1
|
Danforth CG, Portier C, Ensor KB, Hopkins L, Evans B, Quist AJL, McGraw KE, Craft E. Development and demonstration of a data visualization platform of short-term guidelines for ambient air levels of benzene during disaster response in Houston, Texas. Integr Environ Assess Manag 2024; 20:533-546. [PMID: 37462252 DOI: 10.1002/ieam.4814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023]
Abstract
Industrial disasters have caused hazardous air pollution and public health impacts. Response officials have developed limited exposure guidelines to direct them during the event; often, guidelines are outdated and may not represent relevant elevated-exposure periods. The 2019 Intercontinental Terminals Company (ITC) fire in Houston, Texas led to large-scale releases of benzene and presented a public health threat. This incident highlights the need for effective response and nimble, rapid public health communication. We developed a data-driven visualization tool to store, display, and interpret ambient benzene concentrations to assist health officials during environmental emergencies. Guidance values to interpret risk from acute exposure to benzene were updated using recent literature that also considers exposure periodicity. The visualization platform can process data from different sampling instruments and air monitors automatically, and displays information publicly in real time, along with the associated risk information and action recommendations. The protocol was validated by applying it retrospectively to the ITC event. The new guidance values are 6-30 times lower than those derived by the Texas regulatory agency. Fixed-site monitoring data, assessed using the protocol and revised thresholds, indicated that eight shelter-in-place and 17 air-quality alerts may have been considered. At least one of these shelter-in-place alerts corresponded to prolonged, elevated benzene concentrations (~1000 ppb). This new tool addresses essential gaps in the timely communication of air pollution measurements, provides context to understand potential health risks from exposure to benzene, and provides a clear protocol for local officials in responding to industrial air releases of benzene. Integr Environ Assess Manag 2024;20:533-546. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).
Collapse
Affiliation(s)
| | | | - Kathy B Ensor
- George R. Brown School of Engineering, Rice University, Houston, Texas, USA
| | | | - Bryan Evans
- Kinder Institute for Urban Research, Rice University, Houston, Texas, USA
| | - Arbor J L Quist
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Katlyn E McGraw
- Environmental Health Sciences Department, Columbia University Mailman School of Public Health, New York, New York, USA
| | | |
Collapse
|
2
|
McGraw KE, Schilling K, Glabonjat RA, Galvez-Fernandez M, Domingo-Relloso A, Martinez-Morata I, Jones MR, Post WS, Kaufman J, Tellez-Plaza M, Valeri L, Brown ER, Kronmal RA, Barr GR, Shea S, Navas-Acien A, Sanchez TR. Urinary Metal Levels and Coronary Artery Calcification: Longitudinal Evidence in the Multi-Ethnic Study of Atherosclerosis (MESA). medRxiv 2023:2023.10.31.23297878. [PMID: 37961623 PMCID: PMC10635251 DOI: 10.1101/2023.10.31.23297878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Objective Growing evidence indicates that exposure to metals are risk factors for cardiovascular disease (CVD). We hypothesized that higher urinary levels of metals with prior evidence of an association with CVD, including non-essential (cadmium , tungsten, and uranium) and essential (cobalt, copper, and zinc) metals are associated with baseline and rate of change of coronary artery calcium (CAC) progression, a subclinical marker of atherosclerotic CVD. Methods We analyzed data from 6,418 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with spot urinary metal levels at baseline (2000-2002) and 1-4 repeated measures of spatially weighted coronary calcium score (SWCS) over a ten-year period. SWCS is a unitless measure of CAC highly correlated to the Agatston score but with numerical values assigned to individuals with Agatston score=0. We used linear mixed effect models to assess the association of baseline urinary metal levels with baseline SWCS, annual change in SWCS, and SWCS over ten years of follow-up. Urinary metals (adjusted to μg/g creatinine) and SWCS were log transformed. Models were progressively adjusted for baseline sociodemographic factors, estimated glomerular filtration rate, lifestyle factors, and clinical factors. Results At baseline, the median and interquartile range (25th, 75th) of SWCS was 6.3 (0.7, 58.2). For urinary cadmium, the fully adjusted geometric mean ratio (GMR) (95%Cl) of SWCS comparing the highest to the lowest quartile was 1.51 (1.32, 1.74) at baseline and 1.75 (1.47, 2.07) at ten years of follow-up. For urinary tungsten, uranium, and cobalt the corresponding GMRs at ten years of follow-up were 1.45 (1.23, 1.71), 1.39 (1.17, 1.64), and 1.47 (1.25, 1.74), respectively. For copper and zinc, the association was attenuated with adjustment for clinical risk factors; GMRs at ten years of follow-up before and after adjustment for clinical risk factors were 1.55 (1.30, 1.84) and 1.33 (1.12, 1.58), respectively, for copper and 1.85 (1.56, 2.19) and 1.57 (1.33, 1.85) for zinc. Conclusion Higher levels of cadmium, tungsten, uranium, cobalt, copper, and zinc, as measured in urine, were associated with subclinical CVD at baseline and at follow-up. These findings support the hypothesis that metals are pro-atherogenic factors.
