14, p<0.01 to 0.3). The effect of steps per day on physical function and function on steps per day remained consistent after accounting for psychosocial factors in each of the mediation models. Depression and fear of movement at 6M mediated 3.4% and 5.4% of the effect of steps per day at 6wk on physical function at 12M, respectively. Pain self-efficacy was not a statistically significant mediator. CONCLUSIONS: The findings of this study suggest that the relationship between physical activity and physical function is stronger than the relationship of function to activity. However, future research is needed to examine whether promoting physical activity during the early postoperative period may result in improvement of long-term physical function. Since depression and fear of movement had a very small mediating effect, additional work is needed to investigate other potential mediating factors such as pain catastrophizing, resilience and exercise self-efficacy.

African American Manhood and self-rated health: What demographic characteristics, health conditions, and aspects of manhood matter?

Few studies have tested what aspects of manhood are associated with health. In this study, we examine how aspects of African American Manhood are related to health. Using cross-sectional data from a criterion sample of 300 African American men 35-73 years old (M = 46.53), we examined how aspects of African American Manhood, demographic characteristics, and health conditions were related to self-rated health. When we controlled for demographics, SES and health conditions, different aspects of manhood were associated with good/excellent health. Across four linear regression models, we found that the Religion and Spirituality factor was the component of African American Manhood most strongly associated with good/excellent self-rated health. The Religion and Spirituality factor was the only aspect of African American Manhood that remained significant when we controlled for SES and health conditions. Neither Reputation, Respectability, nor aspects of role strain remained significantly associated with good/excellent self-rated health when we controlled for SES and health conditions. In analyses examining the relationship between lower odds of good/excellent self-rated health and aspects of ethnic identity, only Afrocentric subscales that highlight behaviors that demonstrate a connection to Africa (e.g., celebrating Kwanzaa) and greater importance of learning about African culture or spiritual beliefs in Africa remained significant. Finally, we found that African American men who reported a body mass index in the normal range, an income level above $50,000, being employed, and having no chronic conditions were more likely to report good/excellent self-rated health than African American men who reported poor/fair health.

Early postoperative physical activity and function: a descriptive case series study of 53 patients after lumbar spine surgery.

BACKGROUND: The purpose of this prospective case series study was to compare changes in early postoperative physical activity and physical function between 6 weeks and 3 and 6 months after lumbar spine surgery. METHODS: Fifty-three patients (mean [95% confidence interval; CI] age = 59.2 [56.2, 62.3] years, 64% female) who underwent spine surgery for a degenerative lumbar condition were assessed at 6 weeks and 3- and 6-months after surgery. The outcomes were objectively-measured physical activity (accelerometry) and patient-reported and objective physical function. Physical activity was assessed using mean steps/day and time spent in moderate to vigorous physical activity (MVPA) over a week. Physical function measures included Oswestry Disability Index (ODI), 12-item Short Form Health Survey (SF-12), Timed Up and Go (TUG), and 10-Meter Walk (10 MW). We compared changes over time in physical activity and function using generalized estimating equations with robust estimator and first-order autoregressive covariance structure. Proportion of patients who engaged in meaningful physical activity (e.g., walked at least 4400 and 6000 steps/day or engaged in at least 150 min/week in MVPA) and achieved clinically meaningful changes in physical function were compared at 3 and 6 months. RESULTS: After surgery, 72% of patients initiated physical therapy (mean [95%CI] sessions =8.5 [6.6, 10.4]) between 6 weeks and 3 months. Compared to 6 weeks post-surgery, no change in steps/day or time in MVPA/week was observed at 3 or 6 months. From 21 to 23% and 9 to 11% of participants walked at least 4400 and 6000 steps/day at 3 and 6 months, respectively, while none of the participants spent at least 150 min/week in MVPA at these same time points. Significant improvements were observed on ODI, SF-12, TUG and 10 MW (p <  0.05), with over 43 to 68% and 62 to 87% achieving clinically meaningful improvements on these measures at 3 and 6 months, respectively. CONCLUSION: Limited improvement was observed in objectively-measured physical activity from 6 weeks to 6 months after spine surgery, despite moderate to large function gains. Early postoperative physical therapy interventions targeting physical activity may be needed.

Prediction of Oswestry Disability Index (ODI) using PROMIS-29 in a national sample of lumbar spine surgery patients.

