Incidence and risk factors for pneumonia following anterior cervical decompression and fusion procedures: an ACS-NSQIP study

BACKGROUND CONTEXT

Postoperative pneumonia has important clinical consequences for both patients and the health-care system. Few studies have examined pneumonia following anterior cervical decompression and fusion (ACDF) procedures.

PURPOSE

This study aimed to determine the incidence and risk factors for development of pneumonia following ACDF procedures.

STUDY DESIGN/SETTING

A retrospective cohort study of data collected prospectively by the American College of Surgeons National Surgical Quality Improvement Program was carried out.

PATIENT SAMPLE

This study comprised 11,353 patients undergoing ACDF procedures during 2011-2013.

OUTCOME MEASURES

The primary outcome was diagnosis of pneumonia in the first 30 postoperative days.

METHODS

Independent risk factors for the development of pneumonia were identified using multivariate regression. Readmission rates were compared between patients who did and did not develop pneumonia using multivariate regression that adjusted for all demographic, comorbidity, and procedural characteristics.

RESULTS

The incidence of pneumonia was 0.45% (95% confidence interval=0.33%-0.57%). In the multivariate analysis, independent risk factors for the development of pneumonia were greater age (p<.001), dependent functional status (relative risk [RR]=5.3, p<.001), chronic obstructive pulmonary disease (RR=4.4, p<.001), and greater operative duration (p=.020). Patients who developed pneumonia following discharge had a higher readmission rate than other patients (72.7% vs. 2.4%, adjusted RR=24.5, p<.001). In total, 10.2% of all readmissions were caused by pneumonia.

CONCLUSIONS

Pneumonia occurs in approximately 1 in 200 patients following ACDF procedures. Patients who are older, are functionally dependent, or have chronic obstructive pulmonary disease are at greater risk. These patients should be counseled, monitored, and targeted with preventative interventions accordingly. Greater operative duration is also an independent risk factor. Approximately three in four patients who develop pneumonia following hospitalization for ACDF procedures are readmitted. This elevated readmission rate has implications for bundled payments and hospital performance reports.

AIMP1 downregulation restores chondrogenic characteristics of dedifferentiated/degenerated chondrocytes by enhancing TGF-β signal

Dedifferentiation and degeneration of chondrocytes critically influences the efficiency of cartilage repair. One of the causes is the defect of transforming growth factor (TGF)-β signaling that promotes chondrogenic differentiation and degeneration. In the present study, we found that aminoacyl-tRNA synthetase-interacting multifunctional protein 1 (AIMP1) negatively regulates TGF-β signaling via interactions with Smad2 and Smad3 in immunoprecipitation assay and luciferase assay. In addition, we observed that the AIMP1 expression level was significantly increased in osteoarthritis (OA) patient-derived degenerated chondrocytes compared with healthy control. So, we hypothesized that downregulation of AIMP1 using small-interfering RNA (siRNA) technology in dedifferentiated (collected at passage #6) and degenerated (obtained from OA-affected areas) chondrocytes could lead to recover TGF-β signaling in both chondrocytes. Indeed, AIMP1 downregulation restored TGF-β signaling by promoting phosphorylation of Smad2 and Smad3, which shows redifferentiated characteristics in both dedifferentiated and degenerated chondrocytes. Additionally, implantation analyses using in vivo mouse model clearly showed that AIMP1 downregulation resulted in the increased chondrogenic potential as well as the enhanced cartilage tissue formation in both dedifferentiated and degenerated chondrocytes. Histological analyses clarified that AIMP1 downregulation increased expression levels of collagen type II (Col II) and aggrecan, but not Col I expression. Taken together, these data indicate that AIMP1 downregulation using siRNA is a novel tool to restore TGF-β signaling and thereby increases the chondrogenic potential of dedifferentiated/degenerated chondrocytes, which could be further developed as a therapeutic siRNA to treat OA.

Regulation of senescence associated signaling mechanisms in chondrocytes for cartilage tissue regeneration

