Congenital Cytomegalovirus Testing Outcomes From the ValEAR Trial.

OBJECTIVE: To determine the positivity rate of congenital cytomegalovirus (cCMV) testing among universal, hearing-targeted CMV testing (HT-cCMV) and delayed targeted dried blood spot (DBS) testing newborn screening programs, and to examine the characteristics of successful HT-cCMV testing programs. STUDY DESIGN: Prospective survey of birth hospitals performing early CMV testing. SETTING: Multiple institutions. METHODS: Birth hospitals participating in the National Institutes of Health ValEAR clinical trial were surveyed to determine the rates of cCMV positivity associated with 3 different testing approaches: universal testing, HT-cCMV, and DBS testing. A mixed methods model was created to determine associations between successful HT-cCMV screening and specific screening protocols. RESULTS: Eighty-two birth hospitals were surveyed from February 2019 to December 2021. Seven thousand six hundred seventy infants underwent universal screening, 9017 infants HT-cCMV and 535 infants delayed DBS testing. The rates of cCMV positivity were 0.5%, 1.5%, and 7.3%, respectively. The positivity rate for universal CMV screening was less during the COVID-19 pandemic than that reported prior to the pandemic. There were no statistically significant drops in positivity for any approach during the pandemic. For HT-cCMV testing, unique order sets and rigorous posttesting protocols were associated with successful screening programs. CONCLUSION: Rates of cCMV positivity differed among the 3 approaches. The rates are comparable to cohort studies reported in the literature. Universal CMV prevalence decreased during the pandemic but not significantly. Institutions with specific order set for CMV testing where the primary care physician orders the test and the nurse facilitates the testing process exhibited higher rates of HT-cCMV testing.

Impact of COVID-19 visitation policies and hospital capacity on discharge readiness in medicine patients.

Background: COVID-19 impacted the experience of being hospitalized with the widespread adoption of strict visitation policies to ensure healthcare worker safety. One result was decreased time of caregivers at the bedside of hospitalized patients. Objective: To understand the impact of pandemic-related system effects on patient-reported discharge preparation. Design: This mixed methods study included interviews with a sample of discharged patients during April 2020, and quantitative hospital data from April 2020 to February 2021. Participants: 616 patients completed a measure of discharge readiness on their day of discharge and 38 patients completed interviews about their discharge experiences. Main measures: Readiness for discharge (RHDS), visitation policies, ward structure changes, COVID-19-unit census, time into the COVID-19 pandemic, patient characteristics (age, sex, race/ethnicity), admission type (planned/unplanned, for COVID-19), and discharge destination (home, home health, skilled nursing). Key results: Adult patients aged 30-45 (vs. young and older adult patients) and those being discharged to places other than home (e.g., skilled nursing facility) or to out-of-state residences report lower readiness (p < 0.05) on RHDS. Patient interviews revealed some gaps in discharge communication but, overall, patients expressed high discharge readiness and few concerns about how COVID-19 system changes impacted their discharge preparation. Conclusions: While there is some evidence that visitation policies and unit census may impact patient perceptions of discharge preparation, personal characteristics contributed more significantly to discharge readiness than system changes during COVID-19. Participant interviews demonstrated agreement, as most participants were discharged home and identified strong personal feelings of readiness for discharge.Clinical trials registration: ClinicalTrials.gov ID NCT04248738, https://clinicaltrials.gov/ct2/show/NCT04248738. Supplementary Information: The online version contains supplementary material available at 10.1007/s44250-023-00060-8.

Headache among combat-exposed veterans and service members and its relation to mild traumatic brain injury history and other factors: a LIMBIC-CENC study.

