Whitney Booker

A retrospective cohort study of pulmonary function, radiographic measures, and quality of life in children with congenital scoliosis: an evaluation of patient outcomes after early spinal fusion.

Study Design. Retrospective cohort study. Objective. The purpose of this study is to evaluate pulmonary function and quality of life (QOL) in children treated with early spinal fusion for progressive congenital scoliosis. Summary of Background Data. The relationships between radiographic measures, pulmonary function tests (PFT), and QOL were examined. Methods. Twenty-one patients with congenital scoliosis treated with early spinal fusion were evaluated using radiographs, PFT, and the Child Health Questionnaire (CHQ) at 12.6 ± 3.5 years. They were 6.9 ± 2.3 years postdefinitive fusion, which occurred at 4.9 ± 3.1 year of age. The cohort was also divided in two groups, “thoracic fusion” (apex above the thoracolumbar T–L junction) and “nonthoracic fusion” (below T–L junction). Results. Forced vital capacity, forced expiratory volume (FEV1), vital capacity (P < 0.0001), and total lung capacity (P = 0.017) were significantly lower compared with healthy children. CHQ scores were significantly lower than in healthy children in physical function (P = 0.036), general health (P = 0.007), physical summary (P = 0.026), and parental impact/emotional (P = 0.01). Correlation analysis showed that the degrees of thoracic curves were negatively correlated with FEV1 (P < 0.05), family activities, role/social physical (P < 0.05), and physical summary (P < 0.01). The degree of kyphosis was negatively correlated with Self-Esteem (P < 0.01). Patients who had thoracic fusions had shorter spinal height (P = 0.049), lower forced vital capacity (P = 0.004), FEV (P = 0.012), vital capacity (P = 0.031), and reported more pain (P = 0.033) than nonthoracic fused. Conclusion. Compared with healthy peers, congenital scoliosis patients treated with early spinal fusion have worse PFT and QOL scores at 6.9 years follow up. Patients with thoracic fusions had shorter spines, worse pulmonary function, and more pain than nonthoracic fused. The results may support alternatives to early spinal fusion such as growing rods, epiphysiodesis, and distraction thoracoplasty. Current efforts are underway to compare outcomes of this study to those of other treatments.

Risk Factors for Spinal Cord Injury During Surgery for Spinal Deformity

BACKGROUND Spinal cord monitoring is now considered standard care during surgery for spinal deformity. Combined somatosensory and motor evoked potential monitoring allows the detection of early spinal cord dysfunction in most patients. The purpose of the current study was to identify clinical factors that increase the risk of intraoperative electrophysical changes and to provide management recommendations. METHODS The records of 162 consecutive patients who underwent surgery for the treatment of spinal deformity at a tertiary referral center were reviewed. Electrophysical monitoring of these patients was considered to have been successful if reproducible signals had been obtained. Relevant electrophysical changes included a reduction, as compared with baseline, of >50% in the amplitude of the somatosensory evoked potentials; an increase, as compared with baseline, of >10% in the latency of the somatosensory evoked potentials; a loss of motor evoked potentials; and an abrupt decrease of >75% in the motor evoked potentials. RESULTS One hundred and fifty-one (93%) of the 162 patients were monitored successfully. Four of the eleven patients with unsuccessful monitoring had neuromuscular scoliosis. Twelve of the 151 successfully monitored patients had a true electrophysical event, and two of them were found to have new postoperative neurologic deficits that represented a change from the findings of their preoperative neurologic examination. The determined causes of these electrophysical events included curve correction in eight patients, hypotension in two, direct cord trauma in one, and malposition of a pedicle screw in one. The patients with a true electrophysical event had a significantly higher rate of neurologic events than did the patients who did not have a true electrophysical event (p < 0.001). The rate of true electrophysical events was significantly higher in the patients with cardiopulmonary comorbidities than it was in the patients with no comorbidities (p = 0.011). CONCLUSIONS Combined somatosensory and motor evoked potential monitoring effectively prevents neurologic injury in most children undergoing surgery for spinal deformity. Despite the potential for false-positive results, we recommend setting a low threshold for defining relevant electrophysical changes. Rapid intervention can reverse these changes and avoid potentially serious neurologic complications. Patients with cardiopulmonary comorbidities may be at a higher risk for having relevant electrophysical events.

