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Recent Research Articles from JPS Health Network
Evaluating the Cost-effectiveness of Prehospital Plasma Transfusion in Unstable Trauma Patients: A Secondary Analysis of the PAMPer Trial
JAMA Surg. 2021 Sep 22. doi: 10.1001/jamasurg.2021.4529. Online ahead of print.
IMPORTANCE: Prehospital plasma transfusion is lifesaving for trauma patients in hemorrhagic shock but is not commonly used owing to cost and feasibility concerns.
OBJECTIVE: To evaluate the cost-effectiveness of prehospital thawed plasma transfusion in trauma patients with hemorrhagic shock during air medical transport.
DESIGN, SETTING, AND PARTICIPANTS: A decision tree and Markov model were created to compare standard care and prehospital thawed plasma transfusion using published and unpublished patient-level data from the Prehospital Plasma in Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial conducted from May 2014 to October 2017, health care and trauma-specific databases, and the published literature. Prehospital transfusion, short-term inpatient care, and lifetime health care costs and quality of life outcomes were included. One-way, 2-way, and Monte Carlo probabilistic sensitivity analyses were performed across clinically plausible ranges. Data were analyzed in December 2019.
MAIN OUTCOMES AND MEASURES: Relative costs and health-related quality of life were evaluated by an incremental cost-effectiveness ratio at a standard willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY).
RESULTS: The trial included 501 patients in the modified intention-to-treat cohort. Median (interquartile range) age for patients in the thawed plasma and standard care cohorts were 44 (31-59) and 46 (28-60) years, respectively. Overall, 364 patients (72.7%) were male. Thawed plasma transfusion was cost-effective with an incremental cost-effectiveness ratio of $50 467.44 per QALY compared with standard care. The preference for thawed plasma was robust across all 1- and 2-way sensitivity analyses. When considering only patients injured by a blunt mechanism, the incremental cost-effectiveness ratio decreased to $37 735.19 per QALY. Thawed plasma was preferred in 8140 of 10 000 iterations (81.4%) on probabilistic sensitivity analysis. A detailed analysis of incremental costs between strategies revealed most were attributable to the in-hospital and postdischarge lifetime care of critically ill patients surviving severe trauma.
CONCLUSIONS AND RELEVANCE: In this study, prehospital thawed plasma transfusion during air medical transport for trauma patients in hemorrhagic shock was lifesaving and cost-effective compared with standard care and should become commonplace.
Mortality Variations of COVID-19 from Different Hospital Settings During Different Pandemic Phases: A Multicenter Retrospective Study
West J Emerg Med. 2021 Sep 2;22(5):1051-1059. doi: 10.5811/westjem.2021.5.52583.
INTRODUCTION: Diverse coronavirus disease 2019 (COVID-19) mortalities have been reported but focused on identifying susceptible patients at risk of more severe disease or death. This study aims to investigate the mortality variations of COVID-19 from different hospital settings during different pandemic phases.
METHODS: We retrospectively included adult (≥18 years) patients who visited emergency departments (ED) of five hospitals in the state of Texas and who were diagnosed with COVID-19 between March-November 2020. The included hospitals were dichotomized into urban and suburban based on their geographic location. The primary outcome was mortality that occurred either during hospital admission or within 30 days after the index ED visit. We used multivariable logistic regression to investigate the associations between independent variables and outcome. Generalized additive models were employed to explore the mortality variation during different pandemic phases.
RESULTS: A total of 1,788 adult patients who tested positive for COVID-19 were included in the study. The median patient age was 54.6 years, and 897 (50%) patients were male. Urban hospitals saw approximately 59.5% of the total patients. A total of 197 patients died after the index ED visit. The analysis indicated visits to the urban hospitals (odds ratio [OR] 2.14, 95% confidence interval [CI], 1.41, 3.23), from March to April (OR 2.04, 95% CI, 1.08, 3.86), and from August to November (OR 2.15, 95% CI, 1.37, 3.38) were positively associated with mortality.
