Ling Chen

Background: For pediatric patients with presumed adolescent idiopathic scoliosis, surgeons rely on abnormal neurological exam, left-sided thoracic curve, or thoracic hyperkyphosis to initiate preoperative magnetic resonance imaging; however, the sensitivity of these screening criteria for detecting neural axis anomalies of Chiari malformation type I (CM1) and syrinx is not well understood. We aim to determine the frequency of abnormal neurological exam, left-sided thoracic curve, and hyperkyphosis of thoracic curves in patients with operative scoliosis and CM1 and/or syrinx. Methods: A retrospective analysis was conducted with patients who underwent surgical management for pediatric scoliosis and were diagnosed with either CM1 (n=4), syrinx (n=23), or both conditions (n=20). Neurological exams before surgery were reviewed and screened for abnormal deep tendon reflexes, abnormal abdominal reflexes, motor disturbance, sensory disturbance, muscle mass asymmetry, spasticity/contracture, abnormal gait, abnormal balance, and ankle clonus. Thoracic curvature direction, T2-T5 kyphosis, and T5-T12 kyphosis were also obtained. Results: Across all patients with CM1 and/or syrinx that underwent surgery for scoliosis, 9 of 47 (19%) had an abnormal preoperative neurological exam, 11 of 43 (26%) had a left-sided thoracic curve, 5 of 41 (12%) had a T2-T5 hyperkyphosis, and 9 of 41 (22%) had a T5-T12 hyperkyphosis. The T1-T12 kyphosis across the whole cohort averaged 38 degrees. In patients with known CM1 and/or syrinx, the sensitivity of neurological exam abnormality, left-sided curve, or hyperkyphosis was 27 of 41 (66%). Patients with both CM1 and syrinx were not more likely to have an abnormality on imaging or physical exam compared to patients with isolated CM1 or syrinx conditions. Conclusions: These results indicate that neurological exam abnormalities, left-sided thoracic curve, and thoracic hyperkyphosis have a relatively low sensitivity when used as a screening metric for detecting CM1 and/or syrinx in patients with scoliosis. Thirty-four percent of patients with CM1/syrinx and operative scoliosis had a normal neurological exam, right-sided curve, and a normal amount of kyphosis. Surgeons should consider the sensitivity of these screening metrics when determining which patients should obtain a preoperative MRI before scoliosis surgery. Levels of Evidence: Diagnostic studies—investigating a diagnostic test level III with a retrospective analysis.

Background: Compared with adults, children with intervertebral disc herniation often face delayed diagnoses due to atypical presentations and symptom overlap with other musculoskeletal disorders. While non-operative treatments such as physical therapy and NSAIDs are typically first-line, they may be insufficient in severe cases, where discectomy can be effective but carries a risk of recurrence. PROMIS (Patient-Reported Outcomes Measurement Information System) offers standardized measures of patient-reported pain and function. This study aims to evaluate PROMIS Pain Interference (Pain) and Mobility scores in pediatric disc herniation patients compared with the population average and assess treatment outcomes between non-operative and surgical cohorts. Methods: A retrospective cohort analysis included patients t tests and linear mixed-effects models (α=0.05). Results: Eighty patients (median age 16) met the inclusion criteria; 42 received non-operative care, and 38 underwent surgery. At presentation, mean PROMIS Pain was 59±7, and Mobility was 35±6, both significantly different from the norm ( P P P <0.001), though final scores were similar. Pain improvements in both groups at final follow-up showed no significant difference between treatment modalities. Conclusion: Pediatric patients with disc herniations experience significant pain and limited mobility. Patients who elect for discectomy present with worse pain and decreased mobility at baseline. However, those who undergo surgery can expect quicker relief of symptoms, and despite initially worse function, ultimately achieve outcome scores comparable to patients successfully managed non-operatively. Our study further validates that PROMIS scores effectively quantify symptom burden in pediatric disc herniation and reflect treatment response, supporting their use in this population. Level of Evidence: Level III—retrospective comparative study.

