Megastudies improve the impact of applied behavioural science.

Policy-makers are increasingly turning to behavioural science for insights about how to improve citizens' decisions and outcomes1. Typically, different scientists test different intervention ideas in different samples using different outcomes over different time intervals2. The lack of comparability of such individual investigations limits their potential to inform policy. Here, to address this limitation and accelerate the pace of discovery, we introduce the megastudy-a massive field experiment in which the effects of many different interventions are compared in the same population on the same objectively measured outcome for the same duration. In a megastudy targeting physical exercise among 61,293 members of an American fitness chain, 30 scientists from 15 different US universities worked in small independent teams to design a total of 54 different four-week digital programmes (or interventions) encouraging exercise. We show that 45% of these interventions significantly increased weekly gym visits by 9% to 27%; the top-performing intervention offered microrewards for returning to the gym after a missed workout. Only 8% of interventions induced behaviour change that was significant and measurable after the four-week intervention. Conditioning on the 45% of interventions that increased exercise during the intervention, we detected carry-over effects that were proportionally similar to those measured in previous research3-6. Forecasts by impartial judges failed to predict which interventions would be most effective, underscoring the value of testing many ideas at once and, therefore, the potential for megastudies to improve the evidentiary value of behavioural science.

Loss aversion, the endowment effect, and gain-loss framing shape preferences for noninstrumental information.

We often talk about interacting with information as we would with a physical good (e.g., "consuming content") and describe our attachment to personal beliefs in the same way as our attachment to personal belongings (e.g., "holding on to" or "letting go of" our beliefs). But do we in fact value information the way we do objects? The valuation of money and material goods has been extensively researched, but surprisingly few insights from this literature have been applied to the study of information valuation. This paper demonstrates that two fundamental features of how we value money and material goods embodied in Prospect Theory-loss aversion and different risk preferences for gains versus losses-also hold true for information, even when it has no material value. Study 1 establishes loss aversion for noninstrumental information by showing that people are less likely to choose a gamble when the same outcome is framed as a loss (rather than gain) of information. Study 2 shows that people exhibit the endowment effect for noninstrumental information, and so value information more, simply by virtue of "owning" it. Study 3 provides a conceptual replication of the classic "Asian Disease" gain-loss pattern of risk preferences, but with facts instead of human lives, thereby also documenting a gain-loss framing effect for noninstrumental information. These findings represent a critical step in building a theoretical analogy between information and objects, and provide a useful perspective on why we often resist changing (or losing) our beliefs.

A 680,000-person megastudy of nudges to encourage vaccination in pharmacies.

Encouraging vaccination is a pressing policy problem. To assess whether text-based reminders can encourage pharmacy vaccination and what kinds of messages work best, we conducted a megastudy. We randomly assigned 689,693 Walmart pharmacy patients to receive one of 22 different text reminders using a variety of different behavioral science principles to nudge flu vaccination or to a business-as-usual control condition that received no messages. We found that the reminder texts that we tested increased pharmacy vaccination rates by an average of 2.0 percentage points, or 6.8%, over a 3-mo follow-up period. The most-effective messages reminded patients that a flu shot was waiting for them and delivered reminders on multiple days. The top-performing intervention included two texts delivered 3 d apart and communicated to patients that a vaccine was "waiting for you." Neither experts nor lay people anticipated that this would be the best-performing treatment, underscoring the value of simultaneously testing many different nudges in a highly powered megastudy.

Curiosity is more than novelty seeking.

The novelty-seeking model (NSM) does not offer a compelling unifying framework for understanding creativity and curiosity. It fails to explain important manifestations and features of curiosity. Moreover, the arguments offered to support a curiosity-creativity link - a shared association with a common core process and various superficial associations between them - are neither convincing nor do they yield useful predictions.

Long-term causes of death among pediatric patients with cancer.

