Search

Background: Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. Methods: As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. Results: The median ORS was 90.0% (interquartile range, 80.0%–90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%–73.6%), with a median difference of 21.8% (interquartile range, 13.7%–34.4%), P P =0.406). The median difference between ORS and RMS for facilities granted initial accreditation was smaller compared with facilities whose accreditation was delayed (17.9% versus 25.5%, P =0.035). The intraclass correlation between ORS and RMS was 0.16, indicating poor agreement. If RMS measurements were used, 72% of symptomatic patients and 10% of asymptomatic patients in the population examined would meet the Centers for Medicare and Medicaid Services criteria for stent placement. Conclusions: Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization.

Postoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population.Our primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure.Following Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period.Ninety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003).There was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.

Despite the high prevalence of obesity and associated health risks in the United States adult population, few primary care providers (PCPs) have time and training to provide weight-management counseling to their patients. This study aims to compare the effect of referral to a comprehensive automated digital weight-loss program, with or without provider email feedback, with usual care on weight loss in patients with overweight or obesity.A total of 550 adults (mean [SD], 51.4 [11.2] years, BMI = 35.1 [5.5] kg/mWeight changes (mean [SE]) at 12 months were -0.92 (0.46), -3.68 (0.46), and -3.58 (0.48) kg in the EUC, IWL, and IWL + PCP groups, respectively. Outcomes were significantly different in EUC versus IWL and EUC versus IWL + PCP (p 0.001), but not in IWL versus IWL + PCP.Referral by PCPs to an automated weight-loss program holds promise for patients with obesity. Future research should explore ways to further promote accountability and adherence.

Many deaths after surgery can be attributed to "failure to rescue," which may be a better surgical quality indicator than the occurrence of a postoperative complication. Acute kidney injury (AKI) is one such postoperative complication associated with high mortality. The purpose of this study is to identify perioperative risk factors associated with failure to rescue among patients who develop postoperative AKI.We identified adult patients who underwent non-cardiac surgery between 2012 and 2018 and experienced postoperative severe AKI (an increase in blood creatinine concentration of2 mg/dL above baseline or requiring hemodialysis) from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue among patients who developed severe AKI.Among 5,765,904 patients who met inclusion criteria, 26,705 (0.46%) patients developed postoperative severe AKI, of which 6834 (25.6%) experienced failure to rescue. Risk factors with the strongest association (adjusted odds ratio1.5) with failure to rescue in patients with AKI included advanced age, higher American Society of Anesthesiologists class, presence of preoperative ascites, disseminated cancer, septic shock, and blood transfusion within 72 h of surgery start time.About one-fourth of patients who develop severe AKI after non-cardiac surgery die within 30 d of surgery. Both patient- and surgery-related risk factors are associated with this failure to rescue. Further studies are needed to identify early and effective interventions in high-risk patients who develop postoperative severe AKI to prevent the antecedent mortality.

OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS Among 4,788 admissions with GIC, average LOS was shorter during the tool’s active periods. LOS reductions occurred for all admissions with GIC (−5.7 h, P = 0.057), diabetes and hyperglycemia (−6.4 h, P = 0.054), stress hyperglycemia (−31.0 h, P = 0.054), patients admitted to medical services (−8.4 h, P = 0.039), and recurrent hypoglycemia (−29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (−82.3 h, P = 0.006) and nonsignificant in two (−5.2 h, P = 0.655) and four or more (−14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.

Children with neuromuscular disorders and syndromic scoliosis who require operative treatment for scoliosis are at increased risk for postoperative complications. Complications may include surgical site infection and pulmonary system problems including respiratory failure, gastrointestinal system disorders, and others. The purpose of our study was to determine the effect of a standardized perioperative pathway specifically designed for management of high-risk pediatric patients undergoing surgery for scoliosis.The High-Risk Protocol (HRP) at our institution is a multidisciplinary process with subspecialty consultations before scoliosis surgery. This was a retrospective chart and radiographic review at a single institution. Inclusion criteria were high-risk subjects, age 8 to 18 years old, who underwent surgery between January, 2009 and April, 2009 with a minimum 2-year follow-up. Diagnoses included neuromuscular scoliosis or Syndromic scoliosis.Seventy one subjects were analyzed. The mean age was 13 (±2 SD) years. Follow-up was 63 (±24 SD) months. The study group consisted of 35 subjects who had fully completed the HRP and the control group consisted of 36 subjects who did not. Nine of the 35 (26%) subjects in the HRP had surgery delayed while interventions were performed. Compared with controls, the study group had larger preoperative and postoperative curve magnitudes: 90 versus 73 degrees ( P =0.002) and 35 versus 22 degrees ( P =0.001). Pulmonary disease was more common in the HRP, 60 versus 31% ( P =0.013). The overall incidence of complications in the study group was 29% (10 of 35 subjects) and for controls 28% (10 of 36). There were no differences between groups for types of complications or Clavien-Dindo grades. Three subjects in the study group and 1 in the controls developed surgical site infection. Eleven subjects required unplanned reoperations during the study period.The findings of our study suggest a structured pathway requiring routine evaluations by pediatric subspecialists may not reduce complications for all high-risk pediatric spine patients. Selective use of consultants may be more appropriate.Level III, Retrospective Cohort study.

