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Study Design: Retrospective cohort study., Objective: To identify factors predictive of returning to work within 90 days of laminoplasty for degenerative cervical myelopathy (DCM)., Background: DCM is a debilitating condition resulting from spinal canal stenosis and spinal cord compression. One surgical option for cord decompression is cervical laminoplasty. Factors influencing return to work (RTW) postsurgery are unknown., Methods: This study included adult patients previously employed, undergoing primary elective laminoplasty for DCM, and with documented RTW status. Variables included demographic information, medical history, illness characteristics, and baseline patient-reported outcomes. The primary outcome of interest was RTW status at 90 days. Statistical analyses were conducted to identify predictors., Results: Forty-six patients (67.6%) returned to work within 90 days, whereas 22 (32.3%) either RTW between 90 and 365 days (n = 3) or did not RTW within 365 days (n = 19). Significantly more patients who RTW within 90 days worked full-time (90.9% vs 64.3%, P = 0.030). Patients who RTW within 90 days had significantly lower preoperative Neck Disability Index scores (23.7 ± 17.5 vs 35.6 ± 14.3, P = 0.008) and higher preoperative modified Japanese Orthopedic Association scores (13.7 ± 2.5 vs 12.2 ± 2.7, P = 0.018) compared with those who did not RTW. No differences were found in other baseline patient-reported outcomes. Patients who RTW within 90 days had significantly lower postoperative 3-month neck pain (2.0 ± 2.1 vs 3.8 ± 2.6, P = 0.007), 3-month arm pain (1.3 ± 1.9 vs 3.6 ± 2.8, P < 0.001), 12-month neck pain (1.4 ± 1.6 vs 3.1 ± 2.4, P = 0.019) and 12-month arm pain (1.1 ± 1.8 vs 2.4 ± 2.4, P = 0.048) compared with those who did not RTW within 90 days. Higher preoperative modified Japanese Orthopedic Association scores were significantly associated with truncated time to RTW (HR: 1.14, 95% CI: 1.01-1.29, P = 0.034)., Conclusion: Patients with better preoperative neck and arm pain and functional scores were more likely to RTW within 90 days postlaminoplasty. Preoperative functional status plays an important role in assessing RTW postlaminoplasty. This information is valuable for preoperative patient counseling., Competing Interests: A.M.A. received an institutional research support from Stryker Spine. R.J.G. is a consultant and teaching surgeon for Joimax, a consultant for Arthrex, a teaching surgeon and consultant with royalties for Integrity Implants, and a consultant with royalties for Spineology. J.S.P. is a consultant for 3Spine and Steamboat Orthopedic and Spine Institute. B.F.S. is a consultant for Globus and receives institutional research funding from Globus and Stryker. S.L.Z. reports being an unaffiliated neurotrauma consultant for the National Football League. The remaining authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Spinal anesthesia (SA) is the preferred anesthesia modality for total joint arthroplasty (TJA). However, studies establishing SA as preferential may be subject to selection bias given that general anesthesia (GA) is often selectively utilized on more difficult, higher-risk operations. The optimal comparison group, therefore, is the patient converted to GA due to a failed attempt at SA. The purpose of this study was to determine risk factors and outcomes following failed SA with conversion to GA during primary total hip arthroplasty (THA) or total knee arthroplasty (TKA)., Methods: A consecutive cohort of 4,483 patients who underwent primary TJA at our institution was identified (2,004 THA and 2,479 TKA). Of these patients, 3,307 underwent GA (73.8%), 1,056 underwent SA (23.3%), and 130 patients failed SA with conversion to GA (2.90%). Primary outcomes included rescue analgesia requirement in the postanesthesia care unit (PACU), time to ambulation, pain scores in the PACU, estimated blood loss, and 90-day complications., Results: Risk factors for SA failure included older age and a higher comorbidity burden. Failure of SA was associated with increased estimated blood loss, rescue intravenous opioid use, and time to ambulation when compared to the successful SA group in both THA and TKA patients (P < .001). The anesthesia modality was not associated with significant differences in PACU pain scores. The 90-day complication rate was similar between the failed SA and GA groups. There was a higher incidence of postoperative pain prompting unplanned visits and thromboembolism when comparing failed SA to successful SA in both THA and TKA patients (P < .05)., Conclusions: In our series, patients who had failed SA demonstrated inferior outcomes to patients receiving successful SA and similar outcomes to patients receiving GA who did not have an SA attempt. This emphasizes the importance of success in the initial attempt at SA for optimizing outcomes following TJA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Socioeconomic disadvantage has been associated with negative outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The area deprivation index (ADI) and distressed communities index (DCI) are composite rankings that score socioeconomic status (SES) using patients' home addresses. The purpose of this study was to examine the association of ADI and DCI with outcomes following THA and TKA while controlling for potential confounding covariates., Methods: A series of 4,146 consecutive patients undergoing primary THA and TKA between January 2018 and May 2023 were queried from our institutional total joint registry. The 90-day medical and surgical complications and resource utilization were collected. The ADI and DCI scores were obtained for each patient, and the association between these scores and postoperative outcomes was analyzed., Results: The ADI and DCI were both associated with patient age, sex, race, comorbidity burden, and smoking status. After controlling for these variables, higher ADI and DCI scores were associated with increased length of stay (P = 0.003 and P = 0.008, respectively), but were not associated with the occurrence of any 90-day complication, reoperation, or revision., Conclusions: The SES, as quantified by ADI and DCI, was associated with multiple known risk factors for complications following THA and TKA, but was not independently associated with complications, reoperations, or revision surgeries at 90 days postoperatively. While convenient metrics for the quantification of SES, in some populations, ADI and DCI may not be independently associated with detrimental outcomes following THA and TKA., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: For the thousands of health systems recognized as Age-Friendly, considerable progress has been made to integrate 4Ms into clinical care. This study evaluated associations between 4Ms documentation and patient characteristics in an inpatient setting., Methods: In this prospective cohort, hospitalizations included were from patients in an Acute Care for Elders (ACE) unit where the 4Ms were adopted and implemented. Each M (What Matters, Medication, Mentation, and Mobility) was stratified into three categories (not documented, partly documented, and fully documented) reflecting "assessment" and "action" clinical care processes. Electronic health records were reviewed for patient and hospitalization characteristics. Descriptive statistics evaluated these characteristics across categories of each M., Results: There were 620 hospital encounters (573 patients) included in the cohort. Patients had a median age of 80 years [IQR 76, 86] and 85% were White. Of all 4Ms, What Matters had the lowest documentation with 413 (67%) of encounters falling into the not documented group. Medication had the highest documentation with 453 (73%) of encounters in the fully documented group. Significant differences in documentation were associated with age and partly versus fully documented Mobility (80 [76, 86] and 82 [77, 88] (p = 0.019)). Hospital length of stay was differentially associated with documentation of all 4M categories. Initial mobility scores were associated with not versus partly documented Medication (6 [2, 7] and 2 [2, 6] (p = 0.041))., Conclusions: We developed a structured way to categorize "assessment" and "action" 4Ms care processes reflective of three documentation categories in the hospital (not, partly, and fully) and identified important patient and hospital characteristics associated with each. These results offer opportunities for future improvement efforts and insight to which characteristics may be important to measure with wider 4Ms adoption and uptake., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations., Methods: This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed., Results: There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = .6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = .9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = .2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P > .9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = .2)., Conclusions: With the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background Context: Unplanned readmissions following lumbar spine surgery have immense clinical and financial implications. However, little is known regarding the impact of unplanned readmissions on patient-reported outcomes (PROs) following lumbar spine surgery., Purpose: To evaluate the impact of unplanned readmissions, including specific readmission reasons, on patient reported outcomes 12 months after lumbar spine surgery., Study Design/setting: A retrospective cohort study of prospectively collected data was conducted using patients included in the lumbar module of the Quality and Outcomes Database (QOD), a national, multicenter spine registry., Patient Sample: A total of 33,447 patients who underwent elective lumbar spine surgery for degenerative diseases were included. Mean age was 59.8 (SD=14.04), 53.6% were male, 89.5% were white, 45.9% were employed, and 47.5% had private insurance., Outcome Measures: Unplanned 90-day readmissions and 12-month patient-reported outcomes (PROs) including numeric rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI) scores, EuroQol-5 Dimension (EQ-5D) scores, and North American Spine Society (NASS) patient-satisfaction scores., Methods: The lumbar module of the QOD was queried for adults undergoing elective lumbar spine surgery for degenerative disease. Unplanned 90-day readmissions were classified into 4 groups: medical, surgical, pain-only, and no readmissions. Medical and surgical readmissions were further categorized into primary reason for readmission. 12-month PROs assessing patient back and leg pain (NRS), disability (ODI), quality of life (EQ-5D), and patient satisfaction were collected. Multivariable models predicting 12-month PROs were built controlling for covariates., Results: A total of 31,430 patients (94%) had no unplanned readmission while 2,017 patients (6%) had an unplanned readmission within 90 days following lumbar surgery. Patients with readmissions had significantly worse 12-month PROs compared with those with no unplanned readmissions in covariate-adjusted models. Using Wald-df as a measure of predictor importance, surgical readmissions were associated with the worst 12-month outcomes, followed by pain-only, then medical readmissions. In separate covariate adjusted models, we found that readmissions for pain, SSI/wound dehiscence, and revisions were among the most important predictors of worse outcomes at 12-months., Conclusions: Unplanned 90-day readmissions were associated with worse