Background: Although reverse total shoulder arthroplasty (rTSA) is widely used to treat a variety of complex shoulder pathologies, the management of the subscapularis tendon during rTSA remains controversial. The aim of this study was to prospectively compare outcomes following rTSA with and without lesser tuberosity repair for subscapularis management. Methods: This patient-blinded randomized controlled trial, conducted at a single institution, enrolled patients with a sufficiently intact subscapularis suitable for reattachment. Patients were randomized to either repair or no repair of the lesser tuberosity osteotomy (LTO) fragment to which the subscapularis was attached. Pre- and postoperative assessments involved radiographs, clinical examinations, and patient-reported outcomes, including a validated internal rotation functional score. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score. Results: Eighty-five shoulders in 81 patients met the inclusion criteria and had at least 2 years of follow-up. Forty-three of these shoulders had been randomized to LTO repair. At 2 years of follow-up, the repair group demonstrated significantly better ASES scores compared with the no-repair group (90.4 versus 82.3, p = 0.01). Repair provided 7 times better odds of achieving improved internal rotation range of motion. There were no significant differences in other active shoulder motions or outcome scores. Conclusions: In primary rTSA, subscapularis reattachment (by repair of the LTO) yielded better functional outcomes and internal rotation range of motion, as well as a trend toward a better internal rotation functional score. These benefits were seen without sacrificing shoulder motion in other planes. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Driving integrates multiple cognitive, sensory, and motor systems and may serve as a real-world indicator of functional decline in aging. Older adults with mild cognitive impairment (MCI) often experience subtle driving changes before formal dementia diagnosis, but longitudinal, real-world evidence is limited. This study examined whether naturalistic driving data can differentiate older adults with MCI from those with normal cognition (NC) over time and evaluated the discriminative ability of driving features compared with conventional risk factors. We conducted a prospective, observational cohort study of community-dwelling older drivers enrolled in the Driving Real-World In-Vehicle Evaluation System Project at Washington University. Participants underwent annual Clinical Dementia Rating assessment, neuropsychological testing, and apolipoprotein ε4 (APOE ε4) genotyping. Driving behaviors were captured daily for up to 40 months using global positioning system-enabled in-vehicle dataloggers, recording trip frequency, duration, distance, time of day, speeding, hard braking, and spatial mobility (entropy, maximum distance, radius of gyration). Longitudinal changes were analyzed using linear mixed-effect models, adjusting for age, sex, race, education, and APOE ε4. Logistic regression with reciever operator curve analysis evaluated discrimination between older adults with MCI and those with NC, compared with conventional sociodemographic and genetic markers. Among 298 participants (MCI, n = 56; NC, n = 242; mean age 75.1 years; 45.6% female), the groups were similar in age, sex, race, and APOE ε4 status at baseline, as well as in most driving behaviors. Over time, drivers with MCI showed greater reductions in monthly trip count (MCI: -0.501, standard error [SE]: 0.21, 95% CI [-0.923 to -0.083] vs NC: -0.523, SE: 0.09, 95% CI [-0.709 to -0.337]; p < 0.001), nightly trips (MCI:-0.334, SE: 0.17, 95% CI [-0.675 to 0.001] vs NC:-0.339, SE: 0.07, 95% CI [-0.480 to -0.197]; p < 0.001), and random entropy (MCI:-0.008, SE: 0.004, 95% CI [-0.016 to -0.001]; NC:-0.014, SE: 0.002, 95% CI [-0.017 to -0.011]; p < 0.001). Key features such as medium trip distance, speeding events, entropy, and maximum distance distinguished drivers with MCI from those with NC (area under the curve [AUC] 0.82, 95% CI 0.75-0.89). Adding demographics, APOE ε4, and cognitive composite improved AUC to 0.87 (95% CI 0.81-0.93). MCI was associated with progressive declines in driving frequency, complexity, and spatial range, supporting naturalistic driving data as a potential unobtrusive digital biomarker for early cognitive decline. Limitations of the study include a predominantly White, highly educated sample and a lack of external validation, warranting cautious interpretation. Continuous monitoring could augment clinical assessments, inform driving safety decisions, and guide interventions to preserve mobility in aging.

Introduction: Abnormal angiogenesis is central to vascular disease and cancer, and noninvasive biomarkers of vascular origin are needed to evaluate patients and therapies. Vascular endothelial growth factor receptors (VEGFRs) are often dysregulated in these diseases, making them promising biomarkers, but the need for an invasive biopsy has limited biomarker research on VEGFRs. Here, we pioneer a blood biopsy approach to quantify VEGFR plasma membrane localization on two circulating vascular proxies: circulating endothelial cells (cECs) and circulating progenitor cells (cPCs). Methods: Using quantitative flow cytometry, we examined VEGFR expression on cECs and cPCs in four age-sex groups: peri/premenopausal females (aged < 50 years), menopausal/postmenopausal females (≥ 50 years), and younger and older males with the same age cut-off (50 years). Results: cECs in peri/premenopausal females consisted of two VEGFR populations: VEGFR-low (~ 55% of population: population medians ~ 3000 VEGFR1 and 3000 VEGFR2/cell) and VEGFR-high (~ 45%: 138,000 VEGFR1 and 39,000–236,000 VEGFR2/cell), while the menopausal/postmenopausal group only possessed the VEGFR-low cEC population; and 27% of cECs in males exhibited high plasma membrane VEGFR expression (206,000 VEGFR1 and 155,000 VEGFR2/cell). The absence of VEGFR-high cEC subpopulations in menopausal/postmenopausal females suggests that their high-VEGFR cECs are associated with menstruation and could be noninvasive proxies for studying the intersection of age-sex in angiogenesis. VEGFR1 plasma membrane localization in cPCs was detected only in menopausal/postmenopausal females, suggesting a menopause-specific regenerative mechanism. Conclusions: Overall, our quantitative, noninvasive approach targeting cECs and cPCs has provided the first insights into how sex and age influence VEGFR plasma membrane localization in vascular cells.