Background: Headache (HA) is a common persistent complaint following mild traumatic brain injury (mTBI), but the association with remote mTBI is not well established, and risk factors are understudied. Objective: Determine the relationship of mTBI history and other factors with HA prevalence and impact among combat-exposed current and former service members (SMs). Design: Secondary cross-sectional data analysis from the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study. Methods: We examined the association of lifetime mTBI history, demographic, military, medical and psychosocial factors with (1) HA prevalence ("lately, have you experienced headaches?") using logistic regression and (2) HA burden via the Headache Impact Test-6 (HIT-6) using linear regression. Each lifetime mTBI was categorized by mechanism (blast-related or not) and setting (combat deployed or not). Participants with non-credible symptom reporting were excluded, leaving N = 1,685 of whom 81% had positive mTBI histories. Results: At a median 10 years since last mTBI, mTBI positive participants had higher HA prevalence (69% overall, 78% if 3 or more mTBIs) and greater HA burden (67% substantial/severe impact) than non-TBI controls (46% prevalence, 54% substantial/severe impact). In covariate-adjusted analysis, HA prevalence was higher with greater number of blast-related mTBIs (OR 1.81; 95% CI 1.48, 2.23), non-blast mTBIs while deployed (OR 1.42; 95% CI 1.14, 1.79), or non-blast mTBIs when not deployed (OR 1.23; 95% CI 1.02, 1.49). HA impact was only higher with blast-related mTBIs. Female identity, younger age, PTSD symptoms, and subjective sleep quality showed effects in both prevalence and impact models, with the largest mean HIT-6 elevation for PTSD symptoms. Additionally, combat deployment duration and depression symptoms were factors for HA prevalence, and Black race and Hispanic/Latino ethnicity were factors for HA impact. In sensitivity analyses, time since last mTBI and early HA onset were both non-significant. Conclusion: The prevalence of HA symptoms among formerly combat-deployed veterans and SMs is higher with more lifetime mTBIs regardless of how remote. Blast-related mTBI raises the risk the most and is uniquely associated with elevated HA burden. Other demographic and potentially modifiable risk factors were identified that may inform clinical care.

A feasibility study to understand the components of behavioral sleep extension.

Objectives: The goal of this study was to examine the contribution of sleep extension intervention components (wearable sleep tracker and coaching) on sleep extension outcomes. Patient involvement: This study collected open ended qualitative responses of treatment preference, acceptability, and feasibility as a key outcome. Methods: Adults aged 25 to 65 years with sleep duration <7 h and BMI ≥ 25 were randomized into one of four groups: Self-Management (control), Fitbit, Telephone Coaching, or Fitbit + Coaching. Self-report questionnaires and actigraphy were completed at baseline, post-intervention (6 weeks), and 12-weeks. Analyses used mixed models. Results: Among the 38 adults randomized, the Fitbit + Coaching group had larger but non-significant improvements in sleep duration compared with the self-management group. The coaching group demonstrated significant improvements in sleep-related impairment. All groups demonstrated feasibility and acceptability but the Fitbit + Coaching group reported themes of accountability. Conclusions: Results suggest that sleep extension interventions are feasible and acceptable but components affect the pattern of sleep and other outcomes. Practical implications: Sleep extension is feasible and acceptable; the combination of coaching and the wearable device may lead to larger changes in sleep due to enhanced accountability.

Greater spatial access to care is associated with lower mortality for emergency general surgery.

BACKGROUND: Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions. METHODS: A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity. RESULTS: A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity. CONCLUSION: This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Circadian Timing, Information processing and Metabolism (TIME) study: protocol of a longitudinal study of sleep duration, circadian alignment and cardiometabolic health among overweight adults.

BACKGROUND: Both short sleep duration and circadian rhythm misalignment are risk factors for metabolic dysfunction, but the underlying mechanisms are unknown. The goal of this study is to examine how sleep duration and circadian alignment predict changes in cardiometabolic risk factors over a 12-month period, and test cognitive function and hedonic eating tendencies as potential mechanisms. METHODS: We will recruit a sample of 120 working aged adults with BMI 25-35 kg/m2 (overweight to class I obesity). The protocol includes 5 visits over a 12-month period. Study visits include wrist actigraphy to measure sleep behaviors, 24-h diet recalls, dim light melatonin collection, a computerized neurobehavioral assessment, eating in the absence of hunger task, and frequently sampled IV glucose tolerance test. DISCUSSION: The results of the TIME study will advance the understanding of how both short sleep duration and circadian misalignment contribute to behavioral aspects of obesity and metabolic dysfunction. TRIAL REGISTRATION: ClinicalTrials.Gov, NCT04759755 , registered retrospectively February 13, 2021.

A Vascular Quality Initiative frailty assessment predicts postdischarge mortality in patients undergoing arterial reconstruction.