BACKGROUND: The objectives of this study were to characterize the risk of death (1) from the primary cancer vs competing cause of death; and (2) from various causes of death vs the general poplation. The relative risk of death after a pediatric cancer diagnosis versus the general population and the risk of death from a primary cancer diagnosis versus competing causes of death. METHODS: This retrospective, population-based study used the Surveillance, Epidemiology, and End Results database (1980-2015) and included patients aged 0 to 19 years at the time of diagnosis. Observed deaths were calculated; the risk of death versus the general population was assessed with standardized mortality ratios (SMRs). Competing risk models for the cause of death were performed. RESULTS: There were 58,356 patients who were diagnosed, and the mortality rate was 22.8%. To assess causes of death, 6996 patients who died during the study period were included (45,580 total person-years at risk): 5128 (73%) died of their primary cancer, and 1868 (27%) died of a competing cause. Among all patients, the rate of death from the index cancer was higher than the rate of death from another cause within the first 5 years after diagnosis. The risk of death from a nonprimary cancer began to supersede the rate of death from the primary cancer 10 years after diagnosis for patients with germ cell tumors, lymphomas, and sarcomas. SMRs for the primary cancer were highest within the first 5 years after diagnosis for all cancers (SMRs, 100-50,000; P < .0001). The risk of death from competing causes (heart disease, suicide, and sepsis) was elevated (SMR, >100; P < .001). The risk of dying of heart disease was high, especially for patients with astrocytomas (SMR, 47.84; 95% confidence interval [CI], 27.87-76.59) and neuroblastomas (SMR, 98.59; 95% CI, 47.28-181.32). The risk of dying of suicide was high in most patients, particularly for those with osteosarcomas (SMR, 111.40; 95% CI, 2.82-620.69), Hodgkin lymphomas (SMR, 62.35; 95% CI, 34.89-102.83), and gonadal germ cell tumors (SMR, 28.97; 95% CI, 12.51-57.09). CONCLUSIONS: The cause of death for patients with gonadal germ cell tumors, lymphomas, and sarcomas is more commonly a secondary cancer or noncancerous cause than the primary disease; their risk of death from competing causes (heart disease, suicide, and sepsis) rises throughout life.

Socioeconomic Disparities in Electronic Cigarette Use and Transitions from Smoking.

INTRODUCTION: Socioeconomic disparities have been established for conventional cigarette use, but not for electronic cigarettes. This study estimates socioeconomic gradients in exclusive use of conventional cigarettes, electronic cigarettes, and dual use (ie, use of both products) among adults in the United States. METHODS: Analyses consider nationally representative data on 25- to 54-year-old respondents to the 2014-2016 National Health Interview Surveys (N = 50306). Demographically adjusted seemingly unrelated regression models estimate how two socioeconomic status measures-respondent education and household income-relate to current exclusive use of conventional cigarettes, electronic cigarettes, and dual use. RESULTS: Conventional cigarette use exhibits negative education and income gradients, consistent with existing research: -12.9 percentage points (confidence interval [CI]: -14.0, -11.8) if college educated, and -9.5 percentage points (CI: -10.9, -8.1) if household income exceeds 400% of the federal poverty level. These gradients are flatter for dual use (-1.4 [CI: -1.8, -0.9] and -1.9 [CI: -2.5, -1.2]), and statistically insignificant for electronic cigarette use (-0.03 [CI: -0.5, 0.4] and -0.3 [CI: -0.8, -0.2]). Limiting the sample to ever-smokers, higher education is associated with a 0.9 percentage point increase in likelihood of exclusive electronic cigarette use at interview (CI: 0.0, 1.9). CONCLUSIONS: Education and income gradients in exclusive electronic cigarette use are small and statistically insignificant, contrasting with strong negative gradients in exclusive conventional cigarette use. Furthermore, more educated smokers are more likely to switch to exclusive e-cigarette use than less educated smokers. Such differential switching may exacerbate socioeconomic disparities in smoking-related morbidity and mortality, but lower the burden of tobacco-related disease. IMPLICATIONS: Research has not yet established whether socioeconomic disparities in electronic cigarette (e-cigarette) use resemble those observed for conventional cigarettes. This article uses nationally representative data on US adults aged 25-54 to estimate income and education gradients in exclusive use of conventional cigarettes, e-cigarettes, and dual use. Both gradients are steep and negative for conventional cigarette use, but flat and statistically insignificant for e-cigarette use. Repeating the analysis among ever-smokers indicates that more educated smokers are more likely to transition toward exclusive e-cigarette use than less educated smokers. Such differential substitution may exacerbate disparities in smoking-related morbidity and mortality.

Correction to: Prior bariatric surgery lowers complication rates following spine surgery in obese patients.

