Primary Cervical Disc Arthroplasty Among Medicare Beneficiaries Versus Alternative Payers: Is It Time to Consider Nationwide Coverage?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

As of 2022, the Centers for Medicare and Medicaid Services does not provide nationwide coverage for cervical disc arthroplasty (CDA). The aim was to determine whether Medicare beneficiaries have differences in: (1) lengths of stay (LOS); (2) complications; (3) readmissions; and (4) costs of care.

METHODS

Using the 2010 to 2020 PearlDiver database, we queried patients undergoing primary CDA for degenerative disc pathology. Study groups patients were those undergoing CDA with Medicare coverage (n = 1467); patients without Medicare coverage were the comparison cohort (n = 15,389). Endpoints were to compare demographics and comorbidities within the Elixhauser comorbidity index (ECI), LOS, 90-day complications, 90-day readmissions, and 90-day reimbursements. A multivariate logistic regression was used to calculate odds (OR) of medical complications and readmissions within 90-days. A P-value less than .003 was significant.

RESULTS

Patients with Medicare coverage undergoing CDA had higher mean ECI compared to alternative payers (5.24 vs 3.26; P < .0001). Mean LOS was significantly higher for Medicare beneficiaries (2.20 vs 1.76 days; P < .010). There was no significant differences in odds of all medical complications (OR: 1.19, 95% CI: .98-1.44; P = .069) or readmission rates (1.77% vs 1.33%, OR:0.82, 95% CI: .50-1.29; P = .417) within 90-days following the index procedure among Medicare beneficiaries vs alternative payers. Non-Medicare beneficiaries had higher 90-day reimbursements compared to Medicare beneficiaries ($6,700 vs $7,086,P < .001).

CONCLUSIONS

Medicare beneficiaries despite having slightly longer lengths of stay did not have higher rates of medical complications or readmissions. Surgeons and policy makers may use this data to consider alternative treatments in Medicare patients.

Risk Factors for Undergoing Surgical Intervention for Vertebral Compression Fractures: An Analysis of 703,499 Patients

STUDY DESIGN

Retrospective Cohort OBJECTIVES: Vertebral compression fractures (VCFs) are typically treated nonoperatively, but can be treated with either kyphoplasty or vertebroplasty when indicated. The decision to treat patients with/without surgical intervention is dependent on the severity of deformity and patient risk profile. The aims of this study were to: 1) compare baseline patient demographics, 2) identify risk factors of patients undergoing operative versus nonoperative management, and 3) identify patient-specific risk factors associated with post-operative re-admissions.

METHODS

This retrospective database study used patient information from January 1st, 2010, to October 31st, 2021. Cohorts were identified by patients diagnosed with VCFs through International Classification of Disease, Ninth Revision (ICD-9), ICD-10 codes, identifying those undergoing kyphoplasty/vertebroplasty via Current Procedural Terminology (CPT) codes. The two research domains utilized in this investigation were baseline demographic profiles of patients who underwent kyphoplasty or vertebroplasty for treatment of VCFs, and those who underwent nonoperative management served as the control cohort.

RESULTS

Of the 703,499 patients diagnosed with VCFs, 76,126 patients (10.8%) underwent kyphoplasty or vertebroplasty within 90 days of diagnosis of a VCF. Univariate analysis demonstrated female sex was associated with increased risk of undergoing surgical management for VCF (p<0.0001). Several co-morbidities were significantly associated with increased rates of readmission including hypertension, tobacco use, coronary artery disease, and COPD (p <0.0001 for all).

CONCLUSIONS

This study highlights specific comorbidities that are significantly associated with higher rates of kyphoplasty or vertebroplasty for the treatment of thoracolumbar wedge compression fractures and increased risk for 90-day post-operative hospital readmission.

Modern Internet Search Analytics: Is There a Difference in What Patients are Searching Regarding the Operative and Nonoperative Management of Scoliosis?

STUDY DESIGN

Observational Study.

OBJECTIVES

This study aimed to investigate the most searched types of questions and online resources implicated in the operative and nonoperative management of scoliosis.

METHODS

Six terms related to operative and nonoperative scoliosis treatment were searched on Google's People Also Ask section on October 12, 2023. The Rothwell classification was used to sort questions into fact, policy, or value categories, and associated websites were classified by type. Fischer's exact tests compared question type and websites encountered between operative and nonoperative questions. Statistical significance was set at the .05 level.

RESULTS

The most common questions concerning operative and nonoperative management were fact (53.4%) and value (35.5%) questions, respectively. The most common subcategory pertaining to operative and nonoperative questions were specific activities/restrictions (21.7%) and evaluation of treatment (33.3%), respectively. Questions on indications/management (13.2% vs 31.2%, P < .001) and evaluation of treatment (10.1% vs 33.3%, P < .001) were associated with nonoperative scoliosis management. Medical practice websites were the most common website to which questions concerning operative (31.9%) and nonoperative (51.4%) management were directed to. Operative questions were more likely to be directed to academic websites (21.7% vs 10.0%, P = .037) and less likely to be directed to medical practice websites (31.9% vs 51.4%, P = .007) than nonoperative questions.

CONCLUSIONS

During scoliosis consultations, spine surgeons should emphasize the postoperative recovery process and efficacy of conservative treatment modalities for the operative and nonoperative management of scoliosis, respectively. Future research should assess the impact of website encounters on patients' decision-making.

Peptide nucleic acid-assisted generation of targeted double-stranded DNA breaks with T7 endonuclease I

Gene-editing technologies have revolutionized biotechnology, but current gene editors suffer from several limitations. Here, we harnessed the power of gamma-modified peptide nucleic acids (γPNAs) to facilitate targeted, specific DNA invasion and used T7 endonuclease I (T7EI) to recognize and cleave the γPNA-invaded DNA. Our data show that T7EI can specifically target PNA-invaded linear and circular DNA to introduce double-strand breaks (DSBs). Our PNA-Guided T7EI (PG-T7EI) technology demonstrates that T7EI can be used as a programmable nuclease capable of generating single or multiple specific DSBs in vitro under a broad range of conditions and could be potentially applied for large-scale genomic manipulation. With no protospacer adjacent motif (PAM) constraints and featuring a compact protein size, our PG-T7EI system will facilitate and expand DNA manipulations both in vitro and in vivo, including cloning, large-fragment DNA assembly, and gene editing, with exciting applications in biotechnology, medicine, agriculture, and synthetic biology.

Multi-Level Posterior Cervical Foraminotomy Associated With Increased Post-operative Infection Rates and Overall Re-Operation Relative to Anterior Cervical Discectomy With Fusion or Cervical Disc Arthroplasty

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Cervical radiculopathy meeting operative criteria has traditionally been managed using anterior cervical discectomy and fusion (ACDF). However, cervical disc arthroplasty (CDA) and posterior cervical foraminotomy (PCF) are also reasonable options. This study aimed to assess differences in postoperative outcomes among patients undergoing multi-level ACDF, CDA, or PCF comparing medical/surgical complications and healthcare utilization parameters.

METHODS

Patients who underwent multi-level ACDF, CDA, or PCF between 2012 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Patients were stratified based on procedure type and propensity score matched to resolve baseline differences. ANOVA was performed to identify differences in medical complications, surgical complications, and healthcare utilization metrics.

