Assessing knowledge of end-stage kidney disease and treatment options in hospitalized African American patients undergoing hemodialysis.

OBJECTIVE: African Americans are more likely to develop end-stage kidney disease (ESKD) than whites and face multiple inequities regarding ESKD treatment, renal replacement therapy (RRT), and overall care. This study focused on determining gaps in participants' knowledge of their chronic kidney disease and barriers to RRT selection in an effort to identify how we can improve health care interventions and health outcomes among this population. METHODS: African American participants undergoing hemodialysis were recruited from an ongoing research study of hospitalized patients at an urban Midwest academic medical center. Thirty-three patients were interviewed, and the transcribed interviews were entered into a software program. The qualitative data were coded using template analysis to analyze text and determine key themes. Medical records were used to obtain demographic and additional medical information. RESULTS: Three major themes emerged from the analysis: patients have limited information on ESKD causes and treatments, patients did not feel they played an active role in selecting their initial dialysis unit, and interpersonal interactions with the dialysis staff play a large role in overall unit satisfaction. DISCUSSION: Although more research is needed, this study provides information and suggestions to improve future interventions and care quality, specifically for this population.

Renal Replacement Knowledge and Preferences for African Americans With Chronic Kidney Disease.

BACKGROUND: Renal replacement therapies (RRT) other than in-centre haemodialyses are underutilised by African Americans with end-stage renal disease (ESRD) even though they are associated with reduced costs, morbidity and mortality as well as improved quality of life for patients. OBJECTIVES: To understand African American patients' knowledge of RRT options and how patient, provider and system-factors contribute to knowledge and preferences. Participants' interviews were conducted at the University of Chicago Medical Center with African American patients with chronic kidney disease (CKD). The final analysis included 28 interviews; 22 patients had CKD not yet on dialysis or having received a transplant, while 6 had reached ESRD and were receiving treatment for kidney failure. Approach Transcripts were uploaded into NVivo8 for coding. Thematic analysis was used for data interpretation. RESULTS: Four themes were identified: (1) limited knowledge of home modalities and deceased donor options, (2) CKD patients gave little thought to choosing RRT options, (3) CKD patients relied on doctors for treatment decisions, and (4) while patients reported knowledge of living kidney donation transplants (LKDT), it did not translate to receiving an LKDT. CONCLUSION: African Americans face significant knowledge and access barriers when deciding on their RRT treatment. Even patients with advanced CKD were still in the early stages of RRT selection. Understanding the knowledge gaps and barriers patients face will inform our subsequent intervention to educate and motivate patients to increase CKD self-care and improve communication between patients, their families and their providers about different RRT treatments.

"I Try Not to Even Think About My Health Going Bad": a Qualitative Study of Chronic Kidney Disease Knowledge and Coping Among a Group of Urban African-American Patients with CKD.

CONTEXT: African-Americans with chronic kidney disease (CKD) are more likely to progress to end-stage renal disease (ESRD). However, African-Americans are less likely to receive care to delay progression of their CKD and to prepare for ESRD treatment. OBJECTIVE: The objectives of the study are to understand knowledge among urban, African-American patients diagnosed with CKD and to discover ways they managed their illness and prepared for kidney disease progression. DESIGN: A qualitative study was conducted using structured interviews. Thematic analysis was used for data interpretation. All 23 participants identified as African-American and had CKD but had not yet reached ESRD requiring renal replacement therapy (RRT). Over half of the participants were women (57%), and the mean age was 53 years old. RESULTS: Three themes emerged from the data. African-Americans often did not know the severity of their CKD. They struggled to complete all of the diet, exercise, and medication tasks recommended to manage their health conditions, including CKD. Finally, participants, even those with stage 5 CKD, viewed progression to RRT in the next 12 months as unlikely. CONCLUSION: African-Americans face many barriers to CKD self-care and preparation for ESRD. Improving outcomes requires clinicians to help patients understand the severity of their CKD, to make informed choices about their care, all the while motivating patients to take actions to prevent CKD progression.

International utilization of the SRS-22 instrument to assess outcomes in adolescent idiopathic scoliosis: what can we learn from a medical outreach group in Ghana?

