"Legislative Impact and Persistent Disparities: Post-Mastectomy Breast Reconstruction Rates in the United States Among 224,506 Patients".

BACKGROUND: Breast reconstruction following mastectomy for the treatment of breast cancer restores form and enhances patient satisfaction. The Affordable Care Act (ACA) of 2010 aimed to impact trends in breast reconstruction, but recent information regarding racial and ethnic disparities is lacking. METHODS: We analyzed National Surgical Quality Improvement Program (NSQIP) data spanning 2005-2022 to investigate the impact of ACA on racial and ethnic diversity in immediate breast reconstruction post-mastectomy. Patient demographics, including race and ethnicity, were considered. Statistical analyses included Pearson chi-square tests and multivariable logistic regressions to assess trends and disparities over time. RESULTS: In total, 224,506 patients met inclusion criteria. Analysis revealed that in the pre-ACA era, American Indian or Alaska Native, Asian, and Black or African American individuals underwent immediate breast reconstruction at lower rates compared to White patients (P < 0.001). Additionally, Hispanic patients were less likely to undergo breast reconstruction compared to non-Hispanic patients (28.0% vs 33.4%; P < 0.001). In the post-ACA period, this trend persisted with all racial groups undergoing immediate breast reconstruction at lower rates compared to White patients (P < 0.001). However, Hispanic patients were more likely to undergo immediate breast reconstruction compared to non-Hispanic patients (53.8% vs 47.9%, P < 0.001). CONCLUSIONS: Despite legislative efforts and a steady increase in immediate breast reconstruction rates over the years, racial disparities in breast reconstruction rates persist, highlighting the need for ongoing monitoring and targeted interventions to ensure equitable reconstructive care for all patients.

Prevalence of self-reported voice and swallowing complaints in an outpatient geriatric population.

Background: Older adults suffer from increased rates of dysphagia and dysphonia, both of which have a profound effect on quality of life and are often underdiagnosed. We sought to better understand the prevalence of these complaints and the potential utility of a patient-reported screening program in a geriatrics clinic. Methods: Using an IRB-approved cross-sectional survey and retrospective cohort design, we recruited participants from a population of new patients seeking care at an academic geriatrics clinic. We used three validated questionnaires to assess self-reported dysphagia, dysphonia, and pill dysphagia: the Eating-Assessment Tool-10 (EAT-10), the Voice Handicap Index-10 (VHI-10), and the PILL-5. Patients who screened positive on any questionnaire were offered referral to a laryngologist for additional evaluation. Patients who screened positive on the PILL-5 were also offered referral to our geriatric pharmacist. Results: Among our 300 patients surveyed, the mean age was 76 (SD 8.46). A total of 82 (27.3%) patients screened positive (73 on EAT-10, 10 on PILL-5, 13 on VHI-10) and were offered referral, of which 36 accepted. These positive screening patients took more prescription medications (p = .024) and had a higher GDS score (p < .001) when compared to the patients who screened negative. Conclusions: Many new patients seeking generalized care at our center screened positively for dysphagia and/or dysphonia on validated questionnaires. Geriatric patients may benefit from integrating screening for these disorders to identify the need of further evaluation. It is unknown if these survey tools are appropriate in a non-otolaryngology clinic. Level of evidence: III.

A management algorithm for idiopathic intracranial hypertension in skull base meningoencephaloceles.