RESULTS

A total of 31 344 patients who underwent an eligible procedure were identified (ACDF: n = 28 089, CDA: n = 1748, PCF: n = 1507), and 684 patients remained in each group following propensity score matching. Patients undergoing multi-level PCF were found to experience longer lengths of hospital stay (PCF: 1.67 ± 1.61 days, ACDF: 1.50 ± 1.32 days, CDA: 1.27 ± 1.05 days, P < .001), higher rates of reoperation (PCF: 3.2%, ACDF: 1.0%, CDA: .4%, P = .020), superficial infection (PCF: 1.3%, ACDF: .3%, CDA: .1%, P = .008) and deep infection (PCF: 1.2%, ACDF: 0%, CDA: 0%, P < .001). There were no outcome differences between multi-level ACDF and CDA.

CONCLUSIONS

Patients undergoing multi-level PCF were at increased risk for longer hospital stay, re-operation, and infection relative to those undergoing ACDF and CDA. Future research should aim to uncover the precise mechanisms underlying these complications, as well as analyze long term outcomes.

LEVEL OF EVIDENCE

III.

Ticagrelor Versus Clopidogrel in Endovascular Therapy for Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Antiplatelet therapy is pivotal in endovascular treatment for intracranial aneurysms. However, there is a lack of studies comparing ticagrelor to clopidogrel in patients with aneurysms undergoing endovascular therapy. Additionally, the existing literature lacks adequate sample size, significant subgrouping, and follow-up, making our study important to cover these gaps.

METHODS

We searched 5 databases to collect all relevant studies. Categorical outcomes were pooled as relative risk (R.R.) with a 95% confidence interval (CI). In the single-arm meta-analysis, outcomes were pooled as proportions and their corresponding 95% CI.

RESULTS

This comprehensive analysis of 18 studies involving 2,427 patients. For thromboembolic events, the pooled (R.R.) did not show significant differences, whether considering overall events. A similar pattern was observed for thromboembolic events stratified by aneurysmal rupture status, with no significant differences in overall events. Hemorrhagic events did not also exhibit significant differences in previously mentioned stratifications. Furthermore, there were no substantial differences in death and mRS (0-2) on discharge between Ticagrelor and Clopidogrel. Single-arm meta-analyses for Ticagrelor demonstrated low rates of thromboembolic events, hemorrhage, death, and favorable mRS scores, with associated confidence intervals (CIs). Main line of endovascular treatment did not significantly affect either thromboembolic or hemorrhagic outcomes with Ticagrelor and Clopidogrel.

CONCLUSIONS

We found no significant differences in key outcomes like thromboembolic events, hemorrhagic events, mortality rates, and favorable mRS (0-2) upon discharge in the studied patients between Ticagrelor and Clopidogrel. Moreover, the single-arm meta-analysis for Ticagrelor revealed low rates of thromboembolic events, hemorrhage, mortality, and high rates of favorable mRS scores.

GPT-4 as a Source of Patient Information for Anterior Cervical Discectomy and Fusion: A Comparative Analysis Against Google Web Search

STUDY DESIGN

Comparative study.

OBJECTIVES

This study aims to compare Google and GPT-4 in terms of (1) question types, (2) response readability, (3) source quality, and (4) numerical response accuracy for the top 10 most frequently asked questions (FAQs) about anterior cervical discectomy and fusion (ACDF).

METHODS

"Anterior cervical discectomy and fusion" was searched on Google and GPT-4 on December 18, 2023. Top 10 FAQs were classified according to the Rothwell system. Source quality was evaluated using JAMA benchmark criteria and readability was assessed using Flesch Reading Ease and Flesch-Kincaid grade level. Differences in JAMA scores, Flesch-Kincaid grade level, Flesch Reading Ease, and word count between platforms were analyzed using Student's t-tests. Statistical significance was set at the .05 level.

RESULTS

Frequently asked questions from Google were varied, while GPT-4 focused on technical details and indications/management. GPT-4 showed a higher Flesch-Kincaid grade level (12.96 vs 9.28, P = .003), lower Flesch Reading Ease score (37.07 vs 54.85, P = .005), and higher JAMA scores for source quality (3.333 vs 1.800, P = .016). Numerically, 6 out of 10 responses varied between platforms, with GPT-4 providing broader recovery timelines for ACDF.

CONCLUSIONS

This study demonstrates GPT-4's ability to elevate patient education by providing high-quality, diverse information tailored to those with advanced literacy levels. As AI technology evolves, refining these tools for accuracy and user-friendliness remains crucial, catering to patients' varying literacy levels and information needs in spine surgery.

Risk Factors for Readmission Following Surgical Decompression for Spinal Epidural Abscesses: An Analysis of 4595 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The study aimed to (1) compare baseline demographics of patients undergoing surgery for SEA who were/were not readmitted; (2) identify risk factors for 90-day readmissions; and (3) quantify 90-day episode-of-care health care costs.

BACKGROUND

Spinal epidural abscess (SEA), while rare, occurring ~2.5-5.1/10,000 admissions, may lead to permanent neurologic deficits and mortality. Definitive treatment often involves surgical intervention via decompression.

METHODS

A search of the PearlDiver database from 2010 to 2021 for patients undergoing decompression for SEA identified 4595 patients. Cohorts were identified through the International Classification of Disease, Ninth Revision (ICD-9), ICD-10, and Current Procedural Terminology codes. Baseline demographics of patients who were/were not readmitted within 90 days following decompression were aggregated/compared, identifying factors associated with readmission. Using Bonferroni correction, a P-value<0.001 was considered statistically significant.

RESULTS

Readmission within 90 days of surgical decompression occurred in 36.1% (1659/4595) of patients. While age/gender were not associated with readmission rate, alcohol use disorder, arrhythmia, chronic kidney disease, ischemic heart disease, and obesity were associated with readmission. Readmission risk factors included fluid/electrolyte abnormalities, obesity, paralysis, tobacco use, and pathologic weight loss (P<0.0001). Mean same-day total costs ($17,920 vs. $8204, P<0.001) and mean 90-day costs ($46,050 vs. $15,200, P<0.001) were significantly higher in the readmission group.

CONCLUSION

A substantial proportion of patients (36.1%) are readmitted within 90 days following surgical decompression for SEA. The top 5 risk factors in descending order are fluid/electrolyte abnormalities, pathologic weight loss, tobacco use, pre-existing paralysis, and obesity. This study highlights areas for perioperative medical optimization that may reduce health care utilization.

Unveiling the Potential of Ambient Air Annealing for Highly Efficient Inorganic CsPbI3 Perovskite Solar Cells

Here, we report a detailed surface analysis of dry- and ambient air-annealed CsPbI3 films and their subsequent modified interfaces in perovskite solar cells. We revealed that annealing in ambient air does not adversely affect the optoelectronic properties of the semiconducting film; instead, ambient air-annealed samples undergo a surface modification, causing an enhancement of band bending, as determined by hard X-ray photoelectron spectroscopy measurements. We observe interface charge carrier dynamics changes, improving the charge carrier extraction in CsPbI3 perovskite solar cells. Optical spectroscopic measurements show that trap state density is decreased due to ambient air annealing. As a result, air-annealed CsPbI3-based n-i-p structure devices achieved a 19.8% power conversion efficiency with a 1.23 V open circuit voltage.

ChatGPT as a Source of Patient Information for Lumbar Spinal Fusion and Laminectomy: A Comparative Analysis Against Google Web Search

STUDY DESIGN

Retrospective Observational Study.

OBJECTIVE

The objective of this study was to assess the utility of ChatGPT, an artificial intelligence chatbot, in providing patient information for lumbar spinal fusion and lumbar laminectomy in comparison with the Google search engine.

SUMMARY OF BACKGROUND DATA

ChatGPT, an artificial intelligence chatbot with seemingly unlimited functionality, may present an alternative to a Google web search for patients seeking information about medical questions. With widespread misinformation and suboptimal quality of online health information, it is imperative to assess ChatGPT as a resource for this purpose.

