Asthma morbidity measures across Black ethnic subgroups

BACKGROUND

Black adults are disproportionately affected by asthma and are often considered a homogeneous group in research studies despite cultural and ancestral differences.

OBJECTIVE

We sought to determine if asthma morbidity differs across adults in Black ethnic subgroups.

METHODS

Adults with moderate-severe asthma were recruited across the continental United States and Puerto Rico for the PREPARE (PeRson EmPowered Asthma RElief) trial. Using self-identifications, we categorized multiethnic Black (ME/B) participants (n = 226) as Black Latinx participants (n = 146) or Caribbean, continental African, or other Black participants (n = 80). African American (AA/B) participants (n = 518) were categorized as Black participants who identified their ethnicity as being American. Baseline characteristics and retrospective asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids [SCs], emergency department/urgent care [ED/UC] visits, hospitalizations) were compared across subgroups using multivariable regression.

RESULTS

Compared with AA/B participants, ME/B participants were more likely to be younger, residing in the US Northeast, and Spanish speaking and to have lower body mass index, health literacy, and <1 comorbidity, but higher blood eosinophil counts. In a multivariable analysis, ME/B participants were significantly more likely to have ED/UC visits (incidence rate ratio [IRR] = 1.34, 95% CI = 1.04-1.72) and SC use (IRR = 1.27, 95% CI = 1.00-1.62) for asthma than AA/B participants. Of the ME/B subgroups, Puerto Rican Black Latinx participants (n = 120) were significantly more likely to have ED/UC visits (IRR = 1.64, 95% CI = 1.22-2.21) and SC use for asthma (IRR = 1.43, 95% CI = 1.06-1.92) than AA/B participants. There were no significant differences in hospitalizations for asthma among subgroups.

CONCLUSIONS

ME/B adults, specifically Puerto Rican Black Latinx adults, have higher risk of ED/UC visits and SC use for asthma than other Black subgroups.

Critical Care Management of Severe Asthma Exacerbations

Severe asthma exacerbations, including near-fatal asthma (NFA), have high morbidity and mortality. Mechanical ventilation of patients with severe asthma is difficult due to the complex pathophysiology resulting from severe bronchospasm and dynamic hyperinflation. Life-threatening complications of traditional ventilation strategies in asthma exacerbations include the development of systemic hypotension from hyperinflation, air trapping, and pneumothoraces. Optimizing pharmacologic techniques and ventilation strategies is crucial to treat the underlying bronchospasm. Despite optimal pharmacologic management and mechanical ventilation, the mortality rate of patients with severe asthma in intensive care units is 8%, suggesting a need for advanced non-pharmacologic therapies, including extracorporeal life support (ECLS). This review focuses on the pathophysiology of acute asthma exacerbations, ventilation management including non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV), the pharmacologic management of acute asthma, and ECLS. This review also explores additional advanced non-pharmacologic techniques and monitoring tools for the safe and effective management of critically ill adult asthmatic patients.

Single-institution experience of extracorporeal membrane oxygenation for near-fatal asthma

Near-fatal asthma (NFA) is the most severe presentation of asthma. It is characterized by hypoxemic and hypercapnic respiratory failure requiring ventilatory assistance, including non-invasive ventilation and mechanical ventilation. However, NFA has a high mortality rate despite conventional therapy. Extracorporeal membrane oxygenation (ECMO) is a treatment modality that is increasingly being utilized as rescue therapy in patients with NFA that is refractory to mechanical ventilation. Prior analyses of the international Extracorporeal Life Support Organization (ELSO) registry data showed a survival rate of over 83% in patients placed on venovenous (VV) ECMO for NFA, but with notable rate of hemorrhagic complications. We report seven cases of adults with NFA requiring ECMO support at our large quaternary care institution between the years 2019 and 2022. All seven patients presented with respiratory failure in the setting of asthma exacerbation that progressed despite standard pharmacotherapy and mechanical ventilation. All patients survived to hospital discharge after ECMO support without hemorrhagic complications, highlighting the effectiveness and safety of ECMO when appropriately used in this population.

Preference for and impact of telehealth vs in-person asthma visits among Black and Latinx adults

BACKGROUND

Black and Latinx adults experience disproportionate asthma-related morbidity and limited specialty care access. The severe acute respiratory syndrome coronavirus 2 pandemic expanded telehealth use.

OBJECTIVE

To evaluate visit type (telehealth [TH] vs in-person [IP]) preferences and the impact of visit type on asthma outcomes among Black and Latinx adults with moderate-to-severe asthma.

METHODS

For this PREPARE trial ancillary study, visit type preference was surveyed by e-mail or telephone post-trial. Emergency medical record data on visit types and asthma outcomes were available for a subset (March 2020 to April 2021). Characteristics associated with visit type preferences, and relationships between visit type and asthma outcomes (control [Asthma Control Test] and asthma-related quality of life [Asthma Symptom Utility Index]), were tested using multivariable regression.

RESULTS

A total of 866 participants consented to be surveyed, with 847 respondents. Among the participants with asthma care experience with both visit types, 42.0% preferred TH for regular checkups, which associated with employment (odds ratio [OR] = 1.61; 95% confidence interval [CI], 1.09-2.39; P = .02), lower asthma medication adherence (OR = 1.06; 95% CI, 1.01-1.11; P = .03), and having more historical emergency department and urgent care asthma visits (OR = 1.10 for each additional visit; 95% CI, 1.02-1.18; P = .02), after adjustment. Emergency medical record data were available for 98 participants (62 TH, 36 IP). Those with TH visits were more likely Latinx, from the Southwest, employed, using inhaled corticosteroid-only controller therapy, with lower body mass index, and lower self-reported asthma medication adherence vs those with IP visits only. Both groups had comparable Asthma Control Test (18.4 vs 18.9, P = .52) and Asthma Symptom Utility Index (0.79 vs 0.84, P = .16) scores after adjustment.

CONCLUSION

TH may be similarly efficacious as and often preferred over IP among Black and Latinx adults with moderate-to-severe asthma, especially for regular checkups.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02995733.

Lung Transplantation for COVID-19 Pulmonary Sequelae

BACKGROUND

The role of lung transplantation for coronavirus disease 2019 (COVID-19)-related lung failure is evolving as the pandemic persists.

METHODS

From January 2021 to April 2022, 20 patients (median age 62 y; range 31-77) underwent lung transplantation for COVID-related lung failure at our institution. We reviewed their clinical and intraoperative characteristics and early outcomes including postoperative complications.