Collapse
Affiliation(s)
- Katlyn E. McGraw
- Columbia University Mailman School of Public Health, Department of Environmental Health Science, 722 W 168th St, New York, NY 10032
| | - Kathrin Schilling
- Columbia University Mailman School of Public Health, Department of Environmental Health Science, 722 W 168th St, New York, NY 10032
| | - Ronald A. Glabonjat
- Columbia University Mailman School of Public Health, Department of Environmental Health Science, 722 W 168th St, New York, NY 10032
| | - Marta Galvez-Fernandez
- Columbia University Mailman School of Public Health, Department of Environmental Health Science, 722 W 168th St, New York, NY 10032
| | - Arce Domingo-Relloso
- Columbia University Mailman School of Public Health, Department of Biostatistics, 722 W 168th St, New York, NY 10032
| | - Irene Martinez-Morata
- Columbia University Mailman School of Public Health, Department of Environmental Health Science, 722 W 168th St, New York, NY 10032
| | - Miranda R. Jones
- Johns Hopkins University School of Medicine, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Baltimore MD 21057
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street. Baltimore MD 212057
| | - Wendy S. Post
- Johns Hopkins University School of Medicine, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Baltimore MD 21057
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street. Baltimore MD 212057
| | - Joel Kaufman
- University of Washington, Department of Medicine
| | - Maria Tellez-Plaza
- National Center for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain, Department of Chronic Diseases Epidemiology
| | - Linda Valeri
- Columbia University Mailman School of Public Health, Department of Biostatistics, 722 W 168th St, New York, NY 10032
| | - Elizabeth R. Brown
- Fred Hutchinson Cancer Center, Vaccine and Infectious Disease Division
- University of Washington, Department of Biostatistics
| | | | - Graham R. Barr
- Columbia University Irving Medical Center, Departments of Medicine and Epidemiology
| | - Steven Shea
- Columbia University Irving Medical Center, Departments of Medicine and Epidemiology
| | - Ana Navas-Acien
- Columbia University Mailman School of Public Health, Department of Environmental Health Science, 722 W 168th St, New York, NY 10032
| | - Tiffany R. Sanchez
- Columbia University Mailman School of Public Health, Department of Environmental Health Science, 722 W 168th St, New York, NY 10032
| |
Collapse
|
3
|
McGraw KE, Nigra AE, Klett J, Sobel M, Oelsner EC, Navas-Acien A, Hu X, Sanchez TR. Blood and Urinary Metal Levels among Exclusive Marijuana Users in NHANES (2005-2018). Environ Health Perspect 2023; 131:87019. [PMID: 37646523 PMCID: PMC10467359 DOI: 10.1289/ehp12074] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 05/19/2023] [Accepted: 07/19/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Marijuana is the third most used drug in the world. OBJECTIVES Because the cannabis plant is a known scavenger of metals, we hypothesized that individuals who use marijuana will have higher metal biomarker levels compared with those who do not use. METHODS We combined data from the National Health and Nutrition Examination Survey (2005-2018) for n = 7,254 participants, classified by use: non-marijuana/non-tobacco, exclusive marijuana, exclusive tobacco, and dual marijuana and tobacco use. Five metals were measured in blood and 16 in urine using inductively coupled plasma mass spectrometry; urinary metals were adjusted for urinary creatinine. RESULTS Participants reporting exclusive marijuana use compared with non-marijuana/non-tobacco use had statistically significantly higher mean cadmium levels in blood [1.22 μ g / L (95% CI: 1.11, 1.34); p < 0.001 ] and urine [1.18 μ g / g (95% CI: 1.0, 1.31); p = 0.004 ] and statistically significantly higher mean lead levels in blood [1.27 μ g / dL (95% CI: 1.07, 1.50); p = 0.006 ] and urine [1.21 μ g / g (95% CI: - 0.006 , 1.50); p = 0.058 ]. DISCUSSION Our results suggest marijuana is a source of cadmium and lead exposure. Research regarding cannabis use and cannabis contaminants, particularly metals, should be conducted to address public health concerns related to the growing number of cannabis users. https://doi.org/10.1289/EHP12074.