METHODS

The first 10 frequently asked questions (FAQs) related to the search terms "lumbar spinal fusion" and "lumbar laminectomy" were extracted from Google and ChatGPT. Responses to shared questions were compared regarding length and readability, using the Flesch Reading Ease score and Flesch-Kincaid Grade Level. Numerical FAQs from Google were replicated in ChatGPT.

RESULTS

Two of 10 (20%) questions for both lumbar spinal fusion and lumbar laminectomy were asked similarly between ChatGPT and Google. Compared with Google, ChatGPT's responses were lengthier (340.0 vs. 159.3 words) and of lower readability (Flesch Reading Ease score: 34.0 vs. 58.2; Flesch-Kincaid grade level: 11.6 vs. 8.8). Subjectively, we evaluated these responses to be accurate and adequately nonspecific. Each response concluded with a recommendation to discuss further with a health care provider. Over half of the numerical questions from Google produced a varying or nonnumerical response in ChatGPT.

CONCLUSIONS

FAQs and responses regarding lumbar spinal fusion and lumbar laminectomy were highly variable between Google and ChatGPT. While ChatGPT may be able to produce relatively accurate responses in select questions, its role remains as a supplement or starting point to a consultation with a physician, not as a replacement, and should be taken with caution until its functionality can be validated.

Atrial arrhythmias and acute pericarditis triggered by bleach ingestion-associated oesophageal perforation: a case report

Background

Acute pericarditis due to oesophageal perforation and caustic injury is a rare presentation of bleach ingestion. Cardiac arrhythmias such as atrial fibrillation and atrial flutter have been associated with certain aetiologies of acute pericarditis. This case report presents a unique occurrence of acute pericarditis following bleach ingestion and intermittent atrial fibrillation and atrial flutter triggered by liquid intake.

Case summary

A 36-year-old male with no significant past medical history presented after attempted suicide by ingesting bleach. He had acute pericarditis resulting from caustic oesophageal perforation and extensive mediastinal injury. In the following days, he developed recurrent episodes of atrial fibrillation and atrial flutter following fluid intake, prompting treatment with metoprolol. On Day 5 of hospitalization, he underwent an oesophagogram and developed persistent atrial arrhythmia with haemodynamic instability requiring cardioversion. He underwent thoracoscopic surgery to address the oesophageal injury. A jejunostomy tube was placed and he had complete resolution of his recurrent atrial arrhythmia.

Discussion

This case highlights a rare presentation of atrial arrhythmias and acute pericarditis caused by corrosive oesophageal injury due to bleach ingestion. The effective management of such cases necessitates a co-ordinated approach, involving the collaboration of cardiothoracic surgeons, cardiologists, and critical care specialists, with the aim of enhancing patient outcomes and mitigating the life-threatening risks associated with oesophageal perforation and cardiac arrhythmias. Furthermore, this case underscores the imperative for further research to better understand the relationship between traumatic acute pericarditis and atrial arrhythmias, offering the potential for improved patient care in these intricate clinical scenarios.

Safety of pregnancy after cerebral venous thrombosis: A case-control study

Background and Aims

Since pregnancy is considered one of the major risk factors of cerebral venous thrombosis (CVT), the safety of pregnancy in women of childbearing age and a previous history of CVT, is concerning in terms of prevention, family planning, and management. This study aims to estimate the prevalence of pregnancies among women of childbearing age with previous CVT, evaluate the pregnancy-associated risk of CVT recurrence, and explore the maternal and fetal outcomes among CVT women in comparison with pregnant women without a history of CVT.

Methods

A retrospective, case-control study was conducted at the Obstetrics Departments of King Fahad Medical City Hospital, Saudi Arabia. It included all women with a history of CVT diagnosed in the last 5 years (cases), as well as CVT history-free pregnant women (control). The prevalence of pregnancy after CVT was estimated and the prepartum and postpartum parameters of the two groups were compared.

Results

Fifty women with CVT and 100 controls were included. Among the 50 CVT cases, 28 (56.0%) have been pregnant. The incidence of pre-eclampsia was significantly more frequent in CVT women (7.1% vs. 0.0%, p = 0.047); however, only one case of deep vein thrombosis (3.6%) was reported in CVT patients versus none in controls (p = 0.219). CVT women delivered at a lower gestational age (mean [SD] = 36.9 [3.5] weeks) compared with controls (38.3 [1.4] weeks) (p = 0.006). No significant differences in other pregnancy or delivery outcomes were observed between the two groups.

Conclusion

More than half of women of childbearing age with a history of CVT opt for pregnancy after the CVT episode, with no major additional risk for pre or postpartum complications.

Cannabis Use Disorder Is Associated With Longer In-Hospital Lengths of Stay, Higher Rates of Medical Complications, and Costs of Care Following Primary 1- to 2-Level Lumbar Fusion

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

The purpose of this study is to assess whether cannabis use disorder (CUD) patients undergoing primary 1- to 2-level lumbar fusion (1-2LF) for the treatment of degenerative lumbar spine disorders have higher rates of: (1) in-hospital lengths of stay (LOS), (2) medical complications, and (3) healthcare expenditures.

MATERIALS AND METHODS

A retrospective case-control study of the MSpine dataset of the PearlDiver claims from January 2007 to March 2018 was performed. Patients with CUD undergoing 1-2LF were queried and matched to a comparison group in a 1:5 ratio by age, sex, and various medical comorbidities yielding 22, 815 patients within the study (CUD = 3805; control = 19 010). Outcomes analyzed included LOS, 90-day medical complications, and costs. A P-value less than .004 was considered significant.

RESULTS

This study found CUD patients undergoing primary 1-2LF experience longer in-hospital LOS (4- vs. 3-days, P < .0001). Additionally, CUD patients were found to have significantly higher frequency and odds-ratios (OR) (31.88 vs. 18.01% OR: 1.41, P < .0001) of adverse events within ninety days following their procedure. CUD patients also had significantly higher day of surgery ($18,946.79 vs. $15,691.02, P < .0001) and 90 days healthcare expenditures ($21,469.01 vs. $19,556.71, P < .0001).

CONCLUSION

Patients with CUD can prepare for increased LOS, complications, and costs following primary 1-2LF. The study can be used to educate these patients of the potential outcomes following their procedure.

[Bond strength of metal brackets to enamel with a Russian adhesive complex: an in vitro study]

BACKGROUND

The era of using adhesives to fix brackets began in the 70s of the last century. There are eight generations of foreign-made adhesive systems for the restoration of teeth. However, until now, in orthodontics, the development of domestic adhesive systems with improved properties of adhesion of brackets to tooth enamel still important, especially in the posterior teeth.

OBJECTIVE

The purpose of this work was to study the shear strength of fifth generation domestic adhesive between metal brackets and the enamel of molar teeth in laboratory conditions.

MATERIAL AND METHODS

The study included 17 specimens of extracted maxillary molars embedded in acrylic resin blocks. Brackets from G&H Orthodontics (G&H Wire Company, USA) were fixed to the tooth enamel using the domestic Compofix (ortho) set. The enamel was treated with etching gel (37% phosphoric acid) for 30 seconds. Then the gel was washed off with water and the surface of the enamel was thoroughly dried. A primer was applied to the prepared surface with an applicator, inflated with a weak air flow for 5-10 seconds and photopolymerized for 20 seconds. The surface of the bracket was treated with degreaser, then a thin layer of adhesive was applied, and the sample was fixed to the enamel. Excess material was removed with an applicator. The samples were photopolymerized for 20 sec. Then, the shear bond strength of the adhesive was determined according to the method of GOST 31574-2012 on a (Zwick/Roell Z010 testing machine, Zwick, Germany).