RESULTS

Eleven patients (55%) had chronic lung disease when they contracted COVID-19. All 20 patients required hospitalization for antivirus treatment. Median lung allocation score was 74.7 (33.1-94.0). Thirteen patients (65%) underwent single-lung transplants, and 7 patients (35%) underwent double-lung transplants. Concomitant coronary artery bypass graft surgery was performed in 2 (10%) patients because of severe coronary artery disease. Postoperatively, venovenous extracorporeal membrane oxygenation was needed in 3 patients (15%) because of severe primary graft dysfunction; all were eventually weaned. Ten patients (50%) experienced deep venous thrombosis, and 1 eventually developed a major pulmonary embolus. The median intensive care unit stay and hospital stays were 6.5 d (3-44) and 18 d (7-77), respectively. During a median follow-up of 201 d (47-418), we experienced 1 late mortality due to COVID-19-related myocarditis. Among the 13 patients with single-lung transplant, 5 demonstrated improvement in their native lungs.

CONCLUSIONS

Lung transplantation yielded favorable early outcomes in a heterogeneous patient cohort that included older patients, obese patients, and patients with coronary artery disease or preexisting chronic lung disease. Our data also shed light on the transforming role of lung transplantation for the pulmonary sequelae of a complex multisystem COVID-19 disorder.

Long-term safety and efficacy of tezepelumab in people with severe, uncontrolled asthma (DESTINATION): a randomised, placebo-controlled extension study

BACKGROUND

Tezepelumab is a human monoclonal antibody that blocks thymic stromal lymphopoietin. The drug has been tested previously in the phase 3 NAVIGATOR (NCT03347279) and SOURCE (NCT03406078) studies, and was subsequently approved as a treatment for severe asthma. This extension study recruited from NAVIGATOR and SOURCE and aimed to evaluate the long-term safety and efficacy of tezepelumab in individuals with severe, uncontrolled asthma.

METHODS

DESTINATION was a phase 3, multicentre, randomised, double-blind, placebo-controlled, long-term extension study. The study was done across 182 sites (including hospitals, clinics, medical centres, clinical trial centres, and private practices) in 18 countries. Participants (aged 12-80 years) were required to have good treatment compliance in the parent study. Randomisation was stratified by the parent study and all participants were re-randomised. Those who were previously randomised to receive tezepelumab in either parent study continued treatment of subcutaneous tezepelumab (210 mg every 4 weeks); those who were previously randomised to receive placebo in either parent study were re-randomised 1:1 to receive either subcutaneous tezepelumab (210 mg every 4 weeks) or placebo (every 4 weeks) using a randomisation list prepared by a computerised system. Total treatment duration (including the parent studies) was 104 weeks for all groups. Participants, investigators, and site staff were masked to treatment assignment. The primary endpoints were exposure-adjusted incidence of adverse events and serious adverse events and the secondary endpoint was the annualised asthma exacerbation rate; these were assessed from week 0 of the parent studies to week 104 of DESTINATION in all participants who were randomised and who received at least one dose of tezepelumab or placebo in either of the parent studies. The trial is registered with ClinicalTrials.gov, NCT03706079, and is closed to new participants.

FINDINGS

Participants were recruited between Jan 7, 2019, and Oct 15, 2020. For individuals who initially received tezepelumab (n=528) in NAVIGATOR, incidence of adverse events over 104 weeks was 49·62 (95% CI 45·16 to 54·39) per 100 patient-years, compared with 62·66 (56·93 to 68·81) for those receiving placebo (n=531; difference -13·04, 95% CI -17·83 to -8·18). For serious adverse events, incidence was 7·85 (6·14 to 9·89) per 100 patient-years for individuals who initially received tezepelumab and 12·45 (9·97 to 15·35) for those who received placebo (difference -4·59, -7·69 to -1·65). In SOURCE, incidence of adverse events was 47·15 (36·06 to 60·56) per 100 patient-years for those who initially received tezepelumab (n=74) and 69·97 (54·54 to 88·40) for those who received placebo (n=76; difference -22·82, -34·77 to -10·01). For serious adverse events, incidence was 13·14 (7·65 to 21·04) per 100 patient-years for those who initially received tezepelumab and 17·99 (10·66 to 28·44) for those who received placebo (difference -4·85, -14·88 to 4·53). Tezepelumab reduced the annualised asthma exacerbation rate over 104 weeks compared with placebo. In participants initially from NAVIGATOR, the annualised asthma exacerbation rate ratio over 104 weeks was 0·42 (95% CI 0·35 to 0·51); in those initially from SOURCE, the ratio over 104 weeks was 0·61 (0·38 to 0·96).

INTERPRETATION

Tezepelumab treatment was well tolerated for up to 2 years and resulted in sustained, clinically meaningful reductions in asthma exacerbations in individuals with severe, uncontrolled asthma. These findings are consistent with previous randomised, placebo-controlled studies and show the long-term safety and sustained efficacy of tezepelumab in individuals with severe, uncontrolled asthma.

FUNDING

AstraZeneca and Amgen.

Caribbean Latinx with moderate-severe asthma bear greater asthma morbidity than other Latinx

BACKGROUND

Hispanic/Latinx (HL) ethnicity encompasses racially and culturally diverse subgroups. Studies suggest that Puerto Ricans (PR) may bear greater asthma-related morbidity than Mexicans, but these were conducted in children or had limited clinical characterization.

OBJECTIVES

This study sought to determine whether disparities in asthma morbidity exist among HL adult subgroups.

METHODS

Adults with moderate-severe asthma were recruited from US clinics, including from Puerto Rico, for the Person Empowered Asthma Relief (PREPARE) trial. Considering the shared heritage between PR and other Caribbean HL (Cubans and Dominicans [C&D]), the investigators compared baseline self-reported clinical characteristics between Caribbean HL (CHL) (PR and C&D: n = 457) and other HLs (OHL) (Mexicans, Spaniards, Central/South Americans; n = 141), and between CHL subgroups (C&D [n = 56] and PR [n = 401]). This study compared asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids, emergency department/urgent care (ED/UC) visits, hospitalizations, health care utilization) through negative binomial regression.

RESULTS

CHL compared to OHL were similar in age, body mass index, poverty status, blood eosinophils, and fractional exhaled nitric oxide but were prescribed more asthma controller therapies. Relative to OHL, CHL had significantly increased odds of asthma exacerbations (odds ratio [OR]: 1.84; 95% CI: 1.4-2.4), ED/UC visits (OR: 1.88; 95% CI: 1.4-2.5), hospitalization (OR: 1.98; 95% CI: 1.06-3.7), and health care utilization (OR: 1.91; 95% CI: 1.44-2.53). Of the CHL subgroups, PR had significantly increased odds of asthma exacerbations, ED/UC visits, hospitalizations, and health care utilization compared to OHL, whereas C&D only had increased odds of exacerbations compared to OHL. PR compared to C&D had greater odds of ED/UC and health care utilization.

CONCLUSIONS

CHL adults, compared with OHL, adults reported nearly twice the asthma morbidity; these differences are primarily driven by PR. Novel interventions are needed to reduce morbidity in this highly impacted population.