The AHRQ (Agency for Healthcare Research and Quality) has requested the correction of the result Tables 1-3 of this study: All stated numbers below 10 shall be modified to read "<10" instead.

Congenital Etiology Is an Independent Risk Factor for Complications in Adolescents Undergoing Corrective Scoliosis Surgery: Comparison of In-hospital Comorbidities Using Nationwide KID's Inpatient Database.

BACKGROUND: Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS: A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS: In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P<0.001), had fewer comorbidities (P<0.001), and sustained similar complication incidence. In the 10 and over age analysis, CS patients similarly had shorter fusions, but greater comorbidities, and significantly more complications (odds ratio, 1.6; confidence interval, 1.4-1.8). CONCLUSIONS: CS patients have higher in-hospital complication rates. With more comorbidities, these patients have increased risk of sustaining procedure-related complications such as shock, infection, and Adult Respiratory Distress Syndrome. These data help to counsel patients and their families before spinal fusion. LEVEL OF EVIDENCE: Level III-retrospective review of a prospectively collected database.

Incidence of Congenital Spinal Abnormalities Among Pediatric Patients and Their Association With Scoliosis and Systemic Anomalies.

BACKGROUND: Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies. METHODS: A retrospective cohort analysis on Health care Cost and Utilization Project's Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. OUTCOME MEASURES: Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies. Frequencies of congenital spine anomalies were estimated using KID hospital-and-year-adjusted weights. Poisson distribution in contingency tables tabulated concurrence of other congenital anomalies, grouped by body system. RESULTS: Of 12,039,432 patients, rates per 100,000 cases were: 9.1 hemivertebra, 4.3 Klippel-Fiel, 56.3 Chiari malformation, 52.6 tethered cord, 83.4 spina bifida, 1.2 absence of vertebra, and 6.2 diastematomyelia. Diastematomyelia had the highest concurrence of other anomalies: 70.1% of diastematomyelia patients had at least one other congenital anomaly. Next, 63.2% of hemivertebra, and 35.2% of Klippel-Fiel patients had concurrent anomalies. Of the other systems deformities cooccuring, cardiac system had the highest concurrent incidence (6.5% overall). In light of VACTERL's definition of a patient being diagnosed with at least 3 VACTERL anomalies, hemivertebra patients had the highest cooccurrence of ≥3 anomalies (31.3%). With detailed analysis of hemivertebra patients, secundum ASD (14.49%), atresia of large intestine (10.2%), renal agenesis (7.43%) frequently cooccured. CONCLUSIONS: Congenital abnormalities of the spine are associated with serious systemic anomalies that may have delayed presentations. These patients continue to be at a very high, and maybe higher than previously thought, risk for comorbidities that can cause devastating perioperative complications if not detected preoperatively, and full MRI workups should be considered in all patients with spinal abnormalities. LEVEL OF EVIDENCE: Level III.

Cluster analysis describes constellations of cardiac anomalies presenting in spinal anomaly patients.

BACKGROUND: Cardiac anomalies are prevalent in patients with bony spinal anomalies. Prior studies evaluating incidences of bony congenital anomalies of the spine are limited. The Kids' Inpatient Database (KID) yields national discharge estimates of rare pediatric conditions like congenital disorders. This study utilized cluster analysis to study patterns of concurrent vertebral anomalies, anal atresia, cardiac malformations, trachea-esophageal fistula, renal dysplasia, and limb anomalies (VACTERL anomalies) co-occurring in patients with spinal congenital anomalies. METHODS: Retrospective review of KID 2003-2012. KID-supplied hospital- and year-adjusted weights allowed for incidence assessment of bony spinal anomalies and cardiac, gastrointestinal, urinary anomalies of VACTERL. K-means clustering assessed relationships between most frequent anomalies within bony spinal anomaly discharges; k set to n - 1(n = first incidence of significant drop/little gain in sum of square errors within clusters). RESULTS: There were 12,039,432 KID patients 0-20 years. Incidence per 100,000 discharges: 2.5 congenital fusion of spine, 10.4 hemivertebra, 7.0 missing vertebra. The most common anomalies co-occurring with bony vertebral malformations were atrial septal defect (ASD 12.3%), large intestinal atresia (LIA 11.8%), and patent ductus arteriosus (PDA 10.4%). Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and ventricular septal defect (VSD); all three anomalies co-occur at 6.6% rate in this vertebral anomaly population. Cluster analysis revealed that of bony anomaly discharges, 55.9% of those with PDA had ASD, 34.2% with VSD had PDA, 22.9% with LIA had ASD, 37.2% with ureter obstruction had LIA, and 35.5% with renal dysplasia had LIA. CONCLUSIONS: In vertebral anomaly patients, the most common co-occurring congenital anomalies were cardiac, renal, and gastrointestinal. Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and VSD. VACTERL patients with vertebral anomalies commonly presented alongside cardiac and renal anomalies.

