Thoracolumbar fusions for adult lumbar deformity show superior QALY gain and lower costs compared with upper thoracic fusions.

PURPOSE: Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion. METHODS: ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively. RESULTS: Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p = 0.01), lower surgical invasiveness (- 30; p < 0.001), and shorter OR time (- 35 min; p = 0.01). Index and total costs were 20% lower in the TL than in the UT group (p < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain (p = 0.03) than UT fusions. CONCLUSION: In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions. LEVEL OF EVIDENCE: III.

Ultrasound- and fluoroscopy-guided percutaneous transhepatic shunt attenuation using a vascular plug in a complex canine intrahepatic portosystemic shunt.

A 5-month-old Pembroke Welsh corgi dog was presented with a 3-month history of lethargy, inappetence, polyuria/polydipsia, and neurological signs. A diagnosis of a complex multiple intrahepatic portosystemic shunt (IHPSS) configuration was obtained by computed tomography angiogram, abdominal ultrasonography, and perioperative fluoroscopic angiography. The IHPSS was successfully attenuated by shunt embolization with a vascular plug, using a direct percutaneous hepatic approach under ultrasonographic and fluoroscopic guidance. Long-term (4 y) follow-up revealed resolution of all clinical signs. The owner elected to continue dietary modification and lactulose treatment indefinitely and the outcome was considered good. Key clinical message: Direct percutaneous hepatic approach could be considered for IHPSS attenuation in select cases where traditional transvenous approach access is considered challenging.

Atténuation percutanée trans-hépatique guidée par échographie et fluoroscopie d'un shunt porto-systémique intrahépatique canin complexe à l'aide d'un bouchon vasculaireUn chien Pembroke Welsh corgi âgé de 5 mois a été présenté avec des antécédents de léthargie, d'inappétence, de polyurie/polydipsie et de signes neurologiques depuis 3 mois. Un diagnostic de configuration complexe de shunt porto-systémique intrahépatique multiple (IHPSS) a été obtenu par angiographie par tomodensitométrie, échographie abdominale et angiographie fluoroscopique périopératoire. L'IHPSS a été atténué avec succès par embolisation du shunt avec un bouchon vasculaire, en utilisant une approche hépatique percutanée directe sous guidage échographique et fluoroscopique. Un suivi à long terme (4 ans) a révélé une résolution de tous les signes cliniques. Le propriétaire a choisi de poursuivre indéfiniment la modification du régime alimentaire et le traitement au lactulose et le résultat a été considéré comme bon.Message clinique clé :Une approche hépatique percutanée directe pourrait être envisagée pour l'atténuation de l'IHPSS dans certains cas où l'accès par voie trans-veineuse traditionnelle est considéré comme difficile.(Traduit par Dr Serge Messier).

Use of Hybrid Stage I to Stratify Between Single Ventricle Palliation and Biventricular Repair.

Background: Hybrid stage I palliation (HS1P) has been utilized for patients with single ventricle (SV) congenital heart disease (CHD). To date, reports on the use of HS1P for other indications including biventricular (BiV) CHD have been limited. Methods: We performed a single-center retrospective cohort study of patients who underwent HS1P with an anticipated physiologic outcome of BiV repair, or with an undetermined SV versus BiV outcome. Patient characteristics and outcomes from birth through definitive repair or palliation were collected and reported with descriptive statistics. Results: Nineteen patients underwent HS1P with anticipated BiV repair. Extracardiac and intracardiac risk factors (ICRF) were common. Ultimately, 13 (68%) patients underwent BiV repair, 1 (5%) underwent SV palliation, and 5 (26%) died prior to further palliation or repair. Resolution of ICRF tracked with BiV outcome (6/6, 100%), persistence of ICRF tracked with SV outcome or death (3/3, 100%). Twenty patients underwent HS1P with an undetermined outcome. Ultimately, 13 (65%) underwent BiV repair, 6 (30%) underwent SV palliation, and 1 (5%) underwent transplant. There were no deaths. Intracardiac risk factors were present in 15 of 20 patients (75%); BiV repair only occurred when all ICRF resolved (67%). Post-HS1P complications and reinterventions occurred frequently in both groups, through all phases of care. Conclusions: Hybrid stage 1 palliation can be used to defer BiV repair and to delay decision between SV palliation and BiV repair. Resolution of ICRF was associated with ultimate outcome. In this high-risk group, complications are common, and mortality especially in the marginal BiV patient is high.