Spine Patient Satisfaction With Telemedicine During the COVID-19 Pandemic: A Cross-Sectional Study

STUDY DESIGN

Original research, cross-sectional study.

OBJECTIVES

Evaluate patient satisfaction with spine care delivered via telemedicine. Identify patient- and visit-based factors associated with increased satisfaction and visit preference.

METHODS

Telemedicine visits with a spine surgeon at 2 practices in the United States between March and May 2020 were eligible for inclusion in the study. Patients were sent an electronic survey recording overall satisfaction, technical or clinical issues encountered, and preference for a telemedicine versus an in-person visit. Factors associated with poor satisfaction and preference of telemedicine over an in-person visit were identified using multivariate logistic regression.

RESULTS

A total of 772 responses were collected. Overall, 87.7% of patients were satisfied with their telemedicine visit and 45% indicated a preference for a telemedicine visit over an in-person visit if given the option. Patients with technical or clinical issues were significantly less likely to achieve 5 out of 5 satisfaction scores and were significantly more likely to prefer an in-person visit. Patients who live less than 5 miles from their surgeon's office and patients older than 60 years were also significantly more likely to prefer in-person visits.

CONCLUSIONS

Spine telemedicine visits during the COVID-19 pandemic were associated with high patient satisfaction. Additionally, 45% of respondents indicated a preference for telemedicine versus an in-patient visit in the future. In light of these findings, telemedicine for spine care may be a preferable option for a subset of patients into the future.

Reliever-Triggered Inhaled Glucocorticoid in Black and Latinx Adults with Asthma

BACKGROUND

Black and Latinx patients bear a disproportionate burden of asthma. Efforts to reduce the disproportionate morbidity have been mostly unsuccessful, and guideline recommendations have not been based on studies in these populations.

METHODS

In this pragmatic, open-label trial, we randomly assigned Black and Latinx adults with moderate-to-severe asthma to use a patient-activated, reliever-triggered inhaled glucocorticoid strategy (beclomethasone dipropionate, 80 μg) plus usual care (intervention) or to continue usual care. Participants had one instructional visit followed by 15 monthly questionnaires. The primary end point was the annualized rate of severe asthma exacerbations. Secondary end points included monthly asthma control as measured with the Asthma Control Test (ACT; range, 5 [poor] to 25 [complete control]), quality of life as measured with the Asthma Symptom Utility Index (ASUI; range, 0 to 1, with lower scores indicating greater impairment), and participant-reported missed days of work, school, or usual activities. Safety was also assessed.

RESULTS

Of 1201 adults (603 Black and 598 Latinx), 600 were assigned to the intervention group and 601 to the usual-care group. The annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the intervention group and 0.82 (95% CI, 0.73 to 0.92) in the usual-care group (hazard ratio, 0.85; 95% CI, 0.72 to 0.999; P = 0.048). ACT scores increased by 3.4 points (95% CI, 3.1 to 3.6) in the intervention group and by 2.5 points (95% CI, 2.3 to 2.8) in the usual-care group (difference, 0.9; 95% CI, 0.5 to 1.2); ASUI scores increased by 0.12 points (95% CI, 0.11 to 0.13) and 0.08 points (95% CI, 0.07 to 0.09), respectively (difference, 0.04; 95% CI, 0.02 to 0.05). The annualized rate of missed days was 13.4 in the intervention group and 16.8 in the usual-care group (rate ratio, 0.80; 95% CI, 0.67 to 0.95). Serious adverse events occurred in 12.2% of the participants, with an even distribution between the groups.

CONCLUSIONS

Among Black and Latinx adults with moderate-to-severe asthma, provision of an inhaled glucocorticoid and one-time instruction on its use, added to usual care, led to a lower rate of severe asthma exacerbations. (Funded by the Patient-Centered Outcomes Research Institute and others; PREPARE ClinicalTrials.gov number, NCT02995733.).

Bone Graft Options in Spinal Fusion: A Review of Current Options and the Use of Mesenchymal Cellular Bone Matrices

BACKGROUND

Spinal fusion is the mainstay treatment for various spinal conditions ranging from lumbar and cervical stenosis to degenerative spondylolisthesis as well as extensive deformity corrections. A new emerging category of allograft is cellular bone matrices (CBMs), which take allogeneic mesenchymal stem cells and incorporate them into an osteoconductive and osteoinductive matrix. This study reviewed the current spinal fusion options and new emerging treatment options.

METHODS

Articles were searched using PubMed. The search included English publications since January 1, 2014, using the search terms "cellular bone matrix," "mesenchymal stem cells spinal fusion," "spinal arthrodesis AND mesenchymal stem cells," and "spine fusion AND cellular bone matrix."

RESULTS

Spinal fusion is accomplished through the use of allografts, autografts, and bone graft substitutes in combination or alone. An emerging category of allograft is CBMs, in which an osteoconductive and osteoinductive matrix is filled with mesenchymal stem cells. Studies demonstrate that CBMs have achieved equivalent or better fusion rates compared with traditional options for anterior cervical discectomy and fusions and posterolateral lumbar fusions; however, the studies have been retrospective and lacking control groups and therefore not ideal.

CONCLUSIONS

Many treatment options have been successfully used in spinal fusion. Newer allografts such as CBMs have shown promising results in both animal and clinical studies. Further research is needed to determine the therapeutic dose of mesenchymal stem cells delivered within CBMs.

Venous thromboembolism in lung transplant recipients real world experience from a high volume center

BACKGROUND

Venous thromboembolism (VTE) post lung transplantation is common and has been associated with worse post transplant survival. We report a comprehensive single center review of VTE incidence in the first post transplant year, investigate modifiable risk factors and assess impact on short term outcomes.

METHODS

Retrospective review of all lung transplant recipients between August 2016 to 2018 at Temple University Hospital. Patients were followed for 1 year post transplant. All patients were screened for deep venous thrombosis (DVT) within the first 2 weeks with a venous duplex study. Pre transplant, intra operative, post operative variables, and peri-operative practice patterns were compared between VTE positive and VTE negative groups. Logistic regression modeling was used to identify risk factors for early VTE (VTE within 30 days after transplant).

RESULTS

A total of 235 patients were included in the study, 58 patients (24.7%) developed a VTE in the first post transplant year. Median time to diagnosis was 17 days. Of the patients with VTE, 76% had an isolated DVT, 13.5 % had an isolated pulmonary embolism (PE), and 10.3% had concomitant DVT and PE. In a multivariate logistic regression model, cardiopulmonary bypass (CPB) (OR 1.93 p = 0.015) and interruption of VTE prophylaxis (OR 4.42 p < 0.0001) were predictive of early VTE.