OBJECTIVE: In this study, the authors assessed an algorithm for the diagnosis and management of idiopathic intracranial hypertension (IIH) in patients who had undergone surgical repair of skull base meningoencephaloceles presenting with spontaneous cerebrospinal fluid (sCSF) leakage. METHODS: The authors conducted an institutional retrospective review of patients surgically treated for skull base sCSF leaks between 2014 and 2021. Opening pressure (OP) measurements were taken intraoperatively. The algorithm recommended a ventriculoperitoneal shunt (VPS) for high-risk patients (OP ≥ 30 cm H2O), 4 weeks of acetazolamide plus a 2-week washout and repeat lumbar puncture (LP) at 6 weeks for intermediate-risk patients (OP = 20-29 cm H2O), and repeat LP at 4-6 weeks for low-risk patients (OP < 20 cm H2O). Demographics, radiographic characteristics, management adherence, and outcomes were analyzed. RESULTS: Eighty patients with sCSF leakage were identified. The mean age was 51.9 years, and the mean body mass index was 36.3 kg/m2. The median follow-up was 8.3 months (IQR 3.3-19.7 months). The overall VPS rate was 15.0%. Three patients (3.8%) experienced acute recurrent leakage, and 3 (3.8%) developed remote recurrent leaks (mean time of 48.1 months). For the 50 patients with both intra- and postoperative OPs, the mean OPs were not significantly different (23.3 vs 23.0 cm H2O, respectively, p = 0.82). The mean variability between the two measurements was an absolute difference of 6.6 cm H2O. While 13 patients (26.0%) moved to a higher-risk category based on postoperative OP, 18 patients (36.0%) moved to a lower-risk category. CONCLUSIONS: Utilizing an algorithm of direct meningoencephalocele repair and selective shunting, acute and remote CSF leak recurrence rates were each 3.8%, and the VPS rate was 15.0%. These data provide further insight into CSF dynamics in this population and argue against the theoretical concern that CSF pressure will increase postrepair. Significant intraindividual variability suggests multiple LPs may be necessary before committing to invasive IIH treatment. Further work is necessary to determine the optimal IIH management strategy.

Preoperative Radiographic Features Independently Predict High Blood Loss During Intracranial Meningioma Resection: A Case-Control Study.

BACKGROUND: Surgical resection of intracranial meningioma carries the risk of several complications, including intraoperative blood loss. The objective of this study was to investigate preoperative clinical and radiographic factors predictive of intraoperative estimated blood loss (EBL). METHODS: This case-control study evaluated EBL for all adults who underwent intracranial meningioma resection from January, 2010 to December, 2021 at our institution. Fifty cases of high EBL (i.e., ≥500 mL) and 75 instances of low EBL (i.e., <500 mL) were randomly selected. Patients were excluded if they had a recurrent meningioma, preoperative embolization, or lack of imaging data. A multivariable logistic regression model of high EBL likelihood was created. RESULTS: A total of 92 patients met eligibility criteria, with 48 (52%) cases of high EBL. Bivariable analyses identified maximal tumor diameter, intratumoral flow voids, skull base location, and dural venous sinus invasion as potential predictors of high EBL. Multivariable regression found intratumoral flow voids (adjusted odds ratio [aOR] = 5.68 [1.52-21.23], P = 0.009), maximal tumor diameter (aOR = 1.58 [1.11-2.25] per 1-cm increase, P = 0.01), and skull base location (aOR = 3.35 [1.19-9.41], P = 0.02) to be independent predictors of high EBL. CONCLUSIONS: Intratumoral flow voids, larger maximal tumor diameter, and skull base location were independently predictive of EBL ≥500 mL. Intratumoral flow void presence was the strongest predictor, with 5.68 times the odds of high EBL. Each 1-cm increase in tumor diameter had 58% greater odds of high EBL. Skull base location was associated with 3.35 times the odds of high EBL. These results can inform preoperative patient counseling and blood management preparation.

Virtual Compared With In-Office Postoperative Visits After Urogynecologic Surgery: A Randomized Controlled Trial.

OBJECTIVE: To compare patient satisfaction, health care resource utilization, and adverse events among patients receiving a virtual video compared with in-office postoperative visit after urogynecologic surgery. We hypothesized that virtual video visits would be noninferior to in-office visits. METHODS: This was a randomized noninferiority clinical trial of patients undergoing surgery for pelvic organ prolapse and urinary incontinence at a single academic tertiary referral center. Participants were randomized to receive either a virtual video postoperative visit or a standard in-office postoperative visit. The primary outcome was patient satisfaction measured by the validated PSQ-18 (Patient Satisfaction Questionnaire-18) (noninferiority margin 5 points) at the 6-week postoperative visit. Secondary outcomes included PSQ-18 domain scores (noninferiority margin 0.5 points) and composite health care resource utilization and adverse events after the 6-week postoperative visit up to 12 weeks after surgery (noninferiority margin 10%). A sample size of 100 participants (50 per group) would allow 80% power to assess a 5-point noninferiority margin on the total PSQ-18 with an SD of 10 and α=0.05. RESULTS: From January 2023 to September 2023, 265 patients were screened for eligibility, and 104 were randomized. A total of 100 participants (50 per arm) completed the study and were included in the analysis. The mean±SD age of all participants was 57.0±13.2 years. The mean±SD PSQ-18 total score was 75.18±8.15 in the virtual group and 75.14±8.7 in the in-office group. The mean PSQ-18 total score was 0.04 points higher (ie, greater degree of satisfaction) in the virtual group, with a 95% CI of -2.75 to 2.83, which met the criterion for noninferiority. Between-group differences for all PSQ-18 domain scores likewise met criterion for noninferiority. Composite health care resource utilization was 14.0% lower in the virtual group than in the in-office group (20.0% vs 34.0%, 95% CI, -28.0% to 1.0%). For composite adverse events, the between-group difference was 2.0% (2.0% in virtual group vs 0.0% in in-office group, 95% CI,-3.0% to 8.0%). CONCLUSION: Virtual video postoperative visits were noninferior to in-office visits with regard to patient satisfaction, health care resource utilization, and adverse events and can be offered as an alternative to in-office visits for postoperative follow-up after urogynecologic surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT05641077.

