Jeor, Jeffery D. St.

Objectives: Health literacy is an individual’s capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. Failure to understand and correctly execute a plan of care often leads to poor health outcomes. Determining patient health literacy allows health care providers to tailor their plan of care instructions, increasing the probability of understanding, and adherence. Several validated health literacy tests have been developed to assess the health literacy of individuals and ethnic groups. However, because a proctor is required to administer these tests, their usefulness in clinical settings is limited. The issue of health literacy is especially relevant within minority groups. This research focused on producing a translatable assessment that can be administered quickly without a proctor. Methods: We developed a 15-question instrument (the RIHLA) in English using the Delphi method with a panel of bilingual experts and translated it into Spanish. Internal reliability was assessed using Cronbach’s alpha for 3 groups: Native English-speaking College students (NESC), Native English-speaking patients (NES), and Limited English Proficient Spanish-speaking patients (LEP). External validity was assessed using Pearson’s correlation coefficient to compare our instrument to a previously validated, proctored instrument measuring health literacy (the SAHL-E). Results: Four hundred fifteen subjects completed the RIHLA. Of these, 192 (46.3%) were NESC, 208 (50.1%) were NES, and 15 (3.6%) were LEP. The mean number of correct answers was 11.2, 11.6, and 8.3 respectively with the LEP group scoring lower ( P < .01). Cronbach’s alpha was >.70 for each group. Moderate correlation between the RIHLA and the previously validated instrument was present ( P < .01) with Pearson’s r = .47 (95% CI: 0.18-0.69). Conclusion: The RIHLA is a non-proctored assessment tool that may provide a measure of patients’ health literacy in multiple languages. Further studies with larger sample sizes are necessary to confirm the reliability, validity, and generalizability to a wider population.

Study Design: This was a retrospective chart review. Objective: The objective of this study was to compare the effect of teriparatide on Hounsfield Units (HU) in the cervical spine, thoracic spine, lumbar spine, sacrum, and pelvis. Second, to correlate HU changes at each spinal level with bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). Summary of Background Data: HU represent a method to estimate BMD and can be used either separately or in conjunction with BMD from DXA. Materials and Methods: A retrospective chart review included patients who had been treated with at least 6 months of teriparatide. HU were measured in the vertebral bodies of the cervical, thoracic, and lumbosacral spine and iliac crests. Lumbar and femoral neck BMD as measured on DXA was collected when available. Results: One hundred twenty-five patients were identified for analysis with an average age of 67 years who underwent a mean (±SD) of 22±8 months of teriparatide therapy. HU improvement in the cervical spine was 11% (P=0.19), 25% in the thoracic spine (P=0.002), 23% in the lumbar spine (P=0.027), 17% in the sacrum (P=0.11), and 29% in the iliac crests (P=0.09). Lumbar HU correlated better than cervical HU with BMD as measured on DXA. Conclusions: Teriparatide increased average HU in the thoracolumbar spine to a proportionally greater extent than the cervical spine. The cervical spine had a higher baseline starting HU than the thoracolumbar spine. Lumbar HU correlated better than cervical and thoracic HU with BMD as measured on DXA.

The clinical use of ultrasound has dramatically increased, necessitating early ultrasound education and the development of new tools in ultrasound training and assessment. The goal of this study was to devise a novel low‐resource examination that tested the anatomical knowledge and technical skill of early undergraduate medical students in a gross anatomy course. The team‐based ultrasound objective structured practice examination (OSPE) was created as a method for assessing practical ultrasound competencies, anatomical knowledge, and non‐technical skills such as teamwork and professionalism. The examination utilized a rotation of students through four team roles as they scanned different areas of the body. This station‐based examination required four models and four instructors, and tested ultrasound skills in the heart, abdominal vessels, abdominal organs, and neck regions. A Likert scale survey assessed student attitudes toward the examination. Survey data from participants (n = 46) were examined along with OSPE examination grades (n = 52). Mean and standard deviations were calculated for examination items and survey responses. Student grades were high in both technical (96.5%). and professional (96.5%) competencies with structure identification scoring the lowest (93.8%). There were no statistical differences between performances in each of the body regions being scanned. The survey showed that students deemed the examination to be fair and effective. In addition, students agreed that the examination motivated them to practice ultrasound. The team‐based OSPE was found to be an efficient and student‐favored method for evaluating integrated ultrasound competencies, anatomical knowledge, team‐work, and professional attributes.