Content validity index for the readiness for hospital discharge scale in the skilled nursing facility setting.

OBJECTIVES: The purpose of this study was to determine the appropriateness of using the Readiness for Hospital Discharge Scale (RHDS) in the skilled nursing facility (SNF) setting as a discharge outcome measure. METHODS: Six experts consisting of nurses and physical therapists from two different SNFs in the Midwest were selected to participate in the study. The content validity of the scale was determined by using item and scale content validity index scores to determine the appropriateness of the scale in the SNF setting. RESULTS: The scale content validity index score for the RHDS was 0.96 with an item content validity index score range of 0.83 to 1.0. Kendall's Coefficient of Concordance was 0.278 and the statistical significance had a p-value of 0.031. CONCLUSIONS: The results of this study indicate that the RHDS has good content validity and is an appropriate measure to determine patient discharge readiness in the SNF setting.

Impact of Prior Cervical Fusion on Patients Undergoing Thoracolumbar Deformity Correction.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: Evaluate the impact of prior cervical constructs on upper instrumented vertebrae (UIV) selection and postoperative outcomes among patients undergoing thoracolumbar deformity correction. BACKGROUND: Surgical planning for adult spinal deformity (ASD) patients involves consideration of spinal alignment and existing fusion constructs. METHODS: ASD patients with (ANTERIOR or POSTERIOR) and without (NONE) prior cervical fusion who underwent thoracolumbar fusion were included. Demographics, radiographic alignment, patient-reported outcome measures (PROMs), and complications were compared. Univariate and multivariate analyses were performed on POSTERIOR patients to identify parameters predictive of UIV choice and to evaluate postoperative outcomes impacted by UIV selection. RESULTS: Among 542 patients, with 446 NONE, 72 ANTERIOR, and 24 POSTERIOR patients, mean age was 64.4 years and 432 (80%) were female. Cervical fusion patients had worse preoperative cervical and lumbosacral deformity, and PROMs (P<0.05). In the POSTERIOR cohort, preoperative LIV was frequently below the cervicothoracic junction (54%) and uncommonly (13%) connected to the thoracolumbar UIV. Multivariate analyses revealed that higher preoperative cervical SVA (coeff=-0.22, 95%CI=-0.43--0.01, P=0.038) and C2SPi (coeff=-0.72, 95%CI=-1.36--0.07, P=0.031), and lower preoperative thoracic kyphosis (coeff=0.14, 95%CI=0.01-0.28, P=0.040) and thoracolumbar lordosis (coeff=0.22, 95%CI=0.10-0.33, P=0.001) were predictive of cranial UIV. Two-year postoperatively, cervical patients continued to have worse cervical deformity and PROMs (P<0.05) but had comparable postoperative complications. Choice of thoracolumbar UIV below or above T6, as well as the number of unfused levels between constructs, did not affect patient outcomes. CONCLUSIONS: Among patients who underwent thoracolumbar deformity correction, prior cervical fusion was associated with more severe spinopelvic deformity and PROMs preoperatively. The choice of thoracolumbar UIV was strongly predicted by their baseline cervical and thoracolumbar alignment. Despite their poor preoperative condition, these patients still experienced significant improvements in their thoracolumbar alignment and PROMs after surgery, irrespective of UIV selection. LEVEL OF EVIDENCE: IV.

Implementation Preparation Costs of Virtual Interview Training in Pre-Employment Transition Services: A Budget Impact Analysis.