Development and Initial Validation of the Assessment of Caregiver Experience With Neuromuscular Disease

Background Orthopaedic intervention can have a wide range of functional and psychosocial effects on children with neuromuscular disease (NMD). In the multihandicapped child (Gross Motor Classification System IV/V), functional status, pain, psychosocial function, and health-related quality of life also have effects on the families of these child. The purpose of this study is to report the development and initial validation of an outcomes instrument specifically designed to assess the caregiver impact experienced by parents raising severely affected NMD children: the Assessment of Caregiver Experience with Neuromuscular Disease (ACEND). Methods In the first part of this prospective study, 61 children with NMD and their parents were administered a range of earlier validated pediatric health measures. A framework technique was used to select the most appropriate and relevant subset of questions from this large set. Sensitivity analyses guided the development of a master question list measuring caregiver impact, excluding items with low relevance, and modifying unclear questions. In the second part of the study, the ACEND was administered to the caregivers of 46 children with moderate-to-severe NMD. Statistical analyses were conducted to determine validity of the instrument. Results The resulting ACEND instrument included 2 domains, 7 subdomains, and 41 items. Domain 1, examining physical impact, includes 4 subdomains: feeding/grooming/dressing (6 items), sitting/play (5 items), transfers (5 items), and mobility (7 items). Domain 2, which examines general caregiver impact, included 3 subdomains: time (4 items), emotion (9 items), and finance (5 items). Mean overall relevance rating was 6.21±0.37 and clarity rating was 6.68±0.52 (scale 0 to 7). Multiple floor effects in patients with GMFCS V and ceiling effects in patients with GMFCS III were identified almost exclusively in motor-based items. Virtually no floor or ceiling effects were identified in the time, emotion or finance domains across GMFCS level. Conclusions The initial validation demonstrated that ACEND is a valid, disease-specific measure to quantify experience on caregivers of children with NMD. Larger groups of patients across NMD disease type are currently being tested to strengthen validity findings. Additionally, the ACEND is now being administered before and after orthopaedic interventions to determine responsiveness, which is critical to health outcomes research. Level of Evidence/Relevance IIc.

The Independent Association of a Short Cervix, Positive Fetal Fibronectin, Amniotic Fluid Sludge, and Cervical Funneling with Spontaneous Preterm Birth in Twin Pregnancies

Objective To estimate the independent association of a short cervical length (CL), positive fetal fibronectin (fFN), amniotic fluid (AF) sludge, and cervical funneling with spontaneous preterm birth in twin pregnancies. Methods Retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from June 2005 to February 2014. All patients underwent transvaginal sonographic CL and fFN testing. We reviewed all images from the first CL at 22(0/7) to 25(6/7) weeks for the presence of (1) a short CL, which is defined as ≤25 mm, (2) AF sludge, and (3) cervical funneling, and also recorded (4) the fFN result from that time. Image reviewers were blinded to pregnancy outcomes. Patients with cerclage were excluded. Using logistic regression, we calculated the independent association between these four biomarkers and spontaneous preterm birth. Results A total of 635 patients with twin pregnancies were included. The markers independently associated with spontaneous preterm birth <35 weeks were short CL (adjusted odds ratio [aOR]: 10.73; 95% confidence interval [CI]: 3.21-35.81), positive fFN (aOR: 3.25; 95% CI: 1.13-9.33), and AF sludge (aOR: 2.11; 95% CI: 1.04-4.27). Similarly, these three markers were independently associated with earlier gestational ages at delivery. Cervical funneling was not independently associated with spontaneous preterm birth <35 weeks nor gestational age at delivery. The risk of spontaneous preterm birth increased significantly with the number of positive biomarkers (short CL, positive fFN, and AF sludge). Conclusion In twin pregnancies, a short CL, positive fFN, and AF sludge are independently associated with spontaneous preterm birth. Cervical funneling is not independently associated with spontaneous preterm birth in twins.

The Association between Fetal Fibronectin, Cervical Length, and Amniotic Fluid Sludge with Histological Indicators of Placental Inflammation in Twin Gestations