CONCLUSION

VTE post lung transplant is common despite the use of prophylactic anticoagulation. CPB use and interruption of DVT prophylaxis are risk factors for early post transplant VTE. Measures to ensure consistent and uninterrupted prophylaxis may help decrease VTE incidence after lung transplantation.

An Investigation of a Novel Dural Repair Device for Intraoperative Incidental Durotomy Repair

Incidental durotomies, or dural tears, can be very difficult and time consuming to repair properly when they are encountered in confined spaces. A novel dural repair device was developed to address these situations. In this paper, the novel device was assessed against the use of traditional tools and techniques for dural repairs in two independent studies using an intricate clinical simulation model. The aim was to examine the results of the two assessments and link the outcomes to the clinical use of the novel device in the operating room. The novel device outperformed conventional techniques as measured by dural repair time, CSF leak pressure and nerve root avoidance in the simulation. The results were generally replicable clinically, however, numerous additional clinical scenarios were also encountered that the simulation model was unable to capture due to various inherent limitations. The simulation model design, potential contributors to watertightness, clinical experiences, and limitation are discussed.

Guiding therapeutic plasma exchange for antibody-mediated rejection treatment in lung transplant recipients - a retrospective study

Antibody-Mediated Rejection (AMR) due to donor-specific antibodies (DSA) is associated with poor outcomes after lung transplantation. Currently, there are no guidelines regarding the selection of treatment protocols. We studied how DSA characteristics including titers, C1q, and mean fluorescence intensity (MFI) values in undiluted and diluted sera may predict a response to therapeutic plasma exchange (TPE) and inform patient prognosis after treatment. Among 357 patients consecutively transplanted without detectable pre-existing DSAs between 01/01/16 and 12/31/18, 10 patients were treated with a standardized protocol of five TPE sessions with IVIG. Based on DSA characteristics after treatment, all patients were divided into three groups as responders, partial responders, and nonresponders. Kaplan-Meier Survival analyses showed a statistically significant difference in patient survival between those groups (P = 0.0104). Statistical analyses showed that MFI in pre-TPE 1:16 diluted sera was predictive of a response to standardized protocol (R²  = 0.9182) and patient survival (P = 0.0098). Patients predicted to be nonresponders who underwent treatment with a more aggressive protocol of eight TPE sessions with IVIG and bortezomib showed improvements in treatment response (P = 0.0074) and patient survival (P = 0.0253). Dilutions may guide clinicians as to which patients would be expected to respond to a standards protocol or require more aggressive treatment.

A randomized, open-label, pragmatic study to assess reliever-triggered inhaled corticosteroid in African American/Black and Hispanic/Latinx adults with asthma: Design and methods of the PREPARE trial

BACKGROUND

Asthma prevalence, morbidity, and mortality disproportionately impact African American/Black (AA/B) and Hispanic/Latinx (H/L) communities. Adherence to daily inhaled corticosteroid (ICS), recommended by asthma guidelines in all but the mildest cases of asthma, is generally poor. As-needed ICS has shown promise as a patient-empowering asthma management strategy, but it has not been rigorously studied in AA/B or H/L patients or in a real-world setting. Design and Aim The PeRson EmPowered Asthma RElief (PREPARE) Study is a randomized, open-label, pragmatic study which aims to assess whether a patient-guided, reliever-triggered ICS strategy called PARTICS (Patient-Activated Reliever-Triggered Inhaled CorticoSteroid) can improve asthma outcomes in AA/B and H/L adult patient populations. In designing and implementing the study, the PREPARE research team has relied heavily on advice from AA/B and H/L Patient Partners and other stakeholders. Methods PREPARE is enrolling 1200 adult participants (600 AA/Bs, 600H/Ls) with asthma. Participants are randomized to PARTICS + Usual Care (intervention) versus Usual Care (control). Following a single in-person enrollment visit, participants complete monthly questionnaires for 15 months. The primary endpoint is annualized asthma exacerbation rate. Secondary endpoints include asthma control; preference-based quality of life; and days lost from work, school, or usual activities. Discussion The PREPARE study features a pragmatic design allowing for the real-world assessment of a patient-centered, reliever-triggered ICS strategy in AA/B and H/L patients. Outcomes of this study have the potential to offer powerful evidence supporting PARTICS as an effective asthma management strategy in patient populations that suffer disproportionately from asthma morbidity and mortality.

Clinical predictors and explant lung pathology of acute exacerbation of idiopathic pulmonary fibrosis

Background

Idiopathic pulmonary fibrosis (IPF) is characterised by constant threat of acute exacerbation of IPF (AE-IPF). It would be significant to identify risk factors of AE-IPF. We sought to determine the prognostic value of lung transplantation candidacy testing for AE-IPF and describe explant pathology of recipients with and without AE-IPF before lung transplantation.

Methods

Retrospective cohort study of 89 IPF patients listed for lung transplantation. Data included pulmonary function testing, echocardiography, right heart catheterisation, imaging, oesophageal pH/manometry and blood tests. Explanted tissue was evaluated by pulmonary pathologists and correlated to computed tomography (CT) findings.

Results

Out of 89 patients with IPF, 52 were transplanted during stable IPF and 37 had AE-IPF before transplantation (n=28) or death (n=9). There were no substantial differences in candidacy testing with and without AE-IPF. AE-IPF had higher rate of decline of forced vital capacity (FVC) (21±22% versus 4.8±14%, p=0.00019). FVC decline of >15% had a hazard ratio of 7.2 for developing AE-IPF compared to FVC decline of <5% (p=0.004). AE-IPF had more secondary diverse histopathology (82% versus 29%, p<0.0001) beyond diffuse alveolar damage. There was no correlation between ground-glass opacities (GGO) on chest CT at any point to development of AE-IPF (p=0.077), but GGO during AE-IPF predicted secondary pathological process beyond diffuse alveolar damage.

Conclusions

Lung transplantation candidacy testing including reflux studies did not predict AE-IPF besides FVC absolute decline. CT did not predict clinical or pathological AE-IPF. Secondary diverse lung pathology beyond diffuse alveolar damage was present in most AE-IPF, but not in stable IPF.

Transplant candidacy testing fails to predict acute exacerbation of IPF besides FVC absolute decline. Patients transplanted during acute exacerbation of IPF reveal multiple secondary lung histopathological processes beyond the expected DAD.https://bit.ly/3e1CPjO

Current incidence of adjacent segment pathology following lumbar fusion versus motion-preserving procedures: a systematic review and meta-analysis of recent projections

BACKGROUND CONTEXT

Lumbar fusion has shown to be an effective surgical management option when indicated, improving patient outcomes and functional status. However, concerns of adjacent segment pathology (ASP) due to reduced mobility at the operated segment have fostered the emergence of motion-preserving procedures (MPP).