pain, disability, quality of life, and greater dissatisfaction at 12-months, with surgical readmissions having the greatest impact, followed by pain-only readmissions, then medical readmissions. Readmissions for pain, SSI/wound dehiscence, and revisions were the most important predictors of worse outcomes. These results may help providers better understand the factors that impact outcomes following lumbar spine surgery and promote improved patient counseling and perioperative management., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Retired surgeons often have limited opportunities to disseminate their wisdom and expertise in a structured manner to their younger colleagues. In addition, when asked to reflect on their personal and professional lives, many physicians say they wish they had done something differently. The extent to which this is true of retired orthopedic surgeons is not known. Purpose : We sought to determine the percentage of retired orthopedic surgeons who say that they would like to have changed something in their life/career and delineate the most commonly desired changes. Methods : We conducted a cross-sectional study of retired orthopedic surgeons, by emailing a Qualtrics survey to 5864 emeritus members of the American Academy of Orthopaedic Surgeons (AAOS), with 1 initial email invitation in April 2021 followed by 2 reminders in May 2021. The survey employed a branching logic, with up to 16 questions designed to determine whether they would have done anything differently in their life/career. Results : The survey was completed by 1165 of 5864 emeritus AAOS members, for a response rate of nearly 20%. The 3 most represented surgical subspecialties were general orthopedics, adult reconstruction, and hand and upper extremity surgery. Respondents' average age was 74.9 years and age at retirement was 67.8 years; nearly half worked part-time before retiring. More than 80% of the participants said that they had retired at the appropriate time, and 28.5% said they wished they had done something differently. The wished-for changes most often noted were spending more time with family, spending more time on personal wellness, and selecting better practice partners. Conclusion : The results of our survey of retired orthopedic surgeons show that while most were satisfied with their lives and careers, some had regrets. These findings suggest that there may be factors in the work lives of current surgeons that could be altered to reduce regret. Further study is warranted., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Background: Private insurers use the calendar deductible system, placing pressure on patients and medical personnel to perform medical services before the end of the year to maximize patient savings. The impact of the deductible calendar on patient-reported outcomes (PROs) after spine surgery is poorly understood. The objective of our study was to investigate if patients undergoing surgery in December had different PROs and demographics compared with all other months., Methods: The Quality Outcome Database, a national spine registry, was queried for patients who underwent elective spine surgery between January 2012 and January 2021 for degenerative spine conditions. PROs and demographics were compared between the December and non-December groups using various statistical tests., Results: A total of 978 patients (9.3%) underwent anterior cervical discectomy and fusion in December versus 9548 (90.7%) in other months. There was a significantly higher percentage of patients in December who had private insurance and were employed. A total of 1104 patients (8.5%) underwent lumbar fusion in December versus 11,826 (91.5%) in other months. There was a significantly greater chance of undergoing surgery in December if patients had private insurance and were employed. Although some PROs were statistically significant for the lumbar and cervical cohorts between December and non-December patients, none were clinically significant., Conclusions: Patients undergoing elective spine surgery in December were more likely to have private insurance and be employed. PROs for ACDF and lumbar fusions were not affected by surgical timing (December yes/no). Other spinal procedures directed at more chronic diseases might be more susceptible to external influence of insurance deductibles., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Design: This is a retrospective review of prospectively collected data., Objective: The aim was to evaluate the impact of frailty and sarcopenia on outcomes after lumbar spine surgery., Summary of Background Data: Elderly patients are commonly diagnosed with degenerative spine disease requiring surgical intervention. Frailty and sarcopenia result from age-related decline in physiological reserve and can be associated with complications after elective spine surgery. Little is known about the impact of these factors on patient-reported outcomes (PROs)., Methods: Patients older than 70 years of age undergoing elective lumbar spine surgery were included. The modified 5-item frailty index (mFI-5) was calculated. Sarcopenia was defined using total psoas index, which is obtained by dividing the mid L3 total psoas area by VB area (L3-TPA/VB). PROs included Oswestry disability index (ODI), EuroQual-5D (EQ-5D), numeric rating scale (NRS)-back pain, NRS leg pain (LP), and North American Spine Society (NASS) at postoperative 12 months. Clinical outcomes included length of stay (LOS), 90-day readmission and complications. Univariate and multivariable regression analyses were performed., Results: Total 448 patients were included. The mean mFI-5 index was 1.6±1.0 and mean total psoas index was 1.7±0.5. There was a significant improvement in all PROs from baseline to 12 months ( P <0.0001). After adjusting for