Utilization and timing of surgical intervention for central cord syndrome in the United States.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: CCS is the most common type of incomplete spinal cord injury and can occur without or with bony injury. Surgical intervention and its timing for patients diagnosed with CCS has been controversial. The current study assessed utilization of and factors associated with operative intervention and its timing in patients diagnosed with central cord syndrome (CCS) in the absence of bony injury. METHODS: Adult patients diagnosed with CCS in the absence of vertebral fracture were queried from the national, multi-insurance, administrative 2015-2020 M151 PearlDiver database. The incidence, trends, and timing of operative intervention following CCS were assessed. Patient characteristics associated with surgical intervention and its timing were determined. RESULTS: From 2015 to 2020, 11,653 patients meeting inclusion criteria were identified, of which surgical intervention was identified for 2,003 (17.2%) and thus nonsurgical intervention for 9,650 (82.8%). The proportion of patients undergoing operative intervention evolved from 11.5% in 2015 to 19.7% in 2020 (p < 0.0001). Of those undergoing surgical intervention, the greatest increase was seen for those undergoing surgery within two days of diagnosis (5.5% in 2015 to 12.3% in 2020, p < 0.0001). On multivariable analysis, more recent year of service, region of service, younger age, and higher comorbidity burden were independent predictors of operative management (p < 0.05 for all). CONCLUSION: The majority of a large cohort of patients with first diagnosis CCS in the absence of bony injury were managed non-operatively. Operative management increased over the years of study, were performed earlier after diagnosis, and varied based on patient characteristic and geographic region.

Population immunity to varicella in Canada: A Canadian Immunization Research Network (CIRN) study.

INTRODUCTION: The incidence of varicella in Canada has decreased by almost 99% since vaccination was introduced. However, variation in the timing and eligibility of vaccination programs across the country has resulted in some cohorts being under-vaccinated and therefore potentially susceptible to infection. METHODS: We used nationally representative specimens from the Biobank of Statistics Canada's Canadian Health Measures Survey (CHMS) as well as residual specimens from Ontario collected between 2009-2014 to estimate population immunity across age-groups and geography, and identify any groups at increased risk of varicella infection. RESULTS: The weighted proportion of specimens with antibody levels above the threshold of protection was 93.6% (95% CI: 92.4, 95.0). Protection was lowest among those aged 3-5 years (54.3%; 95% CI: 47.3, 61.4), but increased with age. Individuals born outside Canada had more than twice the odds of varicella susceptibility than those born in Canada (aOR: 2.7; 95% CI: 1.4, 5.0; p = 0.004). There were no differences by sex or geography within Canada, and there were no statistically significant differences when Ontario CHMS sera were compared to Ontario residual sera, apart from in participants aged 12-19 year age-group, for whom the CHMS estimate (91.2%; 95% CI: 86.7, 95.7) was significantly higher (p = 0.03) than that from residual specimens (85.9%, 95% CI: 81.1, 90.8). DISCUSSION: Varicella immunity in Canada is changing. Children appear to have low population immunity, placing them at greater risk of infection and at increased risk of severe disease as they age. Our results underscore the importance of performing periodic serosurveys to monitor further population immunity changes as the proportion of vaccine-eligible birth-cohorts increases, and to continually assess the risk of outbreaks.

Operationalizing the Behaviour Change Wheel and APEASE criteria to co-develop recommendations with stakeholders to address barriers to school-based immunization programs.

INTRODUCTION: School-based immunization programs offer an accessible route to routine vaccines for students. During the COVID-19 pandemic, school closures to comply with public health measures had a drastic effect on school-based immunization program delivery and associated vaccine uptake. We sought to integrate findings from a mixed methods study to co-develop evidence-based and theory-informed recommendations with a diverse group of stakeholders (i.e., decision makers, healthcare providers, school staff, parents and adolescent students) to address barriers to new and existing school-based immunization programs. METHODS: Findings from a mixed methods study were integrated using a joint display and narrative summary. These findings were mapped through the Behaviour Change Wheel, a series of tools designed to facilitate the development of behaviour change interventions. Draft recommendations were provided to previous mixed methods study participants who consented to participating in future phases of the research study (n = 26). Feedback was captured using a Likert-scale survey of acceptability, practicality, effectiveness, affordability, safety and equity (APEASE) criteria, with feedback and additional insights captured using open-ended textboxes. Data was used to revise and finalize recommendations. RESULTS: Applying the Behaviour Change Wheel, we drafted 26 evidence-based, theory-informed recommendations to address barriers to school-based immunization programs. Participants (n = 16) provided feedback, with half of the recommendations scoring 80% or higher across all six APEASE criteria. The remaining 13 recommendations received a moderate score across one or more criteria. Stakeholders identified a high level of interest in expanding the use of e-consent forms, expanding programming to offer a meningitis B vaccine, and recommendations to ease student anxiety. CONCLUSION: We co-developed a range of recommendations to improve school-based immunization programs with stakeholders using data generated from a mixed methods study. Implementation of any single or combination of recommendations will need to be tailored to local clinic procedures, school system and health system resources.