RESULTS

The shear strength of the adhesive joint obtained during the test is 13.54±1.01 MPa, the average value of the index of adhesive residues on the surface of the bracket was 23%±4%, which corresponds to the standard average values according to GOST.

CONCLUSION

The tested domestic adhesive system of the fifth generation can be recommended for the practical work of an orthodontist.

Lower Neighborhood Socioeconomic Status May Influence Medical Complications, Emergency Department Utilization, and Costs of Care After 1- to 2-Level Lumbar Fusion

STUDY DESIGN

Retrospective Case-Control Study.

OBJECTIVES

The objectives were to determine whether patients from poor social determinants of health, undergoing primary 1- to 2-level lumbar fusion, demonstrate differences in (1) medical complications, (2) emergency department (ED) utilizations, (3) readmission rates, and (4) costs of care.

SUMMARY OF BACKGROUND DATA

Measures of socioeconomic disadvantage may enable improved targeting and prevention of potentially increased health care utilization. The Area Deprivation Index (ADI) is a validated index of 17 census-based markers of material deprivation and poverty.

MATERIALS AND METHODS

A retrospective query of the 2010-2020 PearlDiver database was performed for primary 1- to 2-level lumbar fusions for degenerative lumbar pathology. High ADI (scale: 0-100) is associated with a greater disadvantage. Patients with high ADI (90%+) were 1:1 propensity score matched to controls (ADI: 0-89%) by age, sex, and Elixhauser Comorbidity Index. This yielded 34,442 patients, evenly matched between cohorts. Primary outcomes were to compare 90-day complications, ED utilizations, readmissions, and costs of care. Multivariable logistic regression models computed the odds ratios (OR) of ADI on complications, ED utilizations, and readmissions. P -values <0.05 were significant.

RESULTS

Patients with a high ADI incurred higher rates and odds of developing respiratory failures (1.17% vs. 0.87%; OR: 1.35, P =0.005). Acute kidney injuries (2.61% vs. 2.29%; OR: 1.14, P =0.056), deep venous thromboses (0.19% vs. 0.17%; OR: 1.14, P =0.611), cerebrovascular accidents (1.29% vs. 1.31%; OR: 0.99, P =0.886), and total medical complications (23.35% vs. 22.93%; OR: 1.02, P =0.441) were similar between groups. High ADI patients experienced higher rates and odds of ED visits within 90 days (9.67% vs. 8.91%; OR: 1.10, P =0.014) and overall 90-day expenditures ($54,459 vs. $47,044; P <0.001).

CONCLUSIONS

Socioeconomically disadvantaged patients have increased rates and odds of respiratory failure within 90 days. ED utilization within 90 days of surgery was higher in socioeconomically disadvantaged patients. Social determinants of health could be used to inform health care policy and improve postdischarge care.

LEVEL OF EVIDENCE

Level III.

Repetitive Transcranial Magnetic Stimulation With and Without Text4Support for the Treatment of Resistant Depression: Protocol for a Patient-Centered Multicenter Randomized Controlled Pilot Trial

BACKGROUND

Treatment-resistant depression (TRD) is the inability of a patient with major depressive disorder (MDD) to accomplish or achieve remission after an adequate trial of antidepressant treatments. Several combinations and augmentation treatment strategies for TRD exist, including the use of repetitive transcranial magnetic stimulation (rTMS), and new therapeutic options are being introduced. Text4Support, a text message-based form of cognitive behavioral therapy that allows patients with MDD to receive daily supportive text messages for correcting or altering negative thought patterns through positive reinforcement, may be a useful augmentation treatment strategy for patients with TRD. It is however currently unknown if adding the Text4Support intervention will enhance the response of patients with TRD to rTMS treatment.

OBJECTIVE

This study aims to assess the initial comparative clinical effectiveness of rTMS with and without the Text4Support program as an innovative patient-centered intervention for the management of patients diagnosed with TRD.

METHODS

This study is a multicenter, prospective, parallel-design, 2-arm, rater-blinded randomized controlled pilot trial. The recruitment process is scheduled to last 12 months. It will involve active treatment for 6 weeks, observation, and a follow-up period of 6 months for participants in the study arms. In total, 200 participants diagnosed with TRD at rTMS care clinics in Edmonton, Alberta, and rTMS clinics in Halifax, Nova Scotia will be randomized to 1 of 2 treatment arms (rTMS sessions alone or rTMS sessions plus Text4Support intervention). Participants in each group will be made to complete evaluation measures at baseline, and 1, 3, and 6 months. The primary outcome measure will be the mean change in the scores of the Patient Health Questionnaire-9 (PHQ-9). The secondary outcome measures will involve the scores of the 7-item Generalized Anxiety Disorders Scale (GAD-7), Columbia-Suicide Severity Rating Scale (CSSRS), and World Health Organization-Five Well-Being Index (WHO-5). Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses. Qualitative data will be analyzed using the thematic analysis framework.

RESULTS

The results of the study are expected to be available 18 months from the start of recruitment. We hypothesize that participants enrolled in the rTMS plus Text4Support intervention treatment arm of the study will achieve superior outcomes compared with the outcomes of participants enrolled in the rTMS alone arm.

CONCLUSIONS

The application of the combination of rTMS and Text4Support has not been investigated previously. Therefore, we hope that this study will provide a concrete base of data to evaluate the practical application and efficacy of using the novel combination of these 2 treatment modalities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46830.

Transient elastography and platelet count as noninvasive predictors of gastroesophageal varices in patients with compensated hepatitis C virus-related liver cirrhosis

Background

Early detection of esophageal varices (EV) before the first attack of bleeding is crucial for primary prophylaxis. The current work aims to investigate the use of a combination of FibroScan and platelet count as noninvasive means to identify EV in patients with compensated cirrhosis.

Methods

Sixty-two patients with compensated hepatitis C virus (HCV)-related cirrhosis were divided into two groups with and without EV. All patients were exposed to complete history, physical examination, laboratory, and endoscopic evaluation. FibroScan was performed for all patients, and the two groups were compared.

Results

A statistically significant higher mean liver stiffness measurement (LSM) (KPa), lower mean platelet count to splenic diameter ratio (PSR), and higher mean fibrosis-4 (FIB4) score were noticed in those with EV with P < 0.0005. A cutoff value of ≥23.1 for LSM, ≥3.71 for FIB4, and ≥130 mm for splenic diameter have a sensitivity of 94%, 97%, and 97% and a specificity of 81%, 81%, and 68%, respectively, in the detection of varices. Platelet count of ≥112,500 (×103/dl) and of ≥771.33 for PSR have a sensitivity of 84% and 77% and a specificity of 87% and 90%, respectively, to rule out the presence of varices. LSM, FIB4 score, and splenic diameter are predictors of the presence of varices where platelet count and PSR are negative predictors.

Conclusion

The combination of LSM by transient elastography (TE), PSR, or platelet count can be used to detect a relevant category of patients with compensated cirrhosis who have a very low possibility of EV where endoscopy can be avoided.

Opioid Use Disorder in Patients Undergoing Primary 1- to 2-Level Anterior Cervical Discectomy and Fusion Is Associated With Longer In-Hospital Lengths of Stay and Higher Rates of Readmissions, Complications, and Costs of Care

STUDY DESIGN

Retrospective study.

OBJECTIVE

To determine whether opioid use disorder (OUD) patients undergoing 1- to 2-level anterior cervical discectomy and fusion (1-2ACDF) have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) complications; and 4) costs.