We aim to investigate whether the availability of over-the-counter EC varies by neighborhood income level, independent vs chain pharmacies, or urban vs rural pharmacies.We conducted a cross-sectional "mystery shopper" telephone survey in July 2019 to ascertain whether sampled pharmacies stocked EC. Pharmacies located in 12 Pennsylvania counties were randomly sampled after stratification by neighborhood income level.Of 200 pharmacies sampled, 195 responded. Only 76% had EC available for same day purchase, which did not differ by neighborhood-level income. The odds that chain pharmacies stocked EC were nearly 10 times the odds that independent pharmacies stocked EC, with 96/105 chain pharmacies versus 52/90 independent pharmacies having EC available for same day purchase (91% vs 58%; OR 9.50, 95% CI 4.03-22.42). The mean number of barriers (stocking over-the-counter EC behind-the-counter, cost$40, and requiring identification for purchase) was lower among chain vs. independent pharmacies. Pharmacies in low/moderate-income areas (64% vs 44%, p = 0.02) and independent pharmacies (94% vs 32%, p0.01) were more likely to keep over-the-counter EC behind-the-counter. Independent pharmacies were more likely to require identification for purchase (29% vs 59%, p0.01).More than a decade after over-the-counter approval, EC is still not uniformly available at pharmacies in Pennsylvania. Barriers including behind-the-counter stocking and identification requirements disproportionally limit access in low-income neighborhoods and independent pharmacies, threatening equitable access to this contraceptive method.Pharmacies in lower-income neighborhoods and independent pharmacies were more likely to impose undue barriers to EC access and purchasing, disproportionally affecting residents in lower-income areas. A multidisciplinary approach in advocacy and policy reform is necessary to ensure equitable access to EC.

Background: We aimed to examine the attitudes of Pennsylvania rural residents toward data sharing in the setting of the COVID-19 pandemic. Specifically, we were interested in better understanding their willingness to provide personal information for contact tracing to public health staff investigating COVID-19 cases, as well as their concerns. We used a validated scale to describe the influence of distrust of healthcare organizations on their attitudes. Methods: We mailed 4000 surveys to rural residents identified from the electronic medical record of a healthcare system in central Pennsylvania. Data were entered into a REDCap database and analyzed using descriptive summaries, and both binomial and multivariable logistic regression. Results: Binomial logistic regression showed that both distrust in healthcare organizations and political values influence respondents’ willingness to share information with contact tracers as well as their concerns about sharing personal data. When our multivariable model was applied, political values remained and were consistently associated with willingness to share and concerns about sharing their data. Conclusion: This study is a first step in eliciting rural residents’ willingness to share personal data for contact tracing by public health officials. Understanding and addressing rural residents’ willingness to share personal data and their concerns about sharing those data will help public health officials identify effective strategies for managing COVID-19 and future pandemics in rural communities. By involving community members at the ground level, public health staff can ensure residents’ buy-in for the need to collect their personal data, thereby helping to mitigate the public health crises.

Purpose The aim of the study is to investigate sex differences in academic rank, publication productivity, and National Institute of Health (NIH) funding among oculoplastic surgeons and whether there is an association between American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) membership and scholarly output. Methods Sex, residency graduation year, and academic rank were obtained from institutional websites of 113 U.S. ophthalmology programs. H-indices and m-quotients were obtained from the Scopus database. NIH funding information was obtained from the NIH Research Portfolio Online Reporting Tool. Results Of the 272 surgeons, 74 (30.2%) were females. When adjusted for career duration, differences in female to male proportions were only significant at the rank of assistant professor (assistant: 74.3 vs. 48.5%, p = 0.047; associate: 18.9 vs. 24.6%, p = 0.243; full professor: 13.0 vs. 37.2%, p = 0.114). Women had a shorter career duration than men [10.0 (interquartile range or IQR 12.0) vs. 21.0 (IQR 20.0) years; p Conclusion Sex differences in academic ranks and h-indices are likely due to the smaller proportion of females with long career durations. ASOPRS membership may confer opportunities for increased scholarly output.

BACKGROUND: School settings offer an opportunity to impact student health and wellness. Quality wellness policies are important in establishing strong wellness environments, but current resources to support policy development, maintenance, and dissemination are lacking. The Building Healthy Schools Program aimed to develop capacity of school districts to improve the strength and comprehensiveness of wellness policies and sustain these activities. METHODS: Fifteen school districts in Pennsylvania participated in a program to facilitate the improvement of district wellness policies and practices. Program staff provided technical assistance to evaluate wellness policies before and after program implementation. Professional development and tailored training was provided for school personnel to create sustainability. Statistical analysis was performed to evaluate policy improvement. RESULTS: Thirteen of the 15 participating districts completed a policy revision. Median strength (p=0.001) and comprehensiveness (p=0.002) scores improved from baseline to post-program and there were significant improvements in most assessment sub-sections. Some districts were hesitant to make strong language improvements due to their limited capacity (i.e., staff) for implementation. Champions (n=13; 87%) reported confidence to revise wellness policy language independently in the future. CONCLUSIONS: Technical assistance provided to districts facilitated significant improvements to wellness policy language, especially in the implementation, evaluation, and communication; critical components for policy impact on school wellness environments. Additionally, participant feedback suggested an ability to sustain activities in the future. Both external (i.e., technical assistance) and internal resources are needed to facilitate school districts’ ongoing wellness policy improvement and implementation, including improved model wellness policy language and enforcement within schools, respectively.