Collapse
Affiliation(s)
- Katlyn E. McGraw
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Anne E. Nigra
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Joshua Klett
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Marisa Sobel
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Elizabeth C. Oelsner
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ana Navas-Acien
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Xin Hu
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Tiffany R. Sanchez
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, New York, USA
| |
Collapse
|
4
|
McGraw KE, Konkle SL, Riggs DW, Rai SN, DeJarnett N, Xie Z, Keith RJ, Oshunbade A, Hall ME, Shimbo D, Bhatnagar A. Exposure to Volatile Organic Compounds Is Associated with Hypertension in Black Adults: The Jackson Heart Study. Environ Res 2023; 223:115384. [PMID: 36796615 PMCID: PMC10134439 DOI: 10.1016/j.envres.2023.115384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/15/2022] [Accepted: 01/27/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND The prevalence of hypertension is higher among Black adults than among White and Hispanic adults. Nevertheless, reasons underlying the higher rates of hypertension in the Black population remain unclear but may relate to exposure to environmental chemicals such as volatile organic compounds (VOCs). METHODS We evaluated the associations of blood pressure (BP) and hypertension with VOC exposure in non-smokers and smokers in a subgroup of the Jackson Heart Study (JHS), consisting of 778 never smokers and 416 age- and sex-matched current smokers. We measured urinary metabolites of 17 VOCs by mass spectrometry. RESULTS After adjusting for covariates, we found that amoong non-smokers, metabolites of acrolein and crotonaldehyde were associated with a 1.6 mm Hg (95%CI: 0.4, 2.7; p = 0.007) and a 0.8 mm Hg (95%CI: 0.01, 1.6; p = 0.049) higher systolic BP, and the styrene metabolite was associated with a 0.4 mm Hg (95%CI: 0.09, 0.8, p = 0.02) higher diastolic BP. Current smokers had 2.8 mm Hg (95% CI 0.5, 5.1) higher systolic BP. They were at higher risk of hypertension (relative risk = 1.2; 95% CI, 1.1, 1.4), and had higher urinary levels of several VOC metabolites. Individuals who smoke had higher levels of the urinary metabolites of acrolein, 1,3-butadiene, and crotonaldehyde and were associated with higher systolic BP. The associations were stronger among participants who were <60 years of age and male. Using Bayesian kernel machine regression to assess the effects of multiple VOC exposures, we found that the relationship between VOCs and hypertension among non-smokers was driven primarily by acrolein and styrene in non-smokers, and crotonaldehyde in smokers. CONCLUSIONS Hypertension in Black individuals may be attributed, in part, to VOC exposure from the environment or tobacco smoke.
