Early mortality among aboriginal and non-aboriginal women who had a preterm birth in Western Australia: A population-based cohort study.

BACKGROUND: Having a preterm (<37 weeks' gestation) birth may increase a woman's risk of early mortality. Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have higher preterm birth and mortality rates compared with other Australian women. OBJECTIVES: We investigated whether a history of having a preterm birth was associated with early mortality in women and whether these associations differed by Aboriginal status. METHODS: This retrospective cohort study used population-based perinatal records of women who had a singleton birth between 1980 and 2015 in Western Australia linked to Death Registry data until June 2018. The primary and secondary outcomes were all-cause and cause-specific mortality respectively. After stratification by Aboriginal status, rate differences were calculated, and Cox proportional hazard regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cause-specific mortality. RESULTS: There were 20,244 Aboriginal mothers (1349 deaths) and 457,357 non-Aboriginal mothers (7646 deaths) with 8.6 million person-years of follow-up. The all-cause mortality rates for Aboriginal mothers who had preterm births and term births were 529.5 and 344.0 (rate difference 185.5, 95% CI 135.5, 238.5) per 100,000 person-years respectively. Among non-Aboriginal mothers, the corresponding figures were 125.5 and 88.6 (rate difference 37.0, 95% CI 29.4, 44.9) per 100,000 person-years. The HR for all-cause mortality for Aboriginal and non-Aboriginal mothers associated with preterm birth were 1.48 (95% CI 1.32, 1.66) and 1.35 (95% CI 1.26, 1.44), respectively, compared with term birth. Compared with mothers who had term births, mothers of preterm births had higher relative risks of mortality from diabetes, cardiovascular, digestive and external causes. CONCLUSIONS: Both Aboriginal and non-Aboriginal women who had a preterm birth had a moderately increased risk of mortality up to 38 years after the birth, reinforcing the importance of primary prevention and ongoing screening.

Will Medicare Readmission Penalties Motivate Hospitals to Reduce Arthroplasty Readmissions?

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) recently imposed penalties against hospitals with above-average 30-day readmission rates following total joint arthroplasty (TJA). Hospitals must decide whether investments in readmission prevention are worthwhile. This study examines the financial incentives associated with unplanned readmissions before and after invocation of these penalties. METHODS: Financial data were reviewed for 2028 consecutive primary TJAs performed on Medicare beneficiaries over a 2-year period at an urban academic health system. Readmission penalties were estimated in accordance with CMS policies. RESULTS: Unplanned readmissions generated a $4416 median contribution margin. The initial hospitalizations (when the TJA was performed) were financially unfavorable for patients subsequently readmitted relative to those not readmitted due to increased costs of care (P = .002), but these costs were more than outweighed by the increased reimbursement earned during the readmission (P < .001), ultimately making readmitted patients financially preferable (P < .001). Going forward, penalties will be levied for risk-adjusted readmission rates above the national rate of 4.8%. For the institution under review, the penalty per readmission outweighs the financial gains earned through readmission by $12,184, resulting in a net loss from readmissions if the rate exceeds 6.5%. It will be financially optimal to maintain a readmission rate (after risk adjustment) equal to the national average but exceeding that rate will be $7768 more expensive per readmission than undershooting that target. CONCLUSION: If our results are generalizable, unplanned Medicare readmissions have traditionally been financially beneficial, but CMS penalties outweigh this benefit. Thus, penalties should incentivize institutions to maintain below-average arthroplasty readmissions rates.

Early Endoscopic Discectomy in Preventing Degenerative Spinal Changes in Patients With Lumbar Disc Herniation.

In this study, we compare the outcomes of two patients with similar spinal pathologies who chose different treatment options. The first case involves a 38-year-old female with significant lumbar disc herniation and associated degenerative spinal changes, including type I Modic changes. She presented with sciatica and, after conservative treatments failed, underwent an endoscopic discectomy. This intervention led to a marked improvement in her pain and functional status, along with a partial resolution of the Modic changes and a decrease in multifidus atrophy and fatty infiltration, on her follow-up MRI. In the second case, we discuss a 33-year-old patient with a large disc herniation. Despite three years of conservative management, she developed Modic changes and sclerosis in the adjacent vertebral endplates and a worsening of multifidus atrophy and fatty infiltration. This report supports the consideration of early minimally invasive discectomy for young patients who do not benefit from conservative treatment, as a means to prevent the progression of degenerative spinal changes.