Well-being approaches targeted to improve child and youth health post-COVID-19 pandemic: a scoping review.

BACKGROUND: Our previous work synthesized published studies on well-being interventions during COVID-19. As we move into a post-COVID-19 pandemic period there is a need to comprehensively review published strategies, approaches, and interventions to improve child and youth well-being beyond deleterious impacts experienced during COVID-19. METHODS: Seven databases were searched from inception to January 2023. Studies were included if they: (1) presented original data on an approach (i.e., approach applied) or (2) provided recommendations to inform development of a future approach (i.e., approach suggested), (3) targeted to mitigate negative impacts of COVID-19 on child and youth (≤18 year) well-being, and (4) published on or after December 2019. RESULTS: 39 studies (n = 4/39, 10.3% randomized controlled trials) from 2021 to 2023 were included. Twenty-two studies applied an approach (n = 22/39, 56.4%) whereas seventeen studies (n = 17/39, 43.6%) suggested an approach; youth aged 13-18 year (n = 27/39, 69.2%) were most frequently studied. Approach applied records most frequently adopted an experimental design (n = 11/22, 50.0%), whereas approach suggested records most frequently adopted a cross-sectional design (n = 13/22, 59.1%). The most frequently reported outcomes related to good health and optimum nutrition (n = 28/39, 71.8%), followed by connectedness (n = 22/39, 56.4%), learning, competence, education, skills, and employability (n = 18/39, 46.1%), and agency and resilience (n = 16/39, 41.0%). CONCLUSIONS: The rapid onset and unpredictability of COVID-19 precluded meaningful engagement of children and youth in strategy development despite widespread recognition that early engagement can enhance usefulness and acceptability of interventions. Published or recommended strategies were most frequently targeted to improve connectedness, belonging, and socialization among children and youth.

Ankle fracture open reduction and internal fixation in patients with cerebral palsy.

AIM: To examine patients with cerebral palsy (CP) undergoing open reduction and internal fixation (ORIF) for ankle fractures. METHOD: This was a retrospective study of adult patients undergoing ankle fracture ORIF for closed, isolated ankle fractures identified in between 2010 and 2021 in the Q1 PearlDiver M151 database. Patients with CP were identified with International Classification of Diseases (ICD)-9 and ICD-10 codes, and were matched to those without 1:10 on age, sex, and Elixhauser comorbidity index (ECI). Ninety-day adverse events were assessed with multivariable logistic regression. RESULTS: A total of 148 993 patients with isolated ankle fracture ORIF were identified, of whom 407 (0.27%) had CP. After matching, 3863 without CP were compared to 389 with CP. Patients with CP were at increased odds of: 90-day urinary tract infection (odds ratios [OR] 6.26), pneumonia (OR 3.50), minor adverse events (OR 3.46), sepsis (OR 3.30), any adverse events (OR 3.04), emergency department visits (OR 2.28), serious adverse events (OR 1.77), and prolonged length of stay more than 4 days (OR 22.44) (p < 0.001 for all). INTERPRETATION: Patients with CP undergoing ORIF for isolated, closed ankle fractures are at increased odds of several 90-day adverse events and prolonged length of stay compared to matched patients without CP.

Stakeholders' experiences with school-based immunization programs during the COVID-19 pandemic in the Canadian Maritimes: A qualitative study.

