Global, regional, and national burden of disorders affecting the nervous system, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.

METHODS

We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.

FINDINGS

Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378-521), affecting 3·40 billion (3·20-3·62) individuals (43·1%, 40·5-45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7-26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6-38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5-32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7-2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.

INTERPRETATION

As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed.

FUNDING

Bill & Melinda Gates Foundation.

Coronavirus Disease 2019 Infection in Cervical Artery Dissections

OBJECTIVE

Most cervical artery dissection (CeAD) cases are spontaneous or due to minor traumas, and preceding viral infections have been suggested to be a triggering event for CeAD in some. Herein, we analyze the prevalence of coronavirus disease 2019 (COVID-19) in hospitalized patients with CeAD using a national database.

METHODS

The National Inpatient Sample was queried from April 2020 to December 2020 for patients with a diagnosis of CeAD using International Classification of Diseases, 10th edition-Clinical Modification codes. Among these, patients with COVID-19 were identified. Multivariable logistic regression was conducted to assess the patient profile of those with COVID-19, in-patient mortality, and home discharge among patients with CeAD.

RESULTS

There were 360 (2.32%) hospitalizations involving COVID-19 among 15,500 with CeAD. Concomitant acute ischemic stroke constituted 43.06% of those with a COVID-19 diagnosis, whereas it was 43.73% among those without a COVID-19 diagnosis ( P = 0.902). Home discharges were less common in patients with COVID-19 and CeAD compared to CeAD alone (34.85% vs. 48.63%; P = 0.03), but this was likely due to other factors as multivariate regression analysis did not show an association between COVID-19 and home discharges (odds ratio: 0.69; 95% CI: 0.39 to 1.25; P = 0.22). COVID-19 diagnosis had similar odds of inpatient mortality (odds ratio: 1.11; 95% CI: 0.43 to 2.84; P = 0.84).

CONCLUSION

The prevalence of COVID-19 among hospitalized patients with CeAD is low with 2.32% of all CeAD cases. Concomitant COVID infection did not lead to an increased risk of stroke in CeAD. However, potentially worse functional outcomes (fewer home discharges) without an increase in mortality were seen in patients with COVID and CeAD.

Machine learning prediction of hospital discharge disposition for inpatients with acute ischemic stroke following mechanical thrombectomy in the United States

BACKGROUND AND PURPOSE

Predicting patient recovery and discharge disposition following mechanical thrombectomy remains a challenge in patients with ischemic stroke. Machine learning offers a promising prognostication approach assisting in personalized post-thrombectomy care plans and resource allocation. As a large national database, National Inpatient Sample (NIS), contain valuable insights amenable to data-mining. The study aimed to develop and evaluate ML models predicting hospital discharge disposition with a focus on demographic, socioeconomic and hospital characteristics.

MATERIALS AND METHODS

The NIS dataset (2006-2019) was used, including 4956 patients diagnosed with ischemic stroke who underwent thrombectomy. Demographics, hospital characteristics, and Elixhauser comorbidity indices were recorded. Feature extraction, processing, and selection were performed using Python, with Maximum Relevance - Minimum Redundancy (MRMR) applied for dimensionality reduction. ML models were developed and benchmarked prior to interpretation of the best model using Shapley Additive exPlanations (SHAP).

RESULTS

The multilayer perceptron model outperformed others and achieved an AUROC of 0.81, accuracy of 77 %, F1-score of 0.48, precision of 0.64, and recall of 0.54. SHAP analysis identified the most important features for predicting discharge disposition as dysphagia and dysarthria, NIHSS, age, primary payer (Medicare), cerebral edema, fluid and electrolyte disorders, complicated hypertension, primary payer (private insurance), intracranial hemorrhage, and thrombectomy alone.

CONCLUSION

Machine learning modeling of NIS database shows potential in predicting hospital discharge disposition for inpatients with acute ischemic stroke following mechanical thrombectomy in the NIS database. Insights gained from SHAP interpretation can inform targeted interventions and care plans, ultimately enhancing patient outcomes and resource allocation.

Outcomes following surgical and endovascular treatment of extracranial vertebral artery aneurysms (VAA): a systematic evaluation of the literature

Extracranial vertebral artery aneurysms are rare complications resulting from trauma and multiple different diseases. However, the difference between clinical and surgical profiles is well understood. To investigate the clinical and interventional outcomes following extracranial vertebral artery aneurysms (VAA) treatment through a systematic review of the literature to date, an electronic database search for full-text English articles was conducted following PRISMA guidelines. The search yielded results on clinical and surgical outcomes for extracranial VAAs. These results included patient-specific risk factors, indications, and techniques. Our literature search resulted in 561 articles, of which 36 studies were qualified to be included in the analysis. A total of 55 patients with multiple various extracranial VAA incidents were included. The mean age of subjects was 42 years (ranging from 13.0 to 76.0 years), and the majority of patients were males (71%, n =39). Blunt trauma was the most frequent risk factor for extracranial VAA formation (35%, n = 19). The majority of aneurysms (60%) were dissected in nature. The most common form of treatment for extracranial VAAs was the use of a flow diverter (24%, n=13). Overall, five (9%) patients had long-term adverse neurological complications following intervention with 5% (n=3) mortality, 2% (n=1) resulting in unilateral vocal cord paralysis, and 2% (n=1) resulted in a positive Romberg sign. The mortality rate is 15.7% in the surgical group, whereas the endovascular treatment did not result in any mortality. The endovascular approach is a safe and effective treatment of extracranial VAAs due to its relatively low overall complication rate and lack of resulting mortality. This is in contrast to the surgical approach which results in a higher rate of complications, recurrence, and mortality outcomes. An understanding of the factors and clinical outcomes associated with the incidence of extracranial VAAs is essential for the future improvement of patient outcomes.

Racial and Ethnic Disparities in Treatment of Critical Limb Ischemia: A National Perspective

Background Recent guidelines have emphasized the use of medical management, early diagnosis, and a multidisciplinary team to effectively treat patients with critical limb ischemia (CLI). Previous literature briefly highlighted the current racial disparities in its intervention. Herein, we analyze the trend over a 14-year time period to investigate whether the disparities gap in CLI management is closing. Methods and Results The National Inpatient Sample was queried between 2005 and 2018 for hospitalizations involving CLI. Nontraumatic amputations and revascularization were identified. Utilization trends of these procedures were compared between races (White, Black, Hispanic, Asian and Pacific Islander, Native American, and Other). Multivariable regression assessed differences in race regarding procedure usage. There were 6 904 562 admissions involving CLI in the 14-year study period. The rate of admissions in White patients who received any revascularization decreased by 0.23% (P<0.001) and decreased by 0.25% (P=0.025) for Asian and Pacific Islander patients. Among all patients, the annual rate of admission in White patients who received any amputation increased by 0.21% (P<0.001), increased by 0.19% (P=0.001) for Hispanic patients, and increased by 0.19% (P=0.012) for the Other race patients. Admissions involving Black, Hispanic, Asian and Pacific Islander, or Other race patients had higher odds of receiving any revascularization compared with White patients. All races had higher odds of receiving major amputation compared with White patients. Conclusions Our analysis highlights disparities in CLI treatment in our nationally representative sample. Non-White patients are more likely to receive invasive treatments, including major amputations and revascularization for CLI, compared with White patients.

In-hospital stroke and mortality trends after left ventricular assist device implantation in the United States from 2017 to 2019

BACKGROUND

The newer Left Ventricular Assist Device (LVAD), the HeartMate 3 (HM3), was initially approved by the Food and Drug Administration in 2017. We aimed to describe the temporal trends of in-hospital stroke and mortality among patients who underwent LVAD placement between 2017 and 2019.

METHODS

The National Inpatient Sample was queried from 2017 to 2019 to identify all adults with heart failure and reduced ejection fraction (HFrEF) who underwent LVAD implantation using the International Classification of Diseases 10th Revision codes. The Cochran-Armitage test was conducted to assess the linear trend of in-hospital stroke and mortality. In addition, multivariable regression analysis was conducted to assess the association of LVAD placement with in-hospital stroke and death.

RESULTS

A total of 5,087,280 patients met the selection criteria. Of those, 11,750 (0.2%) underwent LVAD implantation. There was a downtrend in in-hospital mortality per year (trend: -1.8%, p = 0.03), but not in the trend of both ischemic and hemorrhagic stroke per year. LVAD placement was associated with greater odds of stroke of any type (OR = 1.96, 95% CI 1.68-2.29, p < 0.001) and in-hospital mortality (OR = 1.37, 95% CI 1.16-1.61, p < 0.001).

CONCLUSIONS

Our study found a significant downtrend in the in-hospital mortality rates among patients with LVAD without substantial changes in stroke rate trends over the study timeframe. As stroke rates remained steady, we hypothesize that improved management along with better control of blood pressure, could have played an important role in survival benefit over the study time frame.

Trends in utilization and outcomes of mechanical thrombectomy for cerebral venous thrombosis: A National Inpatient Sample study

BACKGROUND AND PURPOSE

Cerebral venous thrombosis (CVT) is usually treated with systemic anticoagulation, but mechanical thrombectomy (MT) and local infusion of a thrombolytic agent have been proposed as an alternative therapy. In this study, we analyze National Inpatient Sample (NIS) to determine the trends of MT including discharge other than home (DOTH) and mortality.