CONCLUSION: Visits to the urban hospitals were associated with a higher risk of mortality in patients with COVID-19 when compared to visits to the suburban hospitals. The mortality risk rebounded and showed significant difference between urban and suburban hospitals since August 2020. Optimal allocation of medical resources may be necessary to bridge this gap in the foreseeable future.
Am Fam Physician. 2021 Sep 1;104(3):299-300.
J Natl Med Assoc. 2021 Aug 30:S0027-9684(21)00189-9. doi: 10.1016/j.jnma.2021.08.037. Online ahead of print.
INTRODUCTION: Previous research has shown that patients from historically marginalized groups in the United States tend to have poorer outcomes after joint replacement surgery and that they are less likely to receive joint replacement surgery at high-volume hospitals. However, little is known regarding how this group of patients chooses their joint replacement surgeon. The purpose of this study was to understand the factors influencing the choice of joint replacement surgeon amongst a diverse group of patients.
METHODS: Semi-structured interviews were conducted with Medicare patients who underwent a hip or knee replacement within the last 24 months (N = 38) at an academic and community hospital. Interviews were audio recorded, transcribed and verified for accuracy. Transcripts were reviewed using iterative content analysis to extract key themes related to how respondents chose their joint replacement surgeon.
RESULTS AND DISCUSSION: MD referral/recommendation appears to be the strongest factor influencing joint replacement surgeon choice. Other key considerations are hospital reputation and surgeon attributes-including operative experience, communication skills, and participation in shared decision-making. Gender/ethnicity of a surgeon, industry payments to surgeons, number of publications and cost did not play a large role in surgeon choice.
CONCLUSION AND CLINICAL RELEVANCE: The process of choosing a joint replacement surgeon is a complex decision-making process with several factors at play. Despite growing availability of information regarding surgeons, patients largely relied on referrals for choosing their joint replacement surgeon regardless of ethnicity. Referring physicians need to ensure that patients are able to access hospital and surgeon outcomes, operative volume, and industry-payment information to learn more about their orthopedic surgeons in order to make an informed choice.
The influence of patient perception of physician empathy on patient satisfaction among attending physicians working with residents in an emergent care setting
Health Sci Rep. 2021 Aug 17;4(3):e337. doi: 10.1002/hsr2.337. eCollection 2021 Sep.
BACKGROUND: It is unclear whether the patient's perception of attending physician empathy and the patient's satisfaction can be affected when attending physicians work alongside residents. We aim to determine the influence residents may have on (1) patient perception of attending physician empathy and (2) patient satisfaction as it relates to their respective attending physicians.
METHODS: This is a prospective single-center observational study. Patient perception of physician empathy was measured using Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE) in both attendings and residents in the Emergency Department. Patient satisfaction with attending physicians and residents was measured by real-time patient satisfaction survey. Multivariate logistic regressions were performed to determine the association between patient satisfaction and JSPPPE after patient demographics, attending physician different experience, and residents with different years of training were adjusted.
RESULTS: A total of 351 patients were enrolled. Mean JSPPPE scores were 30.1 among attending working alone, 30.1 in attending working with PGY-1 EM residents, 29.6 in attending working with PGY-2, and 27.8 in attending working with PGY-3 (p < 0.05). Strong correlation occurred between attending JSPPPE score and patient satisfaction to attending physicians (ρ > 0.5). The adjusted odds ratio was 1.32 (95% CI 1.23-1.41, p < 0.001) on attending's JSPPPE score predicting patient satisfaction to the attending physicians. However, there were no significant differences on patient satisfaction among four different groups.
CONCLUSION: Empathy has strong correlation with patient satisfaction. Decreased patient perception of attending physician empathy was found when working with senior residents in comparison to working alone or with junior residents.