Background: School-based immunization programs (SBIP) support access to routine vaccines for adolescents. Across Canada, the COVID-19 pandemic and subsequent public health measures affected SBIP and vaccine uptake. The objectives of this study were to explore 1.) stakeholders' experiences with SBIP and changes to programs during COVID-19 in Nova Scotia, Prince Edward Island and New Brunswick, and 2.) how the pandemic affected parents' and adolescents' vaccine views. Study design: Semi-structured interviews with decision makers, healthcare providers, teachers, parents and adolescents between February-August 2023. Methods: The COM-B model and Theoretical Domains Framework informed interview guides. Deductive and inductive analyses saw participant quotes mapped to relevant model components and domains by two coders. Belief statements were generated within each stakeholder group then compared to identify themes and subthemes. Results: Participants (n = 39) identified five themes: 1) enablers to SBIP delivery, 2) barriers to SBIP delivery, 3) desired changes to SBIP delivery, 4) student anxiety, and 5) vaccination views and changes since the COVID-19 pandemic. Public health measures facilitated more space for clinics, as did taking smaller cohorts of students. School staff-healthcare provider relationships could help or hinder programs, particularly with high turnover in both professions during the pandemic. Adolescents played a passive role in vaccine decision making, with mothers often being the sole decision maker. We did not identify any changes in hesitancy towards routine vaccines since the pandemic. Conclusions: We identified a range of barriers and enablers to SBIP, many of which were exacerbated by the pandemic. Efforts are needed to ensure SBIP and catch-up programming remains accessible for all adolescents to catch-up on missed vaccines before graduation. Parents and adolescents' vaccination views suggest changes in vaccine coverage since the pandemic may be due to accessibility of services rather than vaccine hesitancy. Future research is needed to engage adolescents in their vaccine decisions.

Surgical site infection following isolated lumbar discectomy increases odds of revision lumbar surgery within first 6 months, but not beyond.

BACKGROUND CONTEXT: Lumbar discectomy is a commonly performed surgery following which surgical site infection (SSI) may occur. Prior literature has suggested that, following SSI related to lumbar fusion, the rate of subsequent lumbar surgeries is increased over prolonged periods of time. This has not been studied specifically for lumbar discectomy. PURPOSE: To define factors associated with SSI following lumbar discectomy and determine if subsequently matched cohorts with and without SSI have differential rates of subsequent lumbar surgery beyond irrigation and debridement (I&Ds) over time. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Adult patients undergoing isolated primary lumbar laminotomy/discectomy were identified from the 2010-2021 M157 PearlDiver database. Exclusion criteria included: age<18 years, preoperative diagnosis of infection, neoplastic, or traumatic diagnoses within 90 days prior to index surgery, additional spinal surgeries on the same day as lumbar discectomy, and not being active in the database for at least 90 days postoperative. From this study population, those who developed SSI were identified based on undergoing I&D within 90 days after surgery. Those with versus without SSI were then matched 1:4 based on age, sex, Elixhauser Comorbidity Index (ECI), and obesity. OUTCOME MEASURES: Following initial I&D, incidence of revision lumbar surgery (revision lumbar discectomy, lumbar laminectomy, lumbar fusion) out to 5 years after lumbar discectomy. METHODS: Following index isolated lumbar discectomy, those with versus without SSI requiring I&D were matched and compared for incidence of secondary surgery in defined time intervals (0-6 months, 6-12 months, 1-2 years, 2-5 years) using multivariable logistic regression, controlling for patient age, sex, ECI, and obesity status. RESULTS: Of 323,025 isolated lumbar discectomy patients, SSI requiring I&D was identified for 583 (0.18%). Multivariable analysis revealed several independent predictors of these SSIs: younger age (odds ratio [OR] 0.85 per decade increase), ECI (OR 1.22 per 2-point increase), and obesity (OR 1.30). Following matching of those with versus without SSI requiring I&D, rates of subsequent surgery beyond I&D were compared. Those with SSI had significantly increased odds of lumbar revision in the first six months (OR 5.26, p<.001), but not 6-12 months (p=.462), 1-2 years (p=.515), or 2-5 years (p=.677). CONCLUSIONS: Overall, SSI requiring I&D is a rare postoperative complication following lumbar discectomy. If occurring, subsequent surgery beyond I&D was higher in the first 6 months, but then not increased at subsequent time points out to five years.