ObjectiveTo identify the demographic and clinical characteristics associated with adverse COVID-19 outcomes across a 12-month period in 2020 and 2021.Research design and methodsWe conducted a retrospective cohort study using electronic health records from five academic health systems in Pennsylvania and Maryland, including patients with COVID-19 with type 2 diabetes or at risk of type 2 diabetes. Patients were classified based on 30-day outcomes: (1) no hospitalization; (2) hospitalization only; or (3) a composite measure including admission to the intensive care unit (ICU), intubation, or death. Analyses were conducted in patients with type 2 diabetes and patients at risk of type 2 diabetes separately.ResultsWe included 15 725 patients with COVID-19 diagnoses between March 2020 and February 2021. Older age and higher Charlson Comorbidity Index scores were associated with higher odds of adverse outcomes, while COVID-19 diagnoses later in the study period were associated with lower odds of severe outcomes. In patients with type 2 diabetes, individuals on insulin treatment had higher odds for ICU/intubation/death (OR=1.59, 95% CI 1.27 to 1.99), whereas those on metformin had lower odds (OR=0.56, 95% CI 0.45 to 0.71). Compared with non-Hispanic White patients, Hispanic patients had higher odds of hospitalization in patients with type 2 diabetes (OR=1.73, 95% CI 1.36 to 2.19) or at risk of type 2 diabetes (OR=1.77, 95% CI 1.43 to 2.18.)ConclusionsAdults who were older, in racial minority groups, had multiple chronic conditions or were on insulin treatment had higher risks for severe COVID-19 outcomes. This study reinforced the urgency of preventing COVID-19 and its complications in vulnerable populations.Trial registration numberNCT02788903.

This study examines rural patients' perceived importance of knowing or being consulted about researchers' access and use of their personal data (identifiable and de-identified health information, and identifiable and de-identified non-health information) across five scenarios. This study also examines their views on stewardship or governance of their personal information by researchers in their healthcare systems.We conducted a survey by mail. Data were analyzed using descriptive statistics. Multivariable regression analyses were conducted across each scenario and type of personal data with the same variables included in each model.The majority of participants said it was "very important/absolutely essential" to know the purpose of the study, to be asked every time, and to know the policies governing researcher access and use of their identifiable health information. Just over two-thirds of respondents thought it "very important/absolutely essential" to know who serves on the data governance committee and to have a community member serve. Distrust in healthcare organizations was positively correlated with the scenarios while willingness to give permission to donate leftover biological specimens was negatively correlated.Our study findings indicate that the type of personal information being accessed and used generally matters to 1,407 patients living in rural Pennsylvania. We also demonstrate that knowing their healthcare organizations' governance policies and practices for managing their personal data is important to many rural Pennsylvania patients. Biomedical researchers need to recognize and attend to those differences as much as possible in order to expand opportunities for and participation in research by residents of these rural communities.Supplemental data for this article is available online at.

IntroductionHypoglycemia is the most common serious adverse effect of diabetes treatment and a major cause of medication-related hospitalization. This study aimed to identify trends and predictors of hospital utilization for hypoglycemia among patients with type 2 diabetes using electronic health record data pooled from six academic health systems.Research design and methodsThis retrospective open cohort study included 549 041 adults with type 2 diabetes receiving regular care from the included health systems between 2009 and 2019. The primary outcome was the yearly event rate for hypoglycemia hospital utilization: emergency department visits, observation visits, or inpatient admissions for hypoglycemia identified using a validated International Classification of Diseases Ninth Revision (ICD-9) algorithm from 2009 to 2014. After the transition to ICD-10 in 2015, we used two ICD-10 code sets (limited and expanded) for hypoglycemia hospital utilization from prior studies. We identified independent predictors of hypoglycemia hospital utilization using multivariable logistic regression analysis with data from 2014.ResultsYearly rates of hypoglycemia hospital utilization decreased from 2.7 to 1.6 events per 1000 patients from 2009 to 2014 (p-trend=0.023). From 2016 to 2019, yearly event rates were stable ranging from 5.6 to 6.6, or 6.3 to 7.3, using the limited and expanded ICD-10 code sets, respectively. In 2014, the strongest independent risk factors for hypoglycemia hospital utilization were chronic kidney disease (OR 2.86, 95% CI 2.33 to 3.57), ages 18–39 years (OR 2.43 vs age 40–64 years, 95% CI 1.78 to 3.31), and insulin use (OR 2.13 vs no diabetes medications, 95% CI 1.67 to 2.73).ConclusionsRates of hypoglycemia hospital utilization decreased from 2009 to 2014 and varied considerably by clinical risk factors such that younger adults, insulin users, and those with chronic kidney disease were at especially high risk. There is a need to validate hypoglycemia ascertainment using ICD-10 codes, which detect a substantially higher number of events compared with ICD-9.