Factors associated with initiation of pharmacological therapy and treatment changes in postural orthostatic tachycardia syndrome.

Purpose: Postural Orthostatic Tachycardia Syndrome (POTS) is a heterogenous disorder of the autonomic nervous system that is often disabling. There are no FDA-approved therapies for the treatment of this condition. While some patients recover with baseline non-pharmacological intervention, others require repeated trials of off-label pharmacological therapies. The reasoning for this variable treatment response is unknown. The purpose of this work is to identify potential factors that are associated with higher odds of starting pharmacotherapy and/or a higher rate of POTS treatment changes. Methods: Chart review of demographic, disease and treatment descriptions, medical history, and tilt table examinations of 322 POTS patients who were diagnosed between 2018 and 2020 at our tertiary care center was completed. We first identified the most significant factors associated with an increased odds of starting pharmacotherapy using variable selection techniques and logistic regression. We then identified the most significant factors associated with changes in POTS treatment strategies using variable selection techniques and negative binomial regression modeling. A significance level of 0.05 was utilized. Results: A total of 752 POTS-specific treatment courses were cataloged, and 429 treatment changes were observed. The most cited reason for a change in management was uncontrolled symptoms. History of migraine headaches, reported fatigue, reported palpitations and a previous POTS diagnosis at an outside institution were found to be associated with a higher odds of starting pharmacotherapy for POTS symptoms (Odds Ratio of 2.40, 1.94, 2.62, 2.08, respectively). History of migraine headaches, reported fatigue, and higher heart rate differences on tilt table examination were found to be associated with an increase in the rate of POTS treatment changes (44, 66, 13% increase in incidence rate, respectively), while reported neck pain was associated with a decrease (27% decrease in incidence rate). Conclusion: Our work identifies important areas of focus in the development of high-quality trials involving both the non-pharmacological and pharmacological treatment of POTS and highlights several characteristics of patients that may be more refractory to both baseline non-pharmacological treatments and current pharmacological treatment strategies.

Demographics, Presenting Features, and Outcomes of Adult Patients with Ocular Trauma.

Introduction: Ocular trauma is a common cause of permanent vision loss in adults. The combination of an accurate clinical examination and imaging offers the best prognostic indicators for patients and helps to navigate treatment modalities. This is a retrospective chart review of examination and imaging findings for ocular trauma and how they correlate with treatment course and visual acuity (VA) outcomes. Methods: Adult patients with ocular trauma presenting to a single institution between January 2013 and December 2020 were evaluated. Initial examination and imaging findings were compared for associations with each other and with VA outcomes. Results: 136 ocular traumas on 134 patients were included. The median presenting logMAR VA was 2.7 (interquartile range (IQR) 1.2-3.7) with 62% open globe injuries. The most commonly reported finding on initial CT scan was globe deformity (30%), on B-scan was choroidal detachment (20%), and on ultrasound biomicroscopy was intraocular foreign body, ciliochoroidal effusions, or angle recession (21% each). Worse vision was observed for patients positive for retinal detachment on initial B-scan compared to those negative for this finding at 6-month (median logMAR 2.7 vs. 0.5; P < 0.0001) and at final post-injury evaluation (median logMAR 3.7 vs. 0.4; P < 0.0001). Similarly, worse VA was observed for patients with choroidal detachment on initial B-scan compared to those without this finding at 6-month (median logMAR 1.4 vs. 0.5; P = 0.002) and at final post-injury evaluation (median logMAR 2.0 vs. 0.4; P < 0.0001). If positive conjunctiva/sclera examination findings were identified, 66% had positive findings on B-scan, whereas if the conjunctiva/sclera examination findings were absent, 41% had positive findings on B-scan (P = 0.005). If anterior chamber (AC) examination findings were positive, 59% had positive findings on B-scan, whereas if the AC examination findings were absent, 37% had positive findings on B-scan (P = 0.03). Discussion. The predictive value of examination findings in this study may offer insight as to long-term visual prognosis. Positive B-scan or CT findings should increase suspicion for open globe injuries.