PURPOSE: The primary purpose was to examine the measurement properties of the PROMIS-29 to better understand its use in patients undergoing spine surgery. A secondary objective was to calculate a predictive equation between PROMIS-29 and ODI, to allow clinicians and researchers to determine a predicted ODI score based on PROMIS short form scores. METHODS: 719 patients with PROMIS v2.0 and ODI responses were queried from the quality outcomes database. Validity was assessed using coefficient omega, ceiling/floor effects, and confirmatory factor analysis. Multivariable regression predicting ODI scores from PROMIS-29 domains was used to create a predictive equation. Predicted ODI scores were plotted against ODI scores to determine how well PROMIS-29 domains predicted ODI. RESULTS: Results showed good reliability and validity of PROMIS-29 in patients undergoing lumbar spine surgery: convergent and discriminant validity, low floor/ceiling effects, and unidimensional domains. The conversion equation used 6 PROMIS-29 domains (ODI% =  37.847- 1.475*[PFraw] + 1.842*[PAINraw] + 0.557*[SDraw] - 0.642*[SRraw] + 0.478*[PIraw] + 0.295*[DEPraw]). Correlation between the predicted and actual ODI scores was R = 0.88, R2 = 0.78, suggesting that the equation predicted ODI scores that are strongly correlated with actual ODI scores. CONCLUSIONS: Good measurement properties support the use of PROMIS-29 in spine surgery patients. Findings suggest accurate ODI scores can be derived from PROMIS-29 domains. Clinicians who want to move from ODI to PROMIS-29 can use this equation to obtain estimated ODI scores when only collecting PROMIS-29. These results support the idea that PROMIS-29 domains have the potential to replace disease-specific traditional PROMs.

Which Is the Best Outcome Measure for Rotator Cuff Tears?

BACKGROUND: The American Shoulder and Elbow Surgeons Standardized Shoulder Form (ASES), the Shoulder Pain and Disability Index (SPADI), and the shortened Disability of the Arm, Shoulder, and Hand (quickDASH) are patient-reported upper extremity-specific outcome scales currently used to evaluate patients with rotator cuff tears. This heterogeneity does not allow for a uniform metric for research and patient care. QUESTIONS/PURPOSES: Our objective was to determine psychometric properties (reliability, convergent and discriminant validity, and responsiveness) of five commonly used outcome instruments (the ASES, the SPADI, the quickDASH, the SF-12, and the EuroQol-5D) in a longitudinal study of patients undergoing treatment for rotator cuff tears. METHODS: From February 2011 through June 2015, 120 patients completed a standardized history, the five outcome scales under study, a physical examination, and an MRI. Of these, 47 (39%) were lost to followup before 18 months, and another 24 (20%) were accounted for at 18 months but had missing data at one or more of the earlier prespecified followup intervals (3, 6, or 12 months). Reliability (the reproducibility of an outcome instrument between subjects; tested by Cronbach's alpha), convergent and discriminant validity (determining which outcome measures correlate most strongly with others; tested by Spearman's correlation coefficients), and responsiveness (the change in outcome scales over time based on percent improvement in shoulder functionality using the minimal clinically important difference [MCID] and the subjective shoulder value) were calculated. RESULTS: All outcomes measures had a Cronbach's alpha above 0.70 (range, 0.74-0.94) and therefore were considered reliable. Convergent validity was demonstrated as the upper extremity-specific measures (SPADI, ASES, and quickDASH) were more strongly correlated with each other (rho = 0.74-0.81; p < 0.001) than with any of the other measures. Discriminant validity was demonstrated because the Spearman's correlation coefficients were stronger for the relationships between upper extremity measures compared with the correlations between upper extremity measures and general health measures for 53 of the 54 correlations that were compared. Both internal and external responsiveness of the measures was supported. Patients who achieved the MCID and at least a 30% change on the subjective shoulder value had more positive change in scores over time compared with those who did not. Mixed model linear regressions revealed that all three upper extremity-specific measures had a group by time interaction for the MCID, indicating that patients who achieved the MCID had greater change over time compared with those who did not achieve the MCID. Results showed that the measure with the best discrimination between groups, or best internal responsiveness, was the ASES (beta = -8.26, 95% confidence interval [CI], -11.39 to -5.14; p < 0.001; η = 0.089) followed by the SPADI (beta = 6.88, 95% CI, 3.78-9.97; p < 0.001; η = 0.088) then the quickDASH (beta = 3.43, 95% CI, 0.86-6.01; p = 0.009, η = 0.027). Measures with the best external responsiveness followed the same pattern of results. CONCLUSIONS: All the upper extremity-specific scales had acceptable psychometric properties. Correlations were high and thus only one upper extremity-specific instrument is needed for outcome assessment. Given the overall psychometric assessment, we recommend SPADI be the shoulder-specific instrument used to assess outcomes in patients with rotator cuff tears. LEVEL OF EVIDENCE: Level III, diagnostic study.