Prior bariatric surgery lowers complication rates following spine surgery in obese patients.

BACKGROUND: Bariatric surgery (BS) is an increasingly common treatment for morbid obesity that has the potential to effect bone and mineral metabolism. The effect of prior BS on spine surgery outcomes has not been well established. The aim of this study was to assess differences in complication rates following spinal surgery for patients with and without a history of BS. METHODS: Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years 2004-2013. BS patients and morbidly obese patients (non-BS) were divided into cervical and thoracolumbar surgical groups and propensity score matched for age, gender, and invasiveness and complications compared. RESULTS: One thousand nine hundred thirty-nine spine surgery patients with a history of BS were compared to 1625 non-BS spine surgery patients. The average time from bariatric surgery to spine surgery is 2.95 years. After propensity score matching, 740 BS patients were compared to 740 non-BS patients undergoing thoracolumbar surgery, with similar comorbidity rates. The overall complication rate for BS thoracolumbar patients was lower than non-BS (45.8% vs 58.1%, P < 0.001), with lower rates of device-related (6.1% vs 23.2%, P < 0.001), DVT (1.2% vs 2.7%, P = 0.039), and hematomas (1.5% vs 4.5%, P < 0.001). Neurologic complications were similar between BS patients and non-BS patients (2.3% vs 2.7%, P = 0.62). For patients undergoing cervical spine surgery, BS patients experienced lower rates of bowel issues, device-related, and overall complication than non-BS patients (P < 0.05). CONCLUSIONS: Bariatric surgery patients undergoing spine surgery experience lower overall complication rates than morbidly obese patients. This study warrants further investigation into these populations to mitigate risks associated with spine surgery for bariatric patients.

Despite worse baseline status depressed patients achieved outcomes similar to those in nondepressed patients after surgery for cervical deformity.