Academic Productivity of Applicant and Program as Predictors of a Future Academic Career in Neurosurgery.

BACKGROUND AND OBJECTIVES: Academic productivity is viewed as a critical objective factor for a neurosurgery residency applicant. There has been a consistent rise in academic productivity over the last decade, but a lack of consistent data on the utility of this in helping neurosurgery residency programs identify which applicants will enter academic neurosurgery. This cross-sectional study evaluates the predictiveness of academic productivity before and during residency on career choice, both independent and dependent of training environment. METHODS: The 116 accredited neurosurgery residency programs were split into 4 quartile groups based on their 2022 Doximity rankings. Six neurosurgery residency programs were randomly selected from each quartile. Publicly available information including number and type (before or during residency) of publication and type of employment (academic vs nonacademic) was collected on neurosurgeons who matriculated into residency in the year 2000 or later. Multivariable logistic regression was used to explore the associations among neurosurgeon and program characteristics, and an academic career. RESULTS: A total of 557 neurosurgeons were identified. Group 1 (n = 194) had the highest median publications during residency total (12) and first author (5), as well as the highest percentage of neurosurgeons who attended a top 20 medical school (38.7%), hold a higher educational degree (20.6%), and pursued an academic career (72.2%). Neither attending a top 20 medical school, holding a higher educational degree, nor publications were significant multivariable predictors of an academic career. Being in group 1 was the only significant predictor of entering an academic career across analyses. CONCLUSION: Only residency group ranking, not academic productivity, predicted a future academic career. For residency programs evaluating applicants as future academic neurosurgeons, this suggests that program environment is more predictive than traditionally valued characteristics such as research productivity. Additional work is needed to elucidate characteristics or practices by which future academic neurosurgeons can be identified.

Parenchymal obliteration by renal masses: Functional and oncologic implications.

OBJECTIVES: Most renal tumors merely displace nephrons while others can obliterate parenchyma in an invasive manner. Substantial parenchymal volume replacement (PVR) by renal cell carcinoma (RCC) may have oncologic implications; however, studies regarding PVR remain limited. Our objective was to evaluate the oncologic implications associated with PVR using improved methodology including more accurate and objective tools. PATIENTS/METHODS: A total of 1,222 patients with non-metastatic renal tumors managed with partial nephrectomy (PN) or radical nephrectomy (RN) at Cleveland Clinic (2011-2014) with necessary studies were retrospectively evaluated. Parenchymal volume analysis via semiautomated software was used to estimate split renal function and preoperative parenchymal volumes. Using the contralateral kidney as a control, %PVR was defined: (parenchymal volumecontralateral-parenchymal volumeipsilateral) normalized by parenchymal volumecontralateral x100%. PVR was determined preoperatively and not altered by management. Patients were grouped by degree of PVR: minimal (<5%, N = 566), modest (5%-25%, N = 414), and prominent (≥25%, N = 142). Kaplan-Meier was used to evaluate survival outcomes relative to degree of PVR. Multivariable Cox-regression models evaluated predictors of recurrence-free survival (RFS). RESULTS: Of 1,122 patients, 801 (71%) were selected for PN and 321 (29%) for RN. Overall, median tumor size was 3.1 cm and 6.8 cm for PN and RN, respectively, and median follow-up was 8.6 years. Median %PVR was 15% (IQR = 6%-29%) for patients selected for RN and negligible for those selected for PN. %PVR correlated inversely with preoperative ipsilateral GFR (r = -0.49, P < 0.01) and directly with advanced pathologic stage, high tumor grade, clear cell histology, and sarcomatoid features (all P < 0.01). PVR≥25% associated with shortened recurrence-free, cancer-specific, and overall survival (all P < 0.01). Male sex, ≥pT3a, tumor grade 4, positive surgical margins, and PVR≥25% independently associated with reduced RFS (all P < 0.02). CONCLUSIONS: Obliteration of normal parenchyma by RCC substantially impacts preoperative renal function and patient selection. Our data suggests that increased PVR is primarily driven by aggressive tumor characteristics and independently associates with reduced RFS, although further studies will be needed to substantiate our findings.