No clear policy on administration methods for small-volume intravenous antibiotic bags (≤ 100 mL) for surgical prophylaxis lead to wide variation in anesthesia provider practice at a large academic medical center. Administration via secondary tubing is the recommended practice to minimize significant medication losses from dead volumes. An observation of current practice and measurements of dead volumes was followed by an educational intervention on best practices for administration of small-volume antibiotics. Three postintervention cycles were conducted to evaluate change in practice and reductions in dead volumes over a 6-week period. Mean dead volume losses were evaluated using one-way ANOVA. Statistically significant (P = .0012) decreases in dead volume losses were observed postintervention, from 8.48 mL (SD 6.80) to 0.93 mL (SD 1.46). The most common pre- and postintervention tubing sets used were primary tubing (pre) and secondary tubing (post). Mean dead volume losses for these respective tubing sets were 13.45 mL (SD 4.74) and 0.79 mL (SD 1.40) (P < .0001). Preintervention administration methods resulted in incomplete antibiotic administration. Overall, there was a significant reduction in dead volumes of antibiotic by changing practice to secondary tubing. With strong provider acceptance and sustained reduction in medication wastage, this intervention has shown to be a beneficial new practice moving forward.

The Physical Activity Guidelines for Americans, 2nd edition (PAGA2) is an evidence-based policy for physical activity. The PAGA2 addresses sedentary behavior, promotes physical activity, and elaborates on improved health outcomes associated with physical activity. The Promoting Physical Activity for Americans Act is a bill passed by the Senate but not yet enacted. The Move Your Way campaign is a promotional campaign for the PAGA2. The study promoted physical activity in American adults at a Midwestern church after implementation of a PowerPoint presentation entailing the Move Your Way campaign. The Global Physical Activity Questionnaire (GPAQ) was completed by participants prior to implementation of the Move Your Way campaign. Follow-up GPAQ assessments retrieved via telephone calls occurred at two, four, and eight weeks post intervention. The Move Your Way campaign produced a statistically significant increase in physical activity and reduction in sedentary behavior. The Move Your Way campaign successfully influenced adults to increase their physical activity and reduce their sedentary behavior. This study provides evidence-based practice that promotes and easily assesses physical activity. The results can be used to advocate for the enactment of the Promoting Physical Activity for Americans Act.

Background: Stay-at-home orders associated with the SARS-CoV-2 (COVID-19) pandemic were particularly important for older adults with type 2 diabetes, at risk for severe COVID-19 complications. In response, research shifted to remote telehealth methodology. Study participant interests, equipment needs, and ability to adapt methods to the remote/telehealth environment were unknown. Study purposes to assess (1) resource needs (internet/devices accessibility), (2) future telehealth interests, and (3) ability to adapt common research and clinical measures of glycemic control, physical function, activity measures, and quality of life outcomes to a telehealth setting. Method: Twenty-one participants with type 2 diabetes and peripheral neuropathy were recruited from a longitudinal study (11 female; age: 66.3 ± 8.3 years; DM: 15.1 ± 8.7 years). Technology needs and future telehealth interests were assessed. A glycemic measure (HbA1c), a five-times chair rise, a one-week activity monitor, and surveys (self-efficacy, depression, and balance) were collected. All aspects of the study were completed remotely over email and video/phone call. Results: Twelve participants used computers; nine used phones for study completion. Participants had the following resource needs: connectivity (n = 3), devices (n = 6), and technical support (n = 12). Twenty people expressed interest in participating in future telehealth studies related to balance, exercise, and diabetes management. Methodological considerations were primarily the need for assistance for participants to complete the home HbA1c test, five-time chair rise, wearable activity monitoring, and surveys. Conclusions: Older adults with type 2 diabetes and peripheral neuropathy would need technological and personal assistance (connection, device, guidance) to complete a long-term telehealth intervention. Despite technology needs, participants were interested in telehealth interventions. Clinical Trial: Parent study, “Metatarsal Phalangeal Joint Deformity Progression—R01 (NCT02616263) is registered at https://clinicaltrials.gov/ .