OBJECTIVE Depression and anxiety have been demonstrated to have negative impacts on outcomes after spine surgery. In patients with cervical deformity (CD), the psychological and physiological burdens of the disease may overlap without clear boundaries. While surgery has a proven record of bringing about significant pain relief and decreased disability, the impact of depression and anxiety on recovery from cervical deformity corrective surgery has not been previously reported on in the literature. The purpose of the present study was to determine the effect of depression and anxiety on patients' recovery from and improvement after CD surgery. METHODS The authors conducted a retrospective review of a prospective, multicenter CD database. Patients with a history of clinical depression, in addition to those with current self-reported anxiety or depression, were defined as depressed (D group). The D group was compared with nondepressed patients (ND group) with a similar baseline deformity determined by propensity score matching of the cervical sagittal vertical axis (cSVA). Baseline demographic, comorbidity, clinical, and radiographic data were compared among patients using t-tests. Improvement of symptoms was recorded at 3 months, 6 months, and 1 year postoperatively. All health-related quality of life (HRQOL) scores collected at these follow-up time points were compared using t-tests. RESULTS Sixty-six patients were matched for baseline radiographic parameters: 33 with a history of depression and/or current depression, and 33 without. Depressed patients had similar age, sex, race, and radiographic alignment: cSVA, T-1 slope minus C2-7 lordosis, SVA, and T-1 pelvic angle (p > 0.05). Compared with nondepressed individuals, depressed patients had a higher incidence of osteoporosis (21.2% vs 3.2%, p = 0.028), rheumatoid arthritis (18.2% vs 3.2%, p = 0.012), and connective tissue disorders (18.2% vs 3.2%, p = 0.012). At baseline, the D group had greater neck pain (7.9 of 10 vs 6.6 on a Numeric Rating Scale [NRS], p = 0.015), lower mean EQ-5D scores (68.9 vs 74.7, p < 0.001), but similar Neck Disability Index (NDI) scores (57.5 vs 49.9, p = 0.063) and myelopathy scores (13.4 vs 13.9, p = 0.546). Surgeries performed in either group were similar in terms of number of levels fused, osteotomies performed, and correction achieved (baseline to 3-month measurements) (p < 0.05). At 3 months, EQ-5D scores remained lower in the D group (74.0 vs 78.2, p = 0.044), and NDI scores were similar (48.5 vs 39.0, p = 0.053). However, neck pain improved in the D group (NRS score of 5.0 vs 4.3, p = 0.331), and modified Japanese Orthopaedic Association (mJOA) scores remained similar (14.2 vs 15.0, p = 0.211). At 6 months and 1 year, all HRQOL scores were similar between the 2 cohorts. One-year measurements were as follows: NDI 39.7 vs 40.7 (p = 0.878), NRS neck pain score of 4.1 vs 5.0 (p = 0.326), EQ-5D score of 77.1 vs 78.2 (p = 0.646), and mJOA score of 14.0 vs 14.2 (p = 0.835). Anxiety/depression levels reported on the EQ-5D scale were significantly higher in the depressed cohort at baseline, 3 months, and 6 months (all p < 0.05), but were similar between groups at 1 year postoperatively (1.72 vs 1.53, p = 0.416). CONCLUSIONS Clinical depression was observed in many of the study patients with CD. After matching for baseline deformity, depression symptomology resulted in worse baseline EQ-5D and pain scores. Despite these baseline differences, both cohorts achieved similar results in all HRQOL assessments 6 months and 1 year postoperatively, demonstrating no clinical impact of depression on recovery up until 1 year after CD surgery. Thus, a history of depression does not appear to have an impact on recovery from CD surgery.

Using curiosity to counter health information avoidance.

OBJECTIVE: Information that is beneficial for health decision-making is often ignored or actively avoided. Countering information avoidance can increase knowledge of disease risk factors and symptoms, aiding early diagnoses and reducing disease transmission. We examine whether curiosity can be a useful tool in increasing demand for, and engagement with, potentially aversive but useful health information. METHODS: Four pre-registered randomized online studies were conducted with 5795 participants recruited from online survey platforms. Curiosity for aversive health information was manipulated by providing a 'curiosity incentive' - identity-related information alongside aversive information - (Study 1), obscuring information (Studies 2 and 3), and eliciting guesses about the information (Studies 2 and 4). Willingness to view four types of aversive health information was elicited: alcohol consumption screening scores (Study 1), colon cancer risk scores (Study 2), cancer risk factors (Study 3), and the sugar content of drinks (Study 4). RESULTS: In Study 1, the curiosity manipulation increased the likelihood that participants viewed information about the riskiness of their drinking. Studies 2 and 3 show that curiosity prompts can counter people's reluctance to learn about and assess their cancer risk. And Study 4 shows that using curiosity prompts to encourage engagement with aversive information (sugar content of drinks) also improves health-related choices (opting for a sugar-free drink alternative). CONCLUSION: Curiosity prompts provide an effective and simple way to increase engagement with aversive health information.

Predictors of Complication Severity Following Adult Spinal Deformity Surgery: Smoking Rate, Diabetes, and Osteotomy Increase Risk of Severe Adverse Events.