MATERIAL AND METHODS

Healthcare Utilization Program-NIS (HCUP-NIS) was queried between 2005 and 2018 for CVT and MT. Cochran-Armitage test was conducted to assess linear trend of proportion of utilization and DOTH of MT. Multivariable logistic regression was conducted to assess odds of undergoing MT among CVT admissions, odds of in-hospital mortality, and DOTH for all admissions involving MT for CVT.

RESULTS

A total of 1331 (1.56%) admissions involved MT out of 85,370 CVT cases. Utilization of MT had an upward trend of 0.13% (p < 0.001) per year. Trend in proportion of incidence of DOTH among MT admission remained stationary (trend: 0.70%; p = 0.417). Patients with cerebral edema (odds ratio [OR]: 4.34; p < 0.001) or hematological disorders (OR: 2.28; p < 0.001) were more likely to receive MT for CVT. Additionally, patients with coma (OR: 3.17; p = 0.023) or cerebral edema (OR: 4.40; p = 0.001) had higher odds of mortality.

CONCLUSION

There was an increasing trend of utilization of MT. Proportions of DOTH among MT procedures, however, remained stable. Patients with greater risk factors, including hematological disorders and cerebral edema, were more likely to undergo MT. Among patients treated with MT, those with coma or cerebral edema were more likely to die.

National Trends in Complications of Vascular Access for Hemodialysis and Analysis of Racial Disparities Among Patients With End-Stage Renal Disease in the Inpatient Setting

Introduction

The aim of this study is to assess the trends in access-related complications, as well as the impact of race on these complications, among admitted patients with end-stage kidney disease (ESKD) receiving hemodialysis.

Methods

A retrospective cohort study between 2005 and 2018 was performed using the National Inpatient Sample (NIS). Hospitalizations involving ESKD and hemodialysis were identified. There were 9,246,553 total admissions involving ESKD and hemodialysis, of which 1,167,886 (12.6%) had complications. Trends in complications were assessed and compared among races.

Results

There was a decreasing trend in rates of mechanical (trend: -0.05% per year; P < 0.001), inflammatory or infectious (-0.48%; P < 0.001), and other (-0.19%; P < 0.001) complications from 2005 to 2018. Non-White patients had a greater magnitude in the decrease in trends in rates of complications compared to White patients (-0.69% per year vs. -0.57%; P < 0.001). Compared to the White patients, Black patients (odds ratio [OR]: 1.26; P < 0.001) and those of the other races (OR: 1.11; P < 0.001) had higher odds of complications. These differences were also statistically significant among lower socioeconomic classes (75 percentile vs. 0-25 percentile: P = 0.009) and within southern states (vs. Northeast: P < 0.001).

Conclusion

Although there was an overall decrease in the trends of dialysis-associated complications requiring hospitalization among ESKD patients receiving hemodialysis, non-White patients have higher odds of complications compared to White patients. The findings in this study emphasize the need for more equitable care for hemodialysis patients.

The role of targeted temperature management in 30-day hospital readmissions in cardiac arrest survivors: A national population-based study

Background

Targeted temperature management (TTM) implementation following resuscitation from cardiac arrest is controversial. Although prior studies have shown that TTM improves neurological outcomes and mortality, less is known about the rates or causes of readmission in cardiac arrest survivors within 30 days. We aimed to determine whether the implementation of TTM improves all-cause 30-day unplanned readmission rates in cardiac arrest survivors.

Methods

Using the Nationwide Readmissions Database, we identified 353,379 adult cardiac arrest index hospitalizations and discharges using the International Classification of Diseases, 9th and 10th codes. The primary outcome was 30-day all-cause unplanned readmissions following cardiac arrest discharge. Secondary outcomes included 30-day readmission rates and reasons, including impacts on other organ systems.

Results

Of 353,379 discharges for cardiac arrest with 30-day readmission, 9,898 (2.80%) received TTM during index hospitalization. TTM implementation was associated with lower 30-day all-cause unplanned readmission rates versus non-recipients (6.30% vs. 9.30%, p < 0.001). During index hospitalization, receiving TTM was also associated with higher rates of AKI (41.12% vs. 37.62%, p < 0.001) and AHF (20.13% vs. 17.30%, p < 0.001). We identified an association between lower rates of 30-day readmission for AKI (18.34% vs. 27.48%, p < 0.05) and trend toward lower AHF readmissions (11.32% vs. 17.97%, p = 0.05) among TTM recipients.

Conclusions

Our study highlights a possible negative association between TTM and unplanned 30-day readmission in cardiac arrest survivors, thereby potentially reducing the impact and burden of increased short-term readmission in these patients. Future randomized studies are warranted to optimize TTM use during post-arrest care.

Trends in Reimbursement and Approach Selection for Lumbar Arthrodesis

BACKGROUND

Changes in reimbursement policies have been demonstrated to correlate with clinical practice.

OBJECTIVE

To investigate trends in physician reimbursement for anterior, posterior, and combined anterior/posterior (AP) lumbar arthrodesis and relative utilization of AP.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Project registry for anterior, posterior, and AP lumbar arthrodeses during 2010 and 2020. Work relative value units per operative hour (wRVUs/h) were calculated for each procedure. Trends in reimbursement and utilization of the AP approach were assessed with linear regression. Subgroup analyses of age and underlying pathology of AP arthrodesis were also performed.

RESULTS

During 2010 and 2020, AP arthrodesis was associated with significantly higher average wRVUs/h compared with anterior and posterior arthrodesis (AP = 17.4, anterior = 12.4, posterior = 14.5). The AP approach had a significant yearly increase in wRVUs/h (coefficient = 0.48, P = .042), contrary to anterior (coefficient = -0.01, P = .308) and posterior (coefficient = -0.13, P = .006) approaches. Utilization of AP approaches over all arthrodeses increased from 7.5% in 2010 to 15.3% in 2020 (yearly average increase 0.79%, P < .001). AP fusions increased significantly among both degenerative and deformity cases (coefficients 0.88 and 1.43, respectively). The mean age of patients undergoing AP arthrodesis increased by almost 10 years from 2010 to 2020. Rates of major 30-day complications were 2.7%, 3.1%, and 3.5% for AP, anterior, and posterior arthrodesis, respectively.

CONCLUSION

AP lumbar arthrodesis was associated with higher and increasing reimbursement (wRVUs/h) during the period 2010 to 2020. Reimbursement for anterior arthrodesis was relatively stable, while reimbursement for posterior arthrodesis decreased. The utilization of the combined AP approach relative to the other approaches increased significantly during the period of interest.

Sight the Mite: A Meta-Analysis on the Diagnosis of Scabies

This meta-analysis was performed to assess the efficacy of the diagnostic tests for scabies infections that are currently in wide use. Scabies is most commonly diagnosed through clinical presentations; however, due to the wide array of symptoms, diagnosis is difficult. The most commonly used diagnostic test is skin scraping. However, this test relies on correctly selecting the site of mite infection for sampling. Due to the mobile nature of a live parasitic infection, the mite can often be missed based on its current location within the skin. The goal of this paper is to determine if a gold standard confirmatory test exists for the diagnosis of scabies by comparing Skin Scraping, Adhesive Tape, Dermoscopy, and PCR tests. Medline, PubMed, and Neglected Tropical Diseases databases were utilized in a literature review. Eligible papers were papers published in or after the year 2000, published in the English language, and mainly focused on the diagnosis of scabies. At the time of this meta-analysis, scabies is mostly diagnosed through a correlation of clinical symptoms in conjunction with diagnostic tests such as dermoscopy (sensitivity: 43.47%, specificity: 84.41%), adhesive tape tests (sensitivity: 69.56%, specificity: 100%) and PCR antigen detection (37.9% sensitivity, specificity: 100%). Due to a scarcity of data in the literature, the diagnostic efficacy of other diagnostic tests is difficult to assess. Overall, the efficacies of the tests analyzed vary depending on how similar scabies is to other skin disorders, how challenging it is to get a usable sample and the price and accessibility of essential tools. There is a need for standardized national diagnostic criteria to increase the diagnostic sensitivity of scabies infection.

Unplanned 30-Day Readmissions after Management of Submassive and Massive Acute Pulmonary Embolism: Catheter-Directed versus Systemic Thrombolysis

PURPOSE

To compare 30-day readmission and in-hospital outcomes from the Nationwide Readmissions Database (NRD) for catheter-directed thrombolysis (CDT) versus systemic intravenous thrombolysis (IVT) as treatments for acute submassive or massive pulmonary embolism (PE).

MATERIALS AND METHODS

The NRD was queried from 2016 to 2019 for adult patients with nonseptic acute PE who underwent IVT or CDT. Massive PE was distinguished from submassive PE if patients had concurrent International Classification of Diseases (ICD-10) codes corresponding to mechanical ventilation, vasopressors, or shock. Propensity score-matched analysis was conducted to infer the association of CDT versus IVT in unplanned 30-day readmissions, nonroutine discharge, gastrointestinal bleeding (GIB), and intracranial hemorrhage (ICH). These results are demonstrated as average treatment effects (ATEs) of IVT compared with those of CDT.