Collapse
Affiliation(s)
- Katlyn E McGraw
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville School of Public Health and Information Sciences, 485 E Gray Street, Louisville, KY, 40202, USA
| | - Stacey L Konkle
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville School of Public Health and Information Sciences, 485 E Gray Street, Louisville, KY, 40202, USA
| | - Daniel W Riggs
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville School of Public Health and Information Sciences, 485 E Gray Street, Louisville, KY, 40202, USA
| | - Shesh N Rai
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville School of Public Health and Information Sciences, 485 E Gray Street, Louisville, KY, 40202, USA
| | - Natasha DeJarnett
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA
| | - Zhengzhi Xie
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA
| | - Rachel J Keith
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA
| | - Adebamike Oshunbade
- University of Mississippi Medical Center Department of Medicine - Cardiology, 2500 North State St, Jackson, MS, 39216, USA
| | - Michael E Hall
- University of Mississippi Medical Center Department of Medicine - Cardiology, 2500 North State St, Jackson, MS, 39216, USA
| | - Diachi Shimbo
- Columbia University Department of Medicine, 161 Fort Washington Ave, New York, NY, USA
| | - Aruni Bhatnagar
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; University of Louisville Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA.
| |
Collapse
|
5
|
McGraw KE, Riggs DW, Rai S, Navas-Acien A, Xie Z, Lorkiewicz P, Lynch J, Zafar N, Krishnasamy S, Taylor KC, Conklin DJ, DeFilippis AP, Srivastava S, Bhatnagar A. Exposure to volatile organic compounds - acrolein, 1,3-butadiene, and crotonaldehyde - is associated with vascular dysfunction. Environ Res 2021; 196:110903. [PMID: 33636185 PMCID: PMC8119348 DOI: 10.1016/j.envres.2021.110903] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/03/2021] [Accepted: 02/16/2021] [Indexed: 05/03/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of mortality worldwide. Exposure to air pollution, specifically particulate matter of diameter ≤2.5 μm (PM2.5), is a well-established risk factor for CVD. However, the contribution of gaseous pollutant exposure to CVD risk is less clear. OBJECTIVE To examine the vascular effects of exposure to individual volatile organic compounds (VOCs) and mixtures of VOCs. METHODS We measured urinary metabolites of acrolein (CEMA and 3HPMA), 1,3-butadiene (DHBMA and MHBMA3), and crotonaldehyde (HPMMA) in 346 nonsmokers with varying levels of CVD risk. On the day of enrollment, we measured blood pressure (BP), reactive hyperemia index (RHI - a measure of endothelial function), and urinary levels of catecholamines and their metabolites. We used generalized linear models for evaluating the association between individual VOC metabolites and BP, RHI, and catecholamines, and we used Bayesian Kernel Machine Regression (BKMR) to assess exposure to VOC metabolite mixtures and BP. RESULTS We found that the levels of 3HPMA were positively associated with systolic BP (0.98 mmHg per interquartile range (IQR) of 3HPMA; CI: 0.06, 1.91; P = 0.04). Stratified analysis revealed an increased association with systolic BP in Black participants despite lower levels of urinary 3HPMA. This association was independent of PM2.5 exposure and BP medications. BKMR analysis confirmed that 3HPMA was the major metabolite associated with higher BP in the presence of other metabolites. We also found that 3HPMA and DHBMA were associated with decreased endothelial function. For each IQR of 3HPMA or DHBMA, there was a -4.4% (CI: -7.2, -0.0; P = 0.03) and a -3.9% (CI: -9.4, -0.0; P = 0.04) difference in RHI, respectively. Although in the entire cohort the levels of several urinary VOC metabolites were weakly associated with urinary catecholamines and their metabolites, in Black participants, DHBMA levels showed strong associations with urinary norepinephrine and normetanephrine levels. DISCUSSION Exposure to acrolein and 1,3-butadiene is associated with endothelial dysfunction and may contribute to elevated risk of hypertension in participants with increased sympathetic tone, particularly in Black individuals.