Adult articular chondrocytes undergo slow senescence and dedifferentiation during in vitro expansion, restricting successful cartilage regeneration. A complete understanding of the molecular signaling pathways involved in the senescence and dedifferentiation of chondrocytes is essential in order to better characterize chondrocytes for cartilage tissue engineering applications. During expansion, cell fate is determined by the change in expression of various genes in response to aspects of the microenvironment, including oxidative stress, mechanical stress, and unsuitable culture conditions. Rapid senescence or dedifferentiation not only results in the loss of the chondrocytic phenotype but also enhances production of inflammatory mediators and matrix-degrading enzymes. This review focuses on the two groups of genes that play direct and indirect roles in the induction of senescence and dedifferentiation. Numerous degenerative signaling pathways associated with these genes have been reported. Upregulation of the genes interleukin 1 beta (IL-1β), p53, p16, p21, and p38 mitogen-activated protein kinase (MAPK) is responsible for the direct induction of senescence, whereas downregulation of the genes transforming growth factor-beta (TGF-β), bone morphogenetic protein-2 (BMP-2), SRY (sex determining region Y)-box 9 (SOX9), and insulin-like growth factor-1 (IGF-1), indirectly induces senescence. In senescent and dedifferentiated chondrocytes, it was found that TGF-β, BMP-2, SOX9, and IGF-1 are downregulated, while the levels of IL-1β, p53, p16, p21, and p38 MAPK are upregulated followed by inhibition of the normal molecular functioning of the chondrocytes. This review helps to elucidate the underlying mechanism in degenerative cartilage disease, which may help to improve cartilage tissue regeneration techniques.

Mesenchymal stem cell allograft as a fusion adjunct in one- and two-level anterior cervical discectomy and fusion: a matched cohort analysis

BACKGROUND CONTEXT

Live mesenchymal stem cell (MSC) allograft-containing allogeneic bone grafts have recently gained popularity and currently account for greater than 17% of all bone grafts and bone graft substitutes used in spinal surgery. Although the claim of cellular bone matrices containing osteogenic cells with osteoinductive properties is attractive, little is known about their clinical success when used in anterior cervical discectomy and fusion (ACDF).

PURPOSE

The objective of this study was to report on the radiographic fusion rates in one- and two-level instrumented ACDF using an MSC.

STUDY DESIGN/SETTING

This was a retrospective review of prospectively matched cohort of patients with radiologic assessment of fusion as the primary end point.

PATIENT SAMPLE

Two matched cohorts of adult patients who underwent ACDF with MSC or standard allograft were included.

OUTCOMES MEASURES

The outcome measures included radiographic and clinical evidence of healing at 1 year.

METHODS

A consecutive series of 57 patients who underwent a one- or two-level instrumented ACDF procedure between 2010 and 2012 were retrospectively analyzed. All fusion constructs comprised an interbody allograft, an anterior plate, and Osteocel (NuVasive, San Diego, CA, USA). These patients were matched to a control group of 57 patients.

RESULTS

Of the 57 cases in both cohorts, 29 (50.9%) were single-level, and 28 (49.1%) were two-level instrumented ACDFs. There were no significant differences in patient age (p=.71), gender, comorbidity burden (Charlson Comorbidity Index [CCI]: 1.95; 2.42, p=.71) or body mass index (p=.79). At the 1-year follow-up, 50 of 57 (87.7%) patients in the Osteocel cohort demonstrated a solid fusion compared with 54 of 57 (94.7%) in the control group (p=.19). Seven (12.3%) patients in the Osteocel cohort were reported as having a failed fusion at 1 year.

CONCLUSIONS

This is the first non-industry sponsored study to analyze a matched cohort assessing the 1-year arthrodesis rates associated with a nonstructural MSC allograft in one- and two-level ACDF procedures. Although not statistically significant, patients treated with MSC allografts demonstrated lower fusion rates compared with a matched non-MSC cohort.

Target-specific regulation of presynaptic release properties at auditory nerve terminals in the avian cochlear nucleus

Short-term synaptic plasticity (STP) acts as a time- and firing rate-dependent filter that mediates the transmission of information across synapses. In the auditory brain stem, the divergent pathways that encode acoustic timing and intensity information express differential STP. To investigate what factors determine the plasticity expressed at different terminals, we tested whether presynaptic release probability differed in the auditory nerve projections to the two divisions of the avian cochlear nucleus, nucleus angularis (NA) and nucleus magnocellularis (NM). Estimates of release probability were made with an open-channel blocker ofN-methyl-d-aspartate (NMDA) receptors. Activity-dependent blockade of NMDA receptor-mediated excitatory postsynaptic currents (EPSCs) with application of 20 μM (+)-MK801 maleate was more rapid in NM than in NA, indicating that release probability was significantly higher at terminals in NM. Paired-pulse ratio (PPR) was tightly correlated with the blockade rate at terminals in NA, suggesting that PPR was a reasonable proxy for relative release probability at these synapses. To test whether release probability was similar across convergent inputs onto NA neurons, PPRs of different nerve inputs onto the same postsynaptic NA target neuron were measured. The PPRs, as well as the plasticity during short trains, were tightly correlated across multiple inputs, further suggesting that release probability is coordinated at auditory nerve terminals in a target-specific manner. This highly specific regulation of STP in the auditory brain stem provides evidence that the synaptic dynamics are tuned to differentially transmit the auditory information in nerve activity into parallel ascending pathways.