The data-collection on adverse effects of anti-HIV drugs (D:A:D) model for predicting cardiovascular events: External validation in a diverse cohort of people living with HIV
HIV Med. 2021 Aug 19. doi: 10.1111/hiv.13147. Online ahead of print.
OBJECTIVES: Little is known about the external validity of the Data-collection on Adverse Effects of Anti-HIV Drugs (D:A:D) model for predicting cardiovascular disease (CVD) risk among people living with HIV (PLWH). We aimed to evaluate the performance of the updated D:A:D model for 5-year CVD risk in a diverse group of PLWH engaged in HIV care.
METHODS: We used data from an institutional HIV registry, which includes PLWH engaged in care at a safety-net HIV clinic. Eligible individuals had a baseline clinical encounter between 1 January 2013 and 31 December 2014, with follow-up through to 31 December 2019. We estimated 5-year predicted risks of CVD as a function of the prognostic index and baseline survival of the D:A:D model, which were used to assess model discrimination (C-index), calibration and net benefit.
RESULTS: Our evaluable population comprised 1029 PLWH, of whom 30% were female, 50% were non-Hispanic black, and median age was 45 years. The C-index was 0.70 [95% confidence limits (CL): 0.64-0.75]. The predicted 5-year CVD risk was 3.0% and the observed 5-year risk was 8.9% (expected/observed ratio = 0.33, 95% CL: 0.26-0.54). The model had a greater net benefit than treating all or treating none at a risk threshold of 10%.
CONCLUSIONS: The D:A:D model was miscalibrated for CVD risk among PLWH engaged in HIV care at an urban safety-net HIV clinic, which may be related to differences in case-mix and baseline CVD risk. Nevertheless, the HIV D:A:D model may be useful for decisions about CVD intervention for high-risk patients.
J Psychiatr Pract. 2021 Jul 28;27(4):316-321. doi: 10.1097/PRA.0000000000000564.
The use and availability of cannabis for recreational and medical purposes has become more widespread with increased legalization. Adverse health outcomes of this increased use include cannabinoid hyperemesis syndrome (CHS), which is underrecognized in medical settings. Cessation of substance use is the recommendation of choice for the complete resolution of CHS. However, interventions that provide rapid relief may be necessary in treatment-refractory cases. Little evidence is available to guide care in these cases. Here we report 4 cases of treatment-refractory CHS, all of which remitted after treatment with olanzapine. Olanzapine is known to block multiple neurotransmitter receptors involved in nausea and vomiting in chemotherapy-induced nausea and vomiting. Outcomes of the cases reported here suggest that off-label use of olanzapine may be effective in the symptomatic treatment of refractory CHS and may be the preferred treatment in cases in which comorbid psychotic symptoms or agitation are present.
Dose-dependent association between blood transfusion and nosocomial infections in trauma patients: A secondary analysis of patients from the PAMPer trial
J Trauma Acute Care Surg. 2021 Aug 1;91(2):272-278. doi: 10.1097/TA.0000000000003251.
BACKGROUND: The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a survival benefit to trauma patients who received thawed plasma as part of early resuscitation. The objective of our study was to examine the association between blood transfusion and nosocomial infections among trauma patients who participated in the PAMPer trial. We hypothesized that transfusion of blood products will be associated with the development of nosocomial infections in a dose-dependent fashion.
METHODS: We performed a secondary analysis of prospectively collected data of patients in the PAMPer trial with hospital length of stay of at least 3 days. Demographics, injury characteristics, and number of blood products transfused were obtained to evaluate outcomes. Bivariate analysis was performed to identify differences between patients with and without nosocomial infections. Two logistic regression models were created to evaluate the association between nosocomial infections and (1) any transfusion of blood products, and (2) quantity of blood products. Both models were adjusted for age, sex, and Injury Severity Score.