BACKGROUND: Cross-cultural studies on adolescent idiopathic scoliosis (AIS) populations are limited. This study evaluated the discriminate validity of the Scoliosis Research Society Questionnaire (SRS-22) in Ghana between adolescents with and without AIS. SRS-22 outcomes from AIS and normal adolescents in Ghana were also compared with scores from AIS and normal adolescents in America. METHODS: A retrospective review of preoperative SRS-22 questionnaires from Ghana and New York City was completed. In Ghana, 84 adolescents without scoliosis (healthy-G) (32 female adolescents; mean age, 13.3 y) and 61 patients with AIS (AIS-G) (76 female adolescents; mean age, 15.4 y) were administered with the SRS-22 questionnaire. From the New York City, 450 healthy adolescents (healthy-US) (279 female adolescents; mean age, 16 y) and 302 patients with AIS (AIS-US) (227 female adolescents; mean age, 14.9 y) also completed the SRS-22 questionnaire. Patients with curve magnitudes <40 (nonoperative) were then excluded. All 4 groups were matched based on age and sex, resulting in 4 groups of 40 subjects (25 female adolescents; mean age, 14.5 y for all groups). Differences in SRS-22 scores across the groups were analyzed using analysis of variance and analysis of covariance, with the Bonferroni post hoc tests, to control for differences in curve magnitude. RESULTS: Mean curve magnitude for the matched groups was larger for the AIS-G group [67.2 degrees (range, 42 to 130 degrees)] as compared with the AIS-US group [52 degrees (range, 40 to 76 degrees)] (P<0.01). When controlling for the curve magnitude, a significant difference between all 4 study groups was found within all domains and total score (P<0.01). AIS-G displayed significantly lower scores in the activity, image, pain, and mental health domains (P<0.01); this reached the minimal clinically importance difference for these domains. Healthy-US and healthy-G had better overall and domain-specific scores than AIS-US and AIS-G, respectively (P<0.05). CONCLUSIONS: These findings illustrate the affect of AIS within a culture as well as across cultures. Healthy adolescents had significantly better scores than scoliotic adolescents. Ghanaian adolescents had significantly worse Health-Related Quality-of-Life scores than American adolescents, especially those suffering from AIS. These differences should be kept in mind by those treating this already emotionally vulnerable adolescent population. LEVEL OF EVIDENCE: Level II Prognostic.

Late treatment of tuberculosis-associated kyphosis: literature review and experience from a SRS-GOP site.

INTRODUCTION: Spinal tuberculosis (TB) accounts for approximately half of all cases of musculoskeletal tuberculosis. Kyphosis is the rule in spinal tuberculosis and has potential detrimental effects on both the spinal cord and pulmonary function. Late-onset paraplegia is best avoided with the surgical correction of severe kyphosis, where at the same time anterior decompression of the cord is performed and the remnants of the tuberculosis-destroyed vertebral bodies are excised. MATERIAL AND METHODS: Review of the literature on late surgical treatment of TB-associated kyphosis; description and comparative analysis of the different surgical techniques. RESULTS: Kyphosis can be corrected either at the acute stage or at the healed late stage of tuberculous infection. In the late stage, the stiffness of the spine and chronic lung disease are additional considerations for the surgical approach and technique. Contrary to the traditional anterior transpleural approach used in the acute spinal tuberculosis infection, extrapleural approaches, either antero-lateral or direct posterior, are favored in late treatment. CONCLUSION: The correction of deformity is only feasible with three-column osteotomies, and posterior vertebral column resection (PVCR) is the treatment of choice in extreme kyphosis. The prognosis of the neurologic deficit (late paraplegia) is dependent on the extent of gliosis of the spinal cord.

Axial lumbar interbody fusion (AxiaLIF) approach for adult scoliosis.

BACKGROUND: AxiaLIF was initially advocated as a minimally invasive, presacral lumbar fusion approach. Its use has expanded in to adult scoliosis surgeries. METHODS: Current literature about AxiaLIF for degenerative lumbar surgery and adult scoliosis surgery were reviewed. Anatomy, biomechanical properties, clinical results, and complications were summarized. RESULTS: Anatomically, AxiaLIF is relatively safe even though traversing blood vessels, and the pelvic splanchnic nerve can be at risk. AxiaLIF can provide significant stiffness compared to the intact spine, but posterior supplementation is recommended. AxiaLIF in the long construct for adult scoliosis surgeries can protect the S1 screw as effectively as pelvic fixation. Successful clinical outcomes after AxiaLIF were reported in the degenerative lumbar spine, adult scoliosis, and spondylolisthesis. It can facilitate a high fusion rate up to 96 % without BMP. Complications include pseudarthrosis, rectal injury, transient nerve irritation, and intrapelvic hematoma. CONCLUSION: AxiaLIF is a relatively safe procedure, and it provides good clinical results in both short constructs and long constructs for adult scoliosis surgery. For a safer procedure, surgeons should seek out prior colorectal surgical history and review preoperative imaging studies carefully.