Effectiveness of the 2023-2024 Formulation of the COVID-19 Messenger RNA Vaccine.

BACKGROUND: The purpose of this study was to evaluate whether the 2023-2024 formulation of the coronavirus disease 2019 (COVID-19) messenger RNA vaccine protects against COVID-19. METHODS: Cleveland Clinic employees when the 2023-2024 formulation of the COVID-19 messenger RNA vaccine became available to employees were included. Cumulative incidence of COVID-19 over the following 17 weeks was examined prospectively. Protection provided by vaccination (analyzed as a time-dependent covariate) was evaluated using Cox proportional hazards regression, with time-dependent coefficients used to separate effects before and after the JN.1 lineage became dominant. The analysis was adjusted for the propensity to get tested, age, sex, pandemic phase when the last prior COVID-19 episode occurred, and the number of prior vaccine doses. RESULTS: Among 48 210 employees, COVID-19 occurred in 2462 (5.1%) during the 17 weeks of observation. In multivariable analysis, the 2023-2024 formula vaccinated state was associated with a significantly lower risk of COVID-19 before the JN.1 lineage became dominant (hazard ratio = .58; 95% confidence interval [CI] = .49-.68; P < .001), and lower risk but one that did not reach statistical significance after (hazard ratio = .81; 95% CI = .65-1.01; P = .06). Estimated vaccine effectiveness was 42% (95% CI = 32-51) before the JN.1 lineage became dominant, and 19% (95% CI = -1-35) after. Risk of COVID-19 was lower among those previously infected with an XBB or more recent lineage and increased with the number of vaccine doses previously received. CONCLUSIONS: The 2023-2024 formula COVID-19 vaccine given to working-aged adults afforded modest protection overall against COVID-19 before the JN.1 lineage became dominant, and less protection after.

Propensity-Matched Analysis of the Risk of Age-Related Macular Degeneration with Systemic Immune-Mediated Inflammatory Disease.

PURPOSE: The pathogenesis of age-related macular degeneration (AMD) involves aberrant complement activation and is a leading cause of vision loss worldwide. Complement aberrations are also implicated in many systemic immune-mediated inflammatory diseases (IMIDs), but the relationship between AMD and these conditions remains undescribed. The aim of this study is to first assess the association between AMD and IMIDs, and then assess the risk of AMD in patients with specific IMIDs associated with AMD. DESIGN: Cross-sectional study and cohort study. SUBJECTS AND CONTROLS: Patients with AMD were compared with control patients with cataracts and no AMD to ensure evaluation by an ophthalmologist. Patients with IMIDs were compared with patients without IMIDs but with cataracts. METHODS: This study used deidentified data from a national database (2006-2023), using International Classification of Diseases 10 codes to select for IMIDs. Propensity score matching was based on patients on age, sex, race, ethnicity, and smoking. Odds ratios were generated for IMIDs and compared between AMD and control patients. For IMIDs associated with AMD, the risk of AMD in patients with the IMID versus patients without IMIDs was determined utilizing a cohort study design. MAIN OUTCOME MEASURES: Odds ratio of IMID, risk ratios (RRs), and 95% confidence intervals (CIs) of AMD diagnosis, given an IMID. RESULTS: After propensity score matching, AMD and control cohorts (n = 217 197 each) had a mean ± standard deviation age of 74.7 ± 10.4 years, were 56% female, and 9% of patients smoked. Age-related macular degeneration showed associations with systemic lupus erythematosus (SLE), Crohn's disease, ulcerative colitis, rheumatoid arthritis (RA), psoriasis, sarcoidosis, scleroderma, giant cell arteritis, and vasculitis. Cohorts for each positively associated IMID were created and matched to control cohorts with no IMID history. Patients with RA (RR, 1.40; 95% CI, 1.30-1.49), SLE (RR, 1.73; 95% CI, 1.37-2.18), Crohn's disease (RR, 1.42; 95% CI, 1.20-1.71), ulcerative colitis (RR, 1.45; 95% CI, 1.29-1.63), psoriasis (RR, 1.48; 95% CI, 1.37-1.60), vasculitis (RR, 1.48; 95% CI, 1.33-1.64), scleroderma (RR, 1.65; 95% CI, 1.35-2.02), and sarcoidosis (RR, 1.42; 95% CI, 1.24-1.62) showed a higher risk of developing AMD compared with controls. CONCLUSIONS: The results suggest that there is an increased risk of developing AMD in patients with RA, SLE, Crohn's disease, ulcerative colitis, psoriasis, vasculitis, scleroderma, and sarcoidosis compared with patients with no IMIDs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinical and immunological outcomes of HIV-exposed uninfected and HIV-unexposed uninfected children in the first 24 months of life in Western Kenya.