Abstract Objective The objective of this study was to evaluate the association of screening tests for preterm birth (short cervical length [CL], positive fetal fibronectin (FFN), and amniotic fluid [AF] sludge) in twin gestations with histologic evidence of placental inflammation. Study Design Historical cohort study of 596 twin gestations delivered in a single maternal‐fetal medicine practice with CL and FFN testing from 22 to 25 6/7 weeks. A short CL was defined as ≤25 mm. Placental lesions evaluated were chronic and acute membrane inflammation and funisitis. Fischers exact test and logistic regression were used. Results None of the screening tests was associated with chronic inflammation. All were associated with acute inflammation. On regression analysis, a short CL and positive FFN remained independently associated with acute inflammation (adjusted odds ratio [aOR]: 5.66 and 2.51, respectively) and funisitis (aOR: 5.66 and 7.17, respectively). AF sludge was not independently associated with acute inflammation nor funisitis. Conclusion In twin gestations, a short CL and a positive FFN at 22 to 26 weeks are associated with acute but not chronic inflammation on placental histology. These findings imply that mechanisms underlying preterm birth in twins that result in positive screening tests weeks prior to delivery are not reflected as chronic placental inflammation. Therefore, pathologic interpretation of etiologic mechanisms for preterm birth may be limited using solely histologic reports.

Double versus single thrombophilias during pregnancy

Abstract Objective: The primary objective of this study was to evaluate whether women with double thrombophilias have a greater risk for obstetric complications as compared with women who have single thrombophilias. Study design: This is a retrospective cohort study of all patients in a single practice with a clinically significant inherited thrombophilia and treated with anticoagulation between 2005 and 2013. Thrombophilias evaluated include: factor V Leiden, prothrombin G20210A gene mutation, protein S deficiency, protein C deficiency, and antithrombin III deficiency. Double thrombophilia was defined as the presence of two thrombophilias or homozygosity for factor V Leiden or prothrombin Gene Mutation. Demographic and obstetrical outcome data were collected. Data on all patients with double thrombophilias who met inclusion criteria was reported. Data was then compared between the patients with double thrombophilias and single thrombophilias with singleton gestations. The data was analyzed with Pearson’s chi-squared or Student’s t-test as appropriate with p value <.05 used for significance. Results: Eighteen patients with clinically significant double thrombophilias who met inclusion criteria were identified. Most patients delivered full term (88.9%) and appropriate for gestational age (77.8%) infants. One hundred thirty-two patients with single thrombophilias and 14 patients with double thrombophilias with singleton gestations were then compared. Demographic characteristics were not significantly different between the two groups. There were no significant differences in obstetrical outcomes between patients. Conclusions: There were no significant differences in obstetrical outcomes for patients with clinically significant double thrombophilias versus single thrombophilias when treated with anticoagulation.

Trends in comorbidity, acuity, and maternal risk associated with preeclampsia across obstetric volume settings

Abstract Objective: The objective of this study was to characterize morbidity, acuity, and maternal risks associated with preeclampsia across hospitals with varying obstetric volumes. Methods: This retrospective cohort analysis used a large administrative data source, the Perspective database, to characterize the risk for preeclampsia from 2006 to 2015. Hospitals were classified as having either low (≤1000), moderate (1001–2000), or high (≥2000) delivery volume. The primary outcomes included preeclampsia, antihypertensive administration, comorbidity, and related severe maternal morbidity. Severe maternal morbidity was estimated using criteria from the Centers for Disease Control and Prevention. Comorbidity was estimated using an obstetric comorbidity index. Univariable comparisons were made with Chi-squared test. Adjusted log linear regression models were fit to assess factors associated with severe morbidity with risk ratios with 95% confidence intervals as the measures of effect. Population weights were applied to create national estimates. Results: Of 36,985,729 deliveries included, 1,414,484 (3.8%) had a diagnosis of preeclampsia. Of these, 779,511 (2.1%) had mild, 171,109 (0.5%) superimposed, and 463,864 (1.3%) severe preeclampsia. The prevalence of mild, superimposed, and severe preeclampsia each increased over the study period with severe and superimposed preeclampsia as opposed to mild preeclampsia increasing the most proportionately (53.2 and 102.5 versus 10.8%, respectively). The use of antihypertensives used to treat severe range hypertension increased with use of intravenous labetalol increasing 31.5%, 43.2%, and 36.1% at low-, medium-, and high-volume hospitals. Comorbid risk also increased across hospital volume settings as did risk for severe maternal morbidity. Conclusions: Preeclampsia is increasing across obstetric care settings with preeclamptic patients demonstrating increasing comorbid risk, increased risk for severe morbidity, and more frequent need for treatment of acute hypertension.

Antenatal Corticosteroids: Who Should We Be Treating?

Antenatal corticosteroids remain one of the crucial interventions in those at risk for imminent preterm birth. Therapeutic benefits include reducing major complications of prematurity such as respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis, as well as an overall decrease in neonatal deaths. Optimal reductions in neonatal morbidity and mortality require a thoughtful review of the timing of administration. In addition, a thorough understanding is required of which patients maximally benefit from this intervention in the management and counseling of those at risk for preterm birth.