Collapse
Affiliation(s)
- Katlyn E McGraw
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA; University of Louisville School of Public Health and Information Sciences, USA; Department of Environmental and Occupational Health Sciences, USA
| | - Daniel W Riggs
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA; University of Louisville School of Public Health and Information Sciences, USA; Department of Epidemiology and Population Health, USA
| | - Shesh Rai
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA; University of Louisville School of Public Health and Information Sciences, USA; Department of Bioinformatics and Biostatistics, 485 E Gray Street, Louisville, KY, 40202, USA
| | - Ana Navas-Acien
- Columbia University Mailman School of Public Health, USA; Department of Environmental Health Science, 722 W 168th St, New York, NY, 10032, USA
| | - Zhengzhi Xie
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA
| | - Pawel Lorkiewicz
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA
| | - Jordan Lynch
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA
| | - Nagma Zafar
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA
| | - Sathya Krishnasamy
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA
| | - Kira C Taylor
- University of Louisville School of Public Health and Information Sciences, USA; Department of Epidemiology and Population Health, USA
| | - Daniel J Conklin
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA
| | - Andrew P DeFilippis
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA
| | - Sanjay Srivastava
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA; University of Louisville School of Public Health and Information Sciences, USA
| | - Aruni Bhatnagar
- Christina Lee Brown Envirome Institute, 302 E Muhammad Ali Blvd, Louisville, KY, 40202, USA; Superfund Research Center, 302 E Muhammad Ali Blvd, Louisville, KY 40202, USA.
| |
Collapse
|
6
|
Djurasovic M, McGraw KE, Bratcher K, Crawford CH, Dimar JR, Puno RM, Glassman SD, Owens RK, Carreon LY. Randomized trial of Cell Saver in 2- to 3-level lumbar instrumented posterior fusions. J Neurosurg Spine 2019; 29:582-587. [PMID: 30117795 DOI: 10.3171/2018.4.spine18116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to determine efficacy and cost-effectiveness of Cell Saver in 2- and 3-level lumbar decompression and fusion.METHODSPatients seen at a tertiary care spine center who were undergoing a posterior 2- or 3-level lumbar decompression and fusion were randomized to have Cell Saver used during their surgery (CS group, n = 48) or not used (No Cell Saver [NCS] group, n = 47). Data regarding preoperative and postoperative hemoglobin and hematocrit, estimated blood loss, volume of Cell Saver blood reinfused, number of units and volume of allogeneic blood transfused intraoperatively and postoperatively, complications, and costs were collected. Costs associated with Cell Saver use were calculated based on units of allogeneic blood transfusions averted.RESULTSDemographics and surgical parameters were similar in both groups. The mean estimated blood loss was similar in both groups: 612 ml in the CS group and 742 ml in the NCS group. There were 53 U of allogeneic blood transfused in 29 patients in the NCS group at a total blood product cost of $67,688; and 38 U of allogeneic blood transfused in 16 patients in the CS group at a total blood cost of $113,162, resulting in a cost of $3031 per allogeneic blood transfusion averted using Cell Saver.CONCLUSIONSCell Saver use produced lower rates of allogeneic transfusion but was found to be more expensive than using only allogeneic blood for 2- and 3-level lumbar degenerative fusions. This increased cost may be reasonable to patients who perceive that the risks associated with allogeneic transfusions are unacceptable.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class III.
