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

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

Decreasing trend of inpatient mortality rates of aseptic versus septic revision total hip arthroplasty: an analysis of 681,034 cases

BACKGROUND

While most revision total hip arthroplasties (rTHAs) are for aseptic loosening/instability, infection accounts for approximately 16%. The purpose of this study was to: (1) quantify mortality rates of aseptic versus septic rTHA; (2) determine if mortality rates have changed over the past 20 years; and (3) identify associated preoperative risk factors, focusing on the utility/validity of the Elixhauser comorbidity index (ECI).

METHODS

ICD-9/ICD-10 codes were used to identify patients undergoing rTHA in the National Inpatient Sample database between 1998 and 2017. A total of 681,034 cases (576,143 aseptic THA and 104,891 septic THA) were identified. For each patient, demographic variables including age, sex, race, insurance type, ECI, and inhospital mortality were gathered. A logistic regression model was constructed to assess risk of inhospital mortality.

RESULTS

From 1998 to 2017, inpatient mortality rates of aseptic and septic rTHA decreased from 0.83 to 0.45%, and from 2.58 to 1.24%, respectively. Septic rTHA was independently associated with higher odds of mortality relative to aseptic (odds ratio (OR): 2.305, 95% confidence interval (CI): (2.014, 2.638), p < 0.0001). Increased ECI was associated with higher odds of mortality at both medium (OR: 5.147, 95% CI: (4.433,5.977), p < 0.0001) and high index scores (OR: 13.714, 95% CI: (11.519,16.326), p < 0.0001).

CONCLUSIONS

Mortality rates for both aseptic and septic rTHA have been declining over the past 20 years, potentially due to patient selection guidelines and advances in medical management. Our study confirms that the ECI is independently associated with increased inpatient mortality.

Safety and Efficacy of a Single-Stage versus Two-Stage Intramedullary Nailing for Synchronous Impending or Pathologic Fractures of Bilateral Femur for Oncologic Indications: A Systematic Review

Although intramedullary nail (IMN) fixation is the standard of care for most impending and/or complete pathologic fractures of the femur, the optimal timing/sequence of the IMN in cases of synchronous bilateral femoral disease in advanced cancer is not well established. Thus, we compared the outcomes of single-stage (SS) vs. two-stage (TS) IMN of the bilateral femur with a systematic review of the literature on this topic. Bilateral SS and TS IMN cases were identified from 14 studies extracted from four databases according to PRISMA guidelines. Safety (complications, reoperations, mortality, survival, blood loss, and transfusion) and efficacy (length of stay [LOS], time to start rehabilitation and adjuvant therapy, functional scores, and cost) were compared between the groups. A total of 156 IMNs in 78 patients (36 SS and 42 TS) were analyzed. There were one surgical (infection in TS requiring reoperation; p = 0.860) and fifteen medical complications (five in SS, ten in TS; p = 0.045), with SS being associated with lower rates of total and medical complications. Survival, intraoperative mortality, and postoperative same-admission mortality were similar. No cases of implant failure were reported. Data on LOS, rehabilitation, and adjuvant therapy were scarcely reported, although one study favored SS over TS. No study compared cost or functional scores. Our study is the largest and most comprehensive of its kind in supporting the safety and efficacy of a SS bilateral femur IMN approach in these select patients. Further investigations with higher levels of evidence are warranted to optimize treatment protocols for this clinical scenario.

Intramedullary Nailing with and without the Use of Bone Cement for Impending and Pathologic Fractures of the Humerus in Multiple Myeloma and Metastatic Disease

Although intramedullary nailing (IMN) is considered the standard of care for the surgical management of most femur metastatic diseases, the optimal treatment of metastatic humeral impending and/or pathologic fractures is still debatable. Moreover, the use of cemented humeral nails has not been thoroughly studied, and only a few small series have compared their results with uncemented nails. The purpose of this study was to compare the (1) survivorship, (2) functional outcomes, and (3) perioperative complications in patients receiving cemented versus uncemented humerus IMN for impending or complete pathologic fractures resulting from metastatic disease or multiple myeloma. We retrospectively reviewed 100 IMNs in 82 patients, of which 53 were cemented and 47 were uncemented. With a mean survival of 10 months (Cemented: 8.3 months vs. Uncemented: 11.6 months, p = 0.34), the mean Musculoskeletal Tumor Society (MSTS) scores increased from 42.4% preoperatively (Cemented: 40.2% vs. Uncemented: 66.7%, p = 0.01) to 89.2% at 3 months postoperatively (Cemented: 89.8% vs. Uncemented: 90.9%, p = 0.72) for the overall group (p < 0.001). Both cohorts yielded comparable complication rates (overall [22.6% vs. 19.1%)], surgical ([11.3% vs. 4.3%], and medical [13.2% vs. 14.9%], all p > 0.05), but estimated blood loss was significantly higher in the cemented group (203 mL vs. 126 mL, p = 0.003). Thus, intramedullary nailing, with and without cement augmentation in select patients, is a relatively safe and effective therapeutic modality for metastatic humeral disease with similar clinical outcomes and acceptable complication rates. While controlling for possible selection bias, larger-scale, higher-level studies are warranted to validate our results.