Outcome of Revision Surgery in Pediatric Spine Deformity Patients.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To report the complications and outcomes of pediatric revision spine surgery and review the surgical indications and treatment methods. BACKGROUND SUMMARY: Recent reports have shown the necessity of revision spine surgery for pediatric deformities. Many reports have shown the result of revision surgery for pediatric spinal deformity. MATERIALS AND METHODS: We conducted a retrospective review of 638 patients with pediatric spinal deformity who were treated with surgery from 1996 to 2007. We identified 50 patients who underwent revision spinal fusion surgery with a minimum of 3 years of follow-up. RESULTS: Mean follow-up was 4 years (range, 3-8.3 years). The diagnosis at index surgery was idiopathic scoliosis in 18 patients, congenital scoliosis in 13, neuromuscular scoliosis in 13, tumor and spinal arteriovenous malformation in 4, burst fracture in thoracic spine in 1, and Scheuermann kyphosis in 1. The primary surgeries were 1 hemi epiphysiodesis, 3 anterior spinal fusions, 4 posterior decompressions, 8 combined anterior and posterior spinal fusions, and 34 posterior spinal fusions. A total of 16 patients had pseudarthrosis, 12 decompensation, 11 progressive kyphosis, 8 crankshaft phenomenon, 2 infections, and 1 junctional degeneration. All 50 reoperations included spinal instrumentation and fusion. The revision surgeries were 2 anterior spinal fusions, 14 posterior fusions, and 34 combined anterior and posterior spinal fusions. Spine arthrodesis was obtained in 98% of patients (49 of 50) and complications occurred in 14% of patients (7 of 50). The Scoliosis Research Society Patient Questionnaire outcomes at the latest follow-up were as follows: total 3.95, function 3.88, pain 3.83, self-image 3.98, and mental health 4.04. CONCLUSION: Pseudarthrosis was the most common indication for revision surgery, and bony union was achieved in 98% with revision surgery. Despite the complications, pediatric revision spine surgery can achieve successful outcomes.

Long-term Clinical and Radiographic Outcomes of Pedicle Subtraction Osteotomy for Fixed Sagittal Imbalance: Does Level of Proximal Fusion Affect the Outcome? Minimum 5-Year Follow-up.

STUDY DESIGN: Retrospective case series of surgically treated adult patients with fixed sagittal imbalance. OBJECTIVE: To assess clinical and radiographic changes after pedicle subtraction osteotomy (PSO) to treat adult fixed sagittal imbalance. BACKGROUND: Although recent reports have shown favorable clinical outcomes for PSO, few reports have published long-term follow-up outcomes. It is also unknown whether long-term outcomes are correlated with the level of proximal fusion and the radiographic changes that are observed after PSO. MATERIALS AND METHODS: We reviewed the charts, X-rays, and postoperative SRS-22 and Oswestry Disability Index (ODI) scores of 32 adult patients who presented with fixed sagittal imbalance and were treated with lumbar PSO. Long fusions were defined as those proximal to T6, and short fusions were defined as those below T8. Measured radiographic parameters included thoracic kyphosis, lumbar lordosis (LL), sacral slope, pelvic incidence, and sagittal balance (SVA). Statistical analysis included Student t test and chi-square test. A p value of < .05 and a confidence interval of 95% were considered statistically significant. RESULTS: Among the reviewed cases were 23 women and 9 men, with a mean age of 50.9 years (range, 33-76 years) and a mean follow-up 8.6 years (range, 5-16 years). The LL increased from -16.0° preoperatively to -52.1° postoperatively. This metric decreased to -51.0° at final follow-up. The SVA decreased from 10.4 cm preoperatively to 3.6 cm postoperatively. The SVA increased to 5.4 cm at the final follow-up visit. There were 17 long fusions and 15 short fusions. The SRS scores at the final follow-up time point were: total, 3.63; function, 3.59; pain, 3.68; self-image, 3.46; mental health, 3.56; satisfaction, 4.26. A total of 16 patients exhibited minimal disability, 11 exhibited moderate disability, and 2 exhibited severe disability in ODI scores at the final follow-up visit (average, 28.2%). The SRS and ODI scores were not significantly different between groups (p = .64 for SRS; p = .59 for ODI). We observed no significant differences between groups with respect to the LL, sacral slope, or pelvic incidence. The observed increase in SVA at the final follow-up visit was significantly larger in the short fusion group compared with the increase we observed in the long fusion group (p = .03). The thoracic kyphosis (T5-T12) and proximal junctional angle at the final follow-up visit also significantly increased in patients who underwent a short fusion (p < .001). A total of 14 major complications occurred in 12 patients (8 in the short fusion group and 6 in the long fusion group) (p = .43). Eight patients required additional surgery to treat these complications. CONCLUSIONS: In a group of adults presenting with fixed sagittal imbalance, PSO provided good sagittal balance and maintained favorable clinical outcomes in both the short and long fusion groups despite a slight decrease in the SVA and a high complication rate. The data suggest that the loss of sagittal balance may be attributed to increase global and junctional kyphosis in short fusion groups, and should be monitored for long-term outcomes. Particular attention should be paid to the long-term deterioration of the SVA in adults who present with fixed sagittal imbalance after PSO.

Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up.

STUDY DESIGN: A retrospective case series of surgically treated patients with adult scoliosis. OBJECTIVE: The purpose of this study was to evaluate the incidence, risk factors, and natural course of proximal junctional kyphosis (PJK) in a long-term follow-up of patients with adult idiopathic scoliosis undergoing long instrumented spinal fusion. SUMMARY OF BACKGROUND DATA: Although recent reports have showed the prevalence, clinical outcomes, and the possible risk factors of PJK, quite a few reports have showed long-term follow-up outcome. MATERIALS AND METHODS: This is a retrospective review of the charts and radiographs of 76 consecutive patients with adult scoliosis treated with long instrumented spinal fusion. Radiographical measurements and demographic data were reviewed on preoperation, immediate postoperation, 2 years postoperation, 5 years postoperation, and at follow-up. Postoperative Scoliosis Research Society scores and Oswestry Disability Index were also evaluated. Means were compared with Student t test. A P value of less than 0.05 with 95% confidence interval was considered significant. RESULTS: The mean age was 48.8 years (range, 23-75 yr) and the average follow-up was 7.3 years (range, 5-14 yr). PJK has been identified in 17 patients. The Scoliosis Research Society and Oswestry Disability Index did not demonstrate significant differences between PJK group and non-PJK group; 2 patients had additional surgeries performed for local pain. Seventy-six percent of PJK has been identified within 3 months after surgery. Despite the fact that 53% of total degree of PJK was progressed within 3 months after surgery, PJK continuously progressed to the final follow-up. Pre-existing low bone mineral density, posterior spinal fusion (PSF), fusion to sacrum, inappropriate global spine alignment, and greater sagittal vertical axis change were identified as significant risk factors for PJK (P = 0.04, P < 0.001, P = 0.02, P < 0.0001, and P = 0.01). CONCLUSION: In a long-term review of minimum 5 years, 76% of PJK occurred within 3 months after surgery. Pre-existing low bone mineral density, PSF, fusion to the sacrum, inappropriate global spine alignment, and greater sagittal vertical axis change were significant risk factors for PJK. Careful long-term follow-up should be done for a patient with PJK.

Characterization of osteopenia/osteoporosis in adult scoliosis: does bone density affect surgical outcome?

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study is to validate the prevalence of low bone mineral density (BMD) in woman patients with adult scoliosis and to relate that to surgical treatment outcome. Despite reports of the high prevalence of low BMD among female with adolescent idiopathic, these findings have not been substantiated in any comprehensive review of adult scoliosis patients undergoing surgical treatment. SUMMARY OF BACKGROUND DATA: It has been suggested that scoliosis may predispose to osteoporosis and that degenerative scoliosis could falsely elevate spinal BMD measurements with dual energy radiograph absorptiometry (DXA). The discordance between hip and spine BMD measurement using DXA has also been shown in previous cross-sectional study for adult population. METHODS: A retrospective review of 176 women treated surgically for scoliosis. BMD of the lumbar spine and femoral neck were determined by DXA. Patients were categorized as follows: concordance (osteoporosis, osteopenia, or normal BMD on both sites), minor discordance (osteoporosis in one site and osteopenia in the other site), and major discordance (osteoporosis in one site and normal the other site). Body mass index (BMI), preoperative Cobb angle, fusion ratio, and complication were recorded. Statistical analysis included the Student t test, χ(2) test, regression coefficient test, and simple linear regression. P value was set at P < 0.05. RESULTS: The mean age was 51 ± 12 years (26-82 years). The mean T score of the hip was -1.23 ± 0.89 and of the spine was -0.52 ± 1.57. Major discordance in BMD 7 (4%) points, minor discordance 68 (39%) points, and concordance was 101 (57%) points. There was moderate correlation between T score of hip and spine (R = 0.55P < 0.01). T score of the hip and of the spine showed 10.8% and 10.2% of the patients were osteoporotic. The mean Z score of the hip and of the spine showed comparable age and sex matched values. No correlation was observed between BMD and Cobb angle (R = 0.05, P = 0.464). The fusion rate was 93% and surgical complication rate was 14.9%. No significant correlation was observed between BMD and fusion (P = 0.80) complication (P = 0.13). CONCLUSION: Comparable bone density exists among adult scoliosis patients with no correlation between BMD and curve magnitude, fusion and complication rates. The difference in BMD of the hip and of spine cannot be fully explained in the review. These results will guide in surgical planning, patient selection on the treatment options.