PURPOSE

To assess rates of radiographic adjacent segment degeneration (ASDeg) and symptomatic adjacent segment disease (ASDis) as well as reoperation rates due to ASP in patients who have undergone lumbar fusion compared to motion-preservation for degenerative disorders.

STUDY DESIGN

Systematic Review and Meta-Analysis.

METHODS

Following PRISMA guidelines, a systematic review and meta-analysis was conducted to find current (1/2012-12/2019) retrospective cohort studies and randomized controlled trials evaluating rates of ASDeg, ASDis, and reoperations due to lumbar ASP.

RESULTS

A total of 1,751 patients (791 underwent fusion surgery and 960 motion-preserving procedures) in 19 publications were included in the final analysis. Overall incidence rates of ASDeg, ASDis, and reoperation rates were 27.8%, 7.6%, and 4.6%, respectively. Results showed no significant difference between the lumbar fusion versus MPP cohorts in incidence of ASDeg (36.4% vs. 19.2%, p: 0.06), ASDis (10.7% vs. 4.42%, p: 0.25), or reoperation due to ASP (7.40% vs. 1.80%, p: 0.19). Fixed-effects analysis revealed patients who underwent MPP had significantly lower odds of ASDeg (OR: 2.57, CI: 1.95, 3.35, p<.05) and reoperations (OR: 3.18, CI: 1.63, 6.21, p<.05) compared to lumbar fusion patients.

CONCLUSIONS

This meta-analysis revealed no statistically significant difference in incidence of ASDeg, ASDis, or reoperations due to ASP for patients after lumbar fusion versus MPP. Weighted analysis, however, showed that MPP patients had significantly lower odds of ASDeg and reoperations due to ASP. While previous studies have established the biomechanical efficacy of MPP on cadaveric models, further high-quality studies are required to evaluate the long-term consequences of these procedures on patient-reported outcomes, postoperative complications, and associated inpatient/outpatient costs.

Esophageal Evaluation for Patients Undergoing Lung Transplant Evaluation: What Should We Do for Evaluation and Management

Lung transplantation is a high-risk, but lifesaving, procedure for patients with end-stage lung disease. Although 1-year survival is high, long-term survival is not nearly as high, due mainly to acute and chronic rejection. Bronchiolitis obliterans syndrome is the most common type of chronic rejection and often leads to poor outcomes. For this reason, esophageal testing in the lung transplant population has become a major issue, and this article discusses the evidence behind esophageal testing, the importance of esophageal dysmotility gastroesophageal reflux disease, both acidic and nonacidic reflux, and aspiration and the treatment of these findings.

Social Media Presence Correlated with Improved Online Review Scores for Spine Surgeons

BACKGROUND

In the next decade, health care reimbursement will be more aligned to patient clinical outcomes. These outcomes are influenced by the patient's perceived opinion of his or her care. An evaluation into the role of surgeon demographics, social media (SM) accessibility, and office wait times was conducted to identify correlations with these among 3 online review platforms.

METHODS

A total of 206 (148 orthopedic, 58 neurosurgery trained) spine surgeons were included. Spine surgeon ratings and demographics data from 3 physician rating websites (Healthgrades.com [HG], Vitals.com, Google.com [G]) were collected in November 2019. Using the first 10 search results from G we then identified if the surgeons had publicly accessible Facebook, Twitter, or Instagram (IG) accounts.

RESULTS

The mean age of the cohort was 54.3 years (±9.40 years), and 28.2% had one form of publicly accessible SM. Having any SM was significantly correlated with higher scores on HG and G. An IG account was associated with significantly higher scores on all 3 platforms, and having a Facebook account correlated with significantly higher scores on HG in multivariate analysis. An office wait time between 16 and 30 minutes and >30 minutes was associated with worse scores on all 3 platforms (all P < 0.05). An academic practice was associated with higher scores on all 3 platforms (P < 0.05).

CONCLUSIONS

A shorter office wait time and an academic setting practice are associated with higher patient satisfaction scores on all 3 physician review websites. Accessible SM accounts are also associated with higher ratings on physician review websites, particularly IG.

The Military Medical System and Wartime Injuries to the Spine

War has historically been a major catalyst for advancement in military medical care and medicine in general. In our current conflicts, advances in battlefield medicine, evacuation techniques, and personal protective equipment have improved survival rates among members of the armed services. With increased survival, there has been increased prevalence of serious but nonfatal injuries, particularly from blunt and penetrating trauma. Blast injuries are the major cause of trauma and have both blunt and penetrating components. With respect to the spine, blasts have led to open, contaminated wounds that are complex and difficult to treat. Additionally, blasts have led to an increased incidence of lower lumbar burst fractures and lumbosacral dissociation. As these and other injuries are being seen more commonly during war, we must ensure that our military medical system is adapting to ensure we are taking care of our military personnel at the highest level.

Same-Day Anterior Cervical Discectomy and Fusion-Our Protocol and Experience: Same-Day Discharge After Anterior Cervical Discectomy and Fusion in Suitable Patients has Similarly Low Readmission Rates as Admitted Patients

Background

Outpatient anterior cervical discectomy and fusion (ACDF) is performed frequently, with studies demonstrating similar complication and readmission rates compared to traditional admission. Advantages include cost effectiveness, as well as lower risk of nosocomial infections and medical errors, which lead to quicker recovery and higher patient satisfaction. Protocols are needed to ensure that outpatient ACDF occurs safely. The objective of this study was to develop and implement a protocol with patient selection and discharge criteria for patients undergoing same-day discharge (SDD) ACDF and assess readmission rates.

Methods

A retrospective chart review was performed to identify patients undergoing 1 or 2 level primary ACDF between March 2016 and March 2017 who were eligible for SDD according to the institutional protocol (Figure 1, Table 2). Patients with identical surgery and discharge dates were grouped as SDD, and admitted patients were grouped as same-day admission (SDA). Using our electronic health record's analytics, readmissions in the 90-day postoperative period were identified.

Results

Of the 434 patients identified, 126 patients were SDD, and 308 were SDA. Baseline characteristics such as age, operative time, and time in the recovery room were significantly different between the 2 groups (Table 2). The average length of stay of admitted patients was 1.48 days, with 77% discharged on postoperative day 1. There was an overall, noninferior readmission rate of 0.8% in the SDD group compared to 0.6% in the SDA group (P = .86).

Conclusions

The results of this study support the feasibility of outpatient ACDF and add a patient selection and discharge criteria to the literature. Proper identification of suitable patients using our protocol results in a noninferior readmission rate, allowing surgeons to continue to safely perform these surgeries with a low readmission rate.

Level of Evidence

3.

Clinical Relevance

SDD is safe in the appropriate patient population.