BACKGROUND: Frailty assessment adds important prognostic information during preoperative decision-making but can be cumbersome to implement into routine clinical care. We developed and tested an abbreviated method of frailty assessment using variables routinely collected by the Vascular Quality Initiative (VQI) registry. METHODS: An abbreviated frailty score (the simple Vascular Quality Initiative-Frailty Score [VQI-FS]) was developed using 11 or fewer VQI variables (hypertension, congestive heart failure, coronary artery disease, peripheral vascular disease, diabetes, chronic obstructive pulmonary disease, renal impairment, anemia, underweight, nonhome residence, and nonambulatory status) that map to recognized frailty domains in the Comprehensive Geriatric Assessment and the literature. Nonemergent cases registered in the VQI from 2010 to 2017 (n = 265,632) in seven registries (carotid endarterectomy, n = 77,111; carotid artery stenting, n = 13,215; endovascular abdominal aortic aneurysm repair, n = 29,607; open abdominal aortic aneurysm repair, n = 7442; infrainguinal bypass, n = 33,128; suprainguinal bypass, n = 10,661; and peripheral vascular intervention, n = 94,468) were analyzed using logistic regression models to determine the predictive power of the VQI-FS for perioperative and longer term (9-month) mortality. Nomograms were created using weighted regression coefficients to assist in individualized frailty assessment and estimation of 9-month mortality. RESULTS: The VQI-FS, using equal weighting of these 11 VQI variables, effectively predicted 9-month mortality with an area under the curve of 0.724 by receiver operating characteristic curve analysis. However, differential weighting of the variables allowed simplification of the model to only seven variables (congestive heart failure, renal impairment, chronic obstructive pulmonary disease, not living at home, not ambulatory, anemia, and underweight status); hypertension, coronary artery disease, peripheral vascular disease, and diabetes had relatively low predictive power. Adding procedure-specific risk further improved performance of the model with a final area under the curve on receiver operating characteristic curve analysis of 0.758. Model calibration was excellent with predicted/observed regression line slope of 0.991 and intercept of 5.449e-04. CONCLUSIONS: A differentially weighted abbreviated VQI-FS using seven variables in addition to procedure-specific risk has strong correlation with 9-month mortality. Nomograms incorporating patient- and procedure-adjusted risk can effectively predict 9-month mortality. Reliable estimates of longer term mortality should assist in preoperative decision-making for vascular procedures that often carry substantial risk of mortality.

Does training paradigm matter? A comparison of outcomes of frail patients treated by integrated vascular surgery residency and vascular surgery fellowship-trained surgeons.

BACKGROUND: It is unclear whether shortened training of integrated vascular surgery residencies (IVSR) has detrimental effects on graduates' performance. We sought to investigate whether there is a difference in frail patient outcomes based on the training paradigm completed by their surgeon. METHODS: IVSR and vascular surgery fellowship (VSF)-trained surgeons were identified in the American Board of Surgery database and linked to the Vascular Quality Initiative registry (2013-2019) to evaluate provider-specific patient outcomes for frail patients following vascular procedures using mixed-effects logistic regression. RESULTS: 105 IVSR graduates (31%) and 233 VSF graduates (69%) were included. Composite 1-year outcomes of frail patients were comparable between IVSR and VSF-trained surgeons following carotid endarterectomy (16%-IVSR vs 25%-VSF; p = 0.76), lower extremity revascularization (37%-IVSR vs 36%-VSF; p = 0.83), and aortic aneurysm repair (25%-IVSR vs 23%-VSF; p = 0.89). CONCLUSIONS: The type of training paradigm completed by vascular surgeons was not associated with differences in their post-operative outcomes in frail patients.

Comparison of Patient Outcomes Among Integrated Residency Versus Fellowship-trained Vascular Surgeons.

OBJECTIVE: This study aims to evaluate whether graduates of integrated vascular surgery residency (IVSR) programs achieve similar surgical outcomes in clinical practice as compared to graduates of vascular surgery fellowships (VSF). SUMMARY OF BACKGROUND DATA: Early sub-specialization through IVSR programs decreases the total years of surgical training. However, it is unclear whether IVSR graduates achieve comparable outcomes to fellowship-trained surgeons once in clinical practice. METHODS: We identified all vascular surgeons who finished IVSR and VSF programs between 2013-2017 using American Board of Surgery data, which was linked to the Vascular Quality Initiative registry (2013-2019) to evaluate provider-specific clinical outcomes following carotid, lower extremity, and aortic aneurysm repair procedures. The association between training models and the composite outcome of 1-year mortality, major adverse cardiac events and/or other major complications were analyzed using mixed-effects logistic regression models. RESULTS: A total of 338 surgeons (31% IVSR, 69% VSF) submitted cases into the Vascular Quality Initiative registry, including 8155 carotid, 21,428 lower extremity, and 5800 aortic aneurysm repair procedures. Composite 1-year outcome rates were comparable between IVSR and VSF-trained surgeons following carotid endarterectomy (8%-IVSR vs 7%-VSF), lower extremity revascularization (19%-IVSR vs 16%-VSF), and aortic aneurysm repair (13%-IVSR vs 13%-VSF) procedures. These findings among IVSR-trained surgeons persisted following risk adjustment for severity of patient disease and indications for undertaking carotid [aOR: 1.04 (0.84-1.28)], lower extremity [aOR: 1.03 (0.84-1.26)], and aortic [aOR: 0.96 (0.76-1.21)] procedures when compared to VSF-trained surgeons. CONCLUSIONS: Despite fewer total years of training, graduates of IVSR programs achieve equivalent surgical outcomes as fellowship-trained vascular surgeons once in practice. These results suggest that concerns about differential competence among integrated residency graduates are not warranted.