AimTo quantify the areas of burden experienced by patients requiring repeated intravitreal injections (IVI) in the management of exudative retinal diseases.MethodsThe validated Questionnaire to Assess Life Impact of Treatment by Intravitreal Injections survey was administered to patients at four retina clinical practices across four US states. The primary outcome measure was Treatment Burden Score (TBS), a single score assessing overall burden.ResultsOf 1416 (n=657 age-related macular degeneration; n=360 diabetic macular oedema/diabetic retinopathy; n=221 retinal vein occlusion; n=178 other/uncertain) patients, 55% were women with an average age of 70 years. Patients most frequently reported receiving IVI every 4–5 weeks (40%). The mean TBS was 16.1±9.2 (range 1–48; scale of 1–54), and the TBS was higher in patients with diabetic macular oedema and/or diabetic retinopathy (DMO/DR) (17.1) compared with those with age-related macular degeneration (15.5) or retinal venous occlusive (15.3) (p=0.028). Though the mean level of discomfort was quite low (1.86) (scale 0–6), 50% of patients reported experiencing side effects more than half of the visits. Patients having received fewer than 5 IVI reported higher mean anxiety levels before (p=0.026), during (p=0.050) and after (p=0.016) treatment compared with patients having received more than 50 IVI. After the procedure, 42% of patients reported restrictions from usual activities due to discomfort. Patients reported a high mean satisfaction rating of 5.46 (scale 0–6) with the care of their diseases.ConclusionsThe mean TBS was moderate and highest among patients with DMO/DR. Patients with more total injections reported lower levels of discomfort and anxiety but higher disruption to daily life. Despite the challenges related to IVI, the overall satisfaction with treatment remained high.

Background: Strict adherence to a gluten-free diet is the only known effective treatment for celiac disease currently. Multiple organizations recommend follow-up with a dietitian and guideline-directed management after diagnosis. Few studies have evaluated follow-up post diagnosis. However, these do not include a systematic process for monitoring dietary referral among celiac disease patients. We sought to evaluate and compare the frequency of early dietary referral and guideline-directed preventive care and management for celiac disease patients managed by gastroenterologists and primary care providers. Methods: A retrospective chart review of celiac disease patients receiving care at a single tertiary care facility. Our primary outcome was to compare the frequency of dietary intervention between gastroenterologists and primary care providers in an outpatient setting after initial diagnosis. Multivariate analysis was performed to determine associated factors for referral for dietary intervention and recommended follow-up lab work. Results: 261 patients were included in the study, 81.6% were followed by gastroenterologist and only 51% were seen by a dietitian. Patients following up with gastroenterologists had higher odds of referral for dietary intervention on multivariate analysis (OR 3.29, p value Conclusions: Dietary intervention and follow-up of preventive care lab work were low in celiac disease patients. There is an opportunity for further education of both primary care providers and gastroenterologists on the importance of early dietary referral and appropriate medical management at follow-up.

Background Hesitancy and incomplete vaccination against coronavirus disease 2019 (COVID-19) remains an obstacle to achieving herd immunity. Because of fear of vaccine reactions, patients with medical and allergic co-morbidities express heightened hesitancy. Limited information is available to guide these patients. We sought to identify factors associated with mRNA-based COVID-19 vaccines hesitancy and reactogenicity. Methods We surveyed employees of a multi-site health system in central Pennsylvania who were offered the COVID-19 vaccine (N = 18,740) inquiring about their experience with the Moderna and Pfizer-BioNTech mRNA-based vaccines. The survey was administered online using the REDCap platform. We used multivariable regression analysis to determine whether a particular factor(s) (e.g., demographics, selected co-morbid allergic and medical conditions, vaccine brand, and prior COVID-19) were associated with vaccine reactogenicity including the occurrence and severity of local and systemic reactions. We also explored factors and reasons associated with vaccine hesitancy. Results Of the 5709 who completed the survey (response rate, 30.4%), 369 (6.5%) did not receive the vaccine. Black race and allergy to other vaccines were associated with vaccine hesitancy. Reaction intensity following the first vaccine dose and allergic co-morbidities were associated with incomplete vaccination. Older individuals (>60 years) experienced less reactogenicity. Females had higher odds of local and systemic reactions and reported more severe reactions. Asians reported more severe reactions. As compared to Pfizer-BioNTech, the Moderna vaccine was associated with higher odds of vaccine reactions of higher severity. Prior COVID-19 resulted in more severe reactions following the first dose, but less severe reactions following the second dose. Conclusions Targeted campaigns to enhance vaccination acceptance should focus on Black individuals, females, and those with allergic co-morbidities. Prior COVID-19 caused more severe reactions after the first but not the second vaccine dose. Moderna vaccine caused more vaccine reactions. Lessons learned from the early rollout of COVID-19 vaccine may serve to inform future novel vaccine experiences.

OBJECTIVES/GOALS: Vaccination for COVID-19 is a primary public health strategy to control the pandemic. In this study, we examined how various sociodemographic variables influence rural residents intentions to receive the COVID-19 vaccine. We also examined the role of distrust in healthcare organizations in these intentions. METHODS/STUDY POPULATION: sing the electronic medical records of an academic healthcare institution in central Pennsylvania, we obtained names and addresses of patients who had been an inpatient or outpatient within the prior three years, were 18 years or older, and who resided in a community defined as rural by the Commonwealth of Pennsylvania. The survey included three statements about the intent to receive the COVID-19 vaccine, an open-ended question about concerns regarding the vaccine, and validated scales for general trust and for distrust in healthcare organizations. All study variables were summarized to determine their distributions, and then bivariate binomial logistic regression analyses were conducted. Responses to the open-ended question were coded and used as variables in the bivariate analysis. RESULTS/ANTICIPATED RESULTS: Respondents reporting conservative political views were more likely (compared to those liberal political views) to never want to be vaccinated for COVID-19. Those who expressed distrust in healthcare organizations were less likely to want to be vaccinated soon. Conversely those who were more trusting said they were more likely to want to be vaccinated soon. Respondents dominant concerns about the COVID-19 vaccine were that it was new and that the process for its development was rushed. Respondents who believed that COVID-19 was a hoax were unlikely to ever want to be vaccinated, while those who distrusted the process in some way (new vaccine or rushed vaccine) were more likely to want to wait to be vaccinated. DISCUSSION/SIGNIFICANCE: These findings confirm the impact of political orientation on COVID-19 vaccination intention and suggest that distrust in healthcare organizations may prevent people from being vaccinated. These data provide evidence that people delaying vaccination hold different beliefs than those who will never vaccinate.

