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Item Open Access The Oppositional Platform of our Current Healthcare System;(emergency Physicians Monthly Magazine, 2024-12-16) Severance, HarryRising ER Wait Times are just One of a host of Warnings of Bad Things Yet to Come; Unless we can change thy stem to one of Collaboration! (Technology innovation alone is not the answer)Item Open Access Improving Patient and Family Communication in the Care of Patients Undergoing Mechanical VentilationNeiman, Joseph; Chaudhry, Hina; Edmunds, Lavinia; Maheshwari, Ayonija; Young, Samantha; Winters, Bradford; Berenholtz, SeanIntroduction: Approximately 800,000 hospitalized patients are mechanically ventilated each year in the United States, and as the population ages, the incidence of mechanical ventilation (MV) is increasing at a high rate. Patients often describe their experience with mechanical ventilation and the inability to communicate their needs and sensations to their families and providers as the most frightening and frustrating aspect of their care. The mechanically ventilated patient represents a crucial and growing subset of critically ill patients where improvements in patient and family communication are desperately needed. Objectives: Interview former MV patients and family members while engaging a patient and family council to develop a “patient and family-centered ventilator toolkit” to improve communication and to empower families to take an active role in the care of mechanically ventilated patients. Identify: 1) current knowledge and key experiences of mechanical ventilation, and 2) individual-centered approaches to communication. Materials and Methods: Focus groups were conducted with 26 former mechanical ventilation patients and family members using a facilitation guide developed by our multidisciplinary team including former patients and family caregivers. The focus groups were recorded, transcribed, and analyzed using a combination of a priori and inductive thematic codes in NVivo 12, a qualitative data analysis software package. A council of patient and family partners was engaged to develop a communication toolkit. Conclusions: Participants universally stated that mechanical ventilation is frightening, isolating, and in many cases, exceedingly traumatic. They described their challenges and frustrations communicating, as well as communication strategies they improvised. Their strategies were assembled into the toolkit. All participants felt there was an unmet need for communication resources for mechanically ventilated patients and family members. Next Steps: The toolkit is being provided to mechanically ventilated patients and families in an ICU at the Johns Hopkins Hospital. Preliminary survey results suggest patients using the toolkit have greater ease and satisfaction communicating with their care team and loved ones. Surveying and toolkit review are ongoing. Acknowledgements: This work was funded through an Agency for Healthcare Research and Quality award, K18 HS024200.Item Open Access What do mechanically ventilated patients want? A sense of normalcy and partnership.Neiman, Joseph; Chaudhry, Hina; Maheshwari, Ayonija; Winters, Bradford; Leslie, Myles; Berenholtz, Sean1) Background: Research was carried out at the Johns Hopkins Hospital. Mechanically ventilated patients in the ICU and their family members are the target population. 2) Problem: Mechanical ventilation (MV), although life saving, is associated with significant morbidity and mortality. Approximately 35% of patients receiving prolonged MV die in the hospital, and only 31% are discharged home. Of those who are discharged, almost half suffer from persistent debilitating complications including significant physical, cognitive, and psychological disability. Prevalence of psychiatric morbidity including depression, anxiety, and PTSD, and an inability to rejoin the workforce remain unacceptably high with rates as high as 50% at 1 year after discharge. This severe disability and trauma experienced in ICU survivors needs urgent attention, and improving patient care and reducing complications for MV patients is a global priority. While there has been a significant investment of resources to reduce complications from MV, few studies have directly engaged patients and families in this common goal. Our study sought to better understand the experiences of patients