Collapse
|
7
|
Jazini E, Gum JL, Glassman SD, Crawford CH, Djurasovic M, Owens RK, Dimar JR, McGraw KE, Carreon LY. Cost-effectiveness of circumferential fusion for lumbar spondylolisthesis: propensity-matched comparison of transforaminal lumbar interbody fusion with anterior-posterior fusion. Spine J 2018; 18:1969-1973. [PMID: 29705337 DOI: 10.1016/j.spinee.2018.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/10/2018] [Accepted: 03/26/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Transforaminal lumbar interbody fusion (TLIF) and dual-approach anteroposterior (AP) are common techniques to achieve circumferential fusion for lumbar spondylolisthesis. It is unclear which approach is more cost-effective. PURPOSE Our goal was to determine the incremental cost-effectiveness ratio (ICER) by calculating the cost per quality-adjusted life year (QALY) for each approach. STUDY DESIGN/SETTING This study is a propensity-matched cost-effectiveness comparison. PATIENT SAMPLE Patients with lumbar spondylolisthesis undergoing single-level AP fusion or TLIF and enrolled in a prospective observational surgical database were included in this study. OUTCOME MEASURES The outcome measures in this study were the Oswestry Disability Index (ODI) and the Short Form-6D (SF-6D). METHODS From a prospective surgical database, patients with lumbar spondylolisthesis undergoing single-level AP fusion were propensity matched to a TLIF cohort based on age, gender, body mass index, smoking status, workers compensation, preoperative ODI, and back and leg pain numeric scores. Quality-adjusted life years gained were determined using baseline and 1- and 2-yearpostoperative SF-6D scores. Cost was calculated from actual, direct hospital costs and included subsequent postsurgical costs (epidural spinal injections, spine-related emergency department visits, readmissions, and revision surgery). RESULTS Thirty-one cases of AP fusions were identified and propensity matched to 31 TLIF patients. Patients undergoing TLIF had a shorter mean operative time (270 vs. 328 minutes, p=.039) but no difference in estimated blood loss (526 vs. 548 cc, p=.804) or hospital length of stay (4.5 vs. 6.1 days, p=.146). Quality-adjusted life years gained at 2 years were also similar (0.140 vs. 0.130, p=.672). The mean index surgery and the total 2-year costs were lower for TLIF compared with AP (index: $29,428 vs. $31,466; final: $30,684 vs. $331,880). As overall costs were lower and QALYs gained were similar for TLIF compared with AP fusion, TLIF was the dominant intervention with an ICER of $116,327. CONCLUSIONS Under our study parameters, surgical treatment of lumbar spondylolisthesis with TLIF is more cost-effective compared with AP fusion. Because of the short-term follow-up, the longevity of this should be further investigated.
Collapse
Affiliation(s)
- Ehsan Jazini
- Department of Orthopaedic Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd NW PHC Ground Floor, Washington, DC 20007, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Charles H Crawford
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Mladen Djurasovic
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Roge Kirk Owens
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Katlyn E McGraw
- University of Louisville School of Public Health and Information Sciences, 485 E Gray St, Louisville, KY 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA.
| |
Collapse
|
8
|
Laratta JL, Reddy HP, Bratcher KR, McGraw KE, Carreon LY, Owens RK. Outcomes and revision rates following multilevel anterior cervical discectomy and fusion. J Spine Surg 2018; 4:496-500. [PMID: 30547110 DOI: 10.21037/jss.2018.06.16] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Anterior cervical discectomy and fusion (ACDF) for cervical degenerative disease is an accepted treatment for symptomatic cervical radiculopathy and myelopathy. One- and two-level fusions are much more common and more widely studied. Outcomes and revision rates for three- and four-level ACDF have not been well described. The purpose of this study is to report on clinical outcomes and revision rates following multilevel ACDF. Methods Patients who underwent three- or four-level anterior cervical discectomy with plate fixation between 2006 and 2011 from a single-center multi-surgeon practice for symptomatic cervical degenerative disease were identified. Improvements in neck disability index (NDI), neck and arm pain scores two years after surgery and revision rates were analyzed. Results Forty-six patients with a mean age of 55.9 years were included in the analysis. Twenty-one (46%) were male, 10 (22%) were smokers. Forty-one (89%) underwent three-level fusion and 5 (11%) underwent four-level fusion. NDI improved from 34.46 at baseline to 25.47 at 2 years. Neck pain improved from 7.04 at baseline to 3.95 and arm pain improved from 6.24 to 3.09 at 2 year follow up. Sixteen patients (35%) returned to surgery within 2 years with 11 of these patients (24%) returning for non-union. The average number of days to revision surgery was 750.6±570.3 days. Conclusions Patients undergoing three- and four-level ACDF for multilevel cervical disease demonstrate substantial improvement in outcomes. However, the two-year revision rate is relatively high at 35% with the majority of these patients returning due to non-union.