RESULTS: A total of 399 patients were included: age, 46 years (interquartile range, 29-59 years); Injury Severity Score, 22 (interquartile range, 12-29); 73% male; 80% blunt mechanism; and 40 (10%) deaths. Ninety-three (27%) developed nosocomial infections, including pneumonia (n = 67), bloodstream infections (n = 14), catheter-associated urinary tract infection (n = 10), skin and soft tissue infection (n = 8), Clostridium difficile colitis (n = 7), empyema (n = 6), and complicated intra-abdominal infections (n = 3). Nearly 80% (n = 307) of patients received packed red blood cells (PRBCs); 12% received cryoprecipitate, 69% received plasma, and 27% received platelets. Patients who received any PRBCs had more than a twofold increase in nosocomial infections (odds ratio, 2.15; 95% confidence interval, 1.01-4.58; p = 0.047). The number of PRBCs given was also associated with the development of nosocomial infection (odds ratio, 1.10; 95% confidence interval, 1.05-1.16; p < 0.001).
CONCLUSION: Trauma patients in the PAMPer trial who received a transfusion of at least 1 U of PRBCs incurred a twofold increased risk of nosocomial infection, and the risk of infection was dose dependent.
LEVEL OF EVIDENCE: Therapeutic/care management, level IV.
Facial Plast Surg. 2021 Aug 11. doi: 10.1055/s-0041-1732478. Online ahead of print.
Reconstructing mandibular defects presents challenges to dental rehabilitation related to altered bone and soft tissue anatomy. Dental implants are the most reliable method to restore the lost dentition. Immediate dental implants have been placed for many years but with unacceptably low rates of dental/prosthetic success. Current virtual technology allows placement of both fibulas and guided implants in restoratively driven positions that also allow immediate dental rehabilitation. Inexpensive three-dimensional printing platforms can create provisional dental prostheses placed at the time of surgery. This article reviews our digital and surgical workflow to create an immediate dental prosthesis to predictably restore the dentition during major jaw reconstruction with fibula free flaps.
What is the Resident Perception of Physician Assistants in an Oral and Maxillofacial Training Program?
J Oral Maxillofac Surg. 2021 Jul 7:S0278-2391(21)00654-6. doi: 10.1016/j.joms.2021.07.001. Online ahead of print.
PURPOSE: Physician assistants (PAs) are not employed in a widespread manner in the academic oral and maxillofacial surgery setting despite being able to assist with resident workload. We aim to measure residents' perception of PAs employed by an academic oral and maxillofacial surgery department after the addition of 2 PAs to the department.
METHODS: The investigators conducted an anonymous cross-sectional survey study addressing resident perception of PA's on reducing their working hours, the scope of PA's role, and the positive and negatives of working with a PA. The survey was distributed to current oral and maxillofacial surgery residents, non-categorical interns, and recent graduates at Parkland Memorial Hospital and John Peter Smith Hospital between November 1, 2020 and January 31, 2021. A follow up survey to collect demographic data was distributed between May 20, 2021 and June 10, 2021. Descriptive statistics were used to summarize the results, with bootstrapping techniques to calculate 95% confidence intervals (CI).
RESULTS: Investigators contacted 54 residents and recent alumni, and 31 (57%) responded to the original survey and 32 responded to the follow-up survey. All respondents agreed that the addition of PAs decreased resident workload (100%; 95% CI). The majority stated PAs should assist with rounding on inpatients (61%; 95% CI), in hospital consultations (52%; 95% CI), clinic appointments (74%; 95% CI), and patient care coordination (97%; 95% CI). Only 29% (95% CI) stated that PAs should be assisting in the operating room.
CONCLUSION: The results of this study suggest that residents perceive the addition of PAs to the academic oral and maxillofacial surgery program to be beneficial when it comes to reducing overall workload and increasing potential educational opportunities, by assisting with care coordination, outpatient appointments, and inpatient rounding.
Int J Burns Trauma. 2021 Jun 15;11(3):267-274. eCollection 2021.