BACKGROUND: Given the physical and economic burden of complications in spine surgery, reducing the prevalence of perioperative adverse events is a primary concern of both patients and health care professionals. This study aims to identify specific perioperative factors predictive of developing varying grades of postoperative complications in adult spinal deformity (ASD) patients, as assessed by the Clavien-Dindo complication classification (Cc) system. METHODS: Surgical ASD patients ≥18 years were identified in the American College of Surgeons' National Surgical Quality Improvement Program from 2005 to 2015. Postoperative complications were stratified by Cc grade severity: minor (I, II, and III) and severe (IV and V). Stepwise regression models generated dataset-specific predictive models for Cc groups. Model internal validation was achieved by bootstrapping and calculating the area under the curve (AUC) of the model. Significance was set at P < 0.05. RESULTS: Included were 3936 patients (59 ± 16 years, 63% women, 29 ± 7 kg/m2) undergoing surgery for ASD (4.4 ± 4.7 levels, 71% posterior approach, 11% anterior, and 18% combined). Overall, 1% of cases were revisions, 39% of procedures involved decompression, 27% osteotomy, and 15% iliac fixation. Additionally, 66% of patients experienced at least 1 complication, 0% of which were Cc grade I, 51% II, 5% III, 43% IV, and 1% V. The final model predicting severe Cc (IV-V) complications yielded an AUC of 75.6% and included male sex, diabetes, increased operative time, central nervous system tumor, osteotomy, cigarette pack-years, anterior decompression, and anterior lumbar interbody fusion. Final models predicting specific Cc grades were created. CONCLUSIONS: Specific predictors of adverse events following ASD-corrective surgery varied for complications of different severities. Multivariate modeling showed smoking rate, osteotomy, diabetes, anterior lumbar interbody fusion, and higher operative time, among other factors, as predictive of severe complications, as classified by the Clavien-Dindo Cc system. These factors can help in the identification of high-risk patients and, consequently, improve preoperative patient counseling. CLINICAL RELEVANCE: The findings of this study provide a foundation for identifying ASD patients at high risk of postoperative complications .

Doctor recommendations and parents' HPV vaccination intentions in Kenya: A randomized survey.

The causal effect of a doctor's recommendation for Human Papillomavirus (HPV) vaccination on parents' decisions in low-resource settings is not well understood. This study investigates how doctors' endorsement of the HPV vaccine communicated through a public health poster affects parents' decisions to vaccinate their daughters in Kenya. In January and February 2021, 600 parents of daughters eligible for the HPV vaccine but not yet vaccinated were recruited and completed a randomized survey. Participants saw a poster from a national campaign about HPV vaccination and either nothing further (Control) or an additional poster containing an HPV vaccine recommendation from a female (FDR) or male doctor (MDR). Primary outcomes are intentions to vaccinate and perceived safety of the HPV vaccine. Both recommendation arms increased the likelihood that participants reported the highest levels of vaccine intentions compared to control (FDR: 33.7% p = 0.01; MDR: 30.5%, p = 0.05, compared to Control (22.4%)) and safety perceptions (FDR: 24.2%. p = 0.09; MDR: 28.0%, p = 0.01, compared to Control (17.1%)) but there was no statistically significant increase in the likelihood to report above moderate vaccine intentions (FDR: 72.6%, p = 0.76; MDR: 72.5%, p = 0.77, compared to Control (71.4%)) or safety perceptions (FDR: 68.9%, p = 0.91; MDR: 75.0%, p = 0.17, compared to Control (68.6%)). We find no differential treatment effect by the recommending doctor's gender. In conclusion, our results suggest that visual communication of a doctor's support for the HPV vaccine can strengthen above-moderate intentions and safety perceptions but may not be enough to persuade the vaccine hesitant to vaccinate.

Defining age-adjusted spinopelvic alignment thresholds: should we integrate BMI?

PURPOSE: To develop age- and BMI-adjusted alignment targets to improve patient-specific management and operative treatment outcomes. METHODS: Retrospective review of a single-center stereographic database. ASD patients receiving operative or non-operative treatment, ≥ 18y/o with complete baseline (BL) ODI scores and radiographic parameters (PT, SVA, PILL, TPA) were included. Patients were stratified by age consistent with US-Normative values (norms) of SF-36(< 35, 35-55, 45-54, 55-64, 65-74, ≥ 75y/o), and dichotomized by BMI (Non-Obese < 30; Obese ≥ 30). Linear regression analysis established normative age- and BMI-specific radiographic thresholds, utilizing previously published age-specific US-Normative ODI values converted from SF-36 PCS (Lafage et al.), in conjunction with BL age and BMI means. RESULTS: 486 patients were included (Age: 52.5, Gender: 68.7%F, mean BMI: 26.2, mean ODI: 32.7), 135 of which were obese. Linear regression analysis developed age- and BMI-specific alignment thresholds, indicating PT, SVA, PILL, and TPA to increase with both increased age and increased BMI (all R > 0.5, p < 0.001). For non-obese patients, PT, SVA, PILL, and TPA ranged from 10.0, - 25.8, - 9.0, 3.1 in patients < 35y/o to 27.8, 53.4, 17.7, 25.8 in patients ≥ 75 y/o. Obese patients' PT, SVA, PILL, and TPA ranged from 10.5, - 7.6, - 7.1, 5.8 in patients < 35 y/o to 28.3, 67.0, 19.15, 27.7 in patients ≥ 75y/o. Normative SVA values in obese patients were consistently ≥ 10 mm greater compared to non-obese values, at all ages. CONCLUSION: Significant associations exist between age, BMI, and sagittal alignment. While BMI influenced age-adjusted alignment norms for PT, SVA, PILL, and TPA at all ages, obesity most greatly influenced SVA, with normative values similar to non-obese patients who were 10 years older. Age-adjusted alignment thresholds should take BMI into account, calling for less rigorous alignment objectives in older and obese patients.