Collapse
Affiliation(s)
| | | | | | | | | | - R Kirk Owens
- Norton Leatherman Spine Center, Louisville, KY, USA
| |
Collapse
|
9
|
Gvozdyev BV, Carreon LY, Graves CM, Riley SA, McGraw KE, Head RJ, Dimar JR, Glassman SD. Patient-reported outcome scores underestimate the impact of major complications in patients undergoing spine surgery for degenerative conditions. J Neurosurg Spine 2017; 27:397-402. [DOI: 10.3171/2017.3.spine161400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVEPatient-reported outcomes (PROs) such as the Oswestry Disability Index (ODI) and EuroQol-5D (EQ-5D) are widely used to evaluate treatment outcomes following spine surgery for degenerative conditions. The goal of this study was to use the Charlson Comorbidity Index (CCMI) as a measure of general health status, for comparison with standard PROs.METHODSThe authors examined serial CCMI scores, complications, and PROs in 371 patients treated surgically for degenerative lumbar spine conditions who were enrolled in the Quality and Outcomes Database from a single center. The cohort included 152 males (41%) with a mean age of 58.7 years. Patients with no, minor, or major complications were compared at baseline and at 1 year postoperatively.RESULTSMinor complications were observed in 177 patients (48%), and major complications in 34 (9%). There were no significant differences in preoperative ODI, EQ-5D, or CCMI among the 3 groups. At 1 year, there was a significantly greater deterioration in CCMI in the major complication group (1.03) compared with the minor (0.66) and no complication groups (0.44, p < 0.006), but no significant difference in ODI or EQ-5D.CONCLUSIONSDespite equivalent improvements in PROs, patients with major complications actually had greater deterioration in their general health status, as evidenced by worse CCMI scores. Because CCMI is predictive of medical and surgical risk, patients who sustained a major complication now carry a greater likelihood of adverse outcomes with future interventions, including subsequent spine surgery. Although PRO scores are a key metric, they fail to adequately reflect the potential long-term impact of major perioperative complications.
Collapse
Affiliation(s)
| | | | | | | | - Katlyn E. McGraw
- 3University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky
| | | | | | | |
Collapse
|
10
|
Owens RK, Djurasovic M, Onyekwelu I, Bratcher KR, McGraw KE, Carreon LY. Outcomes and revision rates in normal, overweight, and obese patients 5 years after lumbar fusion. Spine J 2016; 16:1178-1183. [PMID: 27293121 DOI: 10.1016/j.spinee.2016.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 05/03/2016] [Accepted: 06/02/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Obesity is a growing problem in health care. Studies have demonstrated similar functional outcomes but higher complication rates after spine surgery in obese patients. PURPOSE This study aimed to compare patient-reported outcomes and revision rates 5 years after instrumented posterior lumbar fusion between normal, overweight, and obese patients. STUDY DESIGN Propensity matched case control. PATIENT SAMPLE Patients who had posterior instrumented lumbar spinal fusion from 2001 to 2008 from a single spine specialty center with complete preoperative and 5-year postoperative outcome measures were identified. OUTCOME MEASURES Oswestry Disability Index (ODI), Back Pain (0-10) and Leg Pain (0-10) Numeric Rating Scales, and Short Form-36 Physical Composite Summary Scores (SF-36 PCS). METHODS Three comparison groups, one with body mass index (BMI) ≥20-25 kg/m2 (normal), another with ≥25-<30 kg/m2 (overweight), and another with ≥30-40 kg/m2 (obese) were created using propensity matching techniques based on demographics, baseline clinical outcome measures, and surgical characteristics. Five-year postoperative outcome measures and revision rates in the three groups were compared. One-way analysis of variance was used to compare continuous variables, and Fisher exact test was used to compare categorical variables between the groups. Significance was set at p<.01. RESULTS There were 82 cases matched in each cohort. Estimated blood loss (440 cc vs. 702 cc vs. 798 cc, p=.000) and operative time (234 minutes vs. 263 minutes vs. 275 minutes, p=.003) were significantly greater in the overweight and obese patients. Improvements in ODI (14.2 vs. 9.6 vs. 10.4, p=.226), SF-36 PCS (5.9 vs. 2.9 vs. 3.5, p=.361), back pain (3.0 vs. 2.0 vs. 2.1, p=.028), and leg pain (3.0 vs. 2.3 vs. 2.3, p=.311) scores were similar among the groups. Revision rates (14 vs. 15 vs. 13, p=.917), and time between index and revision surgery (p=.990) were similar among the three groups as well. CONCLUSION When considering a subset of patient-reported outcomes and revision surgery after 5 years, patients with an elevated BMI >25 at baseline did not appear to have worse outcomes than those with a normal BMI of 20-25 when undergoing posterior lumbar fusion surgery. Obesity should not be considered a contraindication to surgery in patients with appropriate surgical indications.