The management of idiopathic clubfoot has transformed over the past several decades as the Ponseti method for the correction of this deformity became the standard of care, and surgical release has almost all but been abandoned. The Ponseti method has shown very high initial success rate and excellent long-term functional results. Relapse of the deformity, however, continues to be a major problem, occurring in up to 40% of patient, and there is no consensus on the definition and management of the relapsed clubfoot. This review discusses the available management options for the treatment of a relapsed clubfoot deformity following initial treatment with the Ponseti method [including repeat casting, tendo-Achilles lengthening, plantar fascia release, and tibialis anterior tendon transfer (TATT)] as well as following initial surgical treatment with posteromedial release (including casting, hemiepiphysiodesis, revised posteromedial release, osteotomies, fusion, and the use of gradual distraction with external fixators). These are discussed from the least to the most invasive. Available evidence, and limitations of the literature, for the management of relapses following both the Ponseti method and initial surgical release is reviewed along with along with the reported outcomes. Future efforts should be geared towards standardizing the definition of a relapse with objective criteria for its management.

OBJECTIVES/GOALS: The goal of this study was to examine the attitudes of central Pennsylvania rural residents toward data sharing in the setting of the COVID-19 pandemic. We determined their willingness to provide cell phone data and personal information to public health staff investigating COVID-19 cases, as well as their concerns about sharing this information. METHODS/STUDY POPULATION: We used the electronic medical records of an academic healthcare institution in central Pennsylvania to obtain names and addresses of patients who had visited an outpatient clinic or been an inpatient within the prior three years, were 18 years or older, and who resided in a community defined as rural by the Commonwealth of Pennsylvania. The survey included four statements about contact tracing, three statements about intent to receive the COVID-19 vaccine, and validated scales for general trust and for distrust in healthcare organizations. All study variables were summarized to determine their distributions, and bivariate binomial logistic regression was conducted. A multivariable model including all of the independent variables was then fit for each outcome variable. RESULTS/ANTICIPATED RESULTS: The response rate was 19.5%. 95 % of respondents were white, 56% were female, and nearly two-thirds were older than 60 years. Binomial logistic regression showed that both distrust in healthcare organizations and political values influenced respondents willingness to share information with contact tracers as well as their concerns about sharing. In multivariate analysis, political values were a consistent predicator of willingness to share and concerns about sharing. Respondents who indicated that they wanted to get vaccinated as soon as possible were significantly more likely than those who did not want to be vaccinated to be willing to share their cell phone location data and personal data. Conversely, they were less likely to be concerned with these data being shared without their permission. DISCUSSION/SIGNIFICANCE: Understanding rural residents concerns about sharing personal information is critical if we are to develop successful strategies for lessening the impact of COVID-19 and managing future pandemics. This study is a first step in eliciting such concerns in the context of COVID-19and has implications for directing a successful pandemic response.