Geriatric Vertebral Compression Fracture: A Database Study Characterizing Use and Trends for Prescribed Thoracic/Lumbar Orthoses.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Geriatric vertebral compression fractures are the most common fracture associated with osteoporosis. Using a large national database, the current study aimed to examine and characterize bracing trends for geriatric thoracic/lumbar compression fracture management. METHODS: The current study utilized the PearlDiver database from 2015-2021. Patients who suffered thoracic/lumbar compression fractures (fifth thoracic to the fifth lumbar vertebra [T5-L5]) were identified. Exclusion criteria included patients less than 65 years old or an indication of infection or neoplasm. Patients who received a brace within 90-days after the initial diagnosis of thoracic/lumbar compression fracture were abstracted and characterized overall and by fracture level. Multivariable logistic regression was performed to assess for correlation with bracing trends. RESULTS: In total 290 388 patients met inclusion criteria and suffered a thoracic/lumbar compression fracture (greatest incidence at the thoracolumbar junction). Of these, bracing was only prescribed for 4263 (1.5%), with the greatest variance of 1.5% by level. Independent predictors of bracing were geographic region (relative to northeast, west WE odds ratio [OR] 1.31, Midwest OR 1.20), younger age (OR 1.27 per decade), female sex (OR 1.17), and ECI (OR 1.02 per 2-point increase) (P < .05 for each). CONCLUSION: Overall, the current study examined over a quarter of a million patients who suffered a T5-L5 compression fractures and found that only 1.5% of patients were braced. This low percentage, and that greatest predictor for bracing was non-clinical (geographic region), highlight the inconsistency of this practice and may be useful for developing treatment algorithms.

Vaccination during pregnancy and modulation of IgG response to pertussis vaccines in infants: The impact of different vaccine formulations.

The IgG response following infant diphtheria-tetanus-acellular pertussis (DTaP) immunization is influenced by the formulation of the infant and/or the adult vaccine (Tdap) given during pregnancy. DTaP vaccines containing either 3 (DTaP3) or 5 (DTaP5) pertussis antigens are commonly used. By conducting a secondary analysis of a large randomized controlled trial, we compared IgG levels against pertussis vaccine antigens in children of Td- and Tdap5-vaccinated mothers, after stratifying by infant vaccine formulation. After immunization with a primary series of DTaP5, but not DTaP3, IgG GMCs against pertussis antigens were significantly lower in infants of Tdap-immunized mothers compared with infants of Td-vaccinated mothers (pertussis toxin: GMC = 52.3[Tdap5] vs 83.5[Td], p < 0.001). Before and after the DTaP booster dose, IgG GMCs were similar in infants of Tdap- and Td-immunized mothers specifically when infants received the DTaP3 vaccine. The combination of the TdaP5 vaccine for mothers and the DTaP3 vaccine for children could attenuate Tdap-associated immunomodulation.

The evolution of vaccine hesitancy through the COVID-19 pandemic: A semi-structured interview study on booster and bivalent doses.

We sought in-depth understanding on the evolution of factors influencing COVID-19 booster dose and bivalent vaccine hesitancy in a longitudinal semi-structured interview-based qualitative study. Serial interviews were conducted between July 25th and September 1st, 2022 (Phase I: univalent booster dose availability), and between November 21st, 2022 and January 11th, 2023 (Phase II: bivalent vaccine availability). Adults (≥18 years) in Canada who had received an initial primary series and had not received a COVID-19 booster dose were eligible for Phase I, and subsequently invited to participate in Phase II. Twenty-two of twenty-three (96%) participants completed interviews for both phases (45 interviews). Nearly half of participants identified as a woman (n = 11), the median age was 37 years (interquartile range: 32-48), and most participants were employed full-time (n = 12); no participant reported needing to vaccinate (with a primary series) for their workplace. No participant reported having received a COVID-19 booster dose at the time of their interview in Phase II. Three themes relating to the development of hesitancy toward continued vaccination against COVID-19 were identified: 1) effectiveness (frequency concerns; infection despite vaccination); 2) necessity (less threatening, low urgency, alternate protective measures); and 3) information (need for data, contradiction and confusion, lack of trust, decreased motivation). The data from interviews with individuals who had not received a COVID-19 booster dose or bivalent vaccine despite having received a primary series of COVID-19 vaccines highlights actionable targets to address vaccine hesitancy and improve public health literacy.

Social factors associated with self-reported changes in mental health symptoms among youth in the COVID-19 pandemic: a cross-sectional survey.