Preoperative narcotic utilization: accuracy of patient self-reporting and its association with postoperative narcotic consumption

OBJECT

Little is known about the accuracy of reporting of preoperative narcotic utilization in spinal surgery. As such, the purpose of this study is to compare postoperative narcotic consumption between preoperative narcotic utilizers who do and do not accurately self-report preoperative utilization.

METHODS

Patients who underwent anterior cervical discectomy and fusion, minimally invasive lumbar discectomy, or minimally invasive transforaminal lumbar interbody fusion procedures between 2013 and 2014 were prospectively identified. The accuracy of self-reporting preoperative narcotic consumption was determined utilizing the Illinois Prescription Monitoring Program. Total inpatient narcotic consumption during postoperative Days 0 and 1 was compared according to the demographics and preoperative narcotic reporting accuracy. Similarly, the proportion of patients who continued to be dependent on narcotic medications at each postoperative visit was compared according to the demographics and preoperative narcotic reporting accuracy.

RESULTS

A total of 195 patients met the inclusion criteria. Of these, 25% did not use narcotics preoperatively, while 47% and 28% did do so with accurate and inaccurate reporting, respectively. Patients who used narcotics preoperatively were more likely to demonstrate elevated inpatient narcotic consumption (adjusted RR 5.3; 95% CI 1.4–20.1; p = 0.013). However, such patients were no more or less likely to be dependent on narcotic medications at the first (p = 0.618) or second (p = 0.798) postoperative visit. Among patients who used narcotics preoperatively, no differences were demonstrated in terms of inpatient narcotic consumption (p = 0.182) or narcotic dependence following the first (p = 0.982) or second (p = 0.866) postoperative visit according to the self-reported accuracy of preoperative narcotic utilization. The only preoperative factors that were independently associated with elevated inpatient narcotic consumption were workers’ compensation status and procedure type. The only preoperative factors that were independently associated with narcotic dependence at the first postoperative visit were female sex, workers’ compensation status, and procedure type. The only preoperative factor that was independently associated with narcotic dependence at the second postoperative visit was procedure type.

CONCLUSIONS

The findings suggest that determining the actual preoperative narcotic utilization in patients who undergo spine surgery may help optimize postoperative pain management. Approximately 75% of patients used narcotics preoperatively. Patients who used narcotics preoperatively demonstrated significantly higher inpatient narcotic consumption, but this difference did not persist following discharge. Finally, postoperative narcotic consumption (inpatient and following discharge) was independent of the self-reported accuracy of preoperative narcotic utilization. Taken together, these findings suggest that corroboration between the patient’s self-reported preoperative narcotic utilization and other sources of information (e.g., family members and narcotic registries) may be clinically valuable with respect to minimizing narcotic requirements, thereby potentially improving the management of postoperative pain.

Identifying bias in CCR1 antagonists using radiolabelled binding, receptor internalization, β-arrestin translocation and chemotaxis assays

BACKGROUND AND PURPOSE

Investigators have suggested that the chemokine receptor CCR1 plays a role in multiple myeloma. Studies using antisense and neutralizing antibodies to CCR1 showed that down-regulation of the receptor altered disease progression in a mouse model. More recently, experiments utilizing scid mice injected with human myeloma cells demonstrated that the CCR1 antagonist BX471 reduced osteolytic lesions, while the CCR1 antagonist MLN-3897 prevented myeloma cell adhesion to osteoclasts. However, information is limited regarding the pharmacology of CCR1 antagonists in myeloma cells.

EXPERIMENTAL APPROACH

We compared several well-studied CCR1 antagonists including AZD4818, BX471, CCX354, CP-481715, MLN-3897 and PS899877 for their ability to inhibit binding of [(125)I]-CCL3 in vitro using membranes prepared from RPMI 8226 cells, a human multiple myeloma cell line that endogenously expresses CCR1. In addition, antagonists were assessed for their ability to modulate CCL3-mediated internalization of CCR1 and CCL3-mediated cell migration using RPMI 8226 cells. As many GPCRs signal through β-arrestin-dependent pathways that are separate and distinct from those driven by G-proteins, we also evaluated the compounds for their ability to alter β-arrestin translocation.

KEY RESULTS

There were clear differences between the CCR1 antagonists in their ability to inhibit CCL3 binding to myeloma cells, as well as in their ability to inhibit G-protein-dependent and -independent functional responses.

CONCLUSIONS AND IMPLICATIONS

Our studies demonstrate that tissue phenotype seems to be relevant with regards to CCR1. Moreover, it appears that for CCR1 antagonists, inhibition of β-arrestin translocation is not necessarily linked to chemotaxis or receptor internalization.