Collapse
Affiliation(s)
- R Kirk Owens
- Norton Leatherman Spine Center, 210 East Gray St, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, KY 40202, USA
| | - Mladen Djurasovic
- Norton Leatherman Spine Center, 210 East Gray St, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, KY 40202, USA
| | - Ikemefuna Onyekwelu
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, KY 40202, USA
| | - Kelly R Bratcher
- Norton Leatherman Spine Center, 210 East Gray St, Suite 900, Louisville, KY 40202, USA
| | - Katlyn E McGraw
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson St, 1st Floor ACB, Louisville, KY 40202, USA; University of Louisville School of Public Health and Information Sciences, 485 East Gray St, Louisville, KY 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray St, Suite 900, Louisville, KY 40202, USA.
| |
Collapse
|
11
|
Carreon LY, Djurasovic M, Dimar JR, Owens RK, Crawford CH, Puno RM, Bratcher KR, McGraw KE, Glassman SD. Can the anxiety domain of EQ-5D and mental health items from SF-36 help predict outcomes after surgery for lumbar degenerative disorders? J Neurosurg Spine 2016; 25:352-6. [DOI: 10.3171/2016.2.spine151472] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Studies have shown that anxious or depressed patients may have poorer outcomes after lumbar fusion. These conclusions were drawn from questionnaires specifically designed to measure anxiety and depression. The objective of this study is to determine if responses to the EQ-5D anxiety/depression domain or the items used to calculate the 36-Item Short-Form Health Survey (SF-36) Mental Component Summary (MCS) can predict outcomes after lumbar fusion surgery.
METHODS
Patients enrolled in the National Neurosurgery Quality and Outcomes Database from a single center with 1-year follow-up were identified. The outcomes collected include the Oswestry Disability Index (ODI), EQ-5D, SF-36, and the back- and leg-pain numeric rating scales (range 0–10). Linear regression modeling was performed to predict the 1-year ODI scores using the EQ-5D anxiety/depression domain and the 14 items used to calculate SF-36 MCS.
RESULTS
Complete data were available for 312 (88%) of 353 eligible patients. The mean patient age was 58.5 years, 175 (56%) patients were women, and 52 patients were smokers. After controlling for other factors, the item in the SF-36 that asks “Have you felt downhearted and depressed?” is the strongest predictor of the 1-year ODI score (r2 = 0.191; p = 0.000) and 1-year EQ-5D score (r2 = 0.205; p = 0.000). Neither the EQ-5D anxiety/depression domain nor the diagnoses of anxiety or depression were predictors of 1-year outcomes.
CONCLUSIONS
Patient responses to SF-36 item “Have you felt downhearted and depressed?” account for 20% of the variability of the 1-year ODI and EQ-5D scores and can be used by clinicians to screen for anxiety or depression in patients prior to lumbar fusion surgery. Clinicians may offer psychological support to these patients preoperatively in order to improve treatment outcomes.
Collapse
Affiliation(s)
| | - Mladen Djurasovic
- 1Norton Leatherman Spine Center, Louisville; and
- 2Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - John R. Dimar
- 1Norton Leatherman Spine Center, Louisville; and
- 2Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | | | - Charles H. Crawford
- 1Norton Leatherman Spine Center, Louisville; and
- 2Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Rolando M. Puno
- 1Norton Leatherman Spine Center, Louisville; and
- 2Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | | | | | - Steven D. Glassman
- 1Norton Leatherman Spine Center, Louisville; and
- 2Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| |
Collapse
|