Virtual Reality Job Interview Training (VR-JIT) and Virtual Interview Training for Transition Age Youth (VIT-TAY) demonstrated initial effectiveness at increasing employment among transition-age youth with disabilities engaged in pre-employment transition services. We characterized activities and estimated the labor and non-labor costs required to prepare schools to implement VR-JIT or VIT-TAY. Implementation preparation and support teams reported labor hours throughout the implementation preparation process. Implementation preparation labor hours at 43 schools cost approximately $1,427 per school, while non-labor costs were $100 per trainee (student). We estimated the replication of implementation preparation labor activities would cost $1,024 per school (range: $841-$1,208). Most costs were spent in delivery planning and teacher training. Given that implementation preparation costs can be barriers to intervention adoption, our results provide critical information for contemplating future implementation of VR-JIT or VIT-TAY.

Virtual Job Interview Training: A Dose Response to Improve Employment for Transition-Age Youth With Disabilities.

Virtual Interview Training for Transition Age Youth and Virtual Reality Job Interview Training are job interview simulators with demonstrated effectiveness in randomized controlled trials. We evaluated their dose responses via secondary data analysis of 558 transition-age youth with disabilities in 47 schools where the simulators were implemented in quasi-experimental studies. Cut-point analyses determined dosing efficiency and efficacy to optimize competitive employment. The most efficient dose when accounting for the balance between dose and employment was completing nine virtual interviews. The most efficacious dose to maximize the likelihood of successful employment was 38, but varied across race, IQ, IDEA categories and employment history. This study provides a novel approach to inform implementation guidelines for virtual interview training in pre-employment transition services. Limitations and implications for research and practice are discussed.

Iliac Accessory Rod Technique for Rod Fracture Prevention in Long Fusion Constructs: 2-Dimensional Operative Video.

Implant-related complications in surgery for adult spinal deformity (ASD) account for roughly $1 billion US health care expenditures over 5 years, with a majority due to primary rod fracture.1,2 Traditional two-rod constructs have demonstrated rod fracture rates of up to 40%, with a median time to fracture of 3 years.3 Current supplementary rod techniques for decreasing rod fractures inadequately address the issue of increased strain across the lumbosacral junction.4 Here, we describe a novel four-rod technique using "iliac accessory rods," designed to mitigate rod fractures by reinforcing osteotomy levels and dispersing biomechanical stress across the lumbosacral junction. Compared with other supplementary rod techniques for ASD, iliac accessory rods anchor to independent iliac bolts.5 The added fixation points across the lumbosacral junction (4 iliac bolts total) substantially offloads stress on primary rods, most of which fracture near the lumbosacral junction.3 Additionally, connecting these rods to primary rods rostrally via side-to-side connectors, above the osteotomy levels, ensures mobile osteotomy segments are reinforced. Presented is a 78-year-old woman with ASD and worsening lower back pain, radiculopathy, and bilateral leg weakness who failed nonoperative management. She underwent T9 to bi-iliac instrumented fusion with L1-S1 posterior column osteotomies, L4-S1 transforaminal lumbar interbody fusions, and bilateral iliac accessory rod fixation. Postoperatively, she recovered well and had improvement in her symptoms. Imaging revealed correction of spinal alignment. The patient consented to the procedure, and the participants and any identifiable individuals consented to publication of his/her image. Institutional Review Board approval was waived because of institutional exemption policy.

Use of Patient-Specific Interbody Cages Through a Minimally Invasive Lateral Approach for Unstable Lumbar Spondylodiskitis.

BACKGROUND AND OBJECTIVES: Patients with diskitis/osteomyelitis who do not respond to medical treatment or develop spinal instability/deformity may warrant surgical intervention. Irregular bony destruction due to the infection can pose a challenge for spinal reconstruction. The authors report a lateral approach using patient-specific interbody cages combined with posterior or lateral instrumentation to achieve spinal reconstruction for spinal instability/deformity from spondylodiskitis. METHODS: This is a retrospective review of 4 cases undergoing debridement, lateral lumbar interbody fusion using patient-specific interbody cages, and supplemental lateral or posterior instrumentation for spinal instability/deformity after spondylodiskitis. The surgical technique is reported, as are the clinical and imaging outcomes. RESULTS: Four male patients with a mean age of 69 years comprised this study. One had lateral lumbar interbody fusion at L2/3 and 3 at L4/5. The mean hospital stay was 5.8 days. The mean follow-up was 8.5 months (range 6-12 months). There were no approach-related neurological injuries or complications. The mean visual analog scale back pain scores improved from 9.5 to 1.5, and the mean Oswestry disability index improved from 68.5 to 23 at the end of the follow-up. The mean lumbar lordosis increased from 18° to 51°. The segmental angle increased from 6.5° to 18°. The coronal shift was 2.8 cm preoperatively and 0.9 cm postoperatively. The coronal Cobb angle reduced from 8.8° preoperatively to 2.8° postoperatively. On postoperative computed tomography, all patients had interval development of bridging bone across the surgical level through or around the cage. None of them developed cage migration or subsidence. CONCLUSION: Patients with irregular bony destruction due to diskitis/osteomyelitis may benefit from patient-specific cages for spinal reconstruction to address spinal instability and deformity.