The effect of audiovisual distraction on patient-controlled sedation under spinal anesthesia: a prospective, randomized trial.

Audiovisual distraction (AVD) has been used to augment or replace procedural sedation. We investigated whether AVD in patients having total hip (THA) or total knee arthroplasty (TKA) under spinal anesthesia would reduce self-administered propofol consumption during surgery. 50 participants were randomized equally into a patient-controlled sedation (PCS) group or AVD group. All participants were given a spinal block and a propofol PCS device prior to surgery. In addition, Group AVD participants selected and watched a movie or documentary film on a tablet device with noise-cancelling headphones during surgery. The primary outcome of this study was total propofol consumption standardized as mcg/kg/min. Secondary outcomes evaluated increased supplemental oxygen use, rescue airway interventions, hypotension, disruptive movement events during surgery, sedation, and satisfaction with anesthesia scores. Historical clinician-controlled propofol usage at our institution over the previous 2 years were recorded. There was no significant difference in median propofol consumption between Groups PCS and AVD, 8.4 mcg/kg/min (1.6-18.9) vs 4 mcg/kg/min (0-9) (P = 0.29), respectively. Historical clinician-controlled usage of propofol demonstrated a median of 39.3 mcg/kg/min (29.2-51.2). There were few differences in the secondary outcome measures. The use of AVD did not reduce patient-controlled propofol consumption in patients having a THA or TKA surgery under spinal anesthesia.

Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population.

BACKGROUND: Athletes demonstrate high levels of physical function, leading to difficulties in patient-reported outcome scoring and interpretation. In particular, the ability of patient-reported outcome (PRO) instruments to adequately discriminate between high levels of upper extremity function-that is, the ceiling effect-is limited. This study evaluated performance characteristics of the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) survey and Patient-Reported Outcomes Measurement Information System (PROMIS) metrics in a population of Division 1 intercollegiate athletes, with specific attention to ceiling effects. METHODS: At a single institution, Division I intercollegiate athletes cleared for full participation in the 2018-2019 season were eligible. The following PROs were collected prospectively via tablet computer: PROMIS upper extremity (UE) computer adaptive test (CAT), PROMIS physical function (PF) CAT, QuickDASH, and QuickDASH Sports/Performing Arts Module. Descriptive statistics, and ceiling and floor effects, were calculated. The proportion of athletes with maximal scores on each PRO were compared to normative values using the 1-sample Wilcoxon signed rank test. RESULTS: A total of 268 participants were included; the mean age was 19.9 ± 1.5 years, 49% were female, and 61% were overhead athletes. Large ceiling effects were observed for the UE CAT (46%), QuickDASH (58%), and QuickDASH Sports Module (82%). The PF CAT demonstrated a relatively low ceiling effect of 6.7%. Athlete scores were all significantly better than published age-matched values from a normative population for all instruments, with the exception of no difference on the QuickDASH for males. DISCUSSION AND/OR CONCLUSION: The PROMIS UE CAT and QuickDash instruments are limited in their ability to assess and discriminate upper extremity function in highly functioning individuals such as Division I athletes. The PROMIS PF CAT, a measure of general physical function, did not suffer from a large ceiling effect.

Reliability of Telephone Acquisition of the PROMIS Upper Extremity Computer Adaptive Test.