Gastrointestinal Symptoms among African Americans Undergoing Hemodialysis.

The incidence of end stage renal disease is more than three times higher in African Americans. Treatment regimens contribute to gastrointestinal (GI) complaints. This study's purpose was to examine the incidence of GI symptoms in African-American patients undergoing hemodialysis. Younger participants were more likely to report mild indigestion, while older participants reported severe indigestion or none at all. Females were more likely to report gastrointestinal symptoms. Commonly reported co-morbidities included hypertension, diabetes, and heart disease. Time on hemodialysis ranged from 1 to 279 months. Those who had been on hemodialysis the longest were more likely to report acid reflux, stomach rumbling and mild diarrhea. This study provides a foundation for early identification of GI symptoms in African-Americans patients undergoing hemodialysis.

Characteristics and prenatal care utilisation of Romanian pregnant women.

OBJECTIVE: To describe the degree to which Romanian women access free prenatal care services, and to describe the demographic profile of women who are at risk for underutilisation. METHODS: Secondary data (n = 914) were taken from a large, nationally representative sample of Romanian mothers and children (N = 2117). Kotelchuck's Adequacy of Prenatal Care Utilisation Index was used to measure the adequacy of prenatal care. RESULTS: Seventy-eight percent of mothers underutilised prenatal care services. Those who did so to the greatest degree were likely to be young, members of an ethnic minority, poor, uneducated, and rural. Conversely, those who utilised care to the greatest degree were likely to be older, members of the ethnic majority, wealthy, educated, and city dwelling. CONCLUSION: Despite the fact that many of the risk factors for underutilisation in this sample were similar to those found elsewhere in Europe and the developed world, these findings illustrate the worrisome magnitude of the problem in Romania, particularly among women with low levels of income and educational attainment. Future studies should examine factors that contribute to underutilisation, whether it corresponds to negative health outcomes, and whether targeted social interventions and outreach could help improve care.

Caregiving and Obesity among Black American Adults.

Black American adults often report higher rates of obesity and caregiving compared with other racial or ethnic groups. Consequently, many Black American caregivers and care recipients are obese or have obesity-related chronic conditions (e.g., diabetes, hypertension). This study investigated associations between caregiving and obesity among Black Americans, including the role of health behaviors and chronic conditions. The sample included data from 2015 and 2017 Behavioral Risk Factor Surveillance System for non-Hispanic Black (NHB) or African American adult caregivers (n = 2,562) and noncaregivers (n = 7,027). The association between obesity (dependent variable) and caregiving status, fruit consumption, vegetable consumption, physical activity, and number of chronic conditions (independent variables) were evaluated using hierarchical binomial logistic regressions. Caregiving, being female, and chronic conditions were associated with higher odds of obesity, while physical activity was associated with lower odds of obesity. Physical activity, diet, and chronic conditions did not account for differences in obesity among caregiving and noncaregiving Black Americans. Increasing understanding of health behaviors and chronic disease burden of NHB caregivers has implications for programs aiming to improve obesity-related outcomes for caregivers and recipients. Future research should investigate multilevel factors that contribute to observed differences.

Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis.

STUDY DESIGN: Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database. OBJECTIVE: To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery. SUMMARY OF BACKGROUND DATA: Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear. MATERIALS AND METHODS: PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively. RESULTS: On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW. CONCLUSIONS: Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

Combining Wearable Technology and Telehealth Counseling for Rehabilitation After Lumbar Spine Surgery: Feasibility and Acceptability of a Physical Activity Intervention.