Perioperative complications of patients with idiopathic pulmonary fibrosis (IPF) are not well described. The aim of this study was to identify risk factors associated with adverse postoperative outcomes in IPF patients.We performed a single-centre historical cohort study of adult patients with IPF who underwent surgery between 2008 and 2018. We analyzed the prognostic utility of select perioperative factors for postoperative acute exacerbation of IPF (AE-IPF), acute respiratory worsening (ARW), pneumonia, and 30-day and one-year mortality using univariable and multivariable regression analyses. To adjust for multiple interactions, the false discovery rate (Q value) was utilized to appropriately adjust P values and a Q value0.05 was considered to be significant.Two hundred and eighty-two patients were identified. After excluding emergency cases and bronchoscopies performed for active pneumonia, 14.2% of the cohort developed ARW that persisted24 hr after surgery, 5.0% had AE-IPF, and 9.2% were diagnosed with postoperative pneumonia within 30 days of surgery. The 30-day mortality was 6.0% and the one-year mortality was 14.9%. Preoperative home oxygen use (relative risk [RR], 2.70; 95% confidence interval [CI], 1.50 to 4.86; P0.001) and increasing surgical time (per 60 min) (RR, 1.03; 95% CI, 1.02 to 1.05; P0.001) were identified as independent risk factors for postoperative ARW.In IPF patients, preoperative home oxygen requirement and increasing surgical time showed a strong relationship with postoperative ARW and may be useful markers for perioperative risk stratification. Facteurs de risque périopératoires des patients atteints de fibrose pulmonaire idiopathique : une étude de cohorte historique.RéSUMé: OBJECTIF: Les complications périopératoires chez les patients atteints de fibrose pulmonaire idiopathique (FPI) ne sont pas bien décrites. L’objectif de cette étude était d’identifier les facteurs de risque associés aux devenirs postopératoires défavorables chez les patients atteints de FPI. MéTHODE: Nous avons réalisé une étude de cohorte historique monocentrique portant sur des patients adultes atteints de FPI et ayant subi une chirurgie entre 2008 et 2018. Nous avons analysé l’utilité pronostique de facteurs périopératoires choisis pour l’exacerbation postopératoire aiguë de la FPI, la détérioration respiratoire aiguë, la pneumonie, et la mortalité à 30 jours et à un an à l’aide d’analyses de régression univariées et multivariées. Afin de tenir compte d’interactions multiples, le taux de fausses découvertes (valeur Q) a été utilisé pour ajuster adéquatement les valeurs P, et une valeur Q0,05 a été considérée significative. RéSULTATS: Deux cent quatre-vingt-deux patients ont été identifiés. Après avoir exclu les cas en urgence et les bronchoscopies réalisées lors de pneumonie active, 14,2 % des patients de la cohorte ont souffert d’une détérioration respiratoire aiguë qui a persisté24 h après la chirurgie, 5,0 % ont subi une exacerbation aiguë de la FPI, et 9,2 % ont reçu un diagnostic de pneumonie postopératoire dans les 30 jours suivant leur chirurgie. La mortalité à 30 jours était de 6,0 %, et la mortalité à un an de 14,9 %. L’utilisation préopératoire d’oxygène à domicile (risque relatif [RR], 2,70; intervalle de confiance [IC] 95 %, 1,50 à 4,86; P0,001) et l’augmentation du temps chirurgical (par tranche de 60 min) (RR, 1,03; IC 95 %, 1,02 à 1,05; P0,001) ont été identifiées comme des facteurs de risque indépendants de détérioration respiratoire aiguë en période postopératoire. CONCLUSION: Chez les patients atteints de FPI, une forte association a été observée entre les besoins préopératoires en oxygène au domicile ainsi que l’augmentation du temps chirurgical et la détérioration respiratoire aiguë en période postopératoire; ces deux facteurs pourraient constituer des marqueurs utiles pour stratifier le risque en période périopératoire.

PURPOSE: Indwelling urinary catheters are commonly inserted when administering general anesthesia. However, there are significant risks to routine IUC insertion. We compared urinary and other outcomes in a population of patients undergoing atrial fibrillation (AF) ablation with or without IUC. METHODS: This was a single center, retrospective review of patients undergoing AF ablation. Patients were identified by procedure codes and patient health characteristics and outcome data were manually extracted from electronic health records. The primary composite endpoint was 7-day periprocedural urinary outcomes including cystitis, dysuria, hematuria, urethral damage, or urinary retention. RESULTS: 404 patients were included in the study, 297 with IUC and 107 without IUC. Uncatheterized patients were less likely to have congestive heart failure (CHF) (31.8% vs 43.4%; P = 0.039) and had a shorter procedure length (4.2 vs 4.9 hours; P < 0.001) with less fluid administered (1485 vs 2040 mL; P < 0.001). No urinary complications occurred in the uncatheterized group versus 14 in the catheterized group (P = 0.026). 3 patients in the uncatheterized group developed serious infections versus none in the catheterized group (P = 0.018). There was no incidence of death and no statistically significant difference in readmission in the 30 days after procedure. CONCLUSIONS: There were no urinary complications in 107 patients who received no IUC during AF ablation. Avoiding bladder catheters during AF ablation procedures may lower incidence of adverse urinary complications without adding substantial risk of urinary retention.

Vascular aberration has been accepted as a potential etiology of clubfoot, and abnormal vasculature has been observed in as high as 85% of children with severe clubfoot. The perfusion index (PI) corresponds to the ratio of pulsatile to nonpulsatile blood flow at a monitoring site and can be used to quantify perfusion of the extremities. The purpose of this study was to use PI to compare the perfusion of clubfeet to controls in order to further assess the role of abnormal vasculature in clubfoot.A Masimo Radical 7 Pulse Oximeter (Masimo Corporation, Irvine, California) was used to measure the PI and oxygen saturation (SpO2) of the feet of children 5 years of age and younger with and without clubfoot. The sensor was placed on the great toe. Patients with clubfoot undergoing non-operative treatment and control patients undergoing treatment in a clinic for orthopedic concerns not involving the foot and with no known vascular issues were assessed. The PI and SpO2 for the following three groups were compared: 1. affected feet of patients with bilateral or unilateral clubfoot, 2. unaffected feet of patients with unilateral clubfoot, and 3. control feet.One hundred and twenty-eight patients were enrolled, 64 with clubfoot (31 bilateral and 33 unilateral) and 64 controls. No significant differences in PI or SpO2 were found between: 64 clubfeet and 64 feet of controls (PI of 2.9 vs. 2.9, p = 0.984; SpO2 of 97.1 vs. 98.1, p = 0.192); unaffected feet of 30 patients with unilateral clubfoot and 64 controls (PI of 3.0 vs.2.9, p = 0.907; SpO2 of 96.9 vs. 98.1, p = 0.224); and affected and unaffected feet of 30 patients with unilateral clubfoot (PI of 3.3 vs.3.0, p = 0.500; SpO2 of 97.4 vs. 96.9, p = 0.527).No difference was observed in the PI or SpO2 when comparing affected clubfoot limbs with unaffected limbs, suggesting that vascular anomalies cannot fully explain the development of clubfoot.