Hip Osteoarthritis in Patients Undergoing Surgery for Severe Adult Spinal Deformity: Prevalence and Impact on Spine Surgery Outcomes.

BACKGROUND: Hip osteoarthritis (OA) is common in patients with adult spinal deformity (ASD). Limited data exist on the prevalence of hip OA in patients with ASD, or on its impact on baseline and postoperative alignment and patient-reported outcome measures (PROMs). Therefore, this paper will assess the prevalence and impact of hip OA on alignment and PROMs. METHODS: Patients with ASD who underwent L1-pelvis or longer fusions were included. Two independent reviewers graded hip OA with the Kellgren-Lawrence (KL) classification and stratified it by severity into non-severe (KL grade 1 or 2) and severe (KL grade 3 or 4). Radiographic parameters and PROMs were compared among 3 patient groups: Hip-Spine (hip KL grade 3 or 4 bilaterally), Unilateral (UL)-Hip (hip KL grade 3 or 4 unilaterally), or Spine (hip KL grade 1 or 2 bilaterally). RESULTS: Of 520 patients with ASD who met inclusion criteria for an OA prevalence analysis, 34% (177 of 520) had severe bilateral hip OA and unilateral or bilateral hip arthroplasty had been performed in 8.7% (45 of 520). A subset of 165 patients had all data components and were examined: 68 Hip-Spine, 32 UL-Hip, and 65 Spine. Hip-Spine patients were older (67.9 ± 9.5 years, versus 59.6 ± 10.1 years for Spine and 65.8 ± 7.5 years for UL-Hip; p < 0.001) and had a higher frailty index (4.3 ± 2.6, versus 2.7 ± 2.0 for UL-Hip and 2.9 ± 2.0 for Spine; p < 0.001). At 1 year, the groups had similar lumbar lordosis, yet the Hip-Spine patients had a worse sagittal vertebral axis (SVA) measurement (45.9 ± 45.5 mm, versus 25.1 ± 37.1 mm for UL-Hip and 19.0 ± 39.3 mm for Spine; p = 0.001). Hip-Spine patients also had worse Veterans RAND-12 Physical Component Summary scores at baseline (25.7 ± 9.3, versus 28.7 ± 9.8 for UL-Hip and 31.3 ± 10.5 for Spine; p = 0.005) and 1 year postoperatively (34.5 ± 11.4, versus 40.3 ± 10.4 for UL-Hip and 40.1 ± 10.9 for Spine; p = 0.006). CONCLUSIONS: This study of operatively treated ASD revealed that 1 in 3 patients had severe hip OA bilaterally. Such patients with severe bilateral hip OA had worse baseline SVA and PROMs that persisted 1 year following ASD surgery, despite correction of lordosis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A mixed methods evaluation of patient perspectives on the implementation of an electronic health record-integrated patient-reported symptom and needs monitoring program in cancer care.