OBJECTIVE: The purpose of this study was to examine the feasibility and acceptability of a wearable device and telehealth counseling physical activity intervention early after lumbar spine surgery. METHODS: Sixteen patients were randomized to an 8-session physical activity intervention or to usual postoperative care after surgery. The intervention included a wearable device (ie, Fitbit) and telehealth counseling by a licensed physical therapist. The feasibility of study procedures was assessed through recruitment, randomization, retention, and participation rates. Acceptability was assessed through a satisfaction survey and median within-participant change in objective physical activity (steps per day and time spent in moderate-to-vigorous physical activity [MVPA]) and patient-reported outcomes. RESULTS: Of 64 participants who were eligible, recruitment and randomization rates were 41 and 62%, respectively. Retention for objective physical activity and patient-reported outcomes was 94 and 100%, respectively, at 6-month follow-up. Seven (88%) participants in the intervention group completed all telehealth sessions, and 6 (75%) met step goals over the 8 sessions. All participants in the intervention group found the wearable device and telehealth counseling to be helpful and reported it much or somewhat more important than other postoperative services. Median within-participant change for steps per day improved from baseline (preoperative) to 6 months after surgery for both the intervention (1070) and usual care (679) groups, while MVPA only improved for the intervention group (2.2. minutes per day). Improvements in back and leg pain and disability were noted for both groups. No adverse events were reported in the study. CONCLUSION: Combining wearable technology and telehealth counseling is a feasible approach to promote the physical activity during the early postoperative period after spine surgery. Future randomized controlled trials are needed to investigate the efficacy of leveraging wearables and telehealth during postoperative rehabilitation. IMPACT: This study has implications for the clinical dissemination of physical activity strategies in the rehabilitation setting.

Comparing Patient-Reported Outcomes, Complications, Readmissions, and Revisions in Posterior Lumbar Fusion With, Versus Without, an Interbody Device.

STUDY DESIGN: Retrospective analysis on prospectively collected data. OBJECTIVES: To compare posterior lumbar fusions with versus without an interbody in: (1) Patient-reported outcomes (PROs) at 1 year and (2) postoperative complications, readmission, and reoperations. SUMMARY OF BACKGROUND DATA: Elective lumbar fusion is commonly used to treat various lumbar pathologies. Two common approaches for open posterior lumbar fusion include posterolateral fusion (PLF) alone without an interbody and with an interbody through techniques, like transforaminal lumbar interbody fusion. Whether fusion with or without an interbody leads to better outcomes remains an area of active research. PATIENTS AND METHODS: The Lumbar Module of the Quality Outcomes Database was queried for adults undergoing elective primary posterior lumbar fusion with or without an interbody. Covariates included demographic variables, comorbidities, primary spine diagnosis, operative variables, and baseline PROs, including Oswestry Disability Index, North American Spine Society satisfaction index, numeric rating scale-back/leg pain, and Euroqol 5-dimension. Outcomes included complications, reoperations, readmissions, return to work/activities, and PROs. Propensity score matching and linear regression modeling were used to estimate the average treatment effect on the treated to assess the impact of interbody use on patient outcomes. RESULTS: After propensity matching, there were 1044 patients with interbody and 215 patients undergoing PLF. The average treatment effect on the treated analysis showed that having an interbody or not had no significant impact on any outcome of interest, including 30-day complications and reoperations, 3-month readmissions, 12-month return to work, and 12-month PROs. CONCLUSION: There were no discernible differences in outcomes between patients undergoing PLF alone versus with an interbody in elective posterior lumbar fusion. These results add to the growing body of evidence that posterior lumbar fusions with and without an interbody seem to have similar outcomes up to 1 year postoperatively when treating degenerative lumbar spine conditions.

Impact of unplanned readmissions on lumbar surgery outcomes: a national study of 33,447 patients.