BACKGROUND: Children and youth experienced marked impacts on day-to-day life in the COVID-19 pandemic that were associated with poorer familial and friend relationships, and greater mental health challenges. Few studies provide self-report data on mental health symptoms from children and youth themselves. We sought to examine the associations between social factors and child and youth self-reported symptoms of worsened mood, anxiety, and irritability during the COVID-19 pandemic. METHODS: A nationally representative cross-sectional survey was administered online to collect self-report data across 10 Canadian provinces among children (11-14 years) and youth (15-18 years), April-May 2022. Age-appropriate questions were based on The Partnership for Maternal, Newborn & Child Health and the World Health Organization of the United Nations H6 + Technical Working Group on Adolescent Health and Well-Being consensus framework and the Coronavirus Health and Impact Survey. Associations between a priori defined social factors (e.g., relationship quality) and respondent self-reported mental health were evaluated using ordinal logistic regression models adjusted for age, sex, and geographic location. RESULTS: We analyzed data from 483 (51.7%) children (11-14 years; 227, 47.0% girls) and 450 (48.3%) youth (15-18 years; 204, 45.3% girls). The parents of most children and youth had resided in Canada for over 20 years (678, 72.7%). Over one-quarter of children and youth self-identified as Black, Indigenous, or a Person of Color (134, 27.7%; 134, 29.8%, respectively). Over one-third of children and youth self-reported symptoms of worsened mood (149, 30.9%; 125, 27.8%, respectively), anxiety (181, 37.5%; 167, 37.1%, respectively), or irritability (160, 33.1%; 160, 35.6%, respectively) during, compared to pre-pandemic. In descending order of odds ratios (OR), for children and youth, worsened familial relationships (during compared to pre-pandemic) was associated with the self-reported symptoms of worsened mood (child: OR 4.22, 95%CI 2.51-6.88; youth: OR 6.65 95%CI 3.98-11.23), anxiety (child: OR 4.24, 95%CI2.69-6.75; youth: OR 5.28, 95%CI 3.17-8.86), and irritability (child: OR 2.83, 95%CI 1.76-4.56; youth: OR 6.46, 95%CI 3.88-10.90). CONCLUSIONS: Self-reported data from a nationally representative sample of children and youth suggest strong associations between social factors and mental health during the COVID-19 pandemic. Interventions targeting child and youth familial relationships may positively impact child and youth mental health.

Corticosteroid Injections Administered Within 4 Weeks Prior to Hip Arthroscopy Are Associated With Higher Rates of Postoperative Infection.

PURPOSE: To evaluate the association between the timing of intra-articular hip corticosteroid injections and the risk of postoperative infection in patients undergoing hip arthroscopy. METHODS: The 2010-2021 PearlDiver M157 administrative claims database was queried for patients who underwent hip arthroscopy. Patients who received intra-articular corticosteroid injections within 12 weeks prior to arthroscopy were matched 1:1 to patients who did not receive such injections based on age, sex, and Elixhauser Comorbidity Index, as well as the presence of diabetes mellitus, hypertension, obesity, and tobacco use. Those with injections prior to arthroscopy were subdivided based on having received injections within 12 weeks prior to surgery. To verify that the corticosteroid injections and surgical procedures were conducted in the hip joint, Current Procedural Terminology codes were used. By use of Current Procedural Terminology and International Classification of Diseases (ninth revision and tenth revision) coding, postoperative surgical-site infection after corticosteroid injection was evaluated. The impact of the timing of preoperative corticosteroid injections on the incidence of postoperative infection was evaluated using multivariable logistic regression analysis. RESULTS: A total of 12,390 hip arthroscopy cases were identified, including 3,579 patients who received corticosteroid injections 0 to 4 weeks prior to surgery; 4,759, within 4 to 8 weeks prior to surgery; and 4,052, within 8 to 12 weeks prior to surgery. Compared with controls, patients who received corticosteroid injections within 0 to 4 weeks preoperatively had a significantly higher rate of surgical-site infection (odds ratio, 2.43; P = .0001). No significant differences in infection rates were observed at the later time intervals (4-8 weeks or 8-12 weeks). Furthermore, in comparison to controls, patients who received corticosteroid injections had a significantly higher rate of wound dehiscence (odds ratio, 1.84; P = .0007). CONCLUSIONS: Intra-articular corticosteroid injections within 4 weeks prior to hip arthroscopy were significantly associated with increased surgical-site infection rates after hip arthroscopy surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Characterizing Gabapentinoid Use Among Patients With Isolated Low Back Pain.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Gabapentinoids have been increasingly studied as a non-narcotic option for neuropathic and postoperative pain. However, there is evidence suggesting that off-label use of these medications for the treatment of isolated LBP is not effective. The purpose of the current study was to evaluate prescription patterns for gabapentinoids among patients with isolated low back pain. METHODS: Adult patients with LBP were abstracted from the 2019 M91Ortho PearlDiver dataset using International Classification of Diseases (ICD-10) code M54.5. Patients were excluded if they had a diagnosis of neurologic symptoms, history of spinal surgery, spinal fracture, or conditions for which gabapentinoids are FDA approved. Gabapentinoid and narcotic prescriptions within one year of LBP diagnosis were identified. Patient characteristics and prescriber specialty were extracted from the dataset and predictors of gabapentinoid prescriptions were determined using univariate and multivariate analyses. RESULTS: Among the 1,158,875 isolated LBP patients, gabapentinoids were prescribed for 11%, narcotics for 8%, and both for 3%. The most common prescriber specialties included: primary care physicians (45%), nurse practitioners (15%), and pain management physicians (5%). Independent predictors of gabapentinoid prescriptions included: female sex, region of the country, and insurance type (P-values <.001). CONCLUSIONS: Of nearly 1.2 million patients with isolated LBP, 14.2% were prescribed gabapentinoids within one year of their LBP diagnosis. Patient characteristics predictive of receiving gabapentinoids were predominantly non-clinical factors.