Exploring the Efficacy and Duration of Therapeutic Effects of a Novel Iliohypogastric and Ilioinguinal Ablation Approach: A Stepwise Radiofrequency Ablation Technique.

Radiofrequency ablation (RFA) targeting the iliohypogastric and ilioinguinal (IH/IL) nerves is a recognized treatment for lower abdominal neuropathic pain. Despite its effectiveness, RFA typically offers only a temporary reprieve, necessitating repeated procedures. RFA procedures of the IH/IL nerves have been well described but often result in patient non-compliance and commonly necessitate the use of increased sedation. This case report details an RFA technique as a novel therapeutic technique for managing neuropathic pain associated with IH and IL pain. The technique described was conducted on a patient with complex pain and profound hyperalgesia with remarkable patient compliance and, more importantly, with reduced sedation. This case report delves into the progressive interventions employed by this novel technique in a patient being treated for IH/IL neuralgia. This case report describes increased patient compliance and potentially increased safety profile associated with this innovative RFA technique in comparison to traditional RFA and steroid injection. The patient, whose pain was unresponsive to standard treatments, was thoroughly assessed and underwent multiple failed interventions requiring sedation before the novel RFA technique was considered. We describe the patient's progression through various treatments, illustrating the benefits of this novel RFA method over the established ones. The discussion highlights the advantages of the new technique in terms of its effectiveness and the duration of its pain relief, offering valuable insights into the pain management field. This case contributes to the growing array of therapeutic strategies in pain medicine, potentially enhancing patient outcomes for those with IH/IL neuropathic pain.

Young adult outcomes following premature birth: A Western Australian experience.

BACKGROUND: Childhood outcomes following preterm birth are widely published, however long-term adult outcomes are less well described. We aimed to determine the quality of life and burden of co-morbidities experienced by preterm-born young adults in Western Australia. METHODS: A retrospective observational study was conducted. Participants born at 23-33 weeks gestation cared for at King Edward Memorial Hospital during 1990 and 1991 were recruited from a historical birth cohort. Participants completed general, medical and reproductive health questionnaires. Results were compared with contemporaneous cohort data and/or population statistics. RESULTS: Questionnaires were received from 73 young adults aged 28 to 30 years. The majority of respondents completed high school (94.5 %), were employed fulltime (74.0 %) and had close friends and family relationships. Almost all the participants considered their health to be good (94.0 %) and participated in light exercise (90.0 %). Increased hypertension, hypercholesterolaemia, asthma, neuropsychiatric conditions and visual impairment were reported. Depression Anxiety and Stress Scale (DASS-21) scoring identified increased mild anxiety. Increased consultation with healthcare workers and use of prescription medications were reported. CONCLUSION: The group of preterm-born adults surveyed reported a good quality of life, supportive interpersonal relationships and they provided significant contributions to society. They did report increased medical and psychological conditions than the general population.

A Trans-pedicle Approach to Avoid Exiting Nerve Root Injury in Full-Endoscopic Transforaminal Decompression: A Case Report.

This report aims to describe a case with an extremely low-located exiting nerve root and introduce the trans-pedicle approach for endoscopic transforaminal decompression, which can enable the safe visualization of the exiting nerve root. We present the medical history, imaging findings, and surgical procedures of a 62-year-old male who underwent left L3/4 and L4/5 endoscopic transforaminal decompression for foraminal stenosis. The patient presented with pain and numbness in the anterior and lateral aspects of the left thigh. MRI revealed left L3/4 and L4/5 foramen stenosis and endoscopic transforaminal decompression was performed. The working channel was guided and positioned at the upper lateral part of the left L4 pedicle. We observed the L3 root being compressed by scar tissues against the upper edge of the L4 pedicle. Then we used a protective diamond burr to drill the upper part of the L4 pedicle, enlarging the L3/4 foramen. Subsequently, pituitary Rongeur, Kerrison, and punches were employed to meticulously remove scar tissues around the exiting root. The same procedure was performed for left L4-5 foramen decompression. The radicular symptoms were relieved immediately after the surgery. Our proposed trans-pedicle endoscopic transforaminal approach can reduce the risk of injuring a low-located exiting nerve root. It can also help standardize the procedure, improves working channel stability, and facilitates the learning process, making it a valuable technique for full-endoscopic transforaminal decompression.

