Come Together to Decrease Depression: Women's mental health, social capital, and participation in a Kenyan combined microfinance program.

BACKGROUND: Tools and systems to improve mental health have been understudied in low-resource environments, such as sub-Saharan Africa. This study explores depression amongst women participating in a community-based intervention combining savings- and lending-groups, entrepreneurial training and other skills training. AIMS: This study aims to determine whether depression decreases with more program participation, and the extent to which social capital variables may explain these changes. METHOD: Survey data were gathered in June 2018, within 6 months of group formation, and again in June 2019 from 400 women participants in the program. Data between 2018 and 2019 were compared using Wilcoxon rank-sum and Chi square tests. Inferential statistics included random effects regression models and general structural equation models. RESULTS: At 1-year follow-up, depression and loneliness amongst Kenyan women (n = 400) participating in the program had decreased. Social capital remained higher within groups than within the broader community, and mediated the association between program participation and decreased depression. CONCLUSIONS: Findings suggest this novel, community-based intervention has the potential to benefit mental health. Future research, including a randomised control trial, is required to establish (1) the extent of the program's benefits and (2) the program's application to particular subject areas and population segments.

RNF41 regulates the damage recognition receptor Clec9A and antigen cross-presentation in mouse dendritic cells.

The dendritic cell receptor Clec9A facilitates processing of dead cell-derived antigens for cross-presentation and the induction of effective CD8+ T cell immune responses. Here, we show that this process is regulated by E3 ubiquitin ligase RNF41 and define a new ubiquitin-mediated mechanism for regulation of Clec9A, reflecting the unique properties of Clec9A as a receptor specialized for delivery of antigens for cross-presentation. We reveal RNF41 is a negative regulator of Clec9A and the cross-presentation of dead cell-derived antigens by mouse dendritic cells. Intriguingly, RNF41 regulates the downstream fate of Clec9A by directly binding and ubiquitinating the extracellular domains of Clec9A. At steady-state, RNF41 ubiquitination of Clec9A facilitates interactions with ER-associated proteins and degradation machinery to control Clec9A levels. However, Clec9A interactions are altered following dead cell uptake to favor antigen presentation. These findings provide important insights into antigen cross-presentation and have implications for development of approaches to modulate immune responses.

40% reoperation rate in adolescents with spondylolisthesis.

STUDY DESIGN: Multicenter retrospective. OBJECTIVE: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population. METHODS: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed. RESULTS: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76). CONCLUSION: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.

Triggered EMG (T-EMG) Values of Pedicle Screws with a Powered Screwdriver vs A Standard Probe in Adolescent Idiopathic Scoliosis Do Not Agree: A Prospective Validation Study.

Triggered electromyography (t-EMG) is a common technique used during spinal instrumentation in surgery for adolescent idiopathic scoliosis. This study tests the validity of t-EMG values obtained with a standard ball-tipped probe after completion of screw placement versus t-EMG values obtained during screw insertion with a powered screwdriver. t-EMG values were collected for screws spanning T7-L5 using both a standard probe and a powered screwdriver. A power analysis determined that a sample size of 300 screws would provide enough precision to estimate limits of agreement within ±2 mA. A monopolar constant current stimulation technique (0.2 ms duration and 3.11 Hz stimulation rate) was used at each level. EMG was acquired with placement of bipolar pairs of subdermal needle electrodes. A Bland-Altman plot was used to assess agreement between threshold readings from the two techniques. Twenty-nine patients were enrolled in this study with 305 screws. t-EMG values measured using a powered screwdriver were on average 1 mA lower than values from a standard probe. When readings less than or equal to 20 mA were considered, the limits of agreement were approximately 4 and 7 mA overall. In total, 28/305 (9%) screws were removed and reinserted, 9/305 (3%) screws were redirected, and 3/305 (1%) screws were aborted based on t-EMG readings. Despite a small overall difference in t-EMG value between the standard probe and screwdriver, there was still large variability in agreement between the two techniques. t-EMG values obtained with a powered screwdriver during screw insertion are not interchangeable with values measured by a probe.