PURPOSE: Our primary purpose was to evaluate the reliability of telephone administration of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 in a hand and upper extremity population, and secondarily to make comparisons with the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH). METHODS: Patients more than 1 year out from hand surgeries performed at a single tertiary institution were enrolled. Half of the patients completed telephone PROMIS UE CAT and QuickDASH surveys first, followed by computer-based surveys 1 to 10 days later, and the other half completed them in the reverse order. Telephone surveys were readministered 2 to 6 weeks later to evaluate test-retest reliability. Concordance correlation coefficients (CCCs) were used to assess agreement between telephone and computer-based scores, and intraclass correlation coefficients (ICCs) were used to assess test-retest reliability. The proportion of patients with discrepancies in follow-up scores that exceeded estimates of the minimal clinically important difference (MCID) was evaluated. RESULTS: For the 89 enrolled patients, the PROMIS UE CAT CCC was 0.82 (83% confidence interval [83% CI], 0.77-0.86; good), which was significantly lower than 0.92 (83% CI, 0.89-0.94; good to excellent) for the QuickDASH. The PROMIS UE CAT ICC did not differ significantly from the QuickDASH (0.85 and 0.91, respectively). Differences in telephone versus computer scores exceeded 5 points (MCID estimate) for the PROMIS UE CAT in 34% of patients versus 5% of patients exceeding 14 points (MCID estimate) for the QuickDASH. CONCLUSIONS: Significantly better reliability was observed for the QuickDASH than the PROMIS UE CAT when comparing telephone with computer-based score acquisition. Over one-third of patients demonstrated a clinically relevant difference in scores between the telephone and the computer-administered tests. We conclude that the PROMIS UE CAT should only be administered through computer-based methods. CLINICAL RELEVANCE: These findings suggest that differences in collection methods for the PROMIS UE CAT may systematically affect the scores obtained, which may erroneously influence the interpretation of postoperative scores for hand surgery patients.

Continence outcomes following a modification of the Mitchell bladder neck reconstruction in myelomeningocele: A single institution experience.

BACKGROUND: Many surgical procedures have been developed to improve continence in myelomeningocele patients. Our modification of the Mitchell bladder neck reconstruction involves removal of a diamond-shaped wedge of the anterior bladder neck, tubularization of the bladder neck and urethra to increase outlet resistance, and addition of a bladder neck autologous fascial sling. OBJECTIVE: We aimed to evaluate rates of continence and re-operation in children with myelomeningocele undergoing this Modified Mitchell bladder neck reconstruction. STUDY DESIGN: We retrospectively identified children with myelomeningocele having undergone bladder neck reconstruction at our tertiary care referral center from 2012 to 2016. RESULTS: We identified twelve patients with myelomeningocele undergoing this modified bladder neck reconstruction with sling, four female and eight male, median age at the time of surgery was 7 years old. After initial bladder neck reconstruction with sling only 33% were dry. All patients with bothersome leakage after reconstruction underwent bladder neck bulking. Two patients of twelve (17%) ultimately underwent bladder neck closure and achieved dryness. 58% of patients ultimately achieved continence (Summary Figure). DISCUSSION: Our modification of the bladder neck reconstruction with autologous fascial sling showed midterm rates of incontinence near 60%, with initial post-operative continence at 33%. Our patients, however, required higher rates of reoperation (43%) than previous results would suggest (27%). The first line of re-treatment was bladder neck bulking, but this showed low success. While this procedure is minimally invasive and safe, reasonable expectations of efficacy should be established with families when offering this option. Two patients (17%) required bladder neck closure to achieve dryness. While bladder neck closure is often considered a procedure of last resort, both of these patients were immediately dry. Perhaps bladder neck closure should be considered earlier in our algorithm of surgical continence. CONCLUSION: Our rates of continence with the Modified Mitchell bladder neck reconstruction with a fascial sling were similar to prior bladder neck reconstructions. We did find higher rates of reoperation, and further modifications are warranted to continue to improve continence after surgical procedures in the myelomeningocele population. Select cases may warrant early consideration of bladder neck closure.

Contributors to Increased Mortality Associated With Care Fragmentation After Emergency General Surgery.