RESULTS

A total of 37,116 patients with acute PE were studied; 18,702 (50.3%) underwent CDT, and 18,414 (49.7%) underwent IVT. A total of 2,083 (11.1%) and 3,423 (18.6%) were massive PEs in the 2 groups, respectively (P < .001). The ATE of IVT was higher than that of CDT regarding unplanned 30-day readmissions (ATE, 0.019; P < .001), GIB (ATE, 0.012; P < .001), ICH (ATE, 0.003; P = .017), and nonroutine discharge (ATE, 0.022; P = .006). The subgroup analysis of patients with submassive PE demonstrated that IVT had a higher ATE regarding unplanned 30-day readmission (ATE, 0.028; P < .001), GIB (ATE, 0.008; P = .003), ICH (ATE, 0.002; P = .035), and nonroutine discharge (ATE, 0.019; P = .022) than CDT.

CONCLUSIONS

CDT had a lower likelihood of unplanned 30-day readmissions, including when stratified by a submassive PE subtype. Additionally, adverse events, including ICH and GIB, were more likely among patients who received IVT than among those who received CDT.

Comparing Outcomes in Transcatheter Embolization for the Management of Penetrating versus Blunt Trauma

Purpose This article assesses potential factors associated with successful embolization and/or mortality benefit among patients with penetrating (PT) compared to those with blunt abdominal trauma (BT) undergoing emergent angiography.

Methods A retrospective study of arterial embolization for BT and PT at a tertiary care academic center in an urban setting between 2018 and 2020 was conducted. Fischer's exact and Student's t-tests were used to assess differences between PT and BT, regarding technical success, in-hospital mortality, number of vessels embolized, and requirement of Operating Room (OR) for bleeding control after embolization.

Results Forty-three patients underwent embolization. Twenty-three presented with BT versus 20 with PT. There was no difference in the rate of success between the two groups (91.3% vs. 100%; p = 0.49). No difference was observed in mean days of survival among BT and PT patients treated by embolization (mean [standard deviation]: 13.7 [2.6] vs. 19.1 [2.79] days; p = 0.160). There was no difference in mortality between the two groups (13.0% vs. 10.5%; p = 1.00). Mean number of vessels embolized was higher in the BT group compared to PT (2.26 [1.32] vs. 1.44 [1.03], p = 0.044). The rate of BT patients who required subsequent OR intervention for hemorrhage control after embolization was similar to those with PT (8.7% vs. 10.5%; p = 0.84).

Conclusion The rate of mortality, technical success, and requirement of subsequent OR intervention for hemorrhage control was comparable between BT and PT. BT was associated with a higher mean number of vessels embolized compared to PT. Our case series may provide insight in the use of embolization for PT, but further investigation is needed with larger cohorts.

Racial disparities in the contemporary utilization and outcomes of left atrial appendage occlusion in the United States

Background

Racial and socioeconomic disparities in the utilization of percutaneous structural heart disease interventions have been described in previous years, reflecting significant gaps. However, it is unclear if increased awareness has created meaningful changes in the utilization of left atrial appendage occlusion (LAAO) in underrepresented populations.

Purpose

We aim to further clarify current practices in the United States and answer questions to help guide further efforts in attenuating health disparities.

Methods

The National Inpatient Sample (NIS) was queried from 2016–2019 to identify all patients &gt;65 years of age diagnosed with atrial fibrillation or atrial flutter who underwent left atrial appendage occlusion (LAAO) using the international classification of diseases, tenth revision clinical modification (ICD-10-CM) codes. We selected this age cutoff to minimize confounding bias from lack of insurance coverage as patients age 65 and older qualify for the Center of Medicare & Medicaid Services. We excluded patients with missing race information. In addition, we confined our analysis to patients of White, Black, and Hispanic ethnicity because the number of other races was insufficient for meaningful analysis. Multivariate linear and logistic regression analysis was performed to compare the odds of procedure utilization, in-hospital mortality, and significant periprocedural complications among study groups.

Results

We identified a total of 14,103,690 patients &gt;65 years of age diagnosed with either atrial fibrillation or atrial flutter. Of those, 53,350 (0.38%) underwent LAAO. The mean age of the sample was 79±7.6 years. Compared to White patients, Black patients had lesser odds of undergoing LAAO when controlling for multiple confounders (AOR = 0.49, 95% CI 0.44–0.55, p&lt;0.001). Among Hispanic patients, there was no statistically significant difference in the odds of undergoing LAAO compared to White patients. There was no statistically significant difference in mortality, vascular complications, non-home discharge, stroke, transient ischemic attack, pericardial tamponade, and length of stay in patients undergoing LAAO among different ethnicities.

Conclusions

Significant disparities, including procedure utilization and patient characteristics prior to the procedure, such as household income, still exist among Black patients compared to White patients undergoing the LAAO in the United States. Nevertheless, adjusted odds of in-hospital outcomes were similar among Black, Hispanic, and White patients. Further research is necessary to identify what mitigation strategies could be effective and what can be changed to close the remaining gap.

Funding Acknowledgement

Type of funding sources: None.

Effect of frailty on in-hospital outcomes after transcatheter mitral valve repair

Background

Mitral regurgitation (MR) is a common valvular disorder associated with significant morbidity and mortality. Transcatheter mitral valve repair (TMVr) is a minimally invasive procedure indicated for the treatment of selected patients with moderate-severe or severe primary MR. Despite a lack of a universal definition, frailty has been associated with poor post-procedural outcomes. Albeit several trials have examined individual prognostic factors in this population, there is a paucity of data regarding the effect of frailty on in-hospital outcomes after TMVr.

Purpose

To further elucidate the association of frailty with in-hospital outcomes in patients undergoing TMVr.

Methods

The national inpatient sample (NIS) database, which is part of the Healthcare Cost and Utilization Project (HCUP), was queried from 2016 to 2019 to identify all who underwent TMVr. International classification of diseases, tenth revision clinical modification (ICD-10-CM) codes were used to divide patients into frail and non-frail study groups. Frailty was defined using Johns Hopkins Adjusted Clinical Groups diagnosis cluster for frailty. Multivariate linear and logistic regression analysis was performed to compare in-hospital mortality, hospital length of stay, non-home discharge, and iatrogenic cardiac complications among Frail and Non-Frail groups.

Results

A total of 30,660 patients who underwent TMVr were identified. The mean age was 76±11.6 years. Of those, 2,950 (9.6%) were identified as frail. The overall in-hospital mortality rate for the entire study population was 1.89%. Compared to non-frail patients, those identified as frail had greater odds of in-hospital mortality (AOR= 2.13, 95% CI 1.29–3.51, p&lt;0.001) and non-home discharge (AOR= 4.34, 95% CI 3.54–5.32, p&lt;0.001). However, there was no statistically significant difference in hospital length of stay and rates of iatrogenic cardiac complications.

Conclusions

Frailty models continue to be underutilized as a prognostic tool in clinical practice. After following HCUP guidelines, our analysis found that frailty is independently associated with increased in-hospital mortality and non-home discharge in patients undergoing TMVr. Therefore, we recommend that further efforts in incorporating frailty models in the pre-procedural assessment of patients undergoing TMVr should be sought along with a standardized predictive model for defining frailty.

Funding Acknowledgement

Type of funding sources: None.

Impact of left bundle branch block in patients with takotsubo cardiomyopathy

Background

Takotsubo cardiomyopathy (TCM) is a syndrome characterized by reversible left-ventricular regional systolic dysfunction in the absence of obstructive coronary artery disease (CAD). The presence of left bundle branch block (LBBB) has been described as an independent predictor of mortality in patients with CAD. One study using the National Inpatient Sample (NIS) for 2016 found that the presence of LBBB was associated with worse outcomes in patients with TCM.

Purpose

To better clarify the association between LBBB and various in-hospital outcomes in patients with TCM.

Methods

The NIS database was queried from 2016–2019 to identify all admissions with a primary diagnosis of TCM that had a cardiac catheterization to improve the specificity of the diagnosis. International classification of diseases, tenth revision clinical modification (ICD-10-CM) codes were used to divide patients based on the presence or absence of LBBB. A 1:3 propensity score matching based on age, race, gender, and risk factor stratification was used to reduce selection bias. Multivariate linear and logistic regression analysis was performed to compare various outcomes among both groups.

Results

A total of 27,125 patients admitted with a primary diagnosis of TCM that also underwent diagnostic coronary angiography were identified. In the study sample, 955 (3.5%) were determined to have a LBBB. After calculating propensity scores, 955 patients with LBBB were paired to 2,865 patients without LBBB. LBBB was associated with higher rates of ventricular arrhythmias (AOR=3.098, 95% CI 1.483–6.471, p=0.003); however, it was not statistically associated with cardiogenic shock, sudden cardiac arrest (SCA), acute kidney injury, acute heart failure, and hospital length of stay. In addition, there was no statistical difference in intra-hospital mortality.

Conclusions

LBBB is associated with left ventricular dyssynchrony. It has been proposed that intraventricular dyssynchrony might be a predisposing factor for ventricular arrhythmias (VA) and SCA. Several trials have demonstrated that cardiac resynchronization therapy alone (i.e., without defibrillation) reduces the rate of VA and SCA. The mechanism for this improvement is unclear but may be related to hemodynamic improvement from ventricular synchrony in heart failure (HF). In fact, LBBB has been reported as an independent risk factor for all-cause mortality and SCA at one year in patients with HF. Our analysis did not find any significant association between LBBB and SCA but did find an association with VA. Moreover, there were not enough events of intra-hospital mortality to assess a possible association between LBBB and mortality. Therefore, a prospective study with a longer follow-up would be needed to clarify the role of LBBB in mortality and establish causality between LBBB and VA in patients with TCM.