and families to help design future interventions to empower them to better understand, participate in their own care, and reduce complications from MV. 3A) Assessment of problem and analysis of its causes: Our study seeks to better understand the experiences of mechanically ventilated patients and their families to design interventions would humanize the ICU environment while maintaining normalcy and restoring dignity for patients and families. Between May 9, 2016 - April 18, 2017, semi-structured interviews were conducted with 25 former MV patients and their family members. Using purposive convenience sampling, potential patient and family partners were identified, screened, and recruited. Pertinent domains discussed in interviews included 1) knowledge of key ICU experiences related to mechanical ventilation, 2) complications and care issues associated with MV, 3) perceptions of commonly recommended strategies to reduced MV complications, 4) effective strategies to communicate this content, and 5) strategies to engage family members in care delivery. Interviews were digitally recorded and transcribed. 4) Intervention: Based on participant feedback, we are developing a multifaceted toolkit to improve the experience and participation of MV patients and their families. The toolkit includes empowering quotes from participants; strategies for maintaining a sense of normality from daily life outside the ICU; a section on incorporating day-to-day activities into routine in the ICU, which participants said gave them a sense of purpose; goal setting strategies; tips for interacting with the ICU staff; and descriptions of common MV and ICU features, e.g., mechanical ventilation, tracheostomy, staff roles, and machine sounds. 5) Strategy for change The proposed toolkit will have two overarching components. The principal is a resource to empower patient and family communication, engagement and wellness. The second section is a guide for staff to enable patients and families to use their portion of the kit. 6) Measurement of improvement: The study design is rooted in phenomenological, theoretical qualitative research. We used a combination of inductive and deductive processes to identify thematic codes. Tentatively, the pilot intervention impact will be measured using tailored MV patient and family satisfaction surveys. 7) Effects of changes: 8) Lessons learnt and 9) Messages for others: Patients and their families consistently and uniformly described MV as a frightening, and isolating experience, and welcomed interventions that would 1) improve their understanding of mechanical ventilation and its complications, and 2) encourage direct patient or family participation to reduce MV complications and create a lasting partnership with their healthcare team. 10) Please describe how you have involved patients, carers or family members in the project: A multidisciplinary team inclusive of MV patients and family caregivers developed the interview facilitator guide. In-depth interviews and focus groups were conducted with 25 former patients and their family members. The toolkit is based on feedback from patients and families, and a Patient and Family Council provided input on the toolkit as it was developed. 11) Please declare any conflicts of interest below. The study is funded by the Agency for Healthcare Research and Quality. We have no conflicts of interest. 12) Ethics Approval: The IRB at Johns Hopkins approved the study.Item Open Access The Art of the Anthropological Diorama: Franz Boas, Arthur C. Parker, and Constructing Authenticity, by Noémie Étienne(Panorama: Journal of the Association of Historians of American Art, 2022-10-11) Bowen, DoreReview of The Art of the Anthropological Diorama: Franz Boas, Arthur C. Parker, and Constructing Authenticity, by Noémie ÉtienneItem Open Access On the site of her own exclusion: strategizing queer feminist art history(2016) Bowen, DoreWhile feminist art history and queer theory both have a strong presence in academic discourse, there is no clear existing queer feminist art history. This book examines how and why this is the case.Item Open Access Item Open Access Italo Svevo and Women's WritingZiolkowski, Saskia ElizabethItem Open Access Paradoxes of gender/politics: Nationalism, feminism, and modernity in contemporary Palestine(1997-08) Hasso, Frances SThis dissertation explores the relationship between