BACKGROUND: As cancer centers have increased focus on patient-centered, evidenced-based care, implementing efficient programs that facilitate effective patient-clinician communication remains critical. We implemented an electronic health record-integrated patient-reported symptom and needs monitoring program ('cPRO' for cancer patient-reported outcomes). To aid evaluation of cPRO implementation, we asked patients receiving care in one of three geographical regions of an academic healthcare system about their experiences. METHODS: Using a sequential mixed-methods approach, we collected feedback in two waves. Wave 1 included virtual focus groups and interviews with patients who had completed cPRO. In Wave 2, we administered a structured survey to systematically examine Wave 1 themes. All participants had a diagnosed malignancy and received at least 2 invitations to complete cPRO. We used rapid and traditional qualitative methods to analyze Wave 1 data and focused on identifying facilitators and barriers to cPRO implementation. Wave 2 data were analyzed descriptively. RESULTS: Participants (n = 180) were on average 62.9 years old; were majority female, White, non-Hispanic, and married; and represented various cancer types and phases of treatment. Wave 1 participants (n = 37) identified facilitators, including cPRO's perceived value and favorable usability, and barriers, including confusion about cPRO's purpose and various considerations for responding. High levels of clinician engagement with, and patient education on, cPRO were described as facilitators while low levels were described as barriers. Wave 2 (n = 143) data demonstrated high endorsement rates of cPRO's usability on domains such as navigability (91.6%), comprehensibility (98.7%), and relevance (82.4%). Wave 2 data also indicated low rates of understanding cPRO's purpose (56.7%), education from care teams about cPRO (22.5%), and discussing results of cPRO with care teams (16.3%). CONCLUSIONS: While patients reported high value and ease of use when completing cPRO, they also reported areas of confusion, emphasizing the importance of patient education on the purpose and use of cPRO and clinician engagement to sustain participation. These results guided successful implementation changes and will inform future improvements.

Establishing evidence criteria for implementation strategies in the US: a Delphi study for HIV services.

BACKGROUND: There are no criteria specifically for evaluating the quality of implementation research and recommending implementation strategies likely to have impact to practitioners. We describe the development and application of the Best Practices Tool, a set of criteria to evaluate the evidence supporting HIV-specific implementation strategies. METHODS: We developed the Best Practices Tool from 2022-2023 in three phases. (1) We developed a draft tool and criteria based on a literature review and key informant interviews. We purposively selected and recruited by email interview participants representing a mix of expertise in HIV service delivery, quality improvement, and implementation science. (2) The tool was then informed and revised through two e-Delphi rounds using a survey delivered online through Qualtrics. The first and second round Delphi surveys consisted of 71 and 52 open and close-ended questions, respectively, asking participants to evaluate, confirm, and make suggestions on different aspects of the rubric. After each survey round, data were analyzed and synthesized as appropriate; and the tool and criteria were revised. (3) We then applied the tool to a set of research studies assessing implementation strategies designed to promote the adoption and uptake of evidence-based HIV interventions to assess reliable application of the tool and criteria. RESULTS: Our initial literature review yielded existing tools for evaluating intervention-level evidence. For a strategy-level tool, additions emerged from interviews, for example, a need to consider the context and specification of strategies. Revisions were made after both Delphi rounds resulting in the confirmation of five evaluation domains - research design, implementation outcomes, limitations and rigor, strategy specification, and equity - and four evidence levels - best, promising, more evidence needed, and harmful. For most domains, criteria were specified at each evidence level. After an initial pilot round to develop an application process and provide training, we achieved 98% reliability when applying the criteria to 18 implementation strategies. CONCLUSIONS: We developed a tool to evaluate the evidence supporting implementation strategies for HIV services. Although specific to HIV in the US, this tool is adaptable for evaluating strategies in other health areas.

Novel method of iliac accessory rods for rod fracture prevention in adult deformity surgery: a case series of 82 patients with outcomes and complications.