Traumatic injury is a major cause of morbidity and mortality in pediatric patients. Hemorrhage is a known but treatable component of these outcomes. Evidence exists that major trauma patients are at high risk for hypocalcemia but the rate of pediatric occurrence is not documented. The purpose of this study was to determine the incidence of hypocalcemia in pediatric trauma patients, as well as to investigate any correlation between hypocalcemia and the need for transfusion and operative intervention. After IRB approval a retrospective analysis was conducted of all pediatric trauma patients seen in our Adult Level One, Pediatric Level Two trauma center. Significance testing for mortality was performed using Pearson's χ2 test. For the remaining numeric variables, association was determined one-way analysis of variance (when comparing all classes) or Welch's two-sample t-test (when comparing subsets based on calcium or mortality). In any event, significance was determined using α=0.05. A total of 2,928 patients were identified, 1623 were excluded, primarily due to incomplete data. Patients were predominantly male following blunt trauma. Initial calcium levels were 8.73 mg/dL, 95% CI [4-10.9] and 8.97 mg/dL, 95% CI [6.42-13.1] when correcting for albumin levels. Acute declines were noted when comparing initial and corrected serum calcium levels in patients requiring transfusion (7.99 mg/dL and 8.72 mg/dL) and operative intervention (8.54 mg/dL and 8.91 mg/dL). 456 (34.9%) patients required operative intervention, 138 (10.6%) required transfusion and 29 (2.2%) required massive transfusion. Patients in our cohort arrived with calcium values on the low end of normal, with a trend towards hypocalcemia if operative intervention or blood transfusion was required. This has been previously associated with increased mortality. Patients requiring operative intervention and transfusion are at increased risk for hypocalcemia and recognition of this potential is key for improved outcomes.
Early versus Late Surgical Decompression for Traumatic Spinal Cord Injury on Neurological Recovery: A Systematic Review and Meta-analysis
J Neurotrauma. 2021 Jul 27. doi: 10.1089/neu.2021.0102. Online ahead of print.
This study aimed to investigate whether early surgical decompression was associated with favourable neurological recovery in patients with traumatic spinal cord injury (tSCI). We searched PubMed and Embase from the database inception through December 2020 and selected studies comparing the impact of early versus late surgical decompression on neurological recovery as assessed by American Spinal Injury Association Impairment Scale (AIS) for adult patients sustaining tSCI. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Subgroup analysis and meta-regression analysis was conducted to identify significant outcome moderator. We included 26 studies involving 3,574 patients in the meta-analysis. The pooled results demonstrated significant association between early surgical decompression and an improvement of at least one AIS grade (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.41-2.41; I2, 48.06%). The benefits of early surgical decompression were consistently observed across different subgroups, including patients with cervical or thoracolumbar injury and patients with complete or incomplete injury. The meta-regression analysis indicated that cut-off timing defining early versus late decompression was a significant effect moderator, with early decompression performed before post-tSCI 8 or 12 h associated with greatest benefits (OR, 3.37; 95% CI, 1.74-6.50; I2, 53.52%). No obvious publication bias was detected by the funnel plot. In conclusion, early surgical decompression was associated with favourable neurological recovery for tSCI patients. However, there was a lack of high-quality evidence and the results need further examination.
J Health Res. 2020 Aug 7;34(4):283-294. doi: 10.1108/jhr-02-2019-0031. Epub 2020 Feb 14.
PURPOSE: We examined ideas about how youth would mitigate non-medical use of prescription medications among their peers.
DESIGN/METHODOLOGY/APPROACH: The National Monitoring of Adolescent Prescription Stimulants Study (N-MAPSS) interviewed 11,048 youth10-18 years of age between 2008 and 2011 from entertainment venues of 10 US urban, suburban, and rural areas. Using a mixed-methods approach, participants completed a survey culminating in open ended questions asking: 1) How should kids your age be told about prescription drugs and their effects?; 2) If you ran the world, how would you stop kids from taking other people's prescription medicines?; 3)Why do people use prescription stimulants without a prescription? Responses from a random sample of 900 children were analyzed using qualitative thematic analyses.