BACKGROUND: Previous studies show increased morbidity in children who are HIV-exposed but uninfected (HEU) compared to children who are HIV-unexposed uninfected (HUU). We sought to evaluate the effects of prenatal HIV exposure on clinical and immunological outcomes in the first 24 months of life. METHODS: Eighty-five HEU and 168 HUU children from Kenya were followed from birth to 24 months. All mothers living with HIV received combination antiretroviral therapy. Children who were HEU received standard-of-care cotrimoxazole prophylaxis through 18 months. Episodes of acute illness were identified through a combination of active and passive follow up. Trajectories of plasma cytokines, vaccine-specific antibodies, and antimalarial antibodies were examined. RESULTS: Children who were HEU and children who were HUU had similar growth curves. Children who were HEU had lower rates of malaria (rate ratio 0.54, 95% CI 0.38, 0.77) and respiratory illness (rate ratio 0.80, 95% CI 0.68, 0.93). Trajectories of plasma cytokines and vaccine-specific antibodies were similar in children who were HEU and HUU. There were subtle differences in antimalarial antibody dynamics, in which children who were HEU had overall lower antibody levels against five of the 14 malaria antigens tested. CONCLUSIONS: Children who were HEU and born to optimally treated mothers living with HIV had similar growth characteristics and immune profiles compared to children who were HUU. Children who were HEU had reduced risk for malaria and respiratory illness, which may be secondary to cotrimoxazole prophylaxis.

Comorbid anxiety is associated with more changes in the Management of Postural Orthostatic Tachycardia Syndrome.

OBJECTIVE: Postural Orthostatic Tachycardia Syndrome (POTS) is not an anxiety disorder, but it shares similar symptomatology. The impact of this comorbidity on management is unknown. This information may lead to better strategies to improve the care of this subgroup. METHOD: The electronic medical records of 322 patients seen at our institution between 2018 and 2022 with confirmed POTS diagnoses were analyzed. Demographics, anxiety comorbidities, questionnaire responses, and treatment course changes were collected. Negative binomial regression models examined if the presence of an anxiety disorder was associated with the number of POTS treatment course changes offset by observation time. RESULTS: When adjusted for sex, age, baseline GAD-7 score, and baseline PROMIS global mental health score, those with a diagnosis of an anxiety disorder had2.6 times the incident rate of treatment changes for POTS management (IRR = 2.66 (95% CI: 1.43-4.95)). CONCLUSION: Individuals carrying the diagnosis of an anxiety disorder had an increase in the incident rate of treatment changes for POTS therapy. This finding may be due to the underlying pathophysiology and treatment of anxiety disorders, the effect of bias, and difficulty with symptom differentiation. More work needs to be done to determine how to best care for POTS patients with comorbid anxiety.

Ergonomics, musculoskeletal disorders, and surgeon gender in spine surgery: a survey of practicing spine surgeons.