Importance: Care fragmentation at time of readmission after emergency general surgery (EGS) is associated with high mortality; however, the factors underlying this finding remain unclear. Objective: To identify patient and hospital factors associated with increased mortality among patients after EGS readmitted within 30 days of discharge to a nonindex hospital. Design, Setting, and Participants: Retrospective cohort study using the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. Participants were all adult patients (18 years or older) who underwent 1 of the 15 most common EGS procedures in the United States from January 1 to November 30, 2014, and survived to discharge. The dates of analysis were October through December 2019. Exposures: Thirty-day readmission to a hospital other than that of the index surgical procedure. The study examined the association of interventions during readmission, change in hospital resource level, and severity of patient illness during readmission. Main Outcomes and Measures: Ninety-day inpatient mortality. Results: In total, 71 944 patients who underwent EGS (mean [SD] age, 59.0 [18.3] years; 53.5% [38 487 of 71 944] female) were readmitted within 30 days of discharge, of whom 10 495 (14.6%) were readmitted to a nonindex hospital. Compared with patients readmitted to index hospitals, patients readmitted to nonindex hospitals were more likely to be readmitted to hospitals with low annual EGS volume (33.5% vs 25.6%, P < .001) and be in the top half of illness severity profile (37.2% vs 31.2%, P < .001). Overall 90-day mortality was higher in the patients readmitted to nonindex hospitals (6.1% vs 4.3%, P < .001). When adjusted for baseline patient and hospital characteristics, care fragmentation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.36; 95% CI, 1.17-1.58; P < .001). After adjustment for interventions performed during readmission, change in EGS hospital volume level, and severity of patient illness, care fragmentation was no longer independently associated with mortality (aOR, 1.05; 95% CI, 0.88-1.26; P = .58). In this complete model, severity of illness was the strongest risk factor of mortality during readmission. Conclusions and Relevance: In this cohort study of adult patients who require rehospitalization after EGS, 14.6% are readmitted to a hospital other than where the index procedure was performed. Although the overall mortality rate is higher for this population, the excess mortality appears to be primarily associated with severity of patient illness at time of readmission. These data underscore the need to develop systems of care to rapidly triage patients to hospitals best equipped to manage their condition.

Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?

OBJECTIVE: To describe the progression of sensorineural hearing loss (SNHL) in the better- and poorer-hearing ears in children with asymptomatic congenital cytomegalovirus (CMV) infection with isolated SNHL. STUDY DESIGN: Longitudinal prospective cohort study. SETTING: Tertiary medical center. SUBJECTS AND METHODS: We analyzed hearing thresholds of the better- and poorer-hearing ears of 16 CMV-infected patients with isolated congenital/early-onset or delayed-onset SNHL identified through hospital-based CMV screening of >30,000 newborns from 1982 to 1992. RESULTS: By 12 months of age, 4 of 7 patients with congenital/early-onset SNHL developed worsening thresholds in the poorer-hearing ear, and 1 had an improvement in the better-hearing ear. By 18 years of age, all 7 patients had worsening thresholds in the poorer-hearing ear and 3 patients had worsening thresholds in the better-hearing ear. Hearing loss first worsened at a mean age of 2 and 6 years in the poorer- and better-hearing ears, respectively. Nine patients were diagnosed with delayed-onset SNHL (mean age of 9 years vs 12 years for the poorer- and better-hearing ears), 6 of whom had worsening thresholds in the poorer-hearing ear and 1 in both ears. CONCLUSION: In most children with congenital CMV infection and isolated SNHL, the poorer-hearing ear worsened earlier and more precipitously than the better-hearing ear. This study suggests that monitoring individual hearing thresholds in both ears is important for appropriate interventions and future evaluation of efficacy of antiviral treatment.

Comparison of Surgical Encounter Direct Costs for Three Methods of Cubital Tunnel Decompression.

BACKGROUND: In situ decompression, subcutaneous transposition, and submuscular transposition for cubital tunnel syndrome have historically yielded similar outcomes. The authors' null hypothesis is that no differences exist in surgical encounter total direct costs for in situ decompression, subcutaneous transposition, and submuscular transposition. METHODS: Adult patients treated surgically for cubital tunnel syndrome by four fellowship-trained hand surgeons between August of 2011 and December of 2016 were identified by CPT code (64718) at their tertiary academic institution. Patients with prior elbow surgery or fracture/dislocation and those undergoing revision or additional simultaneous procedures were excluded. Using their institution's information technology value tools, the authors extracted prospectively collected surgical encounter total direct costs data for each surgical encounter. Costs were compared between groups and modeled using univariate and multivariable gamma regression. RESULTS: In situ decompression, subcutaneous transposition, and submuscular transposition were performed on 45, 62, and 14 unique surgical encounters, respectively, with mean surgical times of 28.0, 46.5, and 50.0 minutes, respectively. Costs differed significantly between surgical methods. Surgical method and provider significantly affected surgical encounter total direct costs in the univariate model. Multivariable modeling demonstrated that subcutaneous transposition was 1.18-fold more costly than in situ decompression and submuscular transposition was 1.55-fold more costly than in situ decompression while controlling for age, sex, and provider. CONCLUSIONS: Surgical costs differed significantly between in situ decompression, subcutaneous transposition, and submuscular transposition. Given historically similar outcomes reported for these techniques, cost differences should be considered in addition to clinical factors to inform surgical decision-making for cubital tunnel syndrome patients.