Funding Acknowledgement

Type of funding sources: None.

Optimizing Door-to-Groin Puncture Time: The Mayo Clinic Experience

OBJECTIVES

To provide a better understanding of methods that can be used to improve patient outcomes by reducing the door-to-groin puncture (DTP) time and present the results of a stroke quality improvement project (QIP) conducted by Mayo Clinic Arizona's stroke center.

METHODS

We conducted a systematic literature search of Ovid MEDLINE(R), Ovid EMBASE, Scopus, and Web of Science for studies that evaluated DTP time reduction strategies. Those determined eligible for the purpose of this analysis were assessed for quality. The strategies for DTP time reduction were categorized on the basis of modified Target: Stroke Phase III recommendations and analyzed using a meta-analysis. The Mayo Clinic QIP implemented a single-call activation system to reduce DTP times by decreasing the time from neurosurgery notification to case start.

RESULTS

Fourteen studies were selected for the analysis, consisting of 2277 patients with acute ischemic stroke secondary to large-vessel occlusions. After intervention, all the studies showed a reduction in the DTP time, with the pooled DTP improvement being the standardized mean difference (1.37; 95% confidence interval, 1.20-1.93; τ²=1.09; P<.001). The Mayo Clinic QIP similarly displayed a DTP time reduction, with the DTP time dropping from 125.1 to 82.5 minutes after strategy implementation.

CONCLUSION

Computed tomography flow modifications produced the largest and most consistent reduction in the DTP time. However, the reduction in the DTP time across all the studies suggests that any systematic protocol aimed at reducing the DTP time can produce a beneficial effect. The relative novelty of mechanical thrombectomy and the consequential lack of research call for future investigation into the efficacy of varying DTP time reduction strategies.

Trends in Utilization of Temporary and Permanent Cerebrospinal Fluid Diversion and Catheter Cerebral Angiography for Patients with Aneurysmal Subarachnoid Hemorrhage in the United States

INTRODUCTION

We sought to analyze the rate of utilization of methods of cerebrospinal fluid diversion over time in a nationally representative cohort of patients admitted with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

The Nationwide Inpatient Sample was queried for patients admitted with aSAH from 2006 to 2018. Patients who received external ventricular drainage (EVD), lumbar drainage, ventriculoperitoneal shunt (VPS), and cerebral angiography were then identified. A Cochrane-Armitage test was conducted to assess the linear trend of proportions of EVD, lumbar drains, VPS, and mean cerebral angiograms per admission. Four regression analyses were conducted to infer the association of baseline variables to EVD, lumbar drain, VPS, and mean number of cerebral angiographies.

RESULTS

A total of 133,567 admissions were identified from 2006-2018 involving aSAH. Of these, 41.82% received EVD, 6.22% received lumbar drainage, 10.58% received VPS, and 75.03% had cerebral angiograms. There was an average upward trend of 1.57% in annual EVD utilization, downward trend of -0.28% in utilization of lumbar drainage, no changes in VPS utilization, and an upward trend of 0.04 angiograms per year (P < 0.001). There was a higher proportion of Black patients treated with EVD and VPS in both urban teaching hospitals and large hospitals.

CONCLUSIONS

Our results show the temporal trends in utilization of temporary and permanent methods of cerebrospinal fluid diversion and catheter cerebral angiography among patients with aSAH in the United States. The underutilization of VPS following EVD and the differences in EVD and VPS utilization depending on race and hospital size deserve further exploration.

Triglyceride-Glucose Index for Early Prediction of Nonalcoholic Fatty Liver Disease: A Meta-Analysis of 121,975 Individuals

Insulin resistance (IR) is a major contributor to the pathogenesis of nonalcoholic fatty liver disease (NAFLD). The triglyceride-glucose (TyG) index has recently gained popularity for the assessment of IR and NAFLD due to its ease of acquisition and calculation. Therefore, we conducted this systematic review and meta-analysis to summarize the existing studies in the literature and provide a quantitative assessment of the significance of the TyG index in predicting the incidence of NAFLD. A comprehensive literature search in PubMed, EMBASE, and Web of Science databases from inception until 25 March 2022 was conducted. Published observational studies that evaluated the association between TyG index and NAFLD among the adult population and reported the hazard ratio (HR) or odds ratio (OR) for this association after multivariate analysis were included. The random-effects model was used as the primary statistical analysis model in the estimation of pooled ORs and HRs with the corresponding confidence intervals (CIs). A total of 17 observational studies, including 121,975 participants, were included. For studies analyzing the TyG index as a categorical variable, both pooled OR (6.00, CI 4.12–8.74) and HR (1.70, CI 1.28–2.27) were significant for the association between TyG index and incident NAFLD. For studies analyzing the TyG index as a continuous variable, pooled OR (2.25, CI 1.66–3.04) showed similar results. Consistent results were obtained in subgroup analyses according to the study design, sample size, ethnicity, and diabetic status. In conclusion, our meta-analysis demonstrates that a higher TyG index is associated with higher odds of NAFLD. TyG index may serve as an independent predictive tool to screen patients at high risk of NAFLD in clinical practice, especially in primary care settings. Patients with a high TyG index should be referred for a liver ultrasound and start intense lifestyle modifications. However, further large-scale prospective cohort studies are necessary to validate our findings.

Abstract 188: Ischemic Heart Disease Burden On Clinical Outcomes After Percutaneous Left Atrial Appendage Closure In Patients With Atrial Fibrillation In The United States

Background: Percutaneous left atrial appendage closure (PLAAC) is an alternative to anticoagulants for atrial fibrillation patients with elevated stroke risk and contraindication to anticoagulation. We examined the burden of IHD on clinical outcomes after PLAAC.

Methods: We identified patients from the Nationwide Readmission Database who underwent PLAAC with a Watchman device between 2014-2018 using ICD-9 and 10 codes. Patients were classified into 2 groups based on the presence of IHD. Outcomes were all-cause and cause-specific 30-day readmissions and mortality rate during readmission. Multivariable regression was conducted for 30 days readmission adjusting for patient demographics,hospital characteristics, and Elixhauser Comorbidity Index.

Results: A total of 18,348 Watchman recipients were identified, of which 8,504 had IHD while 9,844 had no ischemic heart disease (NIHD). Length of stay and cost were not different between groups. However, significant differences were noted in terms of the number of frequent index admission complications between the IHD vs. NIHD group, including transient ischemic attack/Stroke (3.5% Vs. 1.6%, P<0.0001) (Table 1). Although the 30 days readmission rate was higher in the IHD group (7.5% Vs. 6%, P=0.003), there was no difference in mortality. Most frequent causes of readmissions for IHD Vs. NIHD were Acute Kidney Injury (AKI) (26% Vs. 17.3%, P=0.009) and acute heart failure (HF) (24.1% Vs. 17%, P=0.015) (Table 1). In multivariate analysis, ICM PLAAC recipients had higher odds of 30-day readmission compared to NICM (OR=3.7, P=0.4). Renal failure patients have higher odds of 30-day readmission compared to non-renal failure ( OR=1.4, P=0.001).

Conclusion: Thirty-day readmission rate in patients who underwent PLAAC was higher in the IHD group. However, no difference was noted in mortality between both groups. AKI and acute HF were significant causes of readmission in patients with IHD who underwent PLAAC. Further studies exploring these differences may help to prevent these readmissions.

Assessing the differences in operative and patient-reported outcomes between lateral approaches for lumbar fusion: a systematic review and indirect meta-analysis

OBJECTIVE

Anterior-to-psoas lumbar interbody fusion (ATP-LIF), more commonly referred to as oblique lateral interbody fusion, and lateral transpsoas lumbar interbody fusion (LTP-LIF), also known as extreme lateral interbody fusion, are the two commonly used lateral approaches for performing a lumbar fusion procedure. These approaches help overcome some of the technical challenges associated with traditional approaches for lumbar fusion. In this systematic review and indirect meta-analysis, the authors compared operative and patient-reported outcomes between these two select approaches using available studies.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, the authors conducted an electronic search using the PubMed, EMBASE, and Scopus databases for studies published before May 1, 2019. Indirect meta-analysis was conducted on fusion rate, cage movement (subsidence plus migration), permanent deficits, and transient deficits; results were depicted as forest plots of proportions (effect size [ES]).

RESULTS

A total of 63 studies were included in this review after applying the exclusion criteria, of which 26 studies investigated the outcomes of ATP-LIF, while 37 studied the outcomes of LTP-LIF. The average fusion rate was found to be similar between the two groups (ES 0.97, 95% CI 0.84-1.00 vs ES 0.94, 95% CI 0.91-0.97; p = 0.561). The mean incidence of cage movement was significantly higher in the ATP-LIF group compared with the LTP-LIF group (stand-alone: ES 0.15, 95% CI 0.06-0.27 vs ES 0.09, 95% CI 0.04-0.16 [p = 0.317]; combined: ES 0.18, 95% CI 0.07-0.32 vs ES 0.02, 95% CI 0.00-0.05 [p = 0.002]). The mean incidence of reoperations was significantly higher in patients undergoing ATP-LIF than in those undergoing LTP-LIF (ES 0.02, 95% CI 0.01-0.03 vs ES 0.04, 95% CI 0.02-0.07; p = 0.012). The mean incidence of permanent deficits was similar between the two groups (stand-alone: ES 0.03, 95% CI 0.01-0.06 vs ES 0.05, 95% CI 0.01-0.12 [p = 0.204]; combined: ES 0.03, 95% CI 0.01-0.06 vs ES 0.03, 95% CI 0.00-0.08 [p = 0.595]). The postoperative changes in visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were both found to be higher for ATP-LIF relative to LTP-LIF (VAS: weighted average 4.11 [SD 2.03] vs weighted average 3.75 [SD 1.94] [p = 0.004]; ODI: weighted average 28.3 [SD 5.33] vs weighted average 24.3 [SD 4.94] [p < 0.001]).