Background Idiopathic talipes equinovarus (ITEV) is a prevalent structural deformity of the foot and ankle in children. The disease-specific instrument (DSI) has commonly been used as an outcomes metric in these patients. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to examine the quality of life across various medical conditions. PROMIS has been validated for multiple conditions; however, no studies have evaluated the use of the PROMIS in children with ITEV. Methods A prospective analysis was performed whereby the 2 questionnaires were mailed out to the parents of 91 patients, aged 5 to 17 years, with ITEV. Construct validity of the PROMIS Parent Proxy Profile short forms version was assessed by comparing its domains of Mobility, Fatigue, Pain Interference, and Pain Intensity to the DSI Function domain and PROMIS domains of Anxiety, Depressive Symptoms, Peer Relationships, and Pain Intensity to DSI Satisfaction domain. Results Thirty-one complete responses (34% response rate) were returned. The patients' current mean age was 8.8 years, 7 were female individuals, and 12 had unilateral ITEV. Bivariate correlation analysis, using Spearman correlation coefficients, demonstrated a moderate positive correlation between the DSI Function domain and the PROMIS Mobility domain (rs=0.52) and a moderate negative correlation between the DSI Function domain and the PROMIS Pain Interference domain (rs=-0.56), as well as the PROMIS Pain Intensity domain (rs=-0.75). A fair negative correlation (rs=-0.38) with PROMIS Fatigue domain was found. Correlations between the DSI Satisfaction domain and the PROMIS domains were fair or had little relationship. Conclusions These results provide support for the validity of the PROMIS Mobility, Pain Interference, and Pain Intensity domains in this population, however there are no items in PROMIS that can assess overall satisfaction, as with the DSI. Level of evidence Level II-prospective comparative study.

Potocki-Lupski syndrome (PTLS) is a rare chromosomal microduplication syndrome resulting in multiple congenital abnormalities including developmental delays, autistic features, and certain structural anomalies, with cardiovascular being the most common. The phenotype of this contiguous gene duplication syndrome is quite variable and may include musculoskeletal abnormalities. Given the infrequency and novelty of this disorder, full phenotypic characterization of PTLS has not yet been fully elucidated. We present a case of severe bilateral clubfoot in a patient with PTLS. Diagnosis was made by array-based comparative genomic hybridization and confirmed by fluorescence in-situ hybridization. Because clubfoot was also present in an apparently unaffected brother, the presence of PTLS may have acted as a modifier of the phenotype. This report highlights the complex interaction of chromosomal and familial factors that contribute to musculoskeletal birth defects.

We identified all of the patients diagnosed as having CDI from January 2011 to December 2014 at our university-setting hospital. Data were extracted using electronic medical records and chart review. The data of all of the patients who died within 30 days of incident CDI were compared with those who survived beyond 30 days of incident CDI. A multivariable logistic regression model was created for mortality after finding a subset of significant predictor variables by making bivariate comparisons also using logistic regression.A total of 893 patients were diagnosed as having CDI during the study period. The mean age was 62 years and 49.5% were women. The mean length of hospital stay was 11.73 days. Of the 893 patients with CDI, 98 (10.97%) died within 30 days of incident CDI. CDI recurrence was noted in 76 patients (8.51%). On multivariate logistic regression analysis, peptic ulcer disease, advanced age, Charlson comorbidity index, and intensive care unit status were found to be significantly associated with 30-day mortality. There was no significant association between acid suppression and CDI mortality.Advanced age, Charlson comorbidity index, intensive care unit status, and peptic ulcer disease are predictors of all-cause 30-day mortality in hospitalized patients with CDI.

Purpose Calcaneocuboid arthrodesis was used during revision clubfoot surgery in order to maintain midfoot correction. The purposes of this study were to determine: (1) functional level at 17-year follow-up compared to 5-year follow-up; (2) patients’ current functional level, satisfaction, and pain; and (3) current arthropometric measurements. Methods Twenty patients (27 clubfeet) with clubfoot relapse underwent revision soft tissue release and calcaneocuboid fusion between 1991 and 1994. They were previously evaluated at a mean follow-up of 5.5 years. Ten out of 20 patients (13 clubfeet), mean age of 24 years, were reevaluated at mean follow-up of 17.5 years. The Hospital for Joint Diseases Functional Rating System (HJD FRS) for clubfoot surgery, Outcome Evaluation in Clubfoot developed by the International Clubfoot Study Group, the Clubfoot Disease-Specific Instrument, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, Laaveg and Ponseti's functional rating system for clubfoot and pain scale were completed by patient and/or surgeon to assess function, patient satisfaction and pain. Foot and ankle radiographs and anthropometric measurements were reviewed. For HJD FRS, scores from original follow-up were compared to current ones. Results The HJD FRS score of all feet was 65.9, demonstrating a significant decline from the original mean score of 77.8 ( p = 0.03). Excellent/good HJD FRS scores went from 85 to 38 %. Mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 on a scale of 1–10. Patients were very/somewhat satisfied with status of foot in 76 % of feet and appearance of foot in 46 % of feet, based on Clubfoot Disease-Specific Instrument questions. Conclusions Revision clubfoot surgery with calcaneocuboid fusion in patients 5–8 years of age showed an expected decline in functional outcome measures over a 17-year follow-up period. It still produced comparable results to other studies for a similar population of difficult, revision cases, and should have a place in current surgical treatment techniques.