age, body mass index, smoking status, levels fused, and baseline PROs, higher mFI-5 index was associated with higher 12-month ODI ( P <0.001), lower 12-month EQ-5D ( P =0.001), higher NRS-L P ( P =0.039), and longer LOS ( P =0.007). Sarcopenia was not associated with 12-month PROs or LOS. Neither sarcopenia or mFI-5 were associated with 90-day complication and readmission., Conclusions: Elderly patients demonstrate significant improvement in PROs after elective lumbar spine surgery. Frailty was associated with worse 12 months postoperative ODI, EQ-5D, NRS-LP scores, and longer hospital stay. While patients with sarcopenia can expect similar outcomes compared with those without, the mFI-5 should be considered preoperatively in counseling patients regarding expectations for disability, health-related quality of life, and leg pain outcomes after elective lumbar spine surgery., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

This evaluation examined the effects of afterschool programs-supported by an afterschool system intermediary organization (ASIO)-on middle school students' academic performance and examined how those effects varied by student characteristics and program engagement. In this longitudinal, quasi-experimental matched comparison group evaluation, propensity score matching was used to create demographically balanced samples of ASIO-supported afterschool program participants and nonparticipants. Students enrolled in the afterschool programs did not differ from non-participants in growth over time on most academic outcomes. Students attending the afterschool programs showed less growth on certain state test scores compared to nonparticipants. Student demographic characteristics did not consistently influence participant outcomes. Among program participants only, students who were enrolled more than 1 year demonstrated a 7-percentile-point increase in state test scores per year of program engagement. There was no consistent evidence that ASIO-supported afterschool program participation was associated with improved student academic outcomes. However, study results support increased emphasis on afterschool program retention, given that longer duration of participation in the afterschool programs was associated with more growth on multiple academic outcomes., (© 2020 Wiley Periodicals LLC.)

To successfully interact with software agents, people must call upon basic concepts about goals and intentionality and strategically deploy these concepts in a range of circumstances where specific entailments may or may not apply. We hypothesize that people who can effectively deploy agency concepts in new situations will be more effective in interactions with software agents. Further, we posit that interacting with a software agent can itself refine a person's deployment of agency concepts. We investigated this reciprocal relationship in one particularly important context: the classroom. In three experiments we examined connections between middle school students' concepts about agency and their success learning from a teachable-agent-based computer system called "Betty's Brain". We found that the students who made more intentional behavioral predictions about humans learned more effectively from the system. We also found that students who used the Betty's Brain system distinguished human behavior from machine behavior more strongly than students who did not. We conclude that the ability to effectively deploy agency concepts both supports, and is refined by, interactions with software agents.

Background: No studies report whether improvements to commercial weight-loss programs affect retention and weight loss. Similarly, no studies report whether enrolling in a program through work (with a corporate partner) affects retention and weight loss., Objectives: To determine whether: (1) adding evidence-based improvements to a commercial weight-loss program increased retention and weight loss, (2) enrolling in a program through work increased retention and weight loss and (3) whether increased weight loss was because of longer retention., Design, Setting and Participants: Data were collected on 60 164 adults who enrolled in Jenny Craig's Platinum Program over 1 year in 2001-2002. The program was subsequently renamed the Rewards Program and improved by increasing treatment personalization and including motivational interviewing. Data were then collected on 81 505 participants of the Rewards Program who enrolled during 2005 (2418 of these participants enrolled through their employer, but paid out-of-pocket)., Measurements: Retention (participants were considered active until >or=42 consecutive days were missed) and weight loss (percent of original body weight) from baseline to the last visit (data were evaluated through week 52) were determined., Results: Alpha was set at 0.001. Mean (95% confidence interval (CI)) retention (weeks) was significantly higher among Rewards (19.5 (19.4-19.6)) compared with Platinum (16.3 (16.2-16.4)) participants, and Rewards Corporate (25.9 (25.0-26.8)) compared with Noncorporate (21.9 (21.7-22.1)) participants. Modified intent-to-treat analyses indicated that mean (95% CI) percent weight loss was significantly larger among Rewards (6.36 (6.32-6.40)) compared with Platinum (5.45 (5.41-5.49)) participants, and Rewards Corporate (7.16 (6.92-7.40)) compared with Noncorporate (6.20 (6.16-6.24)) participants, with and without adjustment for baseline participant characteristics. In all cases, greater weight loss was secondary to longer retention., Limitations: The study was not a randomized controlled trial, rather, a translational effectiveness study., Conclusions: Improvements to a commercial program and enrolling through a corporate partner are associated with greater weight loss that is because of improved retention.