nationalism and feminism by focusing on the Democratic Front for the Liberation of Palestine (DFLP) and the Palestinian Federation of Women's Action Committees (PFWAC) in the Occupied Territories. The study is based on over 150 interviews conducted in 1989 and 1995 (including 56 longitudinal re-interviews), documents, participant observation, and secondary sources. The dissertation addresses why the DFLP in the territories included a large proportion of women at the leadership and membership levels, concluding that the DFLP's commitment to non-military grassroots mobilization made it particularly attractive to women. DFLP cadres also assumed that Palestinians had to prove they were modern to be worthy of self-determination; women leaders symbolized this modernity. Also addressed is why Palestinian leftist-nationalists were convinced that modernity was a pre-requisite for national self-determination. In part, the answer lies in hegemonic narratives that portrayed Palestinian society as atavistic and uncivilized, and therefore undeserving of self-determination. One Palestinian and Arab response was a self-blame narrative that attributed the loss of Palestine in 1948 and 1967 to backwardness. The dissertation also explores why most Palestinian women were regulated in public space and disenfranchised from the nationalist project during the uprising in the territories. To some extent, the very strength of women's presence in the public sphere threatened the gender order, leading to a systematic reassertion of male power. In addition, in an international context where affairs of state are almost exclusively the concerns of men, de-marginalization required the de-feminization of Palestinian politics. Finally, the dissertation examines whether PFWAC nationalist-feminist mobilization had any long-term effects on the gender consciousness of working-class women. Based on 1989 interviews and 1995 re-interviews, most former PFWAC members demonstrated strong feminist sentiments, largely attributable to PFWAC affiliation, but believed they could not always act on them given social constraints. Thus, while participation in the combined nationalist-feminist PFWAC project led to a feminist consciousness for many women, exploring this consciousness requires disaggregating what subaltern women want from what they are able to accomplish and examining the non-dramatic ways they change their lives.Item Open Access Il Palazzo del Lussemburgo di Maria de’ Medici, Parigi, 1611–1631(2016) Galletti, SItem Open Access Item Open Access Item Open Access Preoperative dysphonia and dysphagia improve following cervical deformity surgery(Spine Journal, 2024-09-01) Soroceanu, A; Gum, JL; Protopsaltis, TS; Hamilton, DK; Passias, PG; Lafage, R; Smith, JS; Kebaish, KM; Eastlack, RK; Klineberg, EO; Gupta, MC; Lafage, V; Schwab, FJ; Shaffrey, CI; Bess, S; Burton, DC; Ames, CPBACKGROUND CONTEXT: Twenty-five percent of adult cervical deformity patients undergoing deformity correction have impairment due to a voice problem prior to surgery. Prior work has shown that these patients tend to be more frail and more likely to report preoperative dysphagia. We hypothesized that these patients could be at increased risk of post operative dysphonia and dysphagia. PURPOSE: The purpose of this study was to quantify how patients with preoperative dysphonia differ from their counterparts in terms postoperative dysphagia, dysphonia and HRQOL 6 weeks post surgery. STUDY DESIGN/SETTING: Retrospective analysis of a prospective multicenter cervical deformity database. PATIENT SAMPLE: Adult cervical deformity patients with preop dysphonia undergoing deformity correction. OUTCOME MEASURES: Voice handicap index-10 (VHI-10). METHODS: Retrospective analysis of a prospective multicenter cervical deformity database. The voice handicap index-10 (VHI-10) was used to assess patient's perception of impairment due to problems with their voice prior to surgery. A score ≥11 was considered indicative of dysphonia. Patients were divided into two groups: normalVHI group (VHI-10 score <11) and highVHI group (VHI score ≥11). The two groups were compared in terms of baseline demographics, alignment, surgical metrics, and 6-week dysphagia (measured on the EAT-10 questionnaire), and post operative outcomes. T-tests and chi2 tests were performed, as appropriate. The significance level was p<0.05. RESULTS: There were 