Quantification of Multifidus Atrophy and Fatty Infiltration Following a Minimally Invasive Microdiscectomy

BACKGROUND

Multifidus muscle degeneration and atrophy have been demonstrated following traditional open spine surgery. The purpose of this study was to quantify multifidus muscle atrophy and fatty infiltration following a 1-level minimally invasive (MIS) lumbar discectomy.

METHODS

Magnetic resonance imaging (MRI) of 24 patients who underwent a primary 1-level MIS microdiscectomy were reviewed. Demographics, operative levels, and time from surgery to imaging were assessed. Total and lean cross-sectional areas (CSA), T1-signal intensity ratio between the multifidus and psoas muscles, and lean-to-total CSA ratio were measured. Pre- and postoperative values were compared within each patient utilizing paired sample T-tests.

RESULTS

The mean age was 47.8±14.2 years. MRI was obtained 182.5±194.4 days following index surgery. On the ipsilateral side, total CSA decreased at the index level (-4.9%) and the lean CSA decreased at the index (-6.2%), inferior pedicle (-13.0%), and inferior disc levels (-18.6%). On the contralateral side, no significant decreases in total or lean CSA were demonstrated. T1-signal intensity ratios increased at all levels, but the differences were not statistically significant. The lean-to-total CSA ratio was decreased at the superior disc (-5.2%), inferior pedicle (-8.4%), and inferior disc levels (-17.2%) on the ipsilateral side and at the contralateral inferior disc level (-5.3%).

CONCLUSIONS

Primary 1-level MIS discectomy results in minimal short-term atrophy and fatty infiltration of the multifidus at the index level. Total CSA atrophy was mainly confined to the ipsilateral side at the index level. Lean CSA atrophy was observed mainly at and below the index level on the ipsilateral side. Fatty infiltration, as measured by the lean-to-total CSA ratio, ranged 1.2-17.2% on the ipsilateral and 0-5.3% on the contralateral side with greater fat content demonstrated caudally to the surgical level.

CLINICAL RELEVANCE

Overall, the majority of the multifidus muscle appears to be radiographically preserved following an MIS lumbar discectomy.

Economic factors in the future delivery of spinal healthcare

The current trajectory of healthcare-related spending in the United States is unsustainable. Currently, the predominant form of reimbursement is the form of a fee-for-service system in which surgeons are reimbursed for each discrete unit of care provided. This system does factor the cost, quality, or outcomes of service provided. For the purposes of cost containment, the bundled episode reimbursement has gained popularity as a potential alternative to the current fee-for-service system. In the newer model, the spinal surgeon will become increasingly responsible for controlling costs. The bundled payment system will initially offer financial incentives to initiate a meaningful national transition from the fee-for-service model. The difficulty will be ensuring that the services of surgeons continue to be valued past this initiation period. However, greater financial responsibilities will be placed upon the individual surgeon in this new system. Over time, the evolving interests of hospital systems could result in the devaluation of the surgeons' services. Significant cooperation on behalf of all involved healthcare providers will be necessary to ensure that quality of care does not suffer while efforts for cost containment continue.

Solid organ transplantation from hepatitis B virus-positive donors: consensus guidelines for recipient management

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non-liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti-HBc+) donors. Organs from anti-HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non-liver recipients but is not recommended in immune non-liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost-effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.

Comparison of international guidelines of dermal absorption tests used in pesticides exposure assessment for operators

The number of farmers who have suffered from non-fatal acute pesticide poisoning has been reported to vary from 5.7% to 86.7% in South Korea since 1975. Absorption through the skin is the main route of exposure to pesticides for farmers who operate with them. Several in vitro tests using the skins of humans or animal and in vivo tests using laboratory animals are introduced for the assessment of human dermal absorption level of pesticides. The objective of this study is to evaluate and compare international guidelines and strategies of dermal absorption assessments and to propose unique approaches for applications into pesticide registration process in our situation. Until present in our situation, pesticide exposure level to operator is determined just using default value of 10 as for skin absorption ratio because of data shortage. Dermal absorption tests are requested to get exposure level of pesticides and to ultimately know the safety of pesticides for operators through the comparison with the value of AOEL. When the exposure level is higher than AOEL, the pesticide cannot be approved. We reviewed the skin absorption test guidelines recommended by OECD, EFSA and EPA. The EPA recommends assessment of skin absorption of pesticides for humans through the TPA which includes all the results of in vitro human and animal and animal in vivo skin absorption studies. OECD and EFSA, employ a tiered approach, which the requirement of further study depends on the results of the former stage study. OECD guidelines accept the analysis of pesticide level absorbed through skin without radioisotope when the recovery using the non-labeled method is within 80~120%. Various factors are reviewed in this study, including the origin of skin (gender, animal species and sites of skin), thickness, temperature and, etc., which can influence the integrity of results.