Patients With Cystic Fibrosis Undergoing Total Hip and Total Knee Arthroplasty Are at Increased Risk for Perioperative Complications.

INTRODUCTION: Patients with cystic fibrosis (CF) are living longer and may be considered for total hip arthroplasty (THA) or total knee arthroplasty (TKA). Perioperative outcomes and implant survival after these procedures performed for those with CF have not been previously described. METHODS: Using the M151 PearlDiver database, a large, national, administrative database, THA and TKA patients with and without CF were identified and matched 1:10 based on age, sex, and Elixhauser Comorbidity Index. Ninety-day perioperative outcomes and 2-year revision rates were assessed and compared with multivariable logistic regression. RESULTS: For THA, 185 patients with CF were matched with 1,846 control subjects without CF. Patients with CF were at significantly increased odds of 90-day postoperative events including sepsis (odd radio [OR] 4.15), pneumonia (OR 3.40), pleural effusion (OR 2.77), minor events (OR 1.73), any adverse event (OR 1.64), urinary tract infection (UTI) (OR 1.63), and severe events (OR 1.60) ( P < 0.05 for each). For TKA, 505 patients with CF were matched with 5,047 control subjects without CF. Patients with CF were at significantly increased odds of 90-day postoperative events including pneumonia (OR 4.95), respiratory failure (OR 4.31), cardiac event (OR 2.29), minor events (OR 2.16), pleural effusion (OR 2.35), severe events (OR 2.06), urinary tract infection (OR 2.06), any adverse event (OR 1.96), atelectasis (OR 1.94), and acute kidney injury (OR 1.61) ( P < 0.05 for each). For both THA and TKA, those with CF were not at greater odds of 2-year rates of revision. DISCUSSION: After THA and TKA, those with CF were found to be at increased odds of multiple defined postoperative events (predominantly infectious/pulmonary), but not 2-year revision rates. These findings help define areas in need of focused optimization and are reassuring regarding risks of surgery.

Are Medical School Curricula Adapting With Their Students? A Survey on How Medical Students Study and How it Relates to USMLE Step 1 Scores.

OBJECTIVES: Over the years, medical schools have evolved their curricula in response to the medical field, faculty, and students. The current study aims to examine how medical students study, what resources they most commonly use, and how it relates to United States Medical Licensing Examination (USMLE) Step 1 scores. METHODS: A cross-sectional survey study of United States medical students was distributed via social media, GroupMe school chats, and school listservs from September 8, 2020, to December 12, 2020. The survey gathered data including, demographic and school information, resources students, time spent using each resource, and USMLE Step 1 scores. RESULTS: The survey was completed by 560 students from 102 different United States medical schools. Study guides as online resources (83.2%) were mostly used, lecture (82.5%), Anki (spaced repetition flashcards, 68.3%), and school-organized sessions (workshops, labs, and small groups) (60.7%). Of the students surveyed, 90% attended schools with a recorded lecture option. Only 54% of these students watched their lectures live. When watched online, the average watching speed was 1.75 ± 0.4× with a mode of 2× speed. In examining different medical school styles, schools with a 1.5-year preclinical curriculum had higher USMLE Step 1 scores (244.5 ± 15.6 vs 236.9 ± 16.2, P-score = .024) compared to schools that did not (1- or 2-year preclinical curriculum). CONCLUSION: Medical students seem to be using third-party resources in addition to their medical school curriculums. Because students are already broadly using these, medical schools could allow their curriculums to reference, require, or complement third-party online resources. Additionally, because of their increased cost, medical schools could consider ways to alleviate the cost on medical students as a means of equitable support. Lastly, Step 1 scores significantly correlated with schools with a 1.5-year preclinical curriculum, although the exact reasoning for this remains uncertain.