METHODS

OUD patients undergoing primary 1-2ACDF were identified within the Medicare database and matched to a control cohort in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 80,683 patients who underwent 1-2 ACDF with (n = 13,448) and without (n = 67,235) OUD. Outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, and costs. Multivariate logistic regression analyses were used to calculate odds-ratios (OR) for medical complications and readmissions. Welch's t-test was used to test for significance for LOS and cost between the cohorts. An alpha value less than 0.002 was considered statistically significant.

RESULTS

OUD patients were found to have significantly longer in-hospital LOS compared to their counterparts (3.41 vs. 2.23-days, P < .0001), in addition to higher frequency and odds of requiring readmissions (21.62 vs. 11.57%; OR: 1.38, P < .0001). Study group patients were found to have higher frequency and odds of developing medical complications (0.88 vs. 0.19%, OR: 2.80, P < .0001) and incurred higher episode of care costs ($20,399.62 vs. $16,812.14, P < .0001).

CONCLUSION

The study can help to push orthopaedic surgeons in better managing OUD patients pre-operatively in terms of safe discontinuation and education of opioid drugs and their effects on complications, leading to more satisfactory outcomes.

Spinal Langerhans cell histiocytosis with cord compression and neurological deficits: A case report

INTRODUCTION AND IMPORTANCE

Langerhans cell histiocytosis (LCH) is a rare idiopathic disease that uncommonly affect the spine in adults.

CASE PRESENTATION

In this report, we presented a rare adult case of symptomatic spinal LCH with asymptomatic systemic involvement. She was a 46-year-old previously healthy lady who presented with subacute thoracic sensory level, urine retention, constipation, and pyramidal paraplegia. Her magnetic resonance imaging (MRI) of the spine revealed T6 compression fracture with an epidural mass compressing the cord.

CLINICAL DISCUSSION

Sellar MRI showed pituitary gland enlargement with hyperintense signal in the posterior lobe. Positron emission tomography (PET)/computed tomography (CT) scan showed an increased uptake in the right parotid gland uptake and renal cortex, indicating systemic involvement.

CONCLUSION

Surgical excision, decompression, and screw fixation were performed, and the patient improved. The prognosis is usually good in patients with solitary spinal LCH.

PREVALENCE OF COMMON RESPIRATORY VIRUSES IN CHILDREN AT A TERTIARY CARE HOSPITAL IN SAUDI ARABIA

Acute lower respiratory viral infections are significant contributors to morbidity/mortality in children less than 2 years of age. In this retrospective study conducted at a major hospital, between 2017 and 2019, it was observed that rhinovirus, respiratory-syncytial-virus and influenza virus are the most frequently detected with the seasonal distribution. Mortality rate was significantly higher in children less than 12 months and significantly increased in males and in those requiring intubation.

On determining conditions and suitable locations for fish survival by using the solution of the two coupled pollution and aeration equations

The coupled equations of pollution and aeration for flow in a river were studied under generalized assumptions in terms of parameter dependency on space and time, as well as general boundary constraints. An analytical solution was obtained in the steady-state case. Also, the system was solved in its unsteady state numerically in a dimensionless form using the finite difference scheme. The effect of different parameters controlling the flow (such as the velocity, Peclet number, injected pollutants, and so on…) was studied. Investigations indicate that the special cases of the proposed model (i.e., uniform distribution of pollutant and Dissolved Oxygen concentrations, and zero injected pollutants along the river) give results that agree with the previous studies. This simple model helps in understanding the behavior of the pollution-aeration process and its relation to the injected pollution along a river and its effect on fish survival. A simple procedure was discussed in this study to help in regulating farming, industrial, and urban practices and impose restrictions if necessary. This study determines with accuracy the intervals of the river at which fish can survive at a given time, as well as the maximum amount of pollutants allowed to be injected along the river for fish survival.

Unravelling the antibacterial potential of biosynthesized selenium nanoparticles against Salmonella Typhimurium food pathogen: in vitro and in vivo investigation

OBJECTIVE

It is highly required to find novel alternatives to the antibiotics currently used due to the increasing dissemination of antibiotic resistance among bacteria, especially enteric bacteria. The current study aimed to produce selenium nanoparticles (SeNPs) by Euphorbia milii Des Moul leaves extract (EME).

MATERIALS AND METHODS

The produced SeNPs were characterized using different techniques. After that, in vitro and in vivo antibacterial activity against Salmonella typhimurium was elucidated. Moreover, phytochemical identification and quantification of the chemical compositions of EME were performed using HPLC. The broth microdilution method determined the minimum inhibitory concentrations (MICs).

RESULTS

The MIC values of SeNPs ranged from 128 to 512 µg/mL. Additionally, the impact of SeNPs on membrane integrity and permeability was investigated. A marked decline in the membrane integrity and inner and outer membrane permeability was noticed in 50%, 46.15%, and 50% of the tested bacteria, respectively. Subsequently, a gastrointestinal tract infection model was used to study the in vivo antibacterial potential of SeNPs. Remarkably, treatment with SeNPs resulted in average-sized intestinal villi and colonic mucosa in the small intestine and caecum, respectively. In addition, it was revealed there was no inflammation or dysplasia in the studied tissues. SeNPs also enhanced the survival rate and significantly decreased the number of colony-forming units per gram tissues in the small intestine and caecum. Concerning the inflammatory markers, SeNPs significantly (p < 0.05) decreased interleukins (6 and 1β).

CONCLUSIONS

The biosynthesized SeNPs revealed antibacterial potential in vivo and in vitro; however, this finding should be elucidated clinically in the future.

The Divergence Between Hospital Charges and Reimbursements For Primary 1-2-level Lumbar Fusion Has Increased Over Time: A Medicare Administrative Claims Analysis

STUDY DESIGN

A retrospective cohort study was performed for patients undergoing 1-2-level lumbar fusion (1-2LF) from 2005 to 2014 using an administrative claims database.

OBJECTIVE

The objective of this study was to determine changes in: (1) annual charges; (2) annual reimbursement rates; and (3) annual difference (charges minus reimbursements) in patients undergoing 1-2LF.

SUMMARY OF BACKGROUND DATA

With implementation of value-based care in orthopaedics, coupled with the rise in number of patients undergoing 1-2LF, understanding the discordance in hospital charges and reimbursements is needed. The difference in hospital charges to reimbursements specifically for 1-2LF for degenerative disc disease has not been studied.

MATERIALS AND METHODS

A Medicare administrative claims database was queried for patients undergoing primary lumbar fusion using ICD-9 procedural code 81.04-81.08. Patients specifically undergoing 1-2LF were filtered from this cohort using ICD-9 procedural code 81.62. The query yielded 547,067 patients who underwent primary 1-2LF. Primary outcomes analyzed included trends in charges, reimbursement rates, and net difference in cost over time and per annual basis. Linear regression evaluated the change in costs over time with a P -value less than 0.05 considered significant.

RESULTS

From 2005 to 2014, total charges increased from $6,085,838,407 to $19,621,979,956 and total reimbursements increased from $1,677,764,831 to $4,656,702,685 (all P <0.001). Per patient charges increased 92.10% from 2005 to 2014 for patients undergoing primary 1-2LF from $129,992 to $249,697 ( P <0.001). Similarly, an increase in reimbursement per patient of 65.35% from $35,836 to $59,258 ( P <0.001) was noted. The annual difference in charges to reimbursements increased 102.26% during the study interval from $94,155 to $190,439 ( P <0.001).

CONCLUSIONS

Per patient charges and reimbursements both increased over the study period; however, charges increased 30% more than reimbursements. Further breakdown of hospital, surgeon, and anesthesiologist reimbursements for 1-2LF is needed.