CONCLUSIONS

These analyses indicate that while both approaches are associated with similar fusion rates, ATP-LIF may be related to higher odds of cage movement and reoperations as compared with LTP-LIF. Furthermore, there is no difference in rates of permanent deficits between the two procedures.

Associations of Stay-at-Home Order Enforcement With COVID-19 Population Outcomes: An Interstate Statistical Analysis

In the United States, state governors initially enacted coronavirus diseases 2019 (COVID-19)-mitigation policies with limited epidemiologic data. One prevailing legislative approach, from March to May 2020, was the implementation of "stay-at-home" (SAH) executive orders. Although social distancing was encouraged, SAH orders varied between states, and the associations between potential legal prosecution and COVID-19 outcomes are currently unknown. Here, we provide empirical evidence on how executive enforcement of movement restrictions may influence population health during an infectious disease outbreak. A generalized linear model with negative binomial regression family compared COVID-19 outcomes in states with law-enforceable stay-at-home (eSAH) orders versus those with unenforceable or no SAH orders (uSAH), controlling for demographic factors, socioeconomic influences, health comorbidities, and social distancing. COVID-19 incidence was less by 1.22 cases per day per capita in eSAH states compared with uSAH states (coefficient = -1.22, 95% confidence interval (CI): -1.83, -0.61; P < 0.001), and each subsequent day without an eSAH order was associated with a 0.03 incidence increase (coefficient = 0.03, 95% CI: 0.03, 0.04; P < 0.001). Daily mortality was 1.96 less for eSAH states per capita (coefficient = -1.96, 95% CI: -3.25, -0.68; P = 0.004). Our findings suggest allowing the enforcement of public health violations, compared with community education alone, is predictive of improved COVID-19 outcomes.

Trends in Admissions and Outcomes for Treatment of Aneurysmal Subarachnoid Hemorrhage in the United States

BACKGROUND

Lifestyle modifications and advances in surgical and endovascular techniques for treating unruptured intracranial aneurysm (UIA) have vastly evolved over the last few decades and may have reduced the incidence of aneurysmal subarachnoid hemorrhage (aSAH). However, the actual impact of these changes on the rates and outcomes of aSAH remain unexplored. Thus, we studied national aSAH admissions and outcome trends and changes of major risk factors over time.

METHODS

We queried the National Inpatient Sample between 2006 and 2018 to identify adult patients admitted and treated for UIA or ruptured aneurysm with aSAH. The Cochran-Armitage test was conducted to assess the linear trend of proportion of prevalence, inpatient mortality, hypertension, and current smoking status among aSAH admissions. Multivariable logistic regression was conducted to assess the odds of presenting with aSAH versus UIA, in addition to the odds of inpatient mortality among patients with aSAH.

RESULTS

A total of 159,913 patients presented with UIA and 133,567 presented with aSAH. Admissions for aSAH decreased by 0.97% (p < 0.001) per year. Current smoking and hypertension were associated with higher odds of being admitted for aSAH compared with the treatment for UIA (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.29-1.48; OR 1.15, 95% CI 1.08-1.22, respectively). Compared with White patients, Black patients (OR 1.32, 95% CI 1.21-1.43), Hispanic patients (OR 1.38, 95% CI 1.25-1.52), and patients of other races and/or ethnicities (OR 1.73, 95% CI 1.54-1.95) had a higher chance of presenting with aSAH. Rates of inpatient mortality among aSAH admissions showed no change over time (p = 0.21). Among patients admitted with aSAH, current smoking and hypertension showed an upward trend of 0.58% (p < 0.001) and 1.60% (p < 0.001) per year, respectively.

CONCLUSIONS

Despite a downward trend in the annual frequency of hospitalizations for aSAH, inpatient mortality rates for patients undergoing treatment of the ruptured aneurysm have remained unchanged in the United States. Smoking and hypertension are increasingly prevalent among patients with aSAH. Thus, efforts to control these modifiable risk factors must be further strengthened.

Radial artery diameter: a comprehensive systematic review of anatomy

AIMS

The objective of this systematic review is to determine with the highest accuracy the average radial artery (RA) diameter overall and in certain subgroups. The aim of this study is to provide assistance in the development of fitting transradial devices, an increasingly popular intervention.

METHODS

Several databases were used to extract appropriate studies highlighting RA diameter. Databases used in the generation of this study were Ovid EBM Reviews, Ovid Embase, Ovid Medline, Scopus and Web of Science Core Collection. RA diameter was determined overall, in males versus females, adults only, adults+children, in the presence of comorbidities, and finally RA diameter in the context of various vasodilators.

RESULTS

A total of 71 studies were included. The average RA diameter overall was determined to be 2.62±0.15 mm in children+adults and 2.70±0.15 mm in adults only. In comparison to an RA diameter of 2.68±0.24 mm in adult males, the diameter was found to be 2.27±0.27 mm in adult females (p=0.028). As for comorbidities, the mean RA diameter in adult patients with hypertension and congestive heart failure was 2.72±0.37 mm and 2.80±0.25 mm, respectively. Finally, the mean RA diameter with nitrate and angiotensin-converting enzyme (ACE) inhibitor use was 2.97±0.53 mm and 2.82±0.29 mm respectively. For comparison, the average outer diameter of a 5 French introducer sheath is 2.29 mm and a 6 French introducer sheath is 2.62 mm.

CONCLUSIONS

The findings presented in this study will help determine the most appropriate transradial device to use in several different populations in the context of vasodilator usage or the absence thereof.

Comparison of Oncologic Outcomes and Treatment-Related Toxicity of Carbon Ion Radiotherapy and En Bloc Resection for Sacral Chordoma

IMPORTANCE

Maximal resection is the preferred management for sacral chordomas but can be associated with unacceptable morbidity. Outcomes with radiotherapy are poor. Carbon ion radiotherapy (CIRT) is being explored as an alternative when surgery is not preferred.

OBJECTIVE

To compare oncologic outcomes and treatment-related toxicity of CIRT and en bloc resection for sacral chordoma.

DESIGN, SETTING, AND PARTICIPANTS

Univariable logistic regression was performed to evaluate the association between treatment type and oncologic and toxicity outcomes in this retrospective cohort study. Nearest-neighbor propensity score matching was used to match the CIRT cohort with the en bloc resection cohort and 10 National Cancer Database (NCDB) cohorts separately, with the objective of obtaining more homogeneous cohorts when comparing treatments. Patient- and tumor-related characteristics from 2 institutional cohorts were collected for patients diagnosed with sacral chordomas between April 1, 1994, and July 31, 2017. The NCDB was queried for data on patients with sacral chordoma from January 1, 2004, to December 31, 2016, as a comparator in overall survival (OS) analyses. Data analysis was conducted from February 24, 2020, to January 16, 2021.

EXPOSURES

En bloc resection, incomplete resection, photon radiotherapy, proton radiotherapy, and CIRT.

MAIN OUTCOMES AND MEASURES

Overall survival was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model. Peripheral motor nerve toxic effects were scored using Common Terminology Criteria for Adverse Events, version 4.03.

RESULTS

A total of 911 patients were included in the study (NCDB: n = 669; median age, 64 [IQR, 52-74] years; 410 [61.3%] men; CIRT: n = 188; median age, 66 [IQR, 58-71] years; 128 [68.1%] men; en bloc surgical resection: n = 54; median age, 53.5 [IQR 49-64] years, 36 [66.7%] men). Comparison of the propensity score-matched institutional en bloc resection and CIRT cohorts revealed no statistically significant difference in OS (CIRT: median OS, 68.1 [95% CI, 44.0-102.6] months; en bloc resection: median OS, 58.6 [95% CI, 25.6-123.5] months; P = .57; hazard ratio, 0.71 [95% CI, 0.25-2.06]; P = .53). The CIRT cohort experienced lower rates of peripheral motor neuropathy (odds ratio, 0.13 [95% CI, 0.04-0.40]; P < .001). On comparison of the propensity score-matched NCDB cohorts with the CIRT cohort, significantly higher OS was found for CIRT compared with margin-positive surgery without adjuvant radiotherapy (CIRT: median OS, 64.7 [95% CI, 57.8-69.7] months; margin-positive surgery without adjuvant radiotherapy: median OS, 60.6 [95% CI, 44.2-69.7] months, P = .03) and primary radiotherapy alone (CIRT: median OS, 64.9 [95% CI 57.0-70.5] months; primary radiotherapy alone: 31.8 [95% CI, 27.9-40.6] months; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that CIRT can be used as treatment for older patients with high performance status and sacral chordoma in whom surgery is not preferred. CIRT might provide additional benefit for patients who undergo margin-positive resection or who are candidates for primary photon radiotherapy.

