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Introduction Colorectal cancer (CRC) is the third most common malignancy worldwide, with the second highest mortality rate among all malignancies. In this review, we describe the current utility of stool diagnostic biomarkers for CRC. Methods We reviewed stool-related tests and biomarker candidates for the diagnosis of CRC. The guaiac-based fecal occult blood test (gFOBT), fecal immunochemical test (FIT), and multitarget stool DNA test (MT-sDNA) have been used as clinical CRC screening tools. Although microRNAs, protein biomarkers, and microbiota have not yet been used in clinical CRC screening, there is growing evidence that they have the potential to function as CRC screening tools. Results According to the literature, the sensitivity of MT-sDNA for detecting CRC was 87.0%-100%, 32.7%-82.0% for advanced adenomas, and the specificity was 86.1%-95.2%. The sensitivity of individual biomarkers of fecal microRNAs for detecting CRC was 34.2%-88.2%, 73.0% for advanced adenomas, and the specificity was 68%-100%. The sensitivity of fecal protein markers for detecting CRC was 63.6-93.0%, 47.7%-69.4% for advanced adenomas, and the specificity was 38.3%-97.5%. The sensitivity of fecal microbiota for detecting CRC was 54.0-100.0%, 32.0%-48.3% for advanced adenomas, and the specificity was 61.3%-90.0%. Conclusion MT-sDNA is the most sensitive CRC screening test, and its sensitivity is the highest for advanced adenomas; however, its detection cost is high. MT-sDNA was more sensitive to CRC and advanced precancerous lesions than FIT, but compared to three years of MT-sDNA, annual FIT as the first non-invasive screening test for CRC seemed to be more effective.

Urinary diversion has always been a great challenge for urologists. There are many reasons and various methods for urinary diversion in clinical practice. In this report, who was diagnosed with a pelvic fracture complicated by enterostomy, urethral stricture, and bilateral inferior ureteral stricture. We performed laparoscopic bilateral ureterorectal reimplantation for this patient. Postoperatively, the patient recovered well and was able to perform volitional emptying. Bilateral DJ stents were removed under ureteroscopy at 6 weeks postoperatively. Six months after operation, no hydronephrosis was found in both kidneys. No increase of blood urea nitrogen (BUN) and creatinine were observed in renal function examination. It is clearly stated that in the present report a modified version of Heitz-Boyer-Houvelac uretero-rectostomy technique was carried out, as the technically demanding surgical step of retrorectal pull-through of the sigmoid colon was unneccesary given that the patient already had enterostomy. This surgery was performed laparoscopically and that the most relevant benefit for the patient was to avoid incontinent urinary diversion or possibly a more complex surgical procedure.

There are few reports of the successful delivery of unicornuate uterus pregnancy after laparoscopic cervical cerclage. Here, we report a 32-year-old woman, gravida 2 para 1, who had been admitted for unicornuate uterus pregnancy by a thawed frozen blastocyst transplantation. She accepted laparoscopic cervical cerclage for cervical insufficiency and delivered successfully via caesarean section at 35+3 weeks. Cervical cerclage may be used as an effective method of preventing abortion in unicornuate uterus pregnancy, while surgery by laparoscopy would be a better choice for patients with poor cervical condition. Obstetricians should pay due attention to complications such as uterine rupture for these high-risk patients.

Background Bevacizumab remains the most widely used and most thoroughly characterized angiogenesis inhibitor for a range of advanced cancers. Bevacizumab-bvzr (Zirabev®), a biosimilar of bevacizumab, was recently approved by the US Food and Drug Administration (FDA), which provides a less costly option. This study aimed to evaluate the financial impact of introducing bevacizumab-bvzr from US commercial and Medicare payer perspectives. Methods A Microsoft Excel-based budget impact model was developed over a 5-year time horizon. Target population was patients to be treated with bevacizumab for FDA-approved indications. Drug costs (2020 US$) were based on average sales price and wholesale acquisition cost, accounting for payer-specific reimbursement models and provider settings. Drug dosing and duration were based on prescribing information and pivotal trial publications. Results In a hypothetical 10-million-member health plan, 503 and 723 patients were estimated to be treated with bevacizumab in year 1 and year 5, respectively. Assuming an annual market shift of 1.7%, 3.6%, 6.7%, 9.4%, and 11.9% to bevacizumab-bvzr, an annual cost saving of $313,363 ($0.003 per member per month [PMPM]) was estimated for a commercial payer and $92,880 ($0.001 PMPM) for Medicare in year 1. Cumulative 5-year cost savings were $7,030,924 ($0.012 PMPM) for a commercial payer and $4,059,257 ($0.007 PMPM) for Medicare. More than half of the cost savings was attributed to patients with metastatic colorectal cancer. Conclusions The introduction of biosimilar bevacizumab-bvzr was estimated to provide substantial cost savings for US payers, which would allow additional patients access to bevacizumab treatment.

NYVEPRIA, a pegfilgrastim (a long-acting granulocyte colony-stimulating factor [G-CSF]) biosimilar, was recently recommended for marketing authorization in Europe for decreasing the incidence of febrile neutropenia (FN) in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs. The present study aimed to evaluate the financial impact of introducing a new pegfilgrastim biosimilar from a French healthcare system perspective.An Excel-based budget impact model was developed to estimate the financial impact by introducing a new pegfilgrastim biosimilar (NYVEPRIA) to France over a 5-year time horizon. Comparators included existing long-acting and short-acting G-CSFs. The burden of FN was obtained from existing literature. Costs (2021 Euros) included drug acquisition and administration, estimated based on drug dosage in both clinical trial and real-world settings. Scenario analyses were conducted to examine the robustness of key model assumptions.In a total French population of 67.19 million, 79,873 patients were estimated to be treated with G-CSFs annually. The annual number of patients to be treated with NYVEPRIA was estimated to be 1593, 3195, 3674, 3782, and 4