High Altitude Is an Independent Risk Factor for Developing a Pulmonary Embolism, but Not a Deep Vein Thrombosis Following a 1- to 2-Level Lumbar Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

To identify if a 1- to 2-level posterior lumbar fusion at higher altitude is an independent risk factor for postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

A national Medicare database was queried for all patients undergoing 1- to 2-level lumbar fusions from 2005 to 2014. Those with a prior history of DVT, PE, coagulopathy, or peripheral vascular complications were excluded to better isolate altitude as the dependent variable. The groups were matched 1:1 based on age, gender, and comorbidities to limit potential cofounders. Using ZIP codes of the hospitals where the procedure occurred, we separated our patients into high (>4000 feet) and low (<100 feet) altitudes to investigate postoperative rates of DVTs and PEs at 90 days.

RESULTS

Compared with lumbar fusions performed at low-altitude centers, patients undergoing the same procedure at high altitude had significantly higher PE rates (P = .010) at 90 days postoperatively, and similar rates of 90-day postoperative DVTs (P = .078). There were no significant differences in age or comorbidities between these cohorts due to our strict matching process (P = 1.00).

CONCLUSION

Spinal fusions performed at altitudes >4000 feet incurred higher PE rates in the first 90 days compared with patients receiving the same surgery at <100 feet but did not incur higher rates of postoperative DVTs.

Suboptimal Age-Adjusted Lumbo-Pelvic Mismatch Predicts Negative Cervical-Thoracic Compensation in Obese Patients

Background

Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes.

Methods

Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index < 30kg/m²) or obese (body mass index ≥ 30). Age-adjusted ideals were calculated for sagittal vertical axis, spino-pelvic mismatch (PI-LL), pelvic tilt, and T1 pelvic angle using established formulas. Patients were stratified as meeting alignment ideals, being above ideal, or being below. Spinal alignment parameters included C0-C2, C2-C7, C2-T3, cervical thoracic pelvic angle, cervical sagittal vertical axis SVA, thoracic kyphosis, T1 pelvic angle, T1 slope, sagittal vertical axis, lumbar lordosis (LL), PI, PI-LL, pelvic tilt. Lower-extremity parameters included sacrofemoral angle, knee flexion (KA), ankle flexion (AA), pelvic shift (PS), and global sagittal angle (GSA). Independent t tests compared parameters between cohorts.

Results

Included: 800 obese, 800 nonobese patients. Both groups recruited lower-extremity compensation: sacrofemoral angle (P = .004), KA, AA, PS, GSA (all P < .001). Obese patients meeting age-adjusted PI-LL had greater lower-extremity compensation than nonobese patients: lower sacrofemoral angle (P = .002), higher KA (P = .008), PS (P = .002), and GSA (P = .02). Obese patients with PI-LL mismatch higher than age-adjusted ideal recruited greater lower-extremity compensation than nonobese patients: higher KA, AA, PS, GSA (all P < .001). Obese patients showed compensation through the cervical spine: increased C0-C2, C2-C7, C2-T3, and cervical sagittal vertical axis (all P < .001), high T1 pelvic angle (P < .001), cervical thoracic pelvic angle (P = .03), and T1 slope (P < .001), with increased thoracic kyphosis (P = .015) and decreased LL (P < .001) compared to nonobese patients with PI-LL larger than age-adjusted ideal.

Conclusions

Regardless of malalignment severity, obese patients recruited lower-limb compensation more than nonobese patients. Obese patients with PI-LL mismatch larger than age-adjusted ideal also develop upper-cervical and cervicothoracic compensation for malalignment.

Level of Evidence

III.

Clinical Relevance

Clinical evaluation should extend to the cervical spine in obese patients not meeting age-adjusted sagittal alignment ideals.

The Anterolateral Ligament (ALL) The New Ligament?

BACKGROUND

Despite advances in technology, graft rupture rates reported in the literature following anterior cruciate ligament (ACL) surgery range from 1.8% to 18%. Recent anatomical studies have identified a lateral structure, the anterolateral ligament (ALL), as a potential source of residual pivoting following ACL reconstruction. The purpose of this report is to review the history surrounding the ALL and recent anatomic studies, identify its biomechanical and clinical implications, and develop a practical approach to utilizing it during ACL reconstruction.

METHODS

An extensive review of the historical and current literature surrounding the identification of the ALL, its biomechanical function, reconstruction, and outcomes of ALL reconstruction was performed.

DISCUSSION

After the storm of media coverage surrounding the "new ligament" known as the ALL, much attention was focused on cadaveric dissection, biomechanical analysis, and reconstruction of this structure. Several techniques have been described, and currently studies are being performed both retrospectively and prospectively to evaluate the added benefit of ALL reconstruction to the rotational stability of the knee and outcomes after ACL reconstruction.

CONCLUSION

The ALL is a lateral-based structure that provides rotational stability to the knee in the presence of ACL deficiency. Reconstruction of this ligament may provide added benefit to stability and outcomes following ACL reconstruction in certain patient populations. Further randomized controlled trials are needed to elucidate the true benefit of ALL reconstruction and those patients who should undergo this added procedure.

Asthma: Diagnosis and Treatment

Asthma is an obstructive lung disease affecting >230 million people worldwide and a significant cause of morbidity in patients of all ages. It is a heterogeneous disease with a complex pathophysiology and phenotype. Diagnosis is made with thorough history-taking and physical examination, and the condition is characterised by variable airflow obstruction and airway hyper-responsiveness. Understanding the severity of the disease is important, and treatment is aimed at symptom control and the prevention of future exacerbations. Pharmacologic treatment with beta-agonists for intermittent asthma and inhaled corticosteroids and a combination of inhaled corticosteroids and long-acting beta-2 agonists for persistent asthma are recommended. Additional and alternative treatments with leukotriene modifiers, anticholinergics, biologics, and bronchial thermoplasty are also available. However, understanding an individual’s disease phenotype, endotype, and comorbidities is necessary for asthma treatment, with appropriate consultation with asthma specialists required for those with severe asthma.

Race and Gender Disparities are Evident in COPD Underdiagnoses Across all Severities of Measured Airflow Obstruction

The COPD Genetic Epidemiology (COPDGene®) study provides a rich cross-sectional dataset of patients with substantial tobacco smoke exposure, varied by race, gender, chronic obstructive pulmonary disease (COPD) diagnosis, and disease. We aimed to determine the influence of race, gender and Global initiative for chronic Obstructive Lung Disease (GOLD) stage on prevalence of prior COPD diagnosis at COPDGene® enrollment. Data from the complete phase 1 cohort of 10,192 participants were analyzed. Participants were non-Hispanic white and African-American, ≥45 years of age with a minimum of 10 pack years of cigarette smoking. Characterization upon enrollment included spirometry, demographics and history of COPD diagnosis determined by questionnaire. We evaluated the effects of race and gender on the likelihood of prior diagnosis of COPD and the interaction of race and GOLD stage, and gender and GOLD stage, as determined at study enrollment, on likelihood of prior diagnosis of COPD. We evaluated the 3-way interaction of race, gender and GOLD stage on prior diagnosis. African-Americans had higher odds of not having a prior COPD diagnosis at all GOLD stages of airflow obstruction versus non-Hispanic whites (p<0.0001). Women had higher odds of having a prior COPD diagnosis at all GOLD stages versus men (p<0.0001). Three-way interaction of race, gender and GOLD stage was not significant. African-Americans were less likely to have prior COPD regardless of the severity of airflow obstruction determined at study enrollment. Women were more likely to have a prior COPD diagnosis regardless of the severity of measured airflow obstruction. Race and gender are associated with significant disparities in COPD diagnosis.