Orbital Metastases: A Systematic Review of Clinical Characteristics, Management Strategies, and Treatment Outcomes

BACKGROUND

Orbital metastases often lead to severe functional impairment. The role of resection, orbital exenteration, and complementary treatments is still debated. We systematically reviewed the literature on orbital metastases.

METHODS

PubMed, Scopus, Web-of-Science, and Cochrane were searched upon PRISMA guidelines to identify studies on orbital metastases. Clinical characteristics, management strategies, and survival were analyzed.

RESULTS

We included 262 studies comprising 873 patients. Median age was 59 years. The most frequent primary tumors were breast (36.3%), melanoma (10.1%), and prostate (8.5%) cancers, with median time interval of 12 months (range, 0-420). The most common symptoms were proptosis (52.3%) and relative-afferent-pupillary-defect (38.7%). Most metastases showed a diffuse location within the orbit (19%), with preferential infiltration of orbital soft tissues (40.2%). In 47 cases (5.4%), tumors extended intracranially. Incisional biopsy (63.7%) was preferred over fine-needle aspiration (10.2%), with partial resection (16.6%) preferred over complete (9.5%). Orbital exenteration was pursued in 26 patients (3%). A total of 305 patients (39.4%) received chemotherapy, and 506 (58%) received orbital radiotherapy. Post-treatment symptom improvement was significantly superior after resection (p = 0.005) and orbital radiotherapy (p = 0.032). Mean follow-up was 14.3 months, and median overall survival was 6 months. Fifteen cases (1.7%) demonstrated recurrence with median local control of six months. Overall survival was statistically increased in patients with breast cancer (p < 0.001) and in patients undergoing resection (p = 0.024) but was not correlated with orbital location (p = 0.174), intracranial extension (p = 0.073), biopsy approach (p = 0.344), extent-of-resection (p = 0.429), or orbital exenteration (p = 0.153).

CONCLUSIONS

Orbital metastases severely impair patient quality of life. Surgical resection safely provides symptom and survival benefit compared to biopsy, while orbital radiotherapy significantly improves symptoms compared to not receiving radiotherapy.

Accuracy of Detecting Atrial Fibrillation: A Systematic Review and Meta-Analysis of Wrist-Worn Wearable Technology

Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia, and ECG remains the gold standard for diagnosing AF. Wrist-worn technologies are appealing for their ability to passively process near-continuous pulse signals. The clinical application of wearable devices is controversial. Our systematic review and meta-analysis qualitatively and quantitatively analyze available literature on wrist-worn wearable devices (Apple Watch, Samsung, and KardiaBand) and their sensitivity and specificity in detecting AF compared to conventional methods. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, yielding nine studies (n = 1,581). Observational studies assessing the sensitivity and specificity of wrist-worn wearables in detecting AF in patients with and without a history of AF were included and analyzed using a fixed-effect model with an inverse-variance method. In patients with a history of AF, the overall sensitivity between device groups did not significantly differ (96.83%; P = 0.207). Specificity significantly differed between Apple, Samsung, and KardiaBand (99.61%, 81.13%, and 97.98%, respectively; P<0.001). The effect size for this analysis was highest in the Samsung device group. Two studies (n = 796) differentiated cohorts to assess device sensitivity in patients with known AF and device specificity in patients with normal sinus rhythm (NSR) (sensitivity: 96.02%; confidence intervals (CI) 93.85%-97.59% and specificity: 98.82%; CI:97.46%-99.57%). Wrist-worn wearable devices demonstrate promising results in detecting AF in patients with paroxysmal AF. However, more rigorous prospective data is needed to understand the limitations of these devices in regard to varying specificities which may lead to unintended downstream medical testing and costs.

Disparities in the Use of Mechanical Thrombectomy Alone Compared with Adjunctive Intravenous Thrombolysis in Acute Ischemic Stroke in the United States

BACKGROUND AND PURPOSE

For patients with large-vessel occlusion, mechanical thrombectomy (MT) without IV-tPA is a proved strategy. The relative benefit of direct MT versus MT+IV-tPA for patients with indications for IV-tPA is being actively investigated. We used a national inpatient database to assess trends in use and patient profiles after MT+IV-tPA versus mechanical thrombectomy alone.

MATERIALS AND METHODS

The National Inpatient Sample was queried between 2013 and 2018 for patients undergoing mechanical thrombectomy for acute ischemic stroke. Patients who received mechanical thrombectomy alone were compared with those who underwent MT+IV-tPA. The Cochran-Armitage test was conducted to assess the linear trend of use of mechanical thrombectomy alone among the entire cohort and between admissions involving non-White and White patients. All estimates were nationalized using discharge weights.

RESULTS

A total of 89,645 weighted admissions were identified pertaining to mechanical thrombectomy for acute ischemic stroke from 2013 to 2018. Of these, 59,935 (66.9%) admissions involved mechanical thrombectomy alone. There was an increase in the trend toward the use of mechanical thrombectomy alone (trend: 3.26%; P < .001) per year. Multivariable regression analysis regarding patient profiles indicated that patients who identified as Black (OR = 0.83, P = .001) or Hispanic (OR = 0.79; P < .001) were more likely to undergo mechanical thrombectomy alone compared with those who identified as White. There was no statistically significant difference in the slope between non-White and White populations receiving mechanical thrombectomy alone (trend: +0.93% in favor of non-White; P = .096).

CONCLUSIONS

Our results indicated that mechanical thrombectomy alone was used more frequently than MT+IV-tPA among patients with acute ischemic stroke. The disparity between those who identify as White and non-White persisted across the years, though it is closing.

Abstract 14581: Impact of Heart Failure on 30-day Readmissions After Transcatheter Left Atrial Appendage Occlusion With the Watchman Device

Background: The Watchman device reduces the risk of stroke in select patients with atrial fibrillation (AF). AF commonly coexists with heart failure (HF) and these conditions harbor interrelated pathophysiological mechanisms and treatment strategies., the impact of comorbid heart failure on outcomes in patients with AF undergoing Watchman device implantation remains unclear.

Methods: We identified patients from the Nationwide Readmission Database who underwent Watchman device placement between 2014-2018 using ICD-9 and 10 codes. Patients were classified into 2 groups based on the presence of HF. Outcomes were all-cause and cause-specific 30-day readmissions and mortality rate during readmission. Kaplan-Meier analysis was used to assess the association of HF with 30-day hospital readmission.

Results: We identified 18,349 recipients, 13,180 had no heart failure (NHF) while 5169 had HF. Mean age was similar between both groups. A total of 789 (5.9%) were readmitted within 30 days in the NHF compared to 439 (8.5%) in the non HF (NHF) group, The 30-day readmission rate was higher and Length of the stay was slightly longer in HF group. Prior stroke was more prevalent in the NHF group. Coronary artery disease, smoking, prior ICD, and obesity were more prevalent among HF group as demonstrated in table 1. The most common causes of readmissions for NHF vs HF were (acute heart failure: 15 vs 30%, p<0.001), (GI bleed: 19 vs 23%, P=0.16), and (AKI: 19 vs 27%, P<0.002). No difference in mortality or time-to readmission observed between both groups (Fig.1).

Conclusion: In this analysis, post-Watchman 30-day readmission frequency was higher in patients with HF compared with NHF, though the time-to readmission was similar. Interestingly, 1 in 7 patients with NHF at baseline was readmitted with acute HF. Additional studies are now needed to identify which triggers are responsible for these readmissions so that effective preventive efforts can be instituted to reduce these readmissions.

The Role of Immune Checkpoint Inhibitors in Leptomeningeal Disease: A Systematic Review

BACKGROUND/AIM

Leptomeningeal disease (LMD) is a debilitating complication of advanced malignancies. Immune-checkpoint inhibitors (ICIs) may alter disease course. We analyzed the role and toxicity of ICIs in LMD.

MATERIALS AND METHODS

We systematically reviewed the literature reporting on outcome data of patients with LMD treated with ICIs.

RESULTS

We included 14 studies encompassing 61 patients. Lung-cancer (44.3%), breast-cancer (27.9%), and melanoma (23.0%) were the most frequent primary tumors. Median duration of ICI-treatment was 7-months (range=0.5-58.0): pembrolizumab (49.2%), nivolumab (32.8%), ipilimumab (18.0%). Radiological responses included complete response (33.3%), partial response (12.5%), stable disease (33.3%), progressive disease (20.8%). Twenty-two patients developed ICI-related adverse-events, mild (100%) and/or severe (15.6%). Median progression-free and overall survival were 5.1 and 6.3 months, and 12-month survival was 32.1%. Survival correlated with ICI agents (p=0.042), but not with primary tumors (p=0.144). Patients receiving concurrent steroids showed worse survival (p=0.040).

CONCLUSION

ICI therapy is well-tolerated in patients with LMD, but concurrent steroids may worsen survival.