OBJECTIVE: The objective of this study was to gain a greater understanding of the burden of musculoskeletal disorders (MSDs) in spine surgeons, their impact on practice, and risk factors contributing to MSDs, including surgical instrument design and surgical ergonomics. METHODS: An anonymous REDCap survey was distributed via email to the departments of several academic and private centers across the United States, as well as to the AANS/CNS Women in Neurosurgery Section email list. Chi-square tests and Wilcoxon rank-sum tests were used to compare responses by gender. Multivariable linear regression analysis was performed to identify predictors of discomfort in instrument utilization. RESULTS: Survey responses were received from 120 spine surgeons (29.1% response rate), of which 73 were included in the analysis. A very high number of respondents had experienced an MSD (70.4%), 38.2% had undergone treatment for at least one MSD, and 13.4% had lost time at work for at least one MSD. Women were more likely than men to have lost time at work due to an MSD (22.6% vs 5.6%, p = 0.04). Women were more likely than men to report difficulty in instrument grip, comfort, and use on a 20-point Likert scale (mean 10.7 vs 15.2 points, p < 0.0001). This effect persisted when adjusting for glove size and days per week spent operating (p = 0.002). Specifically, women were less likely to agree that the handles of surgical instruments were an appropriate grip (p < 0.0001), that they rarely experienced difficulty when using them (p < 0.0001), and that they rarely needed to use two hands with instruments meant to be used with one hand (p = 0.0002). CONCLUSIONS: The MSD burden in spine surgeons is substantial. While there was no evidence of gender differences in MSD rates and severity, female surgeons report significantly more discomfort with the use of surgical instruments. There is a need for more investigation of MSD risk factors in spine surgeons and mitigation strategies. Gender differences in comfort in instrument use should be further explored and addressed by spine surgeons and device manufacturers.

Painless photodynamic therapy for facial actinic keratoses: A retrospective cohort study of the post-treatment inflammatory response.

INTRODUCTION: Photodynamic therapy (PDT) is a safe, non-mutagenic, and non-scarring treatment for actinic keratoses (AK). BACKGROUND: 'Painless' photodynamic therapy (p-PDT) is a regimen for AK that employs simultaneous aminolevulinate incubation and blue light illumination. The efficacy of p-PDT resembles that of traditional PDT, but detailed mechanisms of action for p-PDT are not well understood. METHODS: To characterize the inflammatory effects of the p-PDT procedure 48 h following treatment and determine the association of inflammation with precancer burden, we performed a retrospective cohort study of 104 patients with AK of face or scalp treated with p-PDT between 2017 and 2019. Patients self-reported their side effects 48 h following p-PDT and took photographs of their face and scalp. Photographs were edited to define seven anatomic regions, and erythema was scored by four investigators. RESULTS: Ninety-eight patients provided photographs suitable for erythema evaluation. Most patients experienced 2 or more side effects and some pain 48 h post-procedure. Females experienced more pain (p = 0.01) and side effects (p = 0.002) compared to males. AK burden was positively associated with post p-PDT erythema response (p < 0.0001) at all sites, but particularly in the temples (p = 0.002) and supralabial area (p = 0.009). DISCUSSION: This study confirms a strong clinical inflammatory response after p-PDT. Severity of inflammation is positively associated with AK tumor burden, suggesting that post-treatment inflammation may be a pre-requisite for p-PDT efficacy. Interestingly, the results also identify certain gender-related differences in the severity of side effects experienced by patients post-PDT.

Clinical Utility of Spectral-Domain Optical Coherence Tomography Marker Disorganization of Retinal Inner Layers in Diabetic Retinopathy.

BACKGROUND AND OBJECTIVE: Disorganization of retinal inner layers (DRIL) is a potential spectral-domain optical coherence tomography (SD-OCT) imaging biomarker with clinical utility in diabetic retinopathy (DR). PATIENTS AND METHODS: A cross-sectional study was conducted at a large academic center. The cohort was composed of 1,175 patients with type 2 diabetes with and without retinopathy on initial examination between September 2009 and January 2019 (n = 2,083 eyes). DR risk and progression factors were obtained from the medical record. Trained graders masked to patients' clinical histories evaluated SD-OCT scans for DRIL. RESULTS: Of 2,083 eyes, 28.1% (n = 585) demonstrated presence of DRIL with high interrater reliability (K = 0.88, 95% CI 0.86-0.90). DRIL was associated with worse visual acuity (VA) (P < 0.001) and DR severity (P < 0.0001). Insulin users had more severe DR (P < 0.0001). DR-related factors, race (Black, White) and sex (male) were significantly associated with DRIL (P < 0.05). CONCLUSIONS: DRIL was strongly associated with DR severity and worse VA, supporting its utility as an unfavorable prognostic indicator. [Ophthalmic Surg Lasers Imaging Retina 2023;54:692-700.].

Derivation and external validation of a prediction model for pneumococcal urinary antigen test positivity in patients with community-acquired pneumonia.