The Kumar Technique: A Novel and Effective Approach to Transforaminal Epidural Steroid Injections.

Background Transforaminal epidural steroid injections (TFESIs) are widely used as a minimally invasive treatment for lumbar radicular pain. This study presents an alternative approach for lumbar TFESI, the Kumar Technique, which utilizes a more lateral and inferior needle starting point to better align the trajectory of the needle with the neural foramen. We hypothesize the Kumar Technique will result in safer and more effective outcomes than the traditional approach to TFESI. This article was previously presented as a poster at the 2023 University of Florida College of Medicine Celebration of Research on February 27-28, 2023, and as an abstract and poster at the 2023 University of Florida Department of Anesthesiology Celebration of Research on March 29, 2023. Methods The charts for 1,424 patients who received lumbar TFESIs were retrospectively reviewed, and patients were stratified into groups receiving either the traditional approach or the Kumar Technique. Outcomes measures included numerical pain scores, measures of functional status and activity limitations, duration of pain relief, and procedural complications. Results Compared to the group undergoing the traditional approach, patients receiving the Kumar Technique reported a significantly greater decrease in average pain (-2.3 (95% CI: -3.0 to -1.6) vs -1.1 (95% CI: -1.4 to -0.7)) and maximum pain (-2.4 (95% CI: -3.2 to -1.6) vs -1.3 (95% CI: -1.8 to -0.9)). Patients receiving the Kumar Technique had a significantly greater likelihood of reporting any pain relief (OR: 2.10, 95% CI:1.59 to 2.79) compared to those undergoing the traditional approach. In addition, a greater percentage of patients receiving the Kumar Technique experienced at least one month of pain relief compared to the traditional approach (54% vs 40%; z = 3.85, p < 0.001). The occurrence of complications did not significantly vary between the modified (4.1%) and the traditional (3.0%) approaches. Conclusions The Kumar Technique is a modified TFESI approach that allows for improved access to the nerve roots through a more lateral and inferior needle entry point. The analysis supports the benefits of the Kumar Technique with patients experiencing a greater reduction in pain and longer durations of pain relief without increasing the risk of complications.

Anterolateral intervertebral disc herniation presenting as visceral pain in a patient with renal keratinising desquamative squamous metaplasia.

We report the case of a 70-year-old man who presented to the clinic with back pain and presumed chronic kidney pain from renal keratinising desquamative squamous metaplasia, in which he would intermittently pass keratin plugs in urine. The pain had a visceral-sounding component that was inconsistent with renal colic. MRI of the spine revealed anterolateral disc bulges, which were likely irritating the anterolateral sympathetic nerves of the intervertebral disc, mimicking visceral pain. Transforaminal epidural steroid injection (TFESI) was performed at the levels of the disc bulges. He had no pain during passage of keratin plugs for 6.5 months after the TFESI which could be attributed to the expected duration of symptoms relief after a properly done TFESI.

Complete resolution of chronic pain, sensory impairment, and motor dysfunction following percutaneous transforaminal endoscopic decompression in a failed back surgery syndrome patient-a case report.

Failed back surgery syndrome (FBSS) is an increasingly common problem that presents a clinical challenge. Though usual treatments may improve pain for some period of time, they do not provide clinically significant recovery of subjective numbness and weakness. We describe a case of a 48-year-old female with FBSS, who presented to the pain clinic with a 29-year history of low back pain, and a 7-year history of sensory and motor dysfunction of her left lower extremity, ever since a left hemi-laminectomy. At the time of presentation, she was wheelchair bound with intense pain, 4/5 strength in her left lower extremity proximally, and 3/5 strength distally. She had previously failed conservative management including medications, physical therapy, and epidural and facet injections. During percutaneous transforaminal endoscopic decompression, her transiting left L5 nerve root was found to be encased in thick scar tissue. The entirety of this scar tissue entrapping her L5 nerve was able to be released, resulting in not only complete resolution of pain but full return of sensory and motor function; in fact, the patient was able to walk out of the post anesthesia care unit without any assistive devices. Despite long-standing damage from many years of nerve entrapment, this patient's sensory and motor function was able to be restored simply by freeing her nerve of scar tissue. Thus, if nerve entrapment in scar tissue is the cause of FBSS, transforaminal endoscopic decompression may offer not only pain relief, but also return of sensory and motor function.