LEVEL OF EVIDENCE

Level III.

The Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on Elective Cervical Spine Surgery Utilization and Complications in the United States: A Nationwide Temporal Trends Analysis

OBJECTIVES

As a result of the coronavirus disease 2019 (COVID-19) pandemic, elective surgeries nationwide were suspended. The objective was to compare temporal trends in patient demographics, case volumes, and postoperative complications of patients undergoing elective cervical spine surgery from pre-COVID-19 (2019-2020 Q1) to post-COVID-19 (2020 Q2-Q4).

METHODS

The 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was queried for common elective cervical spine surgeries. Patients pre-COVID-19 (2019-2020 Q1) were compared with those undergoing surgery during post-COVID-19 (2020 Q2-Q4) protocols. Procedural use, patient demographics, and complications were compared. Linear regression was used to evaluate case volume changes over time. P values less than 0.05 were significant.

RESULTS

In total, 31,013 patients underwent elective cervical spine surgery in 2019 (N = 16,316) and 2020 (N = 14,697); an overall 10% decline. Compared with the calendar year 2019 through 2020 Q1 mean, elective surgery volume decreased by 21.6% in 2020 Q2 and never returned to prepandemic baseline. The percentage decline in case volume from 2019 to 2020 Q1 to 2020 Q2 was greatest for anterior cervical discectomy and fusion (23.3%), followed by cervical decompression (23.4%), posterior cervical fusion (15.0%), and cervical disc arthroplasty and vertebral corpectomy (13.7%). Patients undergoing surgery in 2020 Q2-Q4 had overall greater comorbidity burden (American Society of Anesthesiologists grade 3 and 4) (P < 0.001). From 2019-2020 Q1 versus 2020 Q2-Q4, there was a significant increase in total complication (5.5% vs. 6.8%, P < 0.001), reoperation (1.9% vs. 2.2%, P = 0.048), and mortality (0.25% vs. 0.37%, P = 0.049) rates.

CONCLUSIONS

Elective surgery declined drastically during the second quarter of 2020. Patients undergoing surgery during the pandemic had an overall greater comorbidity burden, resulting in increased total complication and mortality rates over the study period.

Design and evaluation of chrysin-loaded nanoemulsion against lithium/pilocarpine-induced status epilepticus in rats; emphasis on formulation, neuronal excitotoxicity, oxidative stress, microglia polarization, and AMPK/SIRT-1/PGC-1α pathway

OBJECTIVES

The present study aims to formulate and evaluate the efficacy of chrysin-loaded nanoemulsion (CH NE) against lithium/pilocarpine-induced epilepsy in rats, as well as, elucidate its effect on main epilepsy pathogenesis cornerstones; neuronal hyperactivity, oxidative stress, and neuroinflammation.

METHODS

NEs were characterized by droplet size, zeta potential, pH, in vitro release, accelerated and long-term stability studies. Anti-convulsant efficacy of the optimized formula and underlying mechanisms involved were assessed and compared to that from CH suspension given orally at a 30 folds higher dose.

RESULTS

Optimized formula displayed a droplet size of 48.09 ± 0.83 nm, PDI 0.25 ± 0.011, sustained release, and good stability. CH treatment reduced seizures scoring, corrected behavioral and histological changes induced by Li/Pilo. Moreover, CH restored neurotransmitters balance and oxidative stress markers levels. Besides, CH induced microglia polarization from M1 to M2 hindering inflammation induced by Li/Pilo. Also, CH restored energy metabolism homeostasis via regulating protein expression of AMPK/SIRT-1/PGC-1α pathway markers. CH NE formulation was found to significantly enhance drug delivery to rats' hippocampus compared to CH suspension.

CONCLUSION

Our findings prove the therapeutic efficacy of CH NE at a lower dose which could be a potential brain targeting platform to combat epilepsy.

Increasing Patient Complexity Is Associated With Longer In-Hospital Lengths of Stay and Higher Rates of Medical Complications Following Primary 1- to 2-Level Lumbar Fusion

BACKGROUND

The Elixhauser Comorbidity Index (ECI) is a stratification tool to predict adverse surgical outcomes. No studies have explored the relationship between ECI and outcomes following primary 1- to 2-level lumbar fusion (1-2LF). The purpose was to determine whether an ECI score greater than 1 correlated with (1) longer in-hospital length of stay (LOS) and (2) greater odds of developing 90-day medical complications.

METHODS

A retrospective review from 2004 to 2015 was performed using the Medicare Standard Analytical Files for patients undergoing primary LF. Patients with ECI scores from 2 to 5 served as the study cohorts (1 for each ECI score), and patients with an ECI score of 1 served as the control cohort. In-hospital LOS and 90-day medical complications were compared between cohorts. A P value of <0.001 was statistically significant.

RESULTS

A total of 105,120 patients were equally distributed between the 5 cohorts. Patients with an ECI score of 2 (6.00 ± 4.51), ECI 3 (6.22 ± 4.67), ECI 4 (7.35 ± 5.05), or ECI 5 (8.99 ± 5.67) had longer in-hospital LOS compared with patients with an ECI score of 1 (4.28 ± 4.36) (all P < 0.001). Patients with an ECI score of 2 (OR: 1.17, 95% CI: 1.05-1.30, P = 0.003; 2.85% vs 2.45%), ECI 3 (OR: 1.22, 95% CI: 1.10-1.36, P < 0.001; 2.98% vs 2.45%), ECI 4 (OR: 1.26, 95% CI: 1.13-1.40, P < 0.001; 3.10% vs 2.45%), or ECI 5 (OR: 1.18, 95% CI: 1.06-1.31, P = 0.001; 2.89% vs 2.45%) had greater incidence and odds of 90-day medical complications such as pneumonia, deep vein thrombosis, cerebrovascular accidents, and myocardial infarctions than patients in the control group (all P < 0.0001).

CONCLUSIONS

Increasing ECI score was associated with longer in-hospital LOS and increased 90-day medical complication rates following 1-2LF. This study is the first to establish a correlation between ECI score, in-hospital LOS, and complication rates following lumbar fusion.

CLINICAL RELEVANCE

ECI score may assist physicians in adjusting pre- and postoperative care for complex patients undergoing 1-2LF.

LEVEL OF EVIDENCE: 3

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

Risks Assessment of Potentially Toxic Elements’ Contamination in the Egyptian Red Sea Surficial Sediments

The potential impact of tourism, industrial, and urban activities on Egypt’s Red Sea coastline, which is well-known for its economic and environmental importance, was investigated at fifteen coastal sites. In the present study, the concentration of cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), iron (Fe), manganese (Mn), nickel (Ni), lead (Pb), and zinc (Zn) in marine sediments from these sites, was determined using Inductively Coupled Plasma Mass Spectrometers (ICP-MS). In detail, various pollution indices, statistical analyses, and spatial distribution patterns were used to assess the pollution status, impacts of human activities, ecological risks, and sources of potentially toxic elements (PTEs) in surface marine sediment. A detailed comparison with up-to-date data was conducted. These sediments were composed predominantly of fine and very fine sands. Mean grain size distribution typically depends on the source of the sediment from the following two prime sources: terrigenous (autochthonous) and biogenic (allochthonous). The detected PTE mean concentrations were as follows: Fe > Mn > Zn > Cr > Ni > Pb > Co > Cu > Cd. Multivariate statistical analysis results revealed their close distribution and association. Cd and Pb levels in the studied area have been slightly impacted by anthropogenic inputs. According to the calculated pollution indices, although a minimal or moderate contamination degree was detected in the study area, it was determined that there was a low to moderate ecological risk. The slightly high degree of contamination and risk centered in the middle of the study area around phosphate mining and related activities. More attention should be given to the concentrations and sources of Cd, Ni, and Pb as the main pollution factors.