Time-to-enrollment in clinical trials investigating neurological recovery in chronic spinal cord injury: observations from a systematic review and ClinicalTrials.gov database

Currently, large numbers of clinical trials are performed to investigate different forms of experimental therapy for patients suffering from chronic spinal cord injury (SCI). However, for the enrollment process, there are different views on how the time period between injury and interventions should be determined. Herein, we sought to evaluate the impact of time-to-enrollment in chronic SCI clinical trials. A data set comprising 957 clinical studies from clinicalTrials.gov was downloaded and analyzed focusing on the eligibility criteria for post-injury time-to-enrollment. We also aggregated individual patient data from nine clinical trials of regenerative interventions for chronic SCI selected by a systematic literature search from 1990 to 2018. Characteristics of the studies were assessed and compared by dividing into three groups based on time-to-enrollment (group 1 ≤ 12 months, group 2 = 12–23 months and group 3 ≥ 24 months). In ClinicalTrials.gov registry, 445 trials were identified for chronic SCI where 87% (385) were unrestricted in the maximum post-injury time for trial eligibility. From systematic literature search, nine studies and 156 patients (group 1 = 30, group 2 = 55 and group 3 = 71) were included. The range of time-to-enrollment was 0.5 to 321 months in those studies. We also observed various degrees of motor and sensory improvement in between three time-to-enrollment groups. Our results indicate that enrolling wide ranges of time-to-enrollment in a group may present imprecise outcomes. Clinical trial designs should consider appropriate post-injury time frames to evaluate therapeutic benefit.

Do all outpatient spine surgeries cost the same? Comparison of economic outcomes data from a state-level database for outpatient lumbar decompression performed in an ambulatory surgery center or hospital outpatient setting

OBJECTIVE

Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings.

METHODS

For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type.

RESULTS

A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO.

CONCLUSIONS

These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.

Interventional resealing of preterm premature rupture of the membranes: a systematic review and meta-analysis

OBJECTIVE

To compare the effectiveness and outcomes of interventional resealing of membranes, "amniopatch" for spontaneous vs. iatrogenic preterm premature rupture of the membranes (sPPROM and iPPROM).

METHODS

We performed a systematic review of literature involving an electronic search of the following databases: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Scopus. An indirect meta-analysis was then performed to compare the obstetric, maternal, fetal, and neonatal outcomes of amniopatch between the sPPROM and iPPROM groups.

RESULTS

The mean gestational age (GA) at the time rupture was 17.8 ± 1.8 and 25.2 ± 3.8 weeks for iPPROM and sPPROM, respectively, p = .005. Mean GA at the time of amniopatch procedure was 19.2 ± 2.07 weeks for iPPROM and 23 ± 3.1 weeks of gestation for sPPROM, p = .023. The rates of fluid re-accumulation (sPPROM 26% and iPPROM 53%, p = .09) were comparable between the sPPROM and iPPROM groups. Neonatal outcomes except for the rate of IUFD were also comparable between the groups. The incidence of IUFD was significantly higher in the iPPROM group (ES: 24%; 95% CI: 8.00-44.0%; p < .001), compared to sPPROM (ES: 0%; 95% CI: 0.00-4.00%). Obstetric and maternal outcomes were comparable between the two groups.

CONCLUSIONS

Amniopatch appears to be a feasible and safe procedure for PPROM treatment. Further research is warranted to investigate the effectiveness of this procedure and establish a standardized criterion for the appropriate selection of patients that could benefit from this intervention.

RADI-14. Bevacizumab vs Laser Interstitial Thermal Therapy in radiation necrosis from brain metastases: a systematic review and meta-analysis

Objective

Radiation necrosis (RN) represents a serious post-radiotherapy complication in patients with brain metastases. Bevacizumab and laser interstitial thermal therapy (LITT) are viable treatment options, but direct comparative data is scarce. We reviewed the literature to compare the two treatment strategies.

Methods

PubMed, EMBASE, Scopus, and Cochrane databases were searched. All studies of patients with RN from brain metastases treated with bevacizumab or LITT were included. Treatment outcomes were analyzed using indirect meta-analysis with random-effect modeling.

Results

Among the 18 studies included, 143 patients received bevacizumab and 148 underwent LITT. Both strategies were equally effective in providing post-treatment symptomatic improvement (P=0.187, I2=54.8%), weaning off steroids (P=0.614, I2=25.5%), and local lesion control (P=0.5, I2=0%). The mean number of lesions per patient was not statistically significant among groups (P=0.624). Similarly, mean T1-contrast-enhancing pre-treatment volumes were not statistically different (P=0.582). Patterns of radiological responses differed at 6-month follow-ups, with rates of partial regression significantly higher in the bevacizumab group (P=0.001, I2=88.9%), and stable disease significantly higher in the LITT group (P=0.002, I2=81.9%). Survival rates were superior in the LITT cohort, and statistical significance was reached at 18 months (P=0.038, I2=73.7%). Low rates of adverse events were reported in both groups (14.7% for bevacizumab and 12.2% for LITT).

Conclusion

Bevacizumab and LITT can be safe and effective treatments for RN from brain metastases. Clinical and radiological outcomes are mostly comparable, but LITT may relate to superior survival benefits in select patients. Further studies are required to identify the best patient candidates for each treatment group.

LMD-10. The role of immune checkpoint inhibitors in leptomeningeal disease: a systematic review

Background

Leptomeningeal disease (LMD) is a devastating complication of advanced malignancy with a poor prognosis and limited therapeutic options. Whether immune checkpoint inhibitors (ICIs) alter disease course is unknown.

Methods

We searched PubMed, EMBASE, Scopus, Cochrane, and clinicaltrials.gov according to PRISMA guidelines to analyze the therapeutic role and toxicity profiles of ICIs in the management of LMD. Studies reporting clinical outcome data of patients with LMD treated with ICIs were included. A comprehensive review of clinical characteristics and survival analysis was conducted.

Results

We included 14 studies encompassing 61 patients. The median age at LMD diagnosis was 57 years (female=63.9%). Lung cancer (44.3%), breast cancer (27.9%), and melanoma (23.0%) were the most frequent primary tumors. Parenchymal brain metastases occurred in 37 patients, mostly treated with radiotherapy (83.3%). LMD most frequently presented with headache (42.1%) and was diagnosed by MRI findings (leptomeningeal T1-contrast enhancement: 96.7%) and/or positive cerebrospinal fluid cytology (86.5%). Patients received ICIs for a median duration of 7 months (range, 0.5–58.0): pembrolizumab (49.2%), nivolumab (32.8%), and/or ipilimumab (18.0%). The most common concurrent LMD treatments were radiotherapy (54.7%) and steroids (35.7%). Radiological responses at 6-months were complete (33.3%) and partial response (12.5%), stable disease (33.3%), and progression (20.8%). 22 patients developed ICI-related adverse events, mostly mild (100%) and uncommonly severe (15.6%). Median progression-free survival was 5.1 months, median overall survival was 6.3 months, and 12-month survival was 32.1%. Survival was correlated with ICIs (P=0.042), but not with primary tumors (P=0.144). Patients concurrently receiving steroids showed worse survival (P=0.040), with a median overall survival of 1.9 months.

Conclusion

ICI therapy shows promise and appears to be well-tolerated in patients with LMD. Concurrent use of steroids is associated with worse survival. The role of ICIs in the multimodal management of LMD and their combination with steroids requires further analysis.

SURG-06. Metastases in the pineal region: a systematic review of clinical features, treatment strategies and survival outcomes

Background

Pineal region metastases are rare but often lead to severe neurological deficits. Surgical resection may play a therapeutic role.

Methods

We searched PubMed, EMBASE, Scopus, and Cochrane according to PRISMA guidelines. Studies reporting clinical outcomes data of patients with pineal region metastases were included. Clinical characteristics, management strategies, and survival data were reviewed.

Results

We included 30 studies comprising 46 patients. The median age at diagnosis was 58 years (range 27–82). Lung cancer (30.4%) and carcinomas of unknown origin (15.2%) were the most frequent primary tumors. In 50% of patients, symptomatic pineal metastases preceded primary tumor diagnosis. Headache (66.7%) and confusion (45.2%) were the most common presenting symptoms. Parinaud’s syndrome (47.6%) and hydrocephalus (87%) were commonly noted. Biopsy (67.4%) was preferred over surgical resection (32.6%). The most common CSF diversion protocols were endoscopic third ventriculostomy (45%) and ventriculoperitoneal shunting (27.5%). Eleven patients received adjuvant chemotherapy and 31 underwent radiotherapy. At post-treatment follow-up, symptomatic improvement (55.2%) and hydrocephalus reduction (80%) were described. Post-treatment performance status scores were statistically superior that pre-treatment scores for patients undergoing biopsy (P<0.001) and tumor resection (P=0.007) coupled with adjuvant chemo/radiotherapy. Mean follow-up was 8 months, and median overall survival was 3 months. Only two cases (4.8%) of pineal metastases recurrence were reported, and median progression-free survival was 3 months. In patients receiving adjuvant chemo/radiotherapy, no survival differences were reported between surgery and biopsy (P=0.912), nor between gross-total and subtotal resection (P=0.220). Overall survival was neither correlated with surgical approach (P=0.157), nor with CSF diversion protocol (P=0.822).

Conclusion

Pineal region metastases can severely impair clinical status. Biopsy or surgical resection may significantly improve symptoms and baseline performance status when combined with adjuvant chemo/radiotherapy and CSF diversion.

Bevacizumab vs laser interstitial thermal therapy in cerebral radiation necrosis from brain metastases: a systematic review and meta-analysis

PURPOSE

Radiation necrosis (RN) represents a serious post-radiotherapy complication in patients with brain metastases. Bevacizumab and laser interstitial thermal therapy (LITT) are viable treatment options, but direct comparative data is scarce. We reviewed the literature to compare the two treatment strategies.