Increasing trend toward joint-preserving procedures for hip osteonecrosis in the United States from 2010 to 2019

INTRODUCTION

The incidence of osteonecrosis of the femoral head is estimated at about 10 to 20,000 patients annually, and, when left untreated, 80% or more of cases progress to femoral head collapse. A series of joint-preserving procedures have been developed to prevent/delay the need for hip arthroplasty. The aim of this study was to provide a five-year update: (1) evaluating temporal trends of arthroplasty vs. joint-preservation techniques such as core decompression, bone grafting, osteotomies, and arthroscopy; (2) determining proportions of procedures in patients aged less than vs. over 50 years; and (3) quantifying rates of specific operative techniques.

METHODS

A total of 10,334 patients diagnosed with osteonecrosis of the femoral head and having received hip surgery were identified from a nationwide database between 1 January 2010 and 31 December 2019, by using the International Classification of Disease, the Ninth/Tenth revision (ICD-9/10) codes. The percentage of patients managed by each operative procedure was calculated annually. To identify trends, patients were grouped by age under/over 50 years and divided into a joint-preserving and a non-joint-preserving (arthroplasty) group. Chi-squared tests were performed to compare the total number of procedures per year.

RESULTS

Rates of arthroplasty far exceeded those for joint-preserving procedures. However, from 2015 to 2019, significantly more joint-preserving procedures were performed than in 2010 to 2014 (4.3% vs. 3.0%, P < 0.001). Significantly more joint-preserving procedures were performed in patients aged < 50 years relative to those ≥ 50 years (7.56% vs. 1.86%, P < 0.001). Overall, total hip arthroplasty was the most common procedure (9,814; 94.97%) relative to core decompression (331; 3.20%), hemiarthroplasty/resurfacing (102; 0.99%), bone grafting (48; 0.46%), and osteotomy (5; 0.05%).

CONCLUSION

Management of patients who have osteonecrosis of the femoral head continues to be predominantly arthroplasty procedures, specifically, total hip arthroplasty. Our findings suggest a small, but significant trend toward increased joint-preserving procedures, especially in patients under 50 years. In particular, the proportion of patients receiving core decompression has increased significantly from 2015 to 2019 relative to prior years.

World Trade Center dust exposure promotes cancer in PTEN-deficient mouse prostates

During the 9/11 attacks individuals were exposed to World Trade Center (WTC) dust which contained a complex mixture of carcinogens. Epidemiological studies have revealed the increased incidence of prostate and thyroid cancer in WTC survivors and responders. While reports have shown that WTC-dust associates with the increased prevalence of inflammatory related disorders, studies to date have not determined whether this exposure impacts cancer progression. In this study, we have used genetically engineered mouse (GEM) models with prostate specific deletion of the PTEN tumor suppressor to study the impact of WTC-dust exposure on deposition of dust particles, inflammation, and cancer progression. In normal C57/BL6 mice, dust exposure increased cellular expression of inflammatory genes with highest levels in the lung and peripheral blood. In normal and tumor bearing GEM mice, increased immune cell infiltration to the lungs was observed. Pathological evaluation of mice at different time points showed that WTC-dust exposure promoted PI3K-AKT activation, increased epithelial proliferation and acinar invasion in prostates with heterozygous and homozygous Pten loss. Using autochthonous and transplant GEM models of prostate cancer we demonstrated that dust exposure caused reduced survival as compared to control cohorts. Finally, we used imaging mass cytometry (IMC) to detect elevated immune cell infiltration and cellular expression of inflammatory markers in prostate tumors isolated from human WTC survivors. Collectively, our study shows that chronic inflammation, induced by WTC dust exposure, promotes more aggressive cancer in genetically predisposed prostates and potentially in patients.

The Psychological Well-Being of Medical Versus Dental GME Residents During the COVID 19 Pandemic: A Cross-Sectional Study

Purpose

Trainees are facing isolation and burnout, due to the fear of contracting and transmitting novel coronavirus-19 (COVID-19). There has been a reduction in clinical activities of residents. The purpose of this paper is to measure and compare the psychological well-being of dental versus medical residents during the COVID-19 outbreak.