A radiographic follow-up study of stand-alone-cage and graft-plate constructs for single-level anterior cervical discectomy and fusion

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) may be performed using an interbody cage or graft with an anterior plate or with a stand-alone (SA) interbody device without the anterior plate. The pros and cons of each vary. This study examined the radiographic outcome of the two techniques with a focus on implant subsidence.

METHODS

A retrospective review of cases of singe level ACDF by a single surgeon was undertaken. Medical and radiographic records were reviewed to determine subsidence, pre- and post-operative segmental and total lordosis in cohorts of both stand-alone and graft-and-plate constructs.

RESULTS

The post-operative radiographs of 35 patients with a SA cage were compared with 41 patients with an allograft block and anterior plate (graft and plate; GP). There was no significant difference in overall subsidence between the two groups although there was a trend toward less clinically significant subsidence (2 mm) in the SA group. For single level ACDF, a SA device appears to be comparable in terms of undesired subsidence.

CONCLUSIONS

Further studies with different implants and materials may offer further insight.

Arthroscopic Repair of Hip Labrum With Suture Anchors

The acetabular labrum and the transverse acetabular ligament form a continuous ring of tissue on the periphery of the acetabulum that provides a seal for the hip joint and increases the surface area to spread load distribution during weight-bearing. When a labral tear is suspected, the treatment algorithm always begins with conservative management, including physical therapy and nonsteroidal anti-inflammatory drugs. When conservative management fails, patients become candidates for arthroscopic labral repair. In the last 2 decades, the rate of hip arthroscopy has increased nearly 4-fold. However, as hip arthroscopy is performed more frequently, there is a need for a proper technique to minimize morbidity, because hip arthroscopy has been known to have a steep learning curve. We present a method for arthroscopic hip labral repair using suture anchors without a capsular repair. This Technical Note highlights our technique for labral repair, along with pearls and pitfalls of hip arthroscopy.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND

Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized.

METHODS

We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy.

RESULTS

We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary.

CONCLUSION

Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Thoracic juxtafacet cyst (JFC): a cause of spinal myelopathy

Spinal cord compression due to synovial facet cyst in thoracolumbar spine is rare. Several etiologies of juxtafacet cysts (JFCs) in this location have been discussed, particularly overload of the arthritic facet joints. Due to the narrow caliber of the thoracic spine, JFC in this location can present with radicular pain or progressive myelopathy. We report an interesting case of a 67 year-old woman who presented with the signs and symptoms of thoracic myelopathy. A left-sided T11/12 JFC was identified on MRI and CT scans correlating with her myelopathy. She experienced a substantial improvement in her myelopathic symptoms after surgical excision of the JFC. The presentation, etiology, and therapeutic aspects of JFC are discussed in detail.

KIT Inhibition by Imatinib in Patients with Severe Refractory Asthma

BACKGROUND

Mast cells are present in the airways of patients who have severe asthma despite glucocorticoid treatment; these cells are associated with disease characteristics including poor quality of life and inadequate asthma control. Stem cell factor and its receptor, KIT, are central to mast-cell homeostasis. We conducted a proof-of-principle trial to evaluate the effect of imatinib, a KIT inhibitor, on airway hyperresponsiveness, a physiological marker of severe asthma, as well as on airway mast-cell numbers and activation in patients with severe asthma.

METHODS

We conducted a randomized, double-blind, placebo-controlled, 24-week trial of imatinib in patients with poorly controlled severe asthma who had airway hyperresponsiveness despite receiving maximal medical therapy. The primary end point was the change in airway hyperresponsiveness, measured as the concentration of methacholine required to decrease the forced expiratory volume in 1 second by 20% (PC₂₀). Patients also underwent bronchoscopy.

RESULTS

Among the 62 patients who underwent randomization, imatinib treatment reduced airway hyperresponsiveness to a greater extent than did placebo. At 6 months, the methacholine PC₂₀ increased by a mean (±SD) of 1.73±0.60 doubling doses in the imatinib group, as compared with 1.07±0.60 doubling doses in the placebo group (P=0.048). Imatinib also reduced levels of serum tryptase, a marker of mast-cell activation, to a greater extent than did placebo (decrease of 2.02±2.32 vs. 0.56±1.39 ng per milliliter, P=0.02). Airway mast-cell counts declined in both groups. Muscle cramps and hypophosphatemia were more common in the imatinib group than in the placebo group.

CONCLUSIONS

In patients with severe asthma, imatinib decreased airway hyperresponsiveness, mast-cell counts, and tryptase release. These results suggest that KIT-dependent processes and mast cells contribute to the pathobiologic basis of severe asthma. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01097694 .).

The Role of Lobe Selection on FEV1 Response in Endobronchial Valve Therapy

Endobronchial valve (EBV) therapy has shown improvement in symptoms and lung function despite limited understanding of ideal patient selection. The impact of lobe selection on EBV therapy is unclear. We performed a retrospective analysis to determine the role of lobe selection and identify preprocedure predictors of response to EBV therapy. A total of 492 patients from the USA and Europe were randomized to EBV or control therapy. Spirometry and functional measurements were taken at baseline and 12 months later. At 365 days patients undergoing EBV therapy showed improvement in FEV1 change compared to control regardless of treatment to upper or lower. There was no difference in FEV1 change between the upper and lower lobe treatment groups ( 5 .99, 7.04, p = 0.75). In addition lobe selection was not identified as a significant modifier of FEV1 change in multiple linear regression analysis. Complete lobe fissure was the only significant predictor of FEV1 change (OR 4.14 (2.29, 7.47)). Our results suggest that lobe selection does not play a major role in EBV therapy response. Complete fissure status preprocedure has the greatest influence on FEV1 improvement. These results have implications on patient selection for current treatment and in future EBV studies.

Extensive ossification of the ligamentum flavum treated with triple stage decompression: a case report

BACKGROUND CONTEXT

Concurrent ossification of the ligamentum flavum (OLF) in the cervical, thoracic, and lumbar spine is a rare occurrence often associated with rheumatologic abnormalities. Although the pathology may be asymptomatic and discovered incidentally on routine imaging, compression of the cord and surrounding nerve roots can produce myelopathic or radiculopathic symptoms that are best treated with surgical decompression. There is limited evidence to support the use of single versus multistage decompression for tandem ossification at multiple levels, although several factors including duration of symptoms have been associated with a worse prognosis.