OBJECTIVE: Primary rod fracture after surgery for adult spinal deformity (ASD) is a leading cause of revision, with recent prospective multicenter fracture rates reported at 11%-14% by 2 years. Consequently, the addition of supplemental rods has been explored to reduce fractures. Here the authors describe their experience with a novel iliac accessory rod technique in which each accessory rod anchors to an independent iliac bolt caudally via lateral connector, and attaches to the primary rod rostrally via side-to-side connector. METHODS: This retrospective, single-center case series included patients who underwent thoracolumbar/lumbar fusion for ASD between March 2019 and August 2023. Data on baseline demographics, radiographic parameters, surgical characteristics, complications, rod fracture, and revision rates were collected. Paired, 2-tailed t-tests were used to compare pre- and postoperative radiographic outcomes. Rod fracture rates were compared to prior investigations via chi-square goodness of fit testing. The technique for iliac accessory rod placement is described. RESULTS: The study consisted of 82 patients (mean age 66 years, 51% female, 26% with prior fusion) with a median follow-up of 2 years (IQR 28-104 weeks). A total of 50 patients (61%) had ≥ 2-year follow-up. Each surgery involved an average of 4 posterior column osteotomies and 8 segments. Iliac accessory rods were cobalt chromium and were placed bilaterally in 87% of constructs. Postoperative alignment improved significantly in the following parameters: maximum coronal Cobb angle, fractional curve, sagittal vertical axis, lumbar lordosis, thoracic kyphosis, and pelvic incidence to lumbar lordosis mismatch (p < 0.001 for all comparisons). Of 50 patients with ≥ 2-year follow-up, rod fracture occurred in 1 (2.0%), which was incidentally found and required no intervention. The present rod fracture rate was significantly lower than the authors' historically reported institutional rate of 21% for traditional dual-rod constructs, and the 11%-14% reported in recent prospective multicenter studies that used traditional and supplemental rod constructs (p < 0.05 for all comparisons). Reoperation occurred in 12 patients (14.6%); 7 (8.5%) for proximal junctional kyphosis and 5 (6.1%) for wound complication. CONCLUSIONS: Here the authors describe their experience with a novel iliac accessory rod technique to prevent rod fracture in patients undergoing surgery for ASD. The 2-year rod fracture rate (2.0%) in this study is significantly lower than the authors' historical dual-rod fracture rate, and other prospective multicenter investigations. Future studies with longer follow-up are needed to determine the durability of this technique.

Multilevel perspectives on the implementation of the collaborative care model for depression and anxiety in primary care.

BACKGROUND: The Collaborative Care Model (CoCM) is an evidence-based mental health treatment in primary care. A greater understanding of the determinants of successful CoCM implementation, particularly the characteristics of multi-level implementers, is needed. METHODS: This study was a process evaluation of the Collaborative Behavioral Health Program (CBHP) study (NCT04321876) in which CoCM was implemented in 11 primary care practices. CBHP implementation included screening for depression and anxiety, referral to CBHP, and treatment with behavioral care managers (BCMs). Interviews were conducted 4- and 15-months post-implementation with BCMs, practice managers, and practice champions (primary care clinicians). We used framework-guided rapid qualitative analysis with the Consolidated Framework for Implementation Research, Version 2.0, focused on the Individuals domain, to analyze response data. These data represented the roles of Mid-Level Leaders (practice managers), Implementation Team Members (clinicians, support staff), Innovation Deliverers (BCMs), and Innovation Recipients (primary care/CBHP patients) and their characteristics (i.e., Need, Capability, Opportunity, Motivation). RESULTS: Mid-level leaders (practice managers) were enthusiastic about CBHP (Motivation), appreciated integrating mental health services into primary care (Need), and had time to assist clinicians (Opportunity). Although CBHP lessened the burden for implementation team members (clinicians, staff; Need), some were hesitant to reallocate patient care (Motivation). Innovation deliverers (BCMs) were eager to deliver CBHP (Motivation) and confident in assisting patients (Capability); their opportunity to deliver CBHP could be limited by clinician referrals (Opportunity). Although CBHP alleviated barriers for innovation recipients (patients; Need), it was difficult to secure services for those with severe conditions (Capability) and certain insurance types (Opportunity). CONCLUSIONS: Overall, respondents favored sustaining CoCM and highlighted the positive impacts on the practice, health care team, and patients. Participants emphasized the benefits of integrating mental health services into primary care and how CBHP lessened the burden on clinicians while providing patients with comprehensive care. Barriers to CBHP implementation included ensuring appropriate patient referrals, providing treatment for patients with higher-level needs, and incentivizing clinician engagement. Future CoCM implementation should include strategies focused on education and training, encouraging clinician buy-in, and preparing referral paths for patients with more severe conditions or diverse needs. TRIAL REGISTRATION: ClinicalTrials.gov(NCT04321876). Registered: March 25,2020. Retrospectively registered.