Long-Term Risk of Death From Heart Disease Among Breast Cancer Patients.

Background: Most breast cancer patients die of non-cancer causes. The risk of death from heart disease, a leading cause of death, is unknown. The aim of this study is to characterize the long-term risk of fatal heart disease in breast cancer patients. Methods: This retrospective study used the Surveillance, Epidemiology, and End Results (SEER) database. Standard mortality ratios (SMR) were calculated for breast cancer patients diagnosed from 1992 to 2014. Patients were stratified by receipt of radiotherapy and/or chemotherapy, disease laterality, and diagnosis era. Hazard ratios (HRs) and odds ratios (ORs) were calculated to compare the risk of death from heart disease among other breast cancer patients. Results: There were 1,059,048 patients diagnosed with breast cancer from 1992 to 2014, of which 47,872 (4.6%) died from heart disease. The SMR for death from heart disease at 10+ years for patients who received only radiotherapy was 2.92 (95% CI 2.81-3.04, p < 0.001) and in patients who received only chemotherapy was 5.05 (95% CI 4.57-5.55, p < 0.001). There was no statistically significant difference in SMR for death from heart disease for left-sided vs. right-sided disease. At 10+ years, heart disease made up 28% of deaths from non-primary cancer. HRs and ORs showed that the risk of death from heart disease was highest in patients older than 70 years of age and with longer follow-up. Conclusion: The risk of fatal heart disease was highest in older breast cancer patients with longer follow-up (i.e., >5-10 years) and who received chemotherapy. These patients should be referred to cardio-oncology clinics to mitigate this risk.

Epidemiology of bone metastases.

BACKGROUND: This study evaluated the incidence of de novo bone metastasis across all primary cancer sites and their impact on survival by primary cancer site, age, race, and sex. QUESTIONS/PURPOSES: Our objectives were (I) characterize the epidemiology of de novo bone metastasis with respect to patient demographics, (II) characterize the incidence by primary site, age, and sex (2010-2015), and (III) compare survival of de novo metastatic cancer patients with and without bone metastasis. METHODS: This is a retrospective, population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results program, 2010-2015. Incidence rates by year of diagnosis, annual percentage changes, Kaplan-Meier, univariate and multiple Cox regression models are included in the analysis. RESULTS: Of patients with cancer in the SEER database, 5.1% were diagnosed with metastasis to bone, equaling ~18.8 per 100,000 bone metastasis diagnoses in the US per year (2010-2015). For adults >25, lung cancer is the most common primary site (2015 rate: 8.7 per 100,000) with de novo bone metastases, then prostate and breast primaries (2015 rates: 3.19 and 2.38 per 100,000, respectively). For patients <20 years old, endocrine cancers and soft tissue sarcomas are the most common primaries. Incidence is increasing for prostate (Annual Percentage Change (APC) = 4.6%, P < 0.001) and stomach (APC = 5.0%, P = 0.001) cancers. The presence of de novo bone metastasis was associated with a limited reduction in overall survival (HR = 1.02, 95%, CI = [1.01-1.03], p < 0.001) when compared to patients with other non-bone metastases. CONCLUSION: The presence of bone metastasis versus metastasis to other sites has disease site-specific impact on survival. The incidence of de novo bone metastasis varies by age, sex, and primary disease site.

Bariatric Surgery Lowers Rates of Spinal Symptoms and Spinal Surgery in a Morbidly Obese Population.