Topical Vancomycin in Pediatric Spine Surgery Does Not Reduce Surgical Site Infection: A Retrospective Cohort Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Evaluate the effectiveness of topical vancomycin in reducing surgical site infection (SSI) in pediatric patients undergoing posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA: There has been increased interest in use of topical vancomycin to reduce SSI in spine surgery with mixed results reported in the literature. In Summer 2012, our institution implemented the use of topical vancomycin in definitive primary and revision PSF as part of our infection control protocol. METHODS: After IRB approval, a consecutive series of 527 patients (538 procedures) undergoing PSF January 2010-December 2014 were retrospectively reviewed to identify the occurrence of SSI. Based on published results from a similar study, an a priori power analysis determined 190 patients were needed per group to achieve 0.90 power. In 228 procedures, topical vancomycin was used (Vanco) and in 310 procedures it was not (No Vanco). Exclusion criteria were <90 days follow-up, >18 years at time of surgery, and combined anterior and posterior fusion. Two-sample t tests, Wilcoxon rank-sum tests, and Fisher exact tests were used to compare the cohorts. RESULTS: Groups were similar in age, sex, implant density, fusion length, risk categorization, and surgical time (p > .05). No Vanco had significantly higher blood loss and incidence and amount of intraoperative allogenic transfusion (p < .001). Incidence of SSI was 3% (7/228) in Vanco and 2% (6/310) in No Vanco (p = .4099). Six of the 7 SSIs occurred in high-risk patients in Vanco and 5 of 6 occurred in high-risk patients in No Vanco (p = 1). Reoperation within 90 days was 6% (13/228) in Vanco and 4% (11/310) in No Vanco (p = .2912). Occurrence of other complications was similar between Vanco, 3% (7/228), and No Vanco, 2% (5/310). CONCLUSION: Use of topical vancomycin did not reduce incidence of SSI for pediatric patients undergoing PSF at our institution. LEVEL OF EVIDENCE: Level III.

Anterior Spinal Fusion and Posterior Spinal Fusion Both Effectively Treat Lenke Type 5 Curves in Adolescent Idiopathic Scoliosis: A Multicenter Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Retrospective comparison of radiographic and clinical outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) in surgical treatment of Lenke 5 curves. SUMMARY OF BACKGROUND DATA: ASF and PSF are used for treatment of Lenke 5 curves in patients with adolescent idiopathic scoliosis (AIS). Currently, no consensus exists for optimal surgical treatment of Lenke 5 curves. METHODS: Patients with Lenke 5 curves treated with either ASF or PSF were prospectively enrolled in a multicenter database and then retrospectively reviewed. Demographic data, perioperative measures, radiographic data, and SRS-22R scores were collected and compared for statistical significance. RESULTS: A total of 149 patients were included in the study; 51 underwent PSF and 98 underwent ASF. There was no difference in demographics between groups. The PSF group was fused one level longer than the ASF group (5.9 levels PSF, 4.6 levels ASF, p < .0001). The PSF group had shorter operative times (223 minutes PSF, 297 minutes ASF; p < .0001) and a higher proportion of patients who received a postoperative blood transfusion (45% vs. 5%, p < .0001). PSF patients had longer hospital stays (6.1d PSF vs. 5d ASF, p = .031). The ASF group had larger preoperative major curve (48.2° ASF, 44.2° PSF; p < .01). Coronal balance, thoracolumbar/lumbar Cobb angle, shoulder height, trunk shift, and overall sagittal balance were not different between groups at two-year follow-up. Curve correction at two-year follow-up was similar between groups (66% ASF vs. 62% PSF). There were no significant differences in clinical outcomes or complication rates between groups. CONCLUSION: There is no difference in radiographic or clinical outcomes in patients treated with ASF or PSF for Lenke 5 curves. ASF may save a fusion level, but has longer operative time than PSF. Ultimately, the risks and benefits of each approach merit consideration by surgeon and patient. LEVEL OF EVIDENCE: Level II.

Complication Severity Score for Growth-friendly Surgery Has Strong Interrater and Intrarater Agreement.