BACKGROUND CONTEXT: Unplanned readmissions following lumbar spine surgery have immense clinical and financial implications. However, little is known regarding the impact of unplanned readmissions on patient-reported outcomes (PROs) following lumbar spine surgery. PURPOSE: To evaluate the impact of unplanned readmissions, including specific readmission reasons, on patient reported outcomes 12 months after lumbar spine surgery. STUDY DESIGN/SETTING: A retrospective cohort study of prospectively collected data was conducted using patients included in the lumbar module of the Quality and Outcomes Database (QOD), a national, multicenter spine registry. PATIENT SAMPLE: A total of 33,447 patients who underwent elective lumbar spine surgery for degenerative diseases were included. Mean age was 59.8 (SD=14.04), 53.6% were male, 89.5% were white, 45.9% were employed, and 47.5% had private insurance. OUTCOME MEASURES: Unplanned 90-day readmissions and 12-month patient-reported outcomes (PROs) including numeric rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI) scores, EuroQol-5 Dimension (EQ-5D) scores, and North American Spine Society (NASS) patient-satisfaction scores. METHODS: The lumbar module of the QOD was queried for adults undergoing elective lumbar spine surgery for degenerative disease. Unplanned 90-day readmissions were classified into 4 groups: medical, surgical, pain-only, and no readmissions. Medical and surgical readmissions were further categorized into primary reason for readmission. 12-month PROs assessing patient back and leg pain (NRS), disability (ODI), quality of life (EQ-5D), and patient satisfaction were collected. Multivariable models predicting 12-month PROs were built controlling for covariates. RESULTS: A total of 31,430 patients (94%) had no unplanned readmission while 2,017 patients (6%) had an unplanned readmission within 90 days following lumbar surgery. Patients with readmissions had significantly worse 12-month PROs compared with those with no unplanned readmissions in covariate-adjusted models. Using Wald-df as a measure of predictor importance, surgical readmissions were associated with the worst 12-month outcomes, followed by pain-only, then medical readmissions. In separate covariate adjusted models, we found that readmissions for pain, SSI/wound dehiscence, and revisions were among the most important predictors of worse outcomes at 12-months. CONCLUSIONS: Unplanned 90-day readmissions were associated with worse pain, disability, quality of life, and greater dissatisfaction at 12-months, with surgical readmissions having the greatest impact, followed by pain-only readmissions, then medical readmissions. Readmissions for pain, SSI/wound dehiscence, and revisions were the most important predictors of worse outcomes. These results may help providers better understand the factors that impact outcomes following lumbar spine surgery and promote improved patient counseling and perioperative management.

Comparing the Upper Instrumented Vertebrae Tilt Angle vs Screw Angle in the Development of Proximal Junction Kyphosis After Adult Spinal Deformity Surgery: Which Matters More?

BACKGROUND: We sought to determine which aspect of the upper instrumented vertebrae (UIV)-tilt angle or screw angle-was more strongly associated with: (1) proximal junctional kyphosis/failure (PJK/F), (2) other mechanical complications and reoperations, and (3) patient-reported outcome measures (PROMs). METHODS: A single-institution, retrospective cohort study was undertaken for patients undergoing adult spinal deformity (ASD) surgery from 2011 to 2017. Only patients with UIV at T7 or below were included. The primary exposure variables were UIV tilt angle (the angle of the UIV inferior endplate and the horizontal) and UIV screw angle (the angle of the UIV screws and superior endplate). Multivariable logistic regression included age, body mass index, osteopenia/osteoporosis, postoperative sagittal vertical axis, postoperative pelvic-incidence lumbar lordosis mismatch, UIV tilt angle, and UIV screw angle. RESULTS: One hundred and seventeen patients underwent adult spinal deformity surgery with a minimum of 2-year follow-up. A total of 41 patients (35.0%) had PJK and 26 (22.2%) had PJF. (1) UIV tilt angle: 96 (82.1%) had lordotic UIV tilt angles, 6 (5.1%) were neutral, and 15 (12.8%) were kyphotic. (2) UIV screw angle: 38 (32.5%) had cranially directed screws, 4 (3.4%) were neutral, and 75 (64.1%) were caudally directed. Both lordotic-angled UIV endplate (OR = 1.06, 95% CI = 1.01-1.12, and P = 0.020) and cranially directed screws (OR = 1.19, 95% CI = 1.07-1.33, and P < 0.001) were associated with higher odds of PJK, with a more pronounced effect of UIV screw angle compared with UIV tilt angle (Wald test, 9.40 vs 4.42). Similar results were found for PJF. Neither parameter was associated with other mechanical complications, reoperations, or patient-reported outcome measures. CONCLUSIONS: UIV screw angle was more strongly associated with development of PJK/F compared with tilt angle. Overall, these modifiable parameters are directly under the surgeon's control and can mitigate the development of PJK/F. CLINICAL RELEVANCE: Surgeons may consider selecting a UIV with a neutral or kyphotically directed UIV tilt angle when performing ASD surgery with a UIV in the lower thoracic or lumbar region, as well as use UIV screw angles that are caudally directed, for the purprose of decreasing the risk of developing PJK/F.