Objective: Derive and externally validate a prediction model for pneumococcal urinary antigen test (pUAT) positivity. Methods: Retrospective cohort study of adults admitted with community-acquired pneumonia (CAP) to 177 U.S. hospitals in the Premier Database (derivation and internal validation samples) or 12 Cleveland Clinic hospitals (external validation sample). We utilized multivariable logistic regression to predict pUAT positivity in the derivation dataset, followed by model performance evaluation in both validation datasets. Potential predictors included demographics, comorbidities, clinical findings, and markers of disease severity. Results: Of 198,130 Premier patients admitted with CAP, 27,970 (14.1%) underwent pUAT; 1962 (7.0%) tested positive. The strongest predictors of pUAT positivity were history of pneumococcal infection in the previous year (OR 6.99, 95% CI 4.27-11.46), severe CAP on admission (OR 1.76, 95% CI 1.56-1.98), substance abuse (OR 1.57, 95% CI 1.27-1.93), smoking (OR 1.23, 95% CI 1.09-1.39), and hyponatremia (OR 1.35, 95% CI 1.17-1.55). Negative predictors included IV antibiotic use in past year (OR 0.65, 95% CI 0.52-0.82), congestive heart failure (OR 0.72, 95% CI 0.63-0.83), obesity (OR 0.71, 95% CI 0.60-0.85), and admission from skilled nursing facility (OR 0.60, 95% CI 0.45-0.78). Model c-statistics were 0.60 and 0.67 in the internal and external validation cohorts, respectively. Compared to guideline-recommended testing of severe CAP patients, our model would have detected 23% more cases with 5% fewer tests. Conclusion: Readily available data can identify patients most likely to have a positive pUAT. Our model could be incorporated into automated clinical decision support to improve test efficiency and antimicrobial stewardship.

Essential team science skills for biostatisticians on collaborative research teams.

Introduction: Despite the critical role that quantitative scientists play in biomedical research, graduate programs in quantitative fields often focus on technical and methodological skills, not on collaborative and leadership skills. In this study, we evaluate the importance of team science skills among collaborative biostatisticians for the purpose of identifying training opportunities to build a skilled workforce of quantitative team scientists. Methods: Our workgroup described 16 essential skills for collaborative biostatisticians. Collaborative biostatisticians were surveyed to assess the relative importance of these skills in their current work. The importance of each skill is summarized overall and compared across career stages, highest degrees earned, and job sectors. Results: Survey respondents were 343 collaborative biostatisticians spanning career stages (early: 24.2%, mid: 33.8%, late: 42.0%) and job sectors (academia: 69.4%, industry: 22.2%, government: 4.4%, self-employed: 4.1%). All 16 skills were rated as at least somewhat important by > 89.0% of respondents. Significant heterogeneity in importance by career stage and by highest degree earned was identified for several skills. Two skills ("regulatory requirements" and "databases, data sources, and data collection tools") were more likely to be rated as absolutely essential by those working in industry (36.5%, 65.8%, respectively) than by those in academia (19.6%, 51.3%, respectively). Three additional skills were identified as important by survey respondents, for a total of 19 collaborative skills. Conclusions: We identified 19 team science skills that are important to the work of collaborative biostatisticians, laying the groundwork for enhancing graduate programs and establishing effective on-the-job training initiatives to meet workforce needs.

Outcomes of a Multicenter 10-Year Review of Postinjection Endophthalmitis and Associated Systemic Medical Comorbidities.

Purpose: To investigate whether any systemic medical conditions may be associated with a higher risk for developing postinjection endophthalmitis. Methods: This case-control study is a retrospective review within the Emory Eye Center from 2009 to 2019 and The Cleveland Clinic Foundation from 2012 to 2019. Each case was matched in a 1:4 case-to-control ratio. The associations between medical comorbidities and endophthalmitis were explored using multivariable logistic regression models on the combined sample. Results: Sixty-six individuals were diagnosed with injection-associated endophthalmitis. Systemic immunocompromised status was found to be a risk factor associated with developing endophthalmitis with an adjusted odds ratio (aOR) of 3.17 (P = .009). Other conditions with increased risk approaching statistical significance included a history of pulmonary disease (aOR, 1.74; P = .08) and a history of smoking (aOR, 1.72; P = .06). Conclusions: This is the first report to our knowledge demonstrating that immunocompromised status is associated with an increased risk for developing postinjection endophthalmitis. While this study may be limited due to its retrospective nature, the result may nevertheless serve as a guidance for risk counseling. Future analysis using a large-scale database will be needed.