Spatial Distribution, Contamination Levels, and Health Risk Assessment of Potentially Toxic Elements in Household Dust in Cairo City, Egypt

Urban areas’ pollution, which is owing to rapid urbanization and industrialization, is one of the most critical issues in densely populated cities such as Cairo. The concentrations and the spatial distribution of fourteen potentially toxic elements (PTEs) in household dust were investigated in Cairo City, Egypt. PTE exposure and human health risk were assessed using the USEPA’s exposure model and guidelines. The levels of As, Cd, Cr, Cu, Hg, Mo, Ni, Pb, and Zn surpassed the background values. Contamination factor index revealed that contamination levels are in the sequence Cd > Hg > Zn > Pb > Cu > As > Mo > Ni > Cr > Co > V > Mn > Fe > Al. The degree of contamination ranges from considerably to very high pollution. Elevated PTE concentrations in Cairo’s household dust may be due to heavy traffic emissions and industrial activities. The calculated noncarcinogenic risk for adults falls within the safe limit, while those for children exceed that limit in some sites. Cairo residents are at cancer risk owing to prolonged exposure to the indoor dust in their homes. A quick and targeted plan must be implemented to mitigate these risks.

Association of Opioid Use Disorder on Postoperative Outcomes Following Lumbar Laminectomy: A Nationwide Retrospective Analysis of the Medicare Population

BACKGROUND

Research focused on the association of opioid use disorder (OUD) on postoperative outcomes in patients undergoing primary lumbar laminectomy is lacking. This study aims to observe the impact of OUD on (1) hospital length of stay (LOS), (2) readmission rates, (3) medical complications, and (4) health care expenditures.

METHODS

A retrospective query was performed using a nationwide claims database from January 2005 to March 2014 for all patients who underwent lumbar laminectomy, yielding a total of 131,635 patients. The study cohort included 3515 patients with OUD, while 128,120 patients served as the comparison cohort. Multivariate binomial logistic regression analyses were used to determine the association of OUD on readmission rates and medical complications, whereas Welch's t tests were used to compare LOS and health care expenditures. A P value less than 0.001 was considered statistically significant.

RESULTS

Patients with OUD undergoing lumbar laminectomy had significantly longer hospital LOS (3.68 vs 1.13 days, P < 0.0001). Readmission rates were significantly higher (14.57% vs 7.39%, OR: 1.73, P < 0.0001) in patients who had an OUD. The study cohort was found to have higher incidence and odds (32.36% vs 9.76%, OR: 3.53, P < 0.0001) of 90-day medical complications and total global 90-day episode of care reimbursement rates ($13,635.81 vs $8131.20, P < 0.0001) compared with their counterparts.

CONCLUSIONS

This study demonstrates OUD to be associated with longer hospital LOS, increased rates of 90-day readmissions, medical complications, and health care expenditures following lumbar laminectomy.

LEVEL OF EVIDENCE: 3

CLINICAL RELEVANCE

Results indicate that OUD is associated with worse outcomes following lumbar laminectomy.

Long-Term Health-Related Quality of Life After Harrington Instrumentation and Fusion for Adolescent Idiopathic Scoliosis: A Minimum 40-Year Follow-up

BACKGROUND

Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms.

METHODS

A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery.

RESULTS

In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means.

CONCLUSIONS

Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short and long-term reproductive outcomes after hysteroscopic adhesiolysis for infertile women

OBJECTIVE

To evaluate reproductive outcomes after hysteroscopic adhesiolysis for patients with Asherman syndrome (AS) who presented with infertility and/or subfertility.

METHODS

A retrospective study was conducted in the Women's Specialized Hospital, King Fahad Medical City, from December 2010 to December 2018. The medical records were reviewed for all infertile women who had hysteroscopic adhesiolysis. The specific study's main reproductive outcomes included: [1] the overall rate of conception, [2] the overall rate of conception according to the severity degree of intrauterine adhesions (IUAs), [3] the reproductive methods for achieving conception, and [4] pregnancy outcomes. Reproductive methods for conception included spontaneous conception, ovulation induction (OI), intrauterine insemination (IUI), and in-vitro fertilization (IVF) with/without intracytoplasmic sperm injection (ICSI). Outcomes of pregnancy included ectopic pregnancy, miscarriage, and live birth events.

RESULTS

Forty-one patients (n=41) were analyzed. Their mean age was 32.2±4.6 years. The most common menstrual pattern amongst these patients was hypomenorrhea 46.4%. All patients resumed regular menstrual cycles after the adhesiolysis procedure. The overall conception rate during the 24 months follow up was 53.6%, and the overall live birth rate was 34.2%. Of the 22 patients who conceived, 12 patients (29.2%) conceived spontaneously, 2 (4.9%) with IUI, and 8 (19.5%) with IVF-ICSI. The patients with minimal IUAs had a significantly higher pregnancy rate (71.4%) when compared to those with moderate (47%) and severe (40%) IUA (two-tailed log-rank test, p=0.041).

CONCLUSIONS

The spontaneous cumulative conception rate following hysteroscopic adhesiolysis was higher in patients with minimal IUAs than those with moderate and severe IUAs.

Racial Differences in Orthopedic Trauma Surgery

Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].

Effect of sustained virological response after direct-acting antivirals on liver fibrosis in patients with chronic HCV infection

Background

Direct-acting antivirals (DAAs) have revolutionized the therapy of HCV infection with higher sustained virological response (SVR) rates. Fibrosis regression after achieving SVR to DAA remains to be evaluated in chronic hepatitis C patients. One of the main inquiries here is what occurs with liver fibrosis after achieving a SVR, albeit the current DAA was not intended to be antifibrotic. Liver biopsy was replaced by various non-invasive methods, like FIB4 score and fibroscan. The aim of the study was to evaluate the impact of SVR following DAAs on liver fibrosis in chronic HCV patients.

Results

Five hundred of 1170 F4 treated patients (42.7%) improved and became 190 F3, 90 F2, and 220 F1. Also, 40 of 60 F3 patients improved and became 10 F2 and 30 F1. Also, 350 of 1230 treated patients (28.4%) transited from significant fibrosis (≥F3) to non-significant fibrosis (≤F2). There was a significant improvement of FIB-4 (p<0.001) in the improved group after DAAs were proved by liver stiffness measurement.

Conclusion

Treatment of chronic HCV with DAAs is associated with regression of liver fibrosis as about 28% of patients improved from significant fibrosis (≥F3) to non-significant fibrosis (≤F2) after treatment.

Effectiveness of esophagogastroduodenoscopy in changing treatment outcome in refractory gastro-esophageal reflux disease

BACKGROUND/AIMS

The effectiveness of screening esophagogastroduodenoscopy (EGD) for refractory gastroesophageal reflux disease (GERD) symptoms alone has not been validated.

METHODS

We performed an observational study of patients with refractory GERD who underwent EGD from 2013 to 2016 at a tertiary hospital. Among 928 patients with GERD, we excluded patients with other alarm features, other indications for EGD, history of gastroesophageal surgery, or EGD done for other diagnostic procedures, and identified 301 patients who underwent EGD solely for persistent reflux symptoms such as heartburn or regurgitation.