Study Design: Retrospective Study. Objective: To compare methods of assessing pre-operative bone density to predict risk for osteoporosis related complications (ORC), defined as proximal junctional kyphosis, pseudarthrosis, accelerated adjacent segment disease, reoperation, compression fracture, and instrument failure following spine fusions. Methods: Chart review of primary posterior thoracolumbar or lumbar fusion patients during a 7 year period. Inclusion criteria: preoperative dual-energy x-ray absorptiometry (DXA) test within 1 year and lumbar CT scan within 6 months prior to surgery with minimum of 1 year follow-up. Exclusion criteria: <18 years at time of index procedure, infection, trauma, malignancy, skeletal dysplasia, neuromuscular disorders, or anterior-posterior procedures. Results: 140 patients were included. The average age was 67.9 years, 83 (59.3%) were female, and 45 (32%) had an ORC. There were no significant differences in patient characteristics between those with and without an ORC. Multilevel fusions were associated with ORCs (46.7% vs 26.3%, p = 0.02). Patients with ORCs had lower DXA t-scores (-1.62 vs -1.10, p = 0.003) and average Hounsfield units (HU) (112.1 vs 148.1, p ≤ 0.001). Multivariable binary logistic regression analysis showed lower average HU (Adj. OR 0.00 595% CI 0.0001-0.1713, p = 0.001) was an independent predictor of an ORC. The odds of an ORC increased by 1.7-fold for every 25 point decrease in average HU. Conclusions: The gold standard for assessing bone mineral density has been DXA t-scores, but the best predictor of ORC remains unclear. While both lower t-scores and average HU were associated with ORC, only HU was an independent predictor of ORC.

OBJECTIVE The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization. METHODS A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ −2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) “expanded spine” criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or “degraded” TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit. RESULTS Two hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors’ proposed “expanded spine” criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools. CONCLUSIONS Limitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.

In recent years, the use of point of care ultrasound (POCUS) in clinical practice has increased substantially . Many medical schools have introduced ultrasound skills training into their curriculum which starts early in anatomy courses . Few, if any, of these programs assess students’ ultrasound knowledge and skills in a simulated clinical team environment. Anatomy Ultrasound Objective Structural Practical Examination (OSPE) implemented as a part of practical examination provides such an opportunity to asses both traditional and non‐traditional discipline‐independent skills, competencies and attributes. As part of the seven‐week anatomy course at Mayo Clinic Alix School of Medicine, first‐year medical students attended four ultrasound sessions. Each session included a short didactic module followed by hands‐on practice guided by near‐peer teachers. For the final examination, four‐member student teams were required to work collaboratively to perform four different scans during which students interacted with multiple standardized patients and rotated responsibility for obtaining an image, orienting the image, and identifying assigned structures. Students were graded using a rubric and received a team‐score based on tasks associated with individual roles of team members. In addition to ultrasound skills, the nature of their professional interactions with patient, communication skills, and situational awareness were assessed. The average team score was 96%. The students completed a survey at the conclusion of the anatomy course in which they rated the OSPE experience very positively. Team‐based OSPE examination was a clinically relevant and effective mechanism to simultaneously evaluate anatomic knowledge, clinical skills, and non‐traditional discipline‐independent skills that were emphasized during the anatomy course. Support or Funding Information

OBJECTIVEThe authors sought to assess whether Hounsfield units (HU) increase following teriparatide treatment and to compare HU increases with changes in bone mineral density (BMD) as measured by dual-energy x-ray absorptiometry (DEXA).METHODSA retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. The authors identified patients who had been treated with at least 6 months of teriparatide and compared HU and BMD as measured on DEXA scans before and after treatment.RESULTSFifty-two patients were identified for analysis (46 women and 6 men, average age 67 years) who underwent an average of 20.9 ± 6.5 months of teriparatide therapy. The mean ± standard deviation HU increase throughout the lumbar spine (L1–4) was from 109.8 ± 53 to 133.9 ± 61 HU (+22%, 95% CI 1.2–46, p value = 0.039). Based on DEXA results, lumbar spine BMD increased from 0.85 to 0.93 g/cm2 (+9%, p value = 0.044). Lumbar spine T-scores improved from −2.4 ± 1.5 to −1.7 ± 1.5 (p value = 0.03). Average femoral neck T-scores improved from −2.5 ± 1.1 to −2.3 ± 1.0 (p value = 0.31).CONCLUSIONSTeriparatide treatment increased both HU and BMD on DEXA in the lumbar spine, without a change in femoral BMD. The 22% improvement in HU surpassed the 9% improvement determined with DEXA. These results support some surgeons’ subjective sense that intraoperative bone quality following teriparatide treatment is better than indicated by DEXA results. To the authors’ knowledge, this is the first study demonstrating an increase in HU with teriparatide treatment.