Ending the HIV Epidemic in Metropolitan Atlanta: a mixed-methods study to support the local HIV/AIDS response.

INTRODUCTION: Four counties within the Atlanta, Georgia 20-county eligible metropolitan area (EMA) are currently prioritized by the US "Ending the HIV Epidemic" (EHE) initiative which aims for a 90% reduction in HIV incidence by 2030. Disparities driving Atlanta's HIV epidemic warrant an examination of local service availability, unmet needs and organizational capacity to reach EHE targets. We conducted a mixed-methods evaluation of the Atlanta EMA to examine geographic HIV epidemiology and distribution of services, service needs and organization infrastructure for each pillar of the EHE initiative. METHODS: We collected 2021 county-level data (during June 2022), from multiple sources including: AIDSVu (HIV prevalence and new diagnoses), the Centers for Disease Control and Prevention web-based tools (HIV testing and pre-exposure prophylaxis [PrEP] locations) and the Georgia Department of Public Health (HIV testing, PrEP screenings, viral suppression and partner service interviews). We additionally distributed an online survey to key local stakeholders working at major HIV care agencies across the EMA to assess the availability of services, unmet needs and organization infrastructure (June-December 2022). The Organizational Readiness for Implementing Change questionnaire assessed the organization climate for services in need of scale-up or implementation. RESULTS: We found racial/ethnic and geographic disparities in HIV disease burden and service availability across the EMA-particularly for HIV testing and PrEP in the EMA's southern counties. Five counties not currently prioritized by EHE (Clayton, Douglas, Henry, Newton and Rockdale) accounted for 16% of the EMA's new diagnoses, but <9% of its 177 testing sites and <7% of its 130 PrEP sites. Survey respondents (N = 48; 42% health agency managers/directors) reported high unmet need for HIV self-testing kits, mobile clinic testing, HIV case management, peer outreach and navigation, integrated care, housing support and transportation services. Respondents highlighted insufficient existing staffing and infrastructure to facilitate the necessary expansion of services, and the need to reduce inequities and address intersectional stigma. CONCLUSIONS: Service delivery across all EHE pillars must substantially expand to reach national goals and address HIV disparities in metro Atlanta. High-resolution geographic data on HIV epidemiology and service delivery with community input can provide targeted guidance to support local EHE efforts.

Mechanisms of lumbar spine "flattening" in adult spinal deformity: defining changes in shape that occur relative to a normative population.

PURPOSE: Previous work comparing ASD to a normative population demonstrated that a large proportion of lumbar lordosis is lost proximally (L1-L4). The current study expands on these findings by collectively investigating regional angles and spinal contours. METHODS: 119 asymptomatic volunteers with full-body free-standing radiographs were used to identify age-and-PI models of each Vertebra Pelvic Angle (VPA) from L5 to T10. These formulas were then applied to a cohort of primary surgical ASD patients without coronal malalignment. Loss of lumbar lordosis (LL) was defined as the offset between age-and-PI normative value and pre-operative alignment. Spine shapes defined by VPAs were compared and analyzed using paired t-tests. RESULTS: 362 ASD patients were identified (age = 64.4 ± 13, 57.1% females). Compared to their age-and-PI normative values, patients demonstrated a significant loss in LL of 17 ± 19° in the following distribution: 14.1% had "No loss" (mean = 0.1 ± 2.3), 22.9% with 10°-loss (mean = 9.9 ± 2.9), 22.1% with 20°-loss (mean = 20.0 ± 2.8), and 29.3% with 30°-loss (mean = 33.8 ± 6.0). "No loss" patients' spine was slightly posterior to the normative shape from L4 to T10 (VPA difference of 2°), while superimposed on the normative one from S1 to L2 and became anterior at L1 in the "10°-loss" group. As LL loss increased, ASD and normative shapes offset extended caudally to L3 for the "20°-loss" group and L4 for the "30°-loss" group. CONCLUSION: As LL loss increases, the difference between ASD and normative shapes first occurs proximally and then progresses incrementally caudally. Understanding spinal contour and LL loss location may be key to achieving sustainable correction by identifying optimal and personalized postoperative shapes.