FINDINGS: The random sample of 900 youth (52% female, 40% white, with a mean age was 15.1 years) believed they should be educated about prescription drugs and their negative effects at schools, at home by parents, through the media, and health professionals. Youth would stop kids from using other people's prescription drugs through more stringent laws that restricted use, and education about negative consequences of use. Peer pressure was the most common reason youth gave for using other's pills, though some reported using for curiosity.
ORIGINALITY/VALUE: This analysis shows the importance of considering youth's opinions on non-medical use of prescription medications, which are often overlooked. Studies should disseminate this data from youth to stop the illicit use of prescription drugs among teens and youth.
Orthop J Sports Med. 2021 Jul 9;9(7):23259671211014496. doi: 10.1177/23259671211014496. eCollection 2021 Jul.
BACKGROUND: Bone stress injuries (BSIs) are a major source of functional impairment in athletes of all sports, with many risk factors, including athlete characteristics and type of sport. In National Collegiate Athletic Association (NCAA) athletics, the stratification of programs into divisions with different characteristics and makeup has been identified as increasing the risk for certain kinds of injuries, but there have been no studies on the difference of BSI rates and characteristics between athletes in Division I (DI) and those in Divisions II and III (DII and DIII).
PURPOSE/HYPOTHESIS: To characterize the BSI rates in each division and compare the incidence and characteristics of BSIs within divisions. Our hypothesis was that BSI rates would be higher in DII and DIII athletes as compared with DI athletes.
STUDY DESIGN: Descriptive epidemiology study.
METHODS: Five years of recorded BSI data in collegiate athletes via the NCAA Injury Surveillance Program were examined for the academic years 2009-2010 to 2013-2014. BSI rates per 100,000 athlete-exposures (AEs) were compared for DI versus DII and DIII athletes using risk ratios and 95% CIs. Time lost to injury, time of season of injury, and class composition of injured athletes were also compared between divisions.
RESULTS: Over the 5 years studied, DII and DIII programs reported 252 BSIs more than 1,793,777 AEs (14.05 per 100,000 AEs), and DI programs reported 235 BSIs over 2,022,592 AEs (11.62 per 100,000 AEs). The risk ratio was significant for D1 versus DII and DIII (1.21; 95% CI, 1.01-1.44). There was a significant difference in time lost to injury in DI versus DII and DIII, χ2(5, n = 449) = 16.54; P = .006. When data were stratified by individual sport, there were no significant divisional differences in high-risk sports.
CONCLUSION: In the current study, NCAA DII and DIII athletes had higher rates of BSI than their DI counterparts. As compared with DII and DIII athletes, the DI athletes had a significantly greater proportion of BSIs that did not result in absence from participation in sport.
The Role of Early Subspeciality Consultation in the Timing of Hemophagocytic Lymphohistiocytosis Diagnosis and Management
J Clin Rheumatol. 2021 Jun 18. doi: 10.1097/RHU.0000000000001759. Online ahead of print.
OBJECTIVE: The aim of this study was to investigate the relation between timing of subspeciality consult and hemophagocytic lymphohistiocytosis (HLH) consideration, immunosuppression initiation, and in-hospital mortality in patients with HLH.
METHODS: We conducted a medical records review study of patients 18 years or older with definite or probable HLH at Montefiore Medical Center between 2006 and 2019. Earlier subspeciality consultation (rheumatology, hematology, and infectious disease) was defined as consultation in less than or equal to 18 hours from time of admission. Demographic, clinical characteristics, and outcomes were compared between patients with early and later subspecialty consultation.