STUDY DESIGN: Retrospective analysis of New York State Inpatient Database years 2004-2013. OBJECTIVE: Assess rates of spinal diagnoses and procedures before and after bariatric surgery (BS). SUMMARY OF BACKGROUND DATA: BS for morbid obesity helps address common comorbidity burdens and improves quality of life for patients. The effects of BS on spinal disorders and surgical intervention have yet to be investigated. MATERIALS AND METHODS: Patients included in analysis if they underwent BS and were seen at the hospital before and after this intervention. Spinal conditions and rates of surgery assessed before and after BS using χ 2 tests for categorical variables. Multivariable logistic regression analysis used to compare rates in BS patients to control group of nonoperative morbidly obese patients. Logistic testing controlled for comorbidities, age, biological sex. RESULTS: A total of 73,046 BS patients included (age 67.88±17.66 y, 56.1% female). For regression analysis, 299,504 nonbariatric, morbidly obese patients included (age 53.45±16.52 y, 65.6% female). Overall, rates of spinal symptoms decreased following BS (7.40%-5.14%, P <0.001). Cervical, thoracic, lumbar spine diagnoses rates dropped from 3.28% to 2.99%, 2.91% to 2.57%, and 5.39% to 3.92% (all P <0.001), respectively. Most marked reductions seen in cervical spontaneous compression fractures, cervical disc herniation, thoracic radicular pain, spontaneous lumbar compression fractures, lumbar spinal stenosis, lumbar spondylosis. Controlling for comorbidities, age and sex, obese nonbariatric patients more likely to have encounters associated with several cervical, thoracic or lumbar spinal diagnoses and procedures, especially for cervical spontaneous compression fracture, radicular pain, lumbar spondylosis, lumbar spinal stenosis, posterior procedures. BS significantly lowered comorbidity burden for many specific factors. CONCLUSIONS: BS lowered rates of documented spinal disorders and procedures in a morbidly obese population. These findings provide evidence of additional health benefits following BS, including reduction in health care encounters for spinal disorders and rates of surgical intervention.

Cervical Deformity Correction Fails to Achieve Age-Adjusted Spinopelvic Alignment Targets.

OBJECTIVE: To assess whether surgical cervical deformity (CD) patients meet spinopelvic age-adjusted alignment targets, reciprocal, and lower limb compensation changes. STUDY DESIGN: Retrospective review. METHODS: CD was defined as C2-C7 lordosis >10°, cervical sagittal vertical angle (cSVA) >4 cm, or T1 slope minus cervical lordosis (TS-CL) >20°. Inclusion criteria were age >18 years and undergoing surgical correction with complete baseline and postoperative imaging. Published formulas were used to create age-adjusted alignment target for pelvic tilt (PT), pelvic incidence and lumbar lordosis (PI-LL), sagittal vertical angle (SVA), and lumbar lordosis and thoracic kyphosis (LL-TK). Actual alignment was compared with age-adjusted ideal values. Patients who matched ±10-year thresholds for age-adjusted targets were compared with unmatched cases (under- or overcorrected). RESULTS: A total of 120 CD patients were included (mean age, 55.1 years; 48.4% women; body mass index, 28.8 kg/m2). For PT, only 24.4% of patients matched age-adjusted alignment, 51.1% overcorrected for PT, and 24.4% undercorrected. For PI-LL, only 27.6% of CD patients matched age-adjusted targets, with 49.4% overcorrected and 23% undercorrected postoperatively. Forty percent of patients matched age-adjusted target for SVA, 41.3% overcorrected, and 18.8% undercorrected. CD patients who had worsened in TS-CL or cSVA postoperatively displayed increased TK (-41.1° to -45.3°, P = 1.06). With lower extremity compensation, CD patients decreased in ankle flexion angle postoperatively (6.1°-5.5°, P = 0.036) and trended toward smaller sacrofemoral angle (199.6-195.6 mm, P = 0.286) and knee flexion (2.6° to -1.1°, P = 0.269). CONCLUSIONS: In response to worsening CD postoperatively, patients increased in TK and recruited less lower limb compensation. Almost 75% of CD patients did not meet previously established spinopelvic alignment goals, of whom a subset of patients were actually made worse off in these parameters following surgery. This finding raises the question of whether we should be looking at the entire spine when treating CD.