METHODS

PubMed, EMBASE, Scopus, and Cochrane databases were searched. All studies of patients with RN from brain metastases treated with bevacizumab or LITT were included. Treatment outcomes were analyzed using indirect meta-analysis with random-effect modeling.

RESULTS

Among the 18 studies included, 143 patients received bevacizumab and 148 underwent LITT. Both strategies were equally effective in providing post-treatment symptomatic improvement (P = 0.187, I² = 54.8%), weaning off steroids (P = 0.614, I² = 25.5%), and local lesion control (P = 0.5, I² = 0%). Mean number of lesions per patient was not statistically significant among groups (P = 0.624). Similarly, mean T1-contrast-enhancing pre-treatment volumes were not statistically different (P = 0.582). Patterns of radiological responses differed at 6-month follow-ups, with rates of partial regression significantly higher in the bevacizumab group (P = 0.001, I² = 88.9%), and stable disease significantly higher in the LITT group (P = 0.002, I² = 81.9%). Survival rates were superior in the LITT cohort, and statistical significance was reached at 18 months (P = 0.038, I² = 73.7%). Low rates of adverse events were reported in both groups (14.7% for bevacizumab and 12.2% for LITT).

CONCLUSION

Bevacizumab and LITT can be safe and effective treatments for RN from brain metastases. Clinical and radiological outcomes are mostly comparable, but LITT may relate with superior survival benefits in select patients. Further studies are required to identify the best patient candidates for each treatment group.

Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis

OBJECTIVE

Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities.

METHODS

We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms.

RESULTS

A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P = 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P < 0.001), perioperative hydrocephalus (P = 0.012), postoperative infarction (P = 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P = 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324).

CONCLUSIONS

Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study.

Economic Burden of Hospitalizations Associated with Opioid Dependence Among Patients Undergoing Spinal Fusion

BACKGROUND

The current study seeks to examine the association between chronic opioid use and postoperative outcomes for patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF).

METHODS

The National Inpatient Sample was queried for patients with and without chronic opioid use undergoing ACDF or PLF for degenerative disc disease between 2012 and 2015 using ICD-9 diagnosis and procedure codes. Multivariable conditional logistic regression was performed to assess the association between chronic opioid use and length of stay (LOS), nonhome discharge, and hospital charge.

RESULTS

A total of 391 patients undergoing ACDF and 644 patients undergoing PLF with opioid dependence were identified. On multivariable regression analysis, opioid dependence was significantly associated with an increased LOS (mean, 3.09 days vs. 2.16 days; odds ratio (OR) for prolonged LOS (>3 days), 2.11; 95% confidence interval [CI], 1.43-3.14; P < 0.001). Although on unadjusted analyses, patients with opioid dependence undergoing ACDF were found to have higher hospital charges (mean, U.S. $18,698.42 vs. $11,378.61; P < 0.001) and higher rates of nonroutine discharge (19.18% vs. 10.21%; P < 0.001), the multivariable regression analyses found no significant association between opioid dependence and odds of hospital charges >75th percentile (OR, 1.44; 95% CI, 0.84-2.47; P = 0.188) or nonroutine discharge (OR, 1.48; 95% CI, 0.93-2.34; P = 0.098). For those undergoing PLF, opioid dependence was significantly associated with increased hospital charges (mean, U.S. $37,712.98 vs. $30,475.43, P < 0.001; OR for hospital charge >75th percentile, 1.78, 95% CL, 1.23-2.58, P = 0.002), LOS (mean, 3.42 days vs. 2.30 days; OR for prolonged LOS, 1.53; 95% CI, 1.16-2.00; P = 0.003), and nonroutine discharge (46.89% vs. 36.47%; OR, 1.74; 95% CI, 1.34-2.26; P < 0.001) on both unadjusted and adjusted multivariable regression analyses.

CONCLUSIONS

Our analysis using a national administrative database showed that opioid dependence may be associated with worse economic outcomes for patients undergoing ACDF and PLF.

Assessing the Differences in Measurement of Degree of Spondylolisthesis Between Supine MRI and Erect X-Ray: An Institutional Analysis of 255 Cases

BACKGROUND

Degenerative spondylolisthesis is the displacement of one vertebral body over the adjacent one. While standing and flexion-extension X-rays are preferred for determining listhesis, magnetic resonance imaging (MRI) is often utilized to assess the compression of nerve root or spinal cord.

OBJECTIVE

To investigate the difference in radiographic measurements of spondylolisthesis between X-rays and MRI.

METHODS

We retrospectively reviewed the records and radiographic images of patients with a confirmed diagnosis of spondylolisthesis undergoing operation in 2016. Primary variable of interest was the degree of slippage as per the Meyerding method. Agreement between the 2 reviewers was assessed using the 2-way intraclass correlation coefficient (ICC) for slippage percentage and Cohen's Kappa for grade. Agreement of Meyerding grade between the 2 imaging techniques was assessed using Cohen's Kappa, while the slip percentage measured for each technique was compared using a Bland-Altman (BA) plot, mean difference (MD), and 1-way ICC.

RESULTS

A total of 255 cases were analyzed. ICC between the 2 reviewers was found to be 0.75 (95% confidence interval [CI] = 0.64-0.83, P < .001) for X-ray and 0.76 (95% CI = 0.66-0.83, P < .001) for MRI. Agreement between X-ray and MRI for grading of spondylolisthesis was found to be poor (kappa = 0.32, P < .001). BA plot between X-ray and MRI measurements revealed an MD of 4.4% (95% limits of agreement: -10.3% to 19.3%) with 5.16% observations outside the limits of agreement and 1-way ICC of 0.35 showing poor agreement.

CONCLUSION

Our results demonstrate the discrepancy of spondylolisthesis grade measurements between weight-bearing X-ray and nonweight-bearing MRI. Careful evaluation of both imaging technique is warranted to determine the final severity of pathology and tailoring of management plan.

Trends in Utilization of Preoperative Embolization for Spinal Metastases: A Study of the National Inpatient Sample 2005-2017

Purpose

While previous studies have suggested that preoperative embolization of hypervascular spinal metastases may alleviate intraoperative blood loss and improve resectability, trends and driving factors for choosing this approach have not been extensively explored. Therefore, we evaluated the trends and assessed the factors associated with preoperative embolization utilization for spinal metastatic tumors using a national inpatient database.

Materials and Methods

The National Inpatient Sample database of the Healthcare Cost and Utilization Project was queried for patients undergoing surgical resection for spinal metastasis between January 1, 2005 and December 31, 2017. Patients undergoing preoperative embolization were identified; trends in the utilization of preoperative embolization were analyzed using the Cochran-Armitage test. Multivariable regression was conducted to assess factors associated with higher preoperative embolization utilization.

Results

A total of 11,508 patients with spinal metastasis were identified; 105 (0.91%) underwent preoperative embolization. Of those 105 patients, 79 (75.24%) patients had a primary renal cancer, as compared to 1,732 (15.19%) of those who did not undergo preoperative embolization (P<0.001). The majority of patients in the non-preoperative embolization cohort had a primary lung tumor (n=3,562, 31.24%). Additionally, patient comorbidities were similar among the 2 groups (P>0.05). Trends in preoperative embolization indicated an increase of 0.16% (standard error: 0.024%, P<0.001) in utilization per year.

Conclusion

Utilization of preoperative embolization for spinal metastasis is increasing yearly, especially for patients with renal cancer, suggesting that surgeons may increasingly consider embolization before surgical resection for hypervascular tumors. Additionally, the literature has shown the intraoperative and postoperative benefits of this procedure.

Determining the Difference in Clinical and Radiologic Outcomes Between Expandable and Nonexpandable Titanium Cages in Cervical Fusion Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Expandable cages have been increasingly used in cervical and lumbar reconstructions; however, there is a paucity in the literature on how they compare with traditional nonexpandable cages in the cervical spine. We present a systematic review and meta-analysis, comparing the clinical and radiologic outcomes of expandable versus nonexpandable corpectomy cage use in the cervical spine.

METHODS

A database search identified studies detailing the outcomes of expandable and nonexpandable titanium cage use in the cervical spine. These studies were screened using the PRISMA protocol. Fixed-effects and random-effects models were used with a 95% confidence interval. Two analyses were carried out for each outcome: one including all studies and the other including only studies reporting on exclusively 1-level and 2-level cases.

RESULTS

Forty-one studies were included. The mean change in segmental lordosis was significantly greater in expandable cages (all, 6.72 vs. 3.69°, P < 0.001; 1-level and 2-level, 6.81° vs. 4.31°, P < 0.001). The mean change in cervical lordosis was also significantly greater in expandable cages (all, 5.71° vs. 3.11°, P = 0.027; 1-level and 2-level, 5.71° vs. 2.07°, P = 0.002). No significant difference was found between the complication rates (all, P = 0.43; 1-level and 2-level, P = 0.94); however, the proportion of revisions was significantly greater in expandable cages (all, 0.06 vs. 0.02, P = 0.03; 1-level and 2-level, 0.08 vs. 0.01, P = 0.017).

CONCLUSIONS

The use of expandable cages may carry a modest improvement in radiologic outcomes compared with nonexpandable cages in the cervical spine; however, they may also lead to a higher rate of revisions based on our analyses.