74 ACD patients included: NormalVHI (n=58, average VHI score 2.77) and HighVHI (n=16, average VHI score 16.37). The groups were similar in terms of baseline demographics and preoperative alignment. There was no statistically significant difference in terms of surgical metrics between the two groups (revision surgery p=0.21, anterior approach p=0.92, use of osteotomies p=0.71, and OR time p=0.15). The two groups had a similar rate of in hospital adverse events (12.2% vs 7.7%, p=0.64), and similar improvements on the NDI, mJOA, and NRS neck and arm pain. HighVHI patients showed significant improvement on the VHI score 6 weeks post-surgery (11.18 vs 16.37, p=0.01). The HighVHI group also showed postoperative improvement on the EAT-10 questionnaire, compared to NormalVHI patients (-3.68 vs 4.03, p=0.003). CONCLUSIONS: Twenty-five percent of adult cervical deformity patients undergoing deformity correction have impairment due to a voice problem prior to surgery. Contrary to our initial hypothesis, these patients exhibited improvement in dysphonia and dysphagia scores 6 weeks post surgery, with 81% reporting improvement in symptoms of dysphonia, and 69% reporting improvement in symptoms of oropharyngeal dysphagia. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Proximal junctional kyphosis and failure: How much can we attribute to known risk factors?(Spine Journal, 2024-09-01) Onafowokan, O; Jankowski, PP; Mir, J; Das, A; Hockley, A; Lorentz, N; Galetta, MS; Lebovic, J; Hamilton, DK; Diebo, BG; Daniels, AH; Anand, N; Pour, PT; Sciubba, DM; Ramos, RDLG; Shaffrey, CI; Lafage, R; Lafage, V; Schoenfeld, AJ; Passias, PGBACKGROUND CONTEXT: Despite advancements in the understanding of spinal alignment and in instrumentation for adult spine deformity (ASD) surgery, complications such as proximal junctional kyphosis and proximal junctional failure (PJK/PJF) continue to be a significant concern. PURPOSE: To assess the attributable risk of various reported contributors to development of PJK/PJF. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 464 ASD patients. OUTCOME MEASURES: Odds ratios of PJK/F risk factors. METHODS: We included ASD patients with complete baseline (BL) and up to 2Y clinical, radiographic and HRQL data. Stratified according to development of PJK/PJF by 2 years. Means comparison analyses compared outcomes between groups. Backstep logistic regression assessed factors predictive of PJK/F development. RESULTS: There were 464 patients included (age: 59.8 ± 14.3 years, BMI: 26.9 ± 5.5 kg/m2, CCI: 1.65 ± 1.68). 80.5% of patients were female; 173 patients (37.3%) formed the PJK/F+ group, as at 2 years (173 PJK and 28 PJF patients). At BL, PJK/F+ patients were older (63.2 vs 57.9 years, p<0.001) and had worse deformity (PI-LL 20.3 vs 11.8, p<0.001). There were no differences between groups in baseline disability, demographic, frailty or comorbidity factors. Controlling for age and baseline deformity, PJK/F+ patients were more likely to develop mechanical complications (OR 2.1, 95% CI: 1.2-3.7, p=0.007). Use of PJK prophylaxis techniques did not have a significant effect on risk of developing PJK/F (p=0.307). Factors associated with increased risk of developing PJK/F were significant baseline deformity (OR 1.02, 95% CI: 1.01-1.03, p=0.026), peripheral vascular disease (OR 5.5, 1.3-23.6, p=0.023), undergoing an osteotomy (OR 1.7, 1.1-2.8, p=0.017) and age >60 (OR 1.1, 1.1-1.2, p=0.026) and hypertension (OR 2.01, 1.04-3.87, p=0.038). Diabetes was associated with lower odds for developing PJK/F+ (OR: 0.3, 95% CI: 0.1-0.8, p=0.018). CONCLUSIONS: Proximal junctional kyphosis/failure remains a significant postoperative concern in the ASD population. With currently known risk factors, we are still unable to fully quantify and predict a patient's total risk for developing postoperative PJK/F. Further work is needed to delineate contributing factors that are yet to be determined. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Quantifying the importance of upper cervical extension reserve in adult cervical deformity surgery and its impact on baseline presentation and outcomes(Spine Journal, 2024-09-01) Passias, PG; Mir, J; Smith, JS; Lafage, V; Lafage, R; Diebo, BG; Daniels, AH; Onafowokan, O; Line, B; Eastlack, RK; Mundis, GM; Kebaish, KM; Soroceanu, A; Scheer, JK; Kelly, MP; Protopsaltis, TS; Kim, HJ; Hostin, RA; Gupta, MC; Riew, KD; Burton, DC; Schwab, FJ; Bess, S; Shaffrey, CI; Ames, CPBACKGROUND CONTEXT: Hyperextension of the upper cervical spine is a prominent compensatory mechanism to maintain horizontal gaze and balance in adult cervical deformity (ACD) patients, akin to pelvic tilt in spinal deformity. The relaxation of ER and its impact on postoperative outcomes is not well understood. PURPOSE: To evaluate upper cervical ER impact on postoperative disability and outcomes. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Adult cervical deformity. OUTCOME MEASURES: ER, HRQLs. METHODS: ACD patients undergoing subaxial cervical fusion with 2Y data were included. Upper cervical extension reserve (ER) was defined as: C0-C2 sagittal Cobb angle between neutral and extension. Relaxation of ER was defined as the ER normative mean in those that met the ideal in all Passias ACD modifiers. Outcomes were defined as "good" if meeting ≥2 of the three: (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Controlled analysis was conducted with ANCOVA and multivariable logistic regressions. Conditional inference tree (CIT) analysis determined thresholds. RESULTS: A total of 108 ACD patients met inclusion. (Age 61.4 ± 12.3, 61% F, BMI 29.4 ± 7.5 kg/m2, mCD-FI .24 ±.12, CCI 0.97 ± 1.30). Radiographic alignment is depicted in Table 1. Preoperative C0-C2 ER was 8.7 ±9.0 ±, and at the last follow-up was 10.3 ± 11.1. ER in those meeting all ideal CD modifiers at 2Y was 12.9 ± 9.0. Preoperatively 29% had adequate ER, while 59.7% had improvement in ER postoperatively, with 50% of patients achieving adequate ER at 2Y. Higher ER significantly correlated with lower cervical deformity (p<.05). Preoperatively, greater ER was predictive of lower preoperative disability, with worse baseline mobility, pain, and anxiety (EQ5D) (B = -6.1, -2.9, -2.9 respectively; R2 =0.212, p<.001). Improvement of ER depicted a higher rate of MCID for NDI (64% vs 39%, p=.008), and meeting good clinical outcomes (72% vs 54%, p=.04). Controlling for baseline deformity and demographic factors found resolution of inadequate ER to have 7x higher likelihood of meeting MCID for NDI (6.941 [1.378-34.961], p=.019) and 4x higher odds of achieving good outcomes (4.022 [1.017-15.900], p=.047). Isolating those with inadequate preoperative ER, found postoperative resolution having 5x odds of good outcomes (p<.05). In those with inadequate ER at baseline, the preoperative C2-C7 of <-18 and TS-CL of >59 for TS-CL was predictive of ER resolution (p<.05). In those with preoperative C2-C7 >-18, a T1PA of >13 was predictive of postoperative return of ER (p<.05). Independently TS-CL of >59, was significant for predicting ER return postoperatively, highlighting its compensatory role for proximal spinal deformities (all p<.05). Surgical correction of C2-C7 by >16 from baseline was found to be predictive of ER return. CONCLUSIONS: Increased preoperative utilization of the extension reserve in the upper cervical spine in cervical deformity was associated with worse baseline regional and global alignment while impacting health-related measures. The majority of patients had relaxation of extension reserve postoperatively, however, in those who didn't, there was a decreased likelihood of achieving good outcomes. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Sarcopenic obesity: an underrated phenomenon impacting adult spinal deformity intervention outcomes(Spine Journal, 2024-09-01) Das, A; Onafowokan, O; Mir, J; Lorentz, N; Lebovic, J; Daniels, AH; Buell, TJ; Hamilton, DK; Lafage, R; Jankowski, PP; Sardar, Z; Shaffrey, CI; Kim, HJ; Lafage, V; Passias, PGBACKGROUND CONTEXT: The amount and quality of tissue do not always positively correlate as is the case with sarcopenic obesity. As the population of elderly people with adult spinal deformity (ASD) continues to increase, sarcopenia (decreased muscle mass) and obesity continue to soar in prevalence, although sarcopenia is underacknowledged. PURPOSE: To determine how sarcopenic obesity may impact adult spinal deformity surgery outcomes and better characterize the health of important surrounding structural tissue that is key to alignment. STUDY DESIGN/SETTING: Retrospective cohort review of prospectively enrolled database. PATIENT SAMPLE: A total of 529 adult spinal deformity patients. OUTCOME MEASURES: radiographic parameters, mechanical complications, complications METHODS: Operative ASD patients with complete baseline (BL) and 2-year (2Y) baseline, radiographic, and health related quality of life (HRQL) data were included. Sarcopenia was defined based on the validated European Working Group of Sarcopenia in Older People (EWGOSOP2). Obesity was classified via traditional BMI categories. The cohort with sarcopenic obesity (SO) was compared to a cohort of patients without. Descriptive statistics, means comparison testing, and regression analyses were applied to identify differences and trends, including a subanalysis of those with SO vs each condition alone. RESULTS: A total of 529 patients met inclusion criteria (mean age: 60.2±14.3, mean BMI: 27.1±5.8, mean CCI 1.6±1.7, mean weighted mASD-FI: 6.5±4.9). In terms of surgical characteristics, mean operative time 414.1±175.3 minutes, mean EBL 1565.9±1387.2, mean levels fused 10.9 ±4.6). 311 patients (58.8%) registered a confirmed diagnosis of sarcopenia, while 100 patients (60.4%) were considered obese. Altogether, 206 (38.9%) of patients demonstrated aspects of SO. The SO cohort was significantly older (61.9 vs 59.1, p=0.032) with a significantly greater number of comorbidities and higher frailty score (p<.001, both). At baseline, patients with SO demonstrated significantly lower baseline lower extremity motor scores (p=.004). Radiographically, SO patients had greater pelvic tilt (25.2 vs 22.9, p=0.018), greater PI-LL (19.6 vs 12.6, p<.001), less lumbar lordosis (41.7 vs 36.3, p=0.004), greater vertebral pelvic angles (p<.01) at T1, T4, T9, L1 and L4, and greater GAP scores indicating higher disproportionality (p=0.032). In terms of complications, SO patients demonstrated considerably higher rates of cardiac complications (83.3% vs 16.7%, p=0.025) and surgical infection (66.7% vs 33.3%, p=0.025).The SO cohort also sustained a significantly greater rates of pseudarthrosis (64.3% vs 35.7%, p=0.049) and failure with reoperation (60.0% vs 40.0%, p=0.027), with a significantly higher rates instrumentation failure (50.7% vs 49.3%, p=0.045). From a prevention perspective, the use of PJK prophylaxis amongst those with SO showed lower rates of screw breakage (p=0.039) and mechanical complications (p=0.004) as opposed to SO patients who did not receive prophylaxis. SO was a positive predictor of instrumentation failure (OR 1.7, p=0.047) while obesity or sarcopenia were not significant predictors alone. SO patients also achieved age-adjusted match goals at a lower rate than non-SO patients (p<.001). Clinically, this manifested as greater back and leg NSR pain scores at every time point up to 2 years. CONCLUSIONS: Sarcopenic obesity appears to significantly hamper outcomes after ASD, and awareness of the patient's muscle quality could guide operative decision-making as well as serve as a valuable target for preoperative optimization through measures such as nutritional counseling and prehabilitation. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Selection of upper instrumented vertebra in adult spinal deformity: risk calculator and recommendations based on proximal junctional kyphosis(Spine Journal, 2024-09-01) Passias, PG; Mir, J; Das, A; Onafowokan, O; Galetta, M; Shaffrey, CI; Lafage, VBACKGROUND CONTEXT: The surgical correction of adult spinal deformity (ASD) presents a complex and multifaceted challenge, further intensified by the need for revision surgery. Determination of the upper instrumented vertebra can often be challenging. PURPOSE: To develop a UIV risk index score for patients undergoing ASD corrective surgery. STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected single-center ASD database. PATIENT SAMPLE: ASD. OUTCOME MEASURES: PJK. METHODS: We included operative ASD patients with a minimum of a 2-year follow-up undergoing fusion from at least L1 and proximal to the sacrum. Patients without PJK were isolated to determine predictive thresholds based on patient and surgical factors. Variable importance was determined utilizing random forest analysis to determine the weighting of variables with multivariable logistic regression. Conditional inference tree (CIT) determined threshold values predictive of UIV level in those who didn't develop PJK. RESULTS: A total of 334 patients met inclusion. (Age 63±10, 77% F, BMI 27.6±5.1 kg/m2, frailty 3.5±1.5, CCI 1.9±1.7). The model for predicting PJK was significant for osteoporosis, LL, TK, TLPA, with