The group IVA calcium-dependent cytosolic phospholipase A2 (cPLA2α) enzyme controls the release of arachidonic acid from membrane bound phospholipids and is the rate-limiting step in production of eicosanoids. A variety of different kidney injuries activate cPLA2α, therefore we hypothesized that cPLA2α activity would regulate pathologic processes in HK-2 cells, a human renal tubular epithelial cell line, by regulating cell phenotype and proliferation. In two lentiviral cPLA2α-silenced knockdowns, we observed decreased proliferation and increased apoptosis compared to control HK-2 cells. cPLA2α-silenced cells also demonstrated an altered morphology, had increased expression E-cadherin, and decreased expression of Ncadherin. Increased levels of E-cadherin were associated with increased promoter activity and decreased levels of SNAIL1, SNAIL2, and ZEB1, transcriptional repressors of E-cadherin expression. Addition of exogenous arachidonic acid, but not PGE2, reversed the phenotypic changes in cPLA2α-silenced cells. These data suggest that cPLA2α may play a key role in renal repair after injury through a PGE2-independent mechanism.

The Ponseti method of clubfoot correction is now widely practiced worldwide. Initial correction rates are nearly 100%, but subsequent relapses may occur in up to one-third of patients. Very little has been written by anyone other than Dr Ponseti about the characterization and treatment of recurrent clubfoot deformity following use of the Ponseti method. This review paper is the first one which draws together the current literature on the topic.

The initial treatment of idiopathic clubfoot was mostly surgical for the 1980s/1990s. In the latter half of the 1990s, there was a surge of interest in the Ponseti method of casting after the publication of Dr. Ponseti's 30-year results. Many authors have since shown correction rates in the high 90th percentile, rendering posteromedial release surgery almost obsolete. The success of the Ponseti method has been brought internationally and extrapolated to more and more difficult cases, such as idiopathic or syndromic, primary or recurrence. This new trend will create a different subset of complications.

Background Many different clubfoot classification systems have been proposed, but no single one is universally accepted. Two frequently cited systems, developed by Dimeglio/Bensahel and Catterall/Pirani, are often used for evaluation purposes in the treatment of idiopathic clubfoot. Our hypothesis was that the initial scores would be positively correlated with the number of casts required for clubfoot correction, indicating to us that the more severe score would require more casts, and therefore truly show the accuracy and usefulness of the scoring system. Methods From May 2000 to April 2008, 123 patients (185 feet) with idiopathic clubfeet were treated. All patients were below 60 days of age (mean 15.3 d, range: 2 to 57 d) at the time of their initial evaluation, and had not received prior clubfoot treatment. All cast placements were under the supervision of the same pediatric orthopedic surgeon. Initial correction was achieved in all patients. Results The mean number of casts required for correction was 5.1 (range: 2 to 8). On the basis of number of casts required, no significant differences were found in final total scores (Dimeglio/Bensahel P=0.14 and Catterall/Pirani P=0.44), indicating a similar level of correction for all feet. The Dimeglio/Bensahel and Catterall/Pirani classification systems were both similarly, poorly correlated with the number of casts needed [Spearman rank correlation coefficients (rs)=0.34 vs. 0.33]. The 2 components with the highest correlations were equinus (rs=0.39) and forefoot adduction (rs=0.35) for the Dimeglio/Bensahel system and coverage of the lateral head of the talus (rs=0.40) and rigid equinus (rs=0.39) for the Catterall/Pirani system. Conclusions When using the initial scores, both the Dimeglio/Bensahel and Catterall/Pirani classification systems had a low correlation with the number of Ponseti casts required. Analysis of the individual components revealed variability in the coefficients, with some having low-to-moderate correlation and others having none. There was no difference between the Dimeglio/Bensahel and Catterall/Pirani classification systems when measuring their correlation with the number of Ponseti casts required for clubfoot correction. An improved classification system is needed to predict the length of treatment and, ultimately, the risk of recurrence. Level of evidence Prognostic Level IV.

Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3-40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4-12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12-18 and 2-9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5-6.0 and 0.0-2.0), and maximum passive dorsiflexion from -45 degrees (range, -75 degrees to -20 degrees ) to 10 degrees (range, 0 degrees to 40 degrees ). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13-70 months), the mean maximum dorsiflexion was 5 degrees (range, -20 degrees to 20 degrees ), two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age.

Lupus mastitis (LM) is a rare presentation of lupus erythematosus profundus or lupus panniculitis, an unusual and rare clinical variant of lupus erythematosus itself in which the inflammatory reaction occurs primarily in the deep subcutaneous adipose. Although not required for diagnosis, essentially all cases of LM present with systemic or discoid lupus. The etiology is uncertain. Histologically it is defined by a lymphocytic lobular panniculitis and a characteristic hyaline sclerosis of the adipose tissue. Treatment is primarily medical due to exacerbation of disease by surgical intervention. A high index of suspicion, and familiarity of the histologic findings, is therefore required to make an accurate diagnosis and prevent further unwarranted diagnostic procedures. Herein, we provide a literature-based review of the clinical, radiologic, and pathologic findings of LM and its treatment and prognosis with the addition of a case for the literature.