A Case Report of High Cervical Spinal Cord Stimulation for Chronic Otalgia and Tinnitus.

Neuromodulation continues to grow in its scope and application in the relief of chronic and debilitating disorders. Both otalgia and tinnitus can be multifactorial in etiology, with diagnostic and treatment challenges. This is a case of spinal cord stimulator placement providing a patient with near total relief of otalgia, total relief of tinnitus, and mild improvement in sensorineural hearing loss. We believe that this is the first report showing benefit of high spinal cord stimulation in tinnitus, and we consider whether there are neuronal connections between upper cervical nerve roots and the auditory pathways.

Potential changes in the distribution of Carnegiea gigantea under future scenarios.

Over the last decades several studies have identified that the directional changes in climate induced by anthropogenic emissions of greenhouse gases are affecting the ecology of desert ecosystems. In the Southwest United States, the impacts of climate change to plant abundance and distribution have already been reported, including in the Sonoran Desert ecosystem, home of the iconic Saguaro (Carnegiea gigantea). Hence, there is an urgent need to assess the potential impacts of climate change on the saguaro. The goals of this study are to provide a map of actual habitat suitability (1), describe the relationships between abiotic predictors and the saguaro distribution at regional extents (2), and describe the potential effect of climate change on the spatial distribution of the saguaro (3). Species Distribution Modeling (SDM) was used to investigate the relationships between abiotic variables and the Saguaro distribution. SDMs were calibrated using presence records, 2,000 randomly-generated pseudo absences, and ten abiotic variables. Of these, annual precipitation and max temperature of the warmest month was found to have the greatest relative influence on saguaro distribution. SDMs indicated that 6.9% and 8.1% of the current suitable habitat is predicted to be lost by 2050 and 2070, respectively. Therefore, predicted changes in climate may result in a substantial contraction of the suitable habitat for saguaro over the next century. By identifying the drivers of saguaro distribution and assessing potential changes in habitat suitability due to climate change, this study will help practitioners to design more comprehensive strategies to conserve the saguaro in the face of climate change.

Combining perceptual regulation and exergaming for exercise prescription in low-active adults with and without cognitive impairment.

BACKGROUND: Exercise adherence in already low-active older adults with and without mild cognitive impairment (MCI) remains low. Perceptual regulation and exergaming may facilitate future exercise behaviour by improving the affective experience, however evidence that this population can perceptually regulate is lacking. To explore this, we investigated 1) perceptual regulation of exercise intensity during either exergaming or regular ergometer cycling and 2) explored affective responses. METHODS: Thirty-two low active older adults (73.9 ± 7.3 years, n = 16, 8 females) with or without MCI (70.9 ± 5.5 years, n = 16, 11 females) participated in a sub-maximal fitness assessment to determine ventilatory threshold (VT) and two experimental sessions (counterbalanced: exergaming or regular ergometer cycling). Experimental sessions consisted 21-min of continuous cycling with 7-min at each: RPE 9, 11 and 13. Oxygen consumption (VO2), heart rate (HR), and affect (Feeling Scale) were obtained throughout the exercise. RESULTS: VO2 (p < 0.01) and HR (p < 0.01) increased linearly with RPE, but were not significantly different between exercise modes or cognitive groups. At RPE 13, participants worked above VT in both modes (exergaming: 115.7 ± 27.3; non-exergaming 114.1 ± 24.3 VO2 (%VT)). Regardless of cognitive group, affect declined significantly as RPE increased (p < 0.01). However on average, affect remained pleasant throughout and did not differ between exercise modes or cognitive groups. CONCLUSIONS: These results suggest low-active older adults can perceptually regulate exercise intensity, regardless of cognition or mode. At RPE 13, participants regulated above VT, at an intensity that improves cardiorespiratory fitness long-term, and affect remained positive in the majority of participants, which may support long-term physical activity adherence.