posterior UIV and IBD UIV (p<.05). Table 1. Baseline UIV slope of >42.4 had a higher rate of PJK postoperatively (63% vs 27%, p<.001). Evaluating factor importance for the selection of UIV determined UIV slope to have the greatest weight, with T1PA, PJK prophylaxis, PI-LL, frailty, osteoporosis, and CCI following in those who didn't have PJK. For those with UIV slope <12.7, selection of upper thoracic UIV was contingent on T1PA being <7 (p=0.018). Patients with UIV slope >27 and T1PA >30 were likely to have UIV in the upper thoracic (T4 mean) in those who didn't develop PJK. Whereas, those with a UIV slope between 12.7 to 30 with T1PA >30 were less likely to develop PJK with a lower thoracic UIV (p<.001). CONCLUSIONS: The selection of UIV was strongly correlated to UIV slope and T1PA for avoidance of proximal junctional kyphosis. Frailty and lumbar lordosis were important contributors to the model for the selection of optimal UIV. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Severe hip and knee osteoarthritis worsens patient-reported disability in adult spinal deformity patients(Spine Journal, 2024-09-01) Balmaceno-Criss, M; Singh, M; Xu, A; Daher, M; Lafage, R; Lewis, SJ; Klineberg, EO; Eastlack, RK; Gupta, MC; Mundis, GM; Gum, JL; Hamilton, DK; Hostin, RA; Passias, PG; Protopsaltis, TS; Kebaish, KM; Kim, HJ; Shaffrey, CI; Smith, JS; Line, B; Lenke, LG; Ames, CP; Burton, DC; Bess, S; Schwab, FJ; Lafage, V; Diebo, BG; Daniels, AHBACKGROUND CONTEXT: The complex interplay between lower extremity osteoarthritis and sagittal alignment in adult spinal deformity patients is of growing clinical interest. PURPOSE: To quantify the sequential effects of lower extremity OA on PROMs in ASD patients. STUDY DESIGN/SETTING: Retrospective review of prospectively collected data. PATIENT SAMPLE: ASD patients with no prior history of thoracolumbar surgery, and available baseline PROMs and standing radiographs were included. OUTCOME MEASURES: Baseline demographics, spinopelvic alignment, and PROMs. METHODS: Included patients with PROMs, standing xrays, no prior thoracolumbar surgery, and bilateral Kellgren-Lawrence (KL) hip/knee grade at baseline. Patients grouped into Spine (KL <3 BL hips & knees), Spine-Hip (KL>3 BL hips, KL <3 BL knees), Spine-Knee (KL>3 BL knees, KL>3 BL hips), Spine-Hip-Knee (KL>3 BL hips & knees). Baseline demographics, spinopelvic alignment, and PROMs were compared. Multivariate regression with forward stepwise selection predicted PROMs with variables (demographic, radiographic, OA severity) with significant association identified on Pearson correlation RESULTS: Included 160 patients: 56 Spine, 32 Spine-Knee, 20 Spine-Hip, and 52 Spine-Hip-Knee. Spine-Hip-Knee patients were older (Spine=62.2, Spine-Knee=61.2, Spine-Hip=59.1, Spine-Hip-Knee=68.5; p<.001) but similar in sex, comorbidities, and frailty; p>.05. Spine-Hip-Knee patients had higher SVA (50.0,30.6,60.5,83.5), T1PA (25.2,20.4,20.3,27.8), GSA (3.7,2.3,4.3,7.5), and KA (0.0,2.1,2.9,10.5); p<.005. SRS total and VR12 PCS scores were similar but VR12-2b climbing stairs (1.73,1.91,1.55,1.40, p=.014) and SRS-8 back pain at rest (2.29,2.84,1.95,2.71, p=.012) were lower in Spine-Hip-Knee and Spine-Hip, respectively. ODI (42.75,35.88,50.30,44.59, p=.040) and ODI Pain (2.88,1.84,2.90,2.46, p=0.019) were higher in Spine-Hip patients; ODI lifting was higher in hip OA patients but not significant (2.95,2.69,3.45,3.35, p>.05). In multivariate analyses, KOA changed the prediction of ODI pain from R2 0.052 to 0.086 and SRS-8 from R2 0.077 to 0.147. HOA changed the prediction of VR12-2b from R2 0.113 to 0.140 and ODI Lifting from R2 0.175 to 0.202. Frailty impacted PROMs across all models (p<.001) and GSA changed ODI, ODI pain, and VR12-2b models (p<.05). CONCLUSIONS: Severe hip and knee OA worsen patient-reported disability and physical function in ASD patients. These results quantify the impact of lower limb arthritis on patient reported outcomes, and highlight the need for integrated assessment and management of both spinal alignment and joint health in patients. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Should pelvic incidence influence realignment strategy? A detailed analysis in adult spinal deformity(Spine Journal, 2024-09-01) Williamson, TK; Onafowokan, O; Owusu-Sarpong, S; Lebovic, J; Mir, J; Das, A; Diebo, BG; Lafage, R; Lafage, V; Passias, PGBACKGROUND CONTEXT: Pelvic incidence (PI) serves as the cornerstone for realignment schema to create a more individualized realignment target. Yet, it is not known if outcomes of realignment schema are dependent on the amount of pelvic incidence. The purpose of this study is to assess how varying realignment strategies affect mechanical failure and clinical outcomes in PI-stratified cohorts following ASD surgery. PURPOSE: The purpose of this study is to assess how varying realignment strategies affect mechanical failure and clinical outcomes in PI-stratified cohorts following ASD surgery. STUDY DESIGN/SETTING: Retrospective cohort study; Single academic center. PATIENT SAMPLE: A total of 445 adult patients met radiographic criteria for adult spinal deformity. OUTCOME MEASURES: Mechanical failure (either a major hardware failure requiring intervention or proximal junctional failure [PJF]); Clinical Improvement at two years: [meeting either: (1) Substantial Clinical Benefit for Oswestry Disability Index (change >18.8), or (2) Oswestry Disability Index <15 and Scoliosis Research Society Total>4.5]; Good Outcome involved meeting Clinical Improvement criteria with absence of mechanical failure by two years. METHODS: Conditional Inference Tree (CIT) analysis was utilized to define subsets within pelvic incidence generating significantly different rates of mechanical failure. These subsets of pelvic incidence were further analyzed as sub-cohorts for the outcomes and effects of realignment within each. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (L1-S1) analyzed the association of age-adjusted realignment (Sagittal Age-Adjusted Score [SAAS]; Lafage et al) and Global and Alignment Proportionment (GAP; Yilgor et al) strategies with meeting Good Outcome within PI-stratified groups. RESULTS: Using CIT analysis, a parabolic relationship between PI and mechanical failure was seen, whereas patients with either less than 51° (n=174; 39.1% of cohort) or greater than 63° (n=114; 25.2% of cohort) of pelvic incidence generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of Good Outcome (80.3% and 77.6%, respectively) than those with moderate (51-63°) pelvic incidence (n=145, 32.6% of cohort; 8.9% mechanical failure, 92.2% Good Outcome). Patients with Lower PI (<51°) more often met Good Outcome when undercorrected in age-adjusted PI-LL and SAAS overall (12.3% vs 0.0%; p=.004). Patients not meeting Good Outcome in this group were more likely to deteriorate in GAP Relative Lordosis from first to final follow-up (OR: 13.4, 95% CI: 1.3-39.2), leading to a higher likelihood of mechanical failure (OR: 3.2, 95% CI: 1.34-7.52; p=.009). In those with moderate pelvic incidence (51-63°), patients were more likely to meet Good Outcome when aligned in GAP Lumbar Distribution Index (OR: 1.7, 95% CI: 1.1-3.3; p=.029), and those not meeting Good Outcome criteria were more likely to deteriorate in Lumbar Distribution Index from first to final follow-up (OR: 5.8, 95% CI: 1.7-19.8; p=.005). While these patients had noticeably higher rates of failure (20.0% vs 8.9%; p=.123), patients losing alignment in LDI had significantly lower rates of reaching Clinical Improvement criteria (30.0% vs 66.7%, p=.004). Patients with higher pelvic incidence (>63°) meeting Good Outcome were more likely to be overcorrected in SVA (OR: 2.4, 95% CI: 1.1-5.2; p=.033) at first follow-up. and were less likely to be undercorrected in T1PA (OR: 0.4, [0.17-0.86]; p=.020) by final follow-up. When assessing GAP alignment, patients were more likely to meet Good Outcome when aligned in GAP Lumbar Distribution Index (OR: 3.5, 95% CI: 1.4-8.9; p=.007). CONCLUSIONS: There is a parabolic relationship between pelvic incidence and both mechanical failure and clinical improvement following correction of adult spinal deformity. Patients with lower pelvic incidence may fare better with undercorrection in age-adjusted alignment, while those with higher pelvic may necessitate proper distribution of lordosis within the lumbar spine. In addition, loss of in-construct alignment led to higher rates of mechanical failure within low pelvic incidence and less clinical improvement among those with a higher grade. Understanding of the associations this fixed parameter has with poor outcomes can aid the surgeon in strategical planning when seeking to realign adult spinal deformity. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.