Evolving Trends in the Use of Sacroiliac Fusion From 2015 to 2020.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To assess the evolution of patients undergoing sacroiliac (SI) fusion with minimally invasive surgery (MIS) relative to open approaches. SUMMARY OF BACKGROUND DATA: The SI joint can be a contributor to lumbopelvic symptoms. The MIS approach to SI fusion has been shown to have fewer complications compared with the open approach. Recent trends and evolved patient populations have not been well-characterized. MATERIALS AND METHODS: Data were abstracted from the large, national, multi-insurance, administrative 2015-2020 M151 PearlDiver database. The incidence, trends, and patient characteristics of MIS, as well as open, SI fusions for adult patients with degenerative indications, were determined. Univariable and multivariable analyses were then performed to compare the MIS relative to open populations. The primary outcome was to assess the trends of MIS and open approaches for SI fusions. RESULTS: In total, 11,217 SI fusions were identified (of which 81.7% were MIS), with a clear increase in numbers over the years from 2015 (n=1318, 62.3% of which were MIS) to 2020 (n=3214 86.6% of which were MIS). Independent predictors of MIS (as opposed to open) SI fusion included: older age (odds ratio [OR] 1.09 per decade increase), higher Elixhauser-Comorbidity Index (OR 1.04 per two-point increase), and geographic region (relative to South, Northeast OR 1.20 and West OR 1.64). As might be expected, 90-day adverse events were lower for MIS than open cases (OR 0.73). CONCLUSION: The presented data quantify the increasing incidence of SI fusions over the years, with the increase being driven by MIS cases. This was largely related to an expanded population (those who are older and with greater comorbidity), fitting the definition of disruptive technology with lesser adverse events than open procedures. Nonetheless, geographic variation highlights the differential adoption of this technology.

Bloodstream Infections in Children Hospitalized for Influenza, the Canadian Immunization Monitoring Program Active.

BACKGROUND: We aimed to estimate the proportion of children hospitalized for influenza whose illness was complicated by bloodstream infection, describe their clinical course, and identify the factors associated with bloodstream infection. METHODS: We performed active surveillance for laboratory-confirmed influenza hospitalizations among children ≤16 years old at the 12 Canadian Immunization Monitoring Program Active hospitals, from the 2010-2011 to 2020-2021 influenza seasons. Factors associated with bloodstream infection were identified using multivariable logistic regression analyses. RESULTS: Among 9179 laboratory-confirmed influenza hospital admissions, bloodstream infection occurred in 87 children (0.9%). Streptococcus pyogenes (22%), Staphylococcus aureus (18%) and Streptococcus pneumoniae (17%) were the most common bloodstream infection pathogens identified. Children with cancer [adjusted odds ratio (aOR): 2.78; 95% confidence interval (CI): 1.23-5.63], a laboratory-confirmed nonbloodstream bacterial infection (aOR: 14.1; 95% CI: 8.04-24.3) or radiographically-confirmed pneumonia (aOR: 1.87; 95% CI: 1.17-2.97) were more likely to experience a bloodstream infection, whereas children with chronic lung disorders were less likely (aOR: 0.41; 95% CI: 0.19-0.80). Disease severity markers such as intensive care unit admission (aOR: 2.11; 95% CI: 1.27-3.46), mechanical ventilation (aOR: 2.84; 95% CI: 1.63-4.80) and longer hospital length of stay (aOR: 1.02; 95% CI: 1.01-1.03) were associated with bloodstream infection. Bloodstream infection also increased the odds of death (aOR: 13.0; 95% CI: 4.84-29.1) after adjustment for age, influenza virus type and the presence of any at-risk chronic condition. CONCLUSIONS: Bloodstream infections, although infrequent, are associated with intensive care unit admission, mechanical ventilation, increased hospital length of stay and in-hospital mortality, thus requiring increased levels of care among pediatric influenza hospitalizations.