RESULTS: A total of 28 patients were included. The median age was 40 years, and 61% of patients were male. Infection was identified as a cause of HLH in 13 patients (46%). Fifteen patients (54%) were classified as having an earlier subspeciality consultation with a median time (interquartile range) to HLH consideration of 1.0 day (0.3-4.2 days) compared with 7.9 days (3.1-9.9 days) for the later consultation group (p = 0.002). The median time (interquartile range) to immunosuppression initiation was 4.6 days (1.7-7.8 days) versus 10.9 days (5.1-13.4 days) (p = 0.01), respectively. Five patients (33%) had in-hospital deaths in the early consultation group compared with 7 patients (54%) in later consultation group (p = 0.27). Among the subset of patients who survived to discharge, the 90-day readmission rate was higher in the later consultation group (83% vs 30%, p = 0.12).
CONCLUSIONS: In patients with HLH, earlier subspeciality consultation may play a role in earlier HLH consideration and treatment initiation.
Sci Rep. 2021 Jul 6;11(1):13876. doi: 10.1038/s41598-021-93334-1.
Cancer is the second leading cause of death in the United States. Although screening facilitates prevention and early detection and is one of the most effective approaches to reducing cancer mortality, participation is low-particularly among underserved populations. In a large, preregistered field experiment (n = 7711), we tested whether deadlines-both with and without monetary incentives tied to them-increase colorectal cancer (CRC) screening. We found that all screening invitations with an imposed deadline increased completion, ranging from 2.5% to 7.3% relative to control (ps < .004). Most importantly, individuals who received a short deadline with no incentive were as likely to complete screening (9.7%) as those whose invitation included a deadline coupled with either a small (9.1%) or large declining financial incentive (12.0%; ps = .57 and .04, respectively). These results suggest that merely imposing deadlines-especially short ones-can significantly increase CRC screening completion, and may also have implications for other forms of cancer screening.
Functional Ability Classification Based on Moderate and Severe Kinesophobia and Demoralization Scores in Degenerative Spine Patients
Spine (Phila Pa 1976). 2021 Aug 1;46(15):E826-E831. doi: 10.1097/BRS.0000000000003943.
STUDY DESIGN: A prospective cohort study.
OBJECTIVE: To assess the relationship of fear avoidance and demoralization on gait and balance and determine a threshold score for the Tampa Scale for Kinesophobia (TSK) and the Demoralization Scale (DS) that identifies spine patients with gait and balance dysfunction amplified by underlying psychological factors.
SUMMARY OF BACKGROUND DATA: Fear avoidance and demoralization are crucial components of mental health that impact the outcomes in spine surgery. However, interpreting their effect on patient function remains challenging. Further establishing this correlation and identifying a threshold of severity can aid in identifying patients in whom a portion of their altered gait and balance may be amplified by underlying psychologic distress.
METHODS: Four hundred five symptomatic spine patients were given the TSK and DS questionnaires. Patient's gait and balance were tested with a human motion capture system. A TSK score of 41 and a DS score of 30 were chosen as thresholds to classify moderate versus severe dysfunction based on literature and statistical analysis.
RESULTS: Higher TSK and DS scores were correlated with worse walking speed (P < 0.001), longer stride time (P = 0.001), decreased stride length (P < 0.048), and wider step width (<0.001) during gait as well as increased sway across planes (P = 0.001) during standing balance. When classified by TSK scores >41, patients with more severe fear avoidance had slower walking speed (P < 0.001), longer stride time (P = 0.001), shorter stride length (P = 0.004), increased step width (P < 0.001), and increased sway (P = 0.001) compared with their lower scoring counterparts. Similarly, patients with DS > 30 had slower walking speed (P = 0.012), longer stride time (P = 0.022), and increased sway (P = 0.003) compared with their lower scoring counterparts.
CONCLUSION: This study demonstrates that fear avoidance and demoralization directly correlate with worsening gait and balance. Furthermore, patients with TSK > 41 and DS > 30 have more underlying psychological factors that contribute to significantly worse function compared with lower scoring peers. Understanding this relationship and using these guidelines can help identify and treat patients whose gait dysfunction may be amplified by psychologic distress.Level of Evidence: 3.