PURPOSE

To describe the presence of extensive symptomatic tandem OLF with concurrent ossification of the posterior longitudinal ligament (PLL) and its treatment using multistage decompression.

STUDY DESIGN

Case report and literature review.

METHODS

The authors describe a case of a 35-year-old woman with OLF extending from the cervical to lumbar spine and tandem ossification of the cervical PLL. Her initial presentation was significant for symptoms consistent with thoracic myelopathy in the absence of radiculopathic findings, and initial imaging also demonstrated disc herniation at L4-L5 and L5-S1.

RESULTS

The patient was first treated with a thoracic laminectomy and fusion from T7 to T11, given her back pain and thoracic myelopathy. Persistence of myelopathic symptoms necessitated further surgical intervention with a posterior cervical decompression and fusion from C3 to T1. Finally, after the appearance of radiculopathic findings, she underwent a microscopic L4-L5 laminectomy with improvements in her symptoms and ambulation.

CONCLUSIONS

Symptomatic OLF in non-East Asian population is a rare occurrence. Its etiology is likely multifactorial, involving both biomechanical and genetic factors. Although early detection and management are necessary, multistage decompression can be an effective intervention for extensive multilevel ossification.

A novel technique for reducing intertrochanteric hip fractures

Intertrochanteric hip fractures typically become deformed by the muscular and gravitational forces acting on the 2 main bony fragments. Traditional use of a fracture table for anatomical reduction normally corrects for the varus angulation, external rotation, and posterior sag that can occur, but, in select unstable and comminuted fractures, reduction may not be possible because of posterior sag and external rotation of the proximal fragment. These aspects of malreduction have been addressed in multiple ways, including use of unscrubbed assistants, crutches, internal rotation of the distal fragment by internal rotation of the foot, bumps and pads, and even intraoperative techniques. However, these techniques tend to adjust only 1 aspect of malreduction and may require intraoperative adjustment. In this article, we describe a novel surgical device, the pneumatic patient positioner, that can be used to address these deformities without the need for intraoperative adjustment.

Application of high hydrostatic pressure to eliminate Listeria monocytogenes from fresh pork sausage

Ground pork patties were inoculated separately with 10(9) CFU/g each of three strains of Listeria monocytogenes obtained from the National Animal Disease Center (NADC). Inoculated patties were packaged under vacuum and treated at 414 megapascals (60,000 lb/in2) for up to 60 min by high hydrostatic pressure (HHP). Survivors were determined by surface plating onto modified Oxford agar and trypticase soy agar with yeast extract, as well as by the most probable number method using Listeria enrichment broth. Average D values ranged from 1.89 to 4.17 min, depending on the strain, with the most virulent strain (reported by the NADC) having the highest D value. We tested the usefulness of applying a mild heat treatment at 50 degrees C, simultaneously with HHP, to lower these values. Average D values ranged from 0.37 to 0.63 min, depending on the strain. Thus, a 10-log10 reduction could be achieved even in the most pressure-resistant strain of L. monocytogenes by a 6-min application of heat and HHP. Shelf life studies were also conducted, with spoilage levels reached after 5 days of storage at 4 degrees C for controls versus 28 days for treated samples. Sensory evaluation of uninoculated grilled patties showed that panelists could not distinguish between those treated by heat and HHP and untreated controls (P<0.05). Thus, treatment by HHP in combination with mild heating can be used successfully to produce safer, longer-lasting fresh pork without affecting quality.

The effect of preoperative dexamethasone on the immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy

In this prospective, randomized, double-blind, placebo-controlled study, we examined the effect of preoperative dexamethasone on postoperative nausea and vomiting (PONV) and 24-h recovery in children undergoing tonsillectomy. One hundred thirty children, 2-12 yr of age, ASA physical status I or II, completed the study. All children received oral midazolam 0.5-0.6 mg/kg preoperatively. Anesthesia was induced with halothane and nitrous oxide in 60% oxygen and maintained with nitrous oxide and isoflurane. Intubation was facilitated by mivacurium 0.2 mg/kg. Each child received fentanyl 1 microgram/kg i.v. before initiation of surgery, as well as dexamethasone 1 mg/kg (maximal dose 25 mg) (steroid group) or an equal volume of saline (control group). Intraoperative fluids were standardized to 25-30 mL/kg lactated Ringer's solution. All tonsillectomies were performed under the supervision of one attending surgeon using an electrodissection technique. Postoperatively, fentanyl and acetaminophen with codeine elixir were administered as needed for pain. Rescue antiemetics were administered when a child experienced two episodes of retching and/or vomiting. Before home discharge, the incidence of PONV, need for rescue antiemetics, quality or oral intake, and analgesic requirements did not differ between groups. However, during the 24 h after discharge, more patients in the control group experienced PONV (62% vs 24% in the steroid group) and complained of poor oral intake. Additionally, more children in the control group (8% vs 0% in the steroid group) returned to the hospital for the management of PONV and/or poor oral intake. The preoperative administration of dexamethasone significantly decreased the incidence of PONV over the 24 h after home discharge in these children.

IMPLICATIONS

In this double blind, placebo-controlled study, we examined the efficacy of a single large dose (1 mg/kg; maximal dose 25 mg) of preoperative dexamethasone on posttonsillectomy postoperative nausea and vomiting (PONV) in children 2-12 yr of age undergoing tonsillectomy. Compared with placebo, dexamethasone significantly decreased the incidence of PONV in the 24 h after discharge, improved oral intake, decreased the frequency of parental phone calls, and resulted in no hospital returns for the management of PONV and/or poor oral intake.

Survival of heat-shocked Yersinia enterocolitica after irradiation in ground pork

Earlier studies conducted in our laboratory showed that heat-shocked Yersinia enterocolitica (45 degrees C for 60 min) are more resistant to a subsequent beat treatment of 55 or 60 degrees C in ground pork than cells not previously heat-shocked. The increased thermotolerance was partly attributed to the production of stress proteins. The present study was performed to determine if the stress proteins produced by heating could also afford protection to the cells to irradiation. As part of the study, the effect of air versus vacuum packaging on survival of Yersinia to irradiation was also examined. Irradiating the inoculated pork at 1.0 kGy was sufficient to completely eliminate this pathogen. The irradiation D value for both heat-shocked and non-heat-shocked cells was statistically the same (0.15 kGy). Neither heat-shocking Yersinia nor packaging under vacuum resulted in increased resistance of this organism to irradiation. In addition, no effect was seen in virulence of the cells after these treatments, when compared with controls.