Maternal age and risk for adverse outcomes

OBJECTIVE: The objective of this study was to characterize the risk for severe maternal morbidity and other pregnancy complications by maternal age during delivery hospitalizations. STUDY DESIGN: This retrospective cohort analysis used the Perspective database to characterize the risk for adverse maternal outcomes from 2006 to 2015 based on maternal age. Women were divided into 7 categories based on maternal age: 15–17, 18–24, 25–29, 30–34, 35–39, 40–44, and 45–54 years of age. The primary outcome of this study was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Secondary outcomes included (1) overall comorbid risk; (2) risk for pregnancy complications such as postpartum hemorrhage, gestational diabetes, preeclampsia, and cesarean delivery; and (3) risk for individual severe morbidity diagnoses such as stroke, embolism, eclampsia, and hysterectomy. Adjusted models were fitted to assess factors associated with severe morbidity with adjusted risk ratios (aRRs) and 95% confidence intervals (CI) as measures of effect. Population weights were applied to create national estimates. RESULTS: Of 36,944,292 deliveries included, 2.5% occurred among women aged 15–17 years (n = 921,236), 29.1% to women aged 18–24 years (n = 10,732,715), 28.6% to women aged 25–29 years (n = 10,564,850), 24.9% to women aged 30–34 years (n = 9,213,227), 12.1% to women aged 35–39 years (n = 4,479,236), 2.6% to women aged 40–44 years (n = 974,289), and 0.2% to women aged 45–54 years (n = 58,739). In unadjusted analyses, severe morbidity was more than 3 times higher (risk ratio [RR], 3.33, 95% confidence interval [CI], 3.03–3.66) for women 45‐54 years compared with women 25–29 years. Women aged 40–44, 35–39, and 15–17 years were also at increased risk (RR, 1.83, 95% CI, 1.77–1.89; RR, 1.36, 95% CI, 1.33–1.39; RR, 1.39, 95% CI, 1.34–1.45, respectively). In the adjusted model, the 45–54 year old group was associated with the highest relative risk (aRR, 3.46, 95% CI, 3.15–3.80) followed by the 40–44 year old group (aRR 1.90, 95% CI, 1.84–1.97), the 35–39 year old group (aRR, 1.43, 95% CI, 1.40–1.47), and the 15–17 year old group (aRR, 1.20, 95% CI, 1.15–1.24). Cesarean delivery, preeclampsia, postpartum hemorrhage, and gestational diabetes were most common among women aged 45–54 years, as were thrombosis and hysterectomy. CONCLUSION: While differential risk was noted across maternal age categories, women aged 45 years old and older were at highest risk for a broad range of adverse outcomes during delivery hospitalizations.

Analysis of Clinically Significant Double Thrombophilias Versus Single Thrombophilias During Pregnancy [8R]

INTRODUCTION: Pregnancy is a hypercoaguable state and for patients with inherited thrombophilias, it may represent a period of heightened risk. There have been some data suggesting that women with double thrombophilias (DT) have an even greater risk of obstetrical complications. A paucity of data analyzing the impact of DT when compared to single thrombophilias (ST) has been published due to the rarity of these conditions identified in patients. METHODS: This is a retrospective cohort study of all patients in a single maternal-fetal medicine practice who were found to have a clinically significant inherited thrombophilia and treated with anticoagulation between 2005–2013. Thrombophilias evaluated included: Factor V Leiden (FVL), Prothrombin G20210A gene mutation (PGM), Protein S deficiency (PSD), Protein C deficiency (PCD), and Antithrombin III deficiency (ATIII). DT were defined as the presence of 2 clinically significant thrombophilias or homozygosity for FVL or PGM. Patients with DT were compared to those patients with ST. Demographic and obstetrical outcome data were collected and compared between the two groups. The data was analyzed with Pearsons chi-squared or Students t test as appropriate. RESULTS: 156 pregnancies with clinically significant thrombophilias were identified. Demographic characteristics were equivalent between the two groups. There were no significant differences for obstetrical outcomes between patients for birthweight <10%, intrauterine fetal demise, preterm delivery (spontaneous or iatrogenic), pregnancy induced hypertension, or neonatal intensive care unit admission. CONCLUSION: There were no significant differences in obstetrical outcomes for patients with clinically significant DT versus ST when treated with anticoagulation. This information may be reassuring for patients with DT.