Methods

This is a cross-sectional study whereby trainees of a hospital in New York City were sent a questionnaire. Participants were from the dental and medical departments. Psychological measures of depression and post traumatic stress disorder were assessed utilizing the Patient Health Questionnaire-9 (PHQ-9) and The Impact of Event Scale–Revised (IES-R) questionnaire. Other variables compared were age, gender, smoking status, living situation and comorbidities. Data analysis utilized chi-squared (X²) and t-tests. Bivariate correlation and linear regression analyses were also utilized.

Results

The survey was sent to 19 dental (Dental) and 171 medical (MD) residents. There were 66 participants. The response rate was 63.16 and 35.09% for the Dental and MD residents, respectively. The mean age for the Dental and MD residents, respectively, was 29.62 ± 2.09 and 34.82 ± 9.32 (P = .014). Eighty-one percent of the Dental respondents were male and 33.3% of the MD respondents were male (P < .001). The mean PHQ-9 score was 18.29 ± 2.88 vs 7.24 ± 7.41 for Dental and MD residents, respectively (P < .001). A higher score represents increased severity of depression. The Dental residents scored 61.9 ± 3.90 on the IES-R vs 30.36 ± 24.67 (P < .001). A higher score indicates a greater frequency of intrusive thoughts and avoidance. Forty-two percent of Dental and 13.3% of MD residents tested positive; 25% of Dental and 28.9% of MD residents self-reported symptoms for COVID-19. Being positive or symptomatic resulted in statistically significant higher IES-R and PHQ-9 scores.

Conclusions

Dental residents and being positive or symptomatic for COVID-19 resulted in higher PHQ-9 and IES-R scores. Being aware of the impact of COVID-19 is an important step in providing intervention.

Attitudes of black South Africans concerning organ donation

The availability of donor organs was analyzed following the placement of a transplant coordinator in Ga-Rankuwa Hospital's kidney transplant program. From February 1, 1992, to January 6, 1994, 44 brain-dead potential donors were identified. In 20 of those cases, relatives could not be reached to acquire consent for donation of cadaveric organs. In the remaining 24 cases, an intensive care resident together with a transplant coordinator obtained consent for 9 potential donors. Over the same period, 119 (80%) of living-related potential donors who had been approached stated that they were willing to donate a kidney. This outcome suggests that among blacks, altruism is a positive factor for acquiring consent for organ donation. Public education is required to correct ignorance, misconception, and cultural beliefs regarding cadaveric donation.

The renal transplant score: A different way of evaluating renal transplant pathology

The renal transplant is a notoriously difficult organ to assess for pathology. Radionuclide imaging can help, but, although sensitive, the evaluation is not very specific. For this reason, a different approach was used to examine renal images and results were correlated with histology. The transplant score is determined from images of perfusion and function on certain criteria such as time of appearance of the kidney after tracer injection, intensity of background, size and homogeneity of tracer uptake by the kidney. Although small, the pilot study could distinguish between hyperacute rejection, acute rejection, chronic rejection and cyclosporin toxicity.

The use of ELISA and nonradioactive DNA hybridization assays for the detection of human cytomegalovirus

A hybridization assay using a biotinylated DNA probe was compared to both ELISA and direct isolation methods for detecting human cytomegalovirus (HCMV). The biotin labeled HCMV AD 169 HindIII-O-DNA fragment was used in a dot-blot assay to screen for the presence of HCMV in 186 urine specimens obtained from kidney transplant patients. The biotinylated HCMV HindIII-O probe could detect 3 log10 TCID50 units of HCMV. Urine specimens were also examined for the presence of HCMV by either ELISA or direct isolation of virus in tissue culture. The HindIII-O fragment detected 12 of 20 culture positive samples (sensitivity, 60%). There were 5 samples which were probe positive and cell culture negative (specificity, 97%). The ELISA assay also detected 12 of 20 culture positive samples (sensitivity, 60%). Eight samples were ELISA positive, cell culture negative (specificity, 95%). Seven specimens were positive by all three criteria. Five specimens which were both ELISA positive and probe positive were cell culture negative. The ELISA positive, probe positive, culture negative specimens originated from patients who gave a culture positive specimen within 10 days of the original sample. The combination of probe and ELISA assays detected 16 of the 20 culture positive specimens (sensitivity, 80%). The combined use of biotinylated DNA probes and ELISA allows the detection of HCMV in urine specimens with good sensitivity and specificity.