RESULTS

Among 301 patients with refractory GERD, 81.4% of patients were taking PPIs. 49.8% of patients had completely normal EGD findings and 33.6% of patients had benign or incidental findings. Two patients (0.6%) had LA grade C or D esophagitis, and 16.3% of patients had irregular Z line or salmon-colored mucosa. 91.0% (122/134) who had a biopsy had normal or benign findings. 4.0% (12/301) of patients had biopsy-proven intestinal metaplasia which is similar to the previously known prevalence of intestinal metaplasia in patients without heartburn (5.6%) and none had dysplasia or malignancy. Male sex was associated with endoscopic intestinal metaplasia suspected lesions in multivariate analysis (OR: 1.96, 95% CI: 1.04-3.70, p = .036) but not biopsy-proven intestinal metaplasia. Elderly age, obesity, alcohol or cigarette consumption, PPI use, GERD duration >3-5 years did not predict endoscopically suspected or biopsy-proven intestinal metaplasia. Only 5% of patients had a pH-impedance study for refractory reflux symptoms.

CONCLUSIONS

Most patients who underwent EGD for refractory GERD symptoms alone did not have pathological findings requiring a change in management. Screening EGD for patients only with persistent reflux symptoms should not be routinely recommended.

Impact of Sprouting under Potassium Nitrate Priming on Nitrogen Assimilation and Bioactivity of Three Medicago Species

Edible sprouts are rich in flavonoids and other polyphenols, as well as proteins, minerals, and vitamins. Increasing sprout consumption necessitates improving their quality, palatability, and bioactivity. The purpose of this study was to test how KNO₃ priming affects the sprouting process species on three Medicago species (Medicago indicus, Medicago interexta, and Medicago polymorpha) and their nutritional values. Targeted species of Medicago were primed with KNO₃, and the levels of different primary and secondary metabolites were determined. KNO₃ induced biomass accumulation in the sprouts of the three species, accompanied by an increased content of total mineral nutrients, pigments, vitamins, and essential amino acids. Besides, our results showed that KNO₃ enhanced the activity of nitrate reductase (NR), glutamate dehydrogenase (GDH), and glutamine synthetase (GS) enzymes, which are involved in the nitrogen metabolism and GOGAT cycle, which, in turn, increase the nitrogen and protein production. KNO₃ treatment improved the bioactive compound activities of Medicago sprouts by increasing total phenolic and flavonoid contents and enhancing the antioxidant and antidiabetic activities. Furthermore, species-specific responses toward KNO₃ priming were noticeable, where Medicago interexta showed the highest antioxidant and antidiabetic activities, followed by Medicago polymorpha. Overall, this study sheds the light on the physiological and biochemical bases of growth, metabolism, and tissue quality improvement impact of KNO₃ on Medicago sprouts.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

235 THROMBOLYSIS DOSING AND WEIGHT ESTIMATION IN ACUTE STROKE: A SINGLE CENTRE AUDIT

Background

Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors.

Methods

This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital.

Results

107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (&gt; ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (&gt;10%).

Conclusion

A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.

236 PREDICTORS OF ADVERSE OUTCOMES IN OLDER PATIENTS DISCHARGED DIRECTLY FROM THE EMERGENCY DEPARTMENT

Background

Over 40% of older patients are discharged directly from the Emergency Department (ED) and this cohort is at increased risk of adverse outcomes.

The purpose of this study was to explore the factors that predict future adverse outcomes in this cohort to inform practice, resource planning and policy.

Methods

A secondary analysis of the OPTIMEND, a single-centre, randomized-controlled trial was completed. OPTIMEND examined the effectiveness of an intervention by a team of Health and Social Care Professionals along with usual care and compared this to standard ED care alone (Dec 2018-May 2019). The inclusion criteria were adults aged 65 years and over presenting to the ED at a University Teaching Hospital with medical complaints and a Manchester Triage System category 2–5.

Results

220 patients were included (median age 79 years; 62% female). Median length of stay in ED was 5.5 hrs. 70 patients re-attended the ED within 6 months with 43 re-hospitalised within 6 months. 9 patients died within six months of discharge.

Multivariant logistic regression was completed. Age was the only independent predictor of mortality within six months of discharge {Odds Ratio (OR) 1.15, p = 0.044}. Past hospitalisation (&lt;6 months) was associated with a lower likelihood of ED re-attendance, and rehospitalization within six months of discharge (OR: 0.452 p = 0.022; OR:0.442, p = 0.046; respectively). Clinical Frailty Score was associated with a significantly higher likelihood of rehospitalization (OR:1.48, p = 0.031) but not with ED revisits (OR: 1.235, p = 0.165).

Conclusion

Older people have a high ED re-attendance rate of 33% after an index visit with 20% hospitalized subsequently. Frailty is a significant predictor of rehospitalisation. Rapid and targeted intervention for frail patients who reattend the ED should be a priority for the integrated care program to enhance admission avoidance.

234 THE IMPACT OF OLDER AGE ON CLINICAL OUTCOMES DURING THE FIRST WAVE OF THE COVID-19 PANDEMIC

Background

Severe acute respiratory coronavirus 2 (SARS-CoV-2) was first recorded in Ireland in February 2020. Several studies have explored the association between age and SARS-CoV-2, showing that there were poorer outcomes in older people. Our objective was to evaluate the impact of age on outcomes such as hospital length of stay, mortality, and re-hospitalisation.

Methods

We performed a single-centre, retrospective observational cohort study, using an electronic microbiology database of recorded index admissions of SARS-CoV-2 positive patients aged 65 years and older during SARS-CoV-2 wave one (March 1^st to May 31^st 2020). PCR testing of nasopharyngeal and/or sputum samples was used to confirm positivity. Our clinical outcomes measured included hospital length of stay, mortality and re-admission rate within 6 months.

Results

153 patients 65 years and above were admitted. The male to female ratio was 1.3 with 90% admitted medically. 79 patients were aged between 65–79 years; 84 patients ≥80 years; and 12 patients ≥90 years. Mortality was 25%, 31% and 42%, respectively. Median length of stay remained 14 days for ages 65–89 rising to 17.5 days for those ≥90 years. Re-hospitalisation rates at 6 months were similar for ages 65–79 and 89–89 years at 42% and 40%, respectively. One patient (14%) over 90 years was re-hospitalised.

Conclusion

SARS-CoV-2 has disproportionately impacted on general medical services treating older hospitalised people. In our centre, mortality for patients ≥65 years was 28.1% which compared favourably with 35.6% internationally as outlined by Victor et al. (2020) based on Spanish data. Treatment of SARS-CoV-2 is not futile in older patients with 58% of nonagenarians and 69% of octogenarians surviving, however re-hospitalisation rates are high at 40%. A targeted approach to discharge support via integrated care may ameliorate this.

Post-coronavirus disease 2019 polyneuropathy with significant response to immunoglobulin therapy: a case report

Background

The symptoms of coronavirus disease 2019, caused by the novel severe acute respiratory syndrome coronavirus 2, were originally assumed to be mainly respiratory. With increasing knowledge, however, it turned out that the spectrum of complaints varies broadly with age and concomitant diseases. While many neurological symptoms were reported in the context of the disease, ranging from permanent fatigue to recurrent headaches and concentration disturbance, treatment approaches are still in development. This case discusses a possible treatment approach with immunoglobulin therapy and its outcomes.

Case presentation

We present the case of a 56-year-old Caucasian female patient who, following coronavirus disease 2019, developed peripheral sensory and autonomic disturbances that fell within subacute demyelinating neuropathy. Because a significant improvement in symptoms as well as in the results of clinical and electrophysiological examination was reported after immunoglobulin therapy, long-term therapy does not appear to be necessary.

Conclusion

Given the significant subjective and objective improvement reported, this case provides additional evidence that immunoglobulin therapy can be considered in post-coronavirus disease 2019 syndrome.