A Scoping Review of Tailoring in Pediatric Obesity Interventions.

Background: Families with children who have or are at risk for obesity have differing needs and a one-size-fits-all approach can negatively impact program retention, engagement, and outcomes. Individually tailored interventions could engage families and children through identifying and prioritizing desired areas of focus. Despite literature defining tailoring as individualized treatment informed by assessment of behaviors, intervention application varies. This review aims to exhibit the use of the term "tailor" in pediatric obesity interventions and propose a uniform definition. Methods: We conducted a scoping review following PRISMA-ScR guidelines among peer-reviewed pediatric obesity prevention and management interventions published between 1995 and 2021. We categorized 69 studies into 6 groups: (1) individually tailored interventions, (2) computer-tailored interventions/tailored health messaging, (3) a protocolized group intervention with a tailored component, (4) only using the term tailor in the title, abstract, introduction, or discussion, e) using the term tailor to describe another term, and (5) interventions described as culturally tailored. Results: The scoping review exhibited a range of uses and lack of explicit definitions of tailoring in pediatric obesity interventions including some that deviate from individualized designs. Effective tailored interventions incorporated validated assessments for behaviors and multilevel determinants, and recipient-informed choice of target behavior(s) and programming. Conclusions: We urge interventionists to use tailoring to describe individualized, assessment-driven interventions and to clearly define how an intervention is tailored. This can elucidate the role of tailoring and its potential for addressing the heterogeneity of behavioral and social determinants for the prevention and management of pediatric obesity.

Expectations of clinical improvement following corrective surgery for adult cervical deformity based on functional disability at presentation.

PURPOSE: To assess impact of baseline disability on HRQL outcomes. METHODS: CD patients with baseline (BL) and 2 year (2Y) data included, and ranked into quartiles by baseline NDI, from lowest/best score (Q1) to highest/worst score (Q4). Means comparison tests analyzed differences between quartiles. ANCOVA and logistic regressions assessed differences in outcomes while accounting for covariates (BL deformity, comorbidities, HRQLs, surgical details and complications). RESULTS: One hundred and sixteen patients met inclusion (Age:60.97 ± 10.45 years, BMI: 28.73 ± 7.59 kg/m2, CCI: 0.94 ± 1.31). The cohort mean cSVA was 38.54 ± 19.43 mm and TS-CL: 37.34 ± 19.73. Mean BL NDI by quartile was: Q1: 25.04 ± 8.19, Q2: 41.61 ± 2.77, Q3: 53.31 ± 4.32, and Q4: 69.52 ± 8.35. Q2 demonstrated greatest improvement in NRS Neck at 2Y (-3.93), compared to Q3 (-1.61, p = .032) and Q4 (-1.41, p = .015). Q2 demonstrated greater improvement in NRS Back (-1.71), compared to Q4 (+ 0.84, p = .010). Q2 met MCID in NRS Neck at the highest rates (69.9%), especially compared to Q4 (30.3%), p = .039. Q2 had the greatest improvement in EQ-5D (+ 0.082), compared to Q1 (+ 0.073), Q3 (+ 0.022), and Q4 (+ 0.014), p = .034. Q2 also had the greatest mJOA improvement (+ 1.517), p = .042. CONCLUSIONS: Patients in Q2, with mean BL NDI of 42, consistently demonstrated the greatest improvement in HRQLs whereas those in Q4, (NDI 70), saw the least. BL NDI between 39 and 44 may represent a disability "Sweet Spot," within which operative intervention maximizes patient-reported outcomes. Furthermore, delaying intervention until patients are severely disabled, beyond an NDI of 61, may limit the benefits of surgery.

Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course.

BACKGROUND: Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described. STUDY DESIGN/SETTING: This is a retrospective study on a prospectively enrolled, complex ASD database. PURPOSE: This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications. METHODS: Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO. RESULTS: 648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086). CONCLUSION: Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.