Lumbar Laminotomy: Variables Affecting 90-day Overall Reimbursement.

INTRODUCTION: Lumbar laminotomy/diskectomy is a common procedure performed to address radiculopathy that persists despite conservative treatment. Understanding cost/reimbursement variability and its drivers has the potential to help optimize related healthcare delivery. The goal of this study was to assess variability and factors associated with reimbursement through 90 days after single-level lumbar laminotomy/diskectomy. METHODS: Lumbar laminotomies/diskectomies were isolated from the 2010 to 2021 PearlDiver M151 data set. Exclusion criteria included patients younger than 18 years; other concomitant spinal procedures; and indications of trauma, oncologic, or infectious diagnoses. Patient, surgical, and perioperative data were abstracted. These variables were examined using a multivariable linear regression model with Bonferroni correction to determine factors independently correlated with reimbursement. RESULTS: A total of 28,621 laminotomies/diskectomies were identified. The average ± standard deviation 90-day postoperative reimbursement was $9,453.83 ± 19,343.99 and, with a non-normal distribution, the median (inner quartile range) was $3,314 ($5,460). By multivariable linear regression, variables associated with greatest increase in 90-day postoperative reimbursement were associated with admission (with the index procedure [+$11,757.31] or readmission [+$31,248.80]), followed by insurance type (relative to Medicare, commercial +$4,183.79), postoperative adverse events (+$2,006.60), and postoperative emergency department visits (+$1,686.89) ( P < 0.0001 for each). Lesser associations were with Elixhauser Comorbidity Index (+$286.67 for each point increase) and age (-$24.65 with each year increase) ( P < 0.001 and P = 0.003, respectively). DISCUSSION: This study assessed a large cohort of lumbar laminotomies/diskectomies and found substantial variations in reimbursement/cost to the healthcare system. The largest increase in reimbursement was associated with admission (with the index procedure or readmission), followed by insurance type, postoperative adverse events, and postoperative emergency department visits. These results highlight the need to balance inpatient versus outpatient surgeries while limiting postoperative readmissions to minimize the costs associated with healthcare delivery.

Low Back Pain: Utilization of Urgent Cares Relative to Emergency Departments.

STUDY DESIGN/SETTING: Retrospective study. OBJECTIVE: To understand why patients utilize emergency departments (EDs) versus urgent care centers for low back pain (LBP). SUMMARY OF BACKGROUND DATA: LBP is a common reason for ED visits. In the setting of trauma or recent surgery, the resources of EDs may be needed. However, urgent care centers may be appropriate for other cases. MATERIALS AND METHODS: Adult patients below 65 years of age presenting to the ED or urgent care on the day of diagnosis of LBP were identified from the 2019 PearlDiver M151 administrative database. Exclusion criteria included history of radiculopathy or sciatica, spinal surgery, spinal cord injury, other traumatic, neoplastic, or infectious diagnoses in the 90 days prior, or Medicare insurance. Patient age, sex, Elixhauser comorbidity index, geographic region, insurance, and management strategies were extracted. Factors associated with urgent care relative to ED utilization were assessed using multivariable analysis. RESULTS: Of 356,284 LBP patients, ED visits were identified for 345,390 (96.9%) and urgent care visits for 10,894 (3.1%). Factors associated with urgent care use relative to the ED were: geographic region [relative to Midwest; Northeast odds ratio (OR): 5.49, South OR: 1.54, West OR: 1.32], insurance (relative to Medicaid; commercial OR: 4.06), lower Elixhauser comorbidity index (OR: 1.28 per two-point decrease), and higher age (OR: 1.10 per decade), female sex (OR: 1.09), and use of advanced imaging (OR: 0.08) within 1 week ( P <0.001 for all). CONCLUSIONS: Most patients presenting for a first diagnosis of isolated LBP went to the ED relative to urgent care. The greatest drivers of urgent care versus ED utilization for LBP were insurance type and geographic region. Utilization of advanced imaging was higher among ED patients, but rates of surgical intervention were similar between those seen in the ED and urgent care.