BACKGROUND: Growth-friendly surgery has high complication rates. The Complication Severity Score for growth-friendly surgery was developed to maintain consistency while reporting complications as part of research in this rapidly evolving field. This study evaluates the interrater and intrarater reliability of this complication classification system. METHODS: After Institutional Review Board approval, complications during treatment for early onset scoliosis were identified from a prospectively collected database. Previous validation studies and a 10-case pilot survey determined that 60 cases were needed to represent a minimum of substantial agreement. In total, 63 of 496 cases were selected randomly to evenly represent each severity classification. The cases comprised an internet survey for classification sent to faculty and research coordinators involved in early onset scoliosis research, 3 weeks apart, with questions shuffled between iterations. Fleiss Kappa and Cohen Kappa were used to assess interrater and intrarater agreement, respectively. RESULTS: A total of 20 participants, 12 faculty and 8 research assistants, completed the survey twice. The overall Fleiss Kappa coefficient for interrater agreement from the second round of the survey was 0.86 (95% confidence interval, 0.86-87), which represents substantial agreement. Reviewers agreed almost perfectly on categorizing complications as Device I (0.85), Disease I (0.91), Disease II (0.94), Device IIB (0.92), and Disease IV (0.98). There was substantial agreement for categorizing Device IIA (0.73) and Device III (0.76) complications. Disease III and Device IV were not evaluated in this survey since none of these occurred in the database. There was almost perfect intrarater agreement among faculty (0.87), research coordinators (0.85), and overall (0.86). CONCLUSIONS: There is strong interrater and intrarater agreement for the published complications classification scheme for growing spine surgery. The complication classification system is a reliable tool for standardizing reports of complications with growth-friendly surgery. Adoption of this classification when reporting on growth-friendly surgery is recommended to allow for comparison of complications between treatment modalities. LEVEL OF EVIDENCE: Level I-diagnostic study.

Spine and Thoracic Height Measurements Have Excellent Interrater and Intrarater Reliability in Patients With Early Onset Scoliosis.

STUDY DESIGN: Reproducibility of measurements. OBJECTIVE: This study investigates the reliability and standard error of measurement of spine and thoracic height radiographic measurements in patients with early onset scoliosis (EOS). SUMMARY OF BACKGROUND DATA: Spine and thoracic height radiographic measurements are often used as a surrogate for pulmonary development in patients with EOS. There is limited literature validating the reliability of spine and thoracic height measurements in the EOS population. METHODS: Using pilot data, we determined measuring 49 unique radiographs would provide 80% power to obtain a 95% confidence interval (CI) width of 0.05 for the interclass correlation coefficients (ICCs). A random sampling strategy, stratified by underlying diagnosis from the Classification of Early Onset Scoliosis (C-EOS), was used to distribute the diagnoses in the study sample. Two attending pediatric spine surgeons, two pediatric orthopedic fellows, and two research assistants measured coronal spine (T1-S1) and thoracic (T1-T12) height on digital radiographs using imaging software (Surgimap; Nemaris, Inc, New York) on two separate occasions at least 3 weeks apart. Order of images was randomized for the second iteration. Linear mixed model regression analyses were used to estimate interrater and intrarater reliability. RESULTS: The study sample included subjects (N = 48) with idiopathic (N = 17, 35%), congenital (N = 16, 33%, 1 patient excluded), neuromuscular (N = 11, 23%), and syndromic (N = 4, 8%) scoliosis. Overall interrater reliability estimates for spine height (ICC: 0.894, 95% CI: 0.847-0.932) and thoracic height (ICC: 0.890, 95% CI: 0.844-0.929) were excellent. Intrarater reliability estimates for spine height (ICC: 0.906, 95% CI: 0.830-0.943) and thoracic height (ICC: 0.898, 95% CI: 0.817-0.938) were also excellent. CONCLUSION: There is excellent interrater and intrarater reliability for radiographic measurements of spine and thoracic height in the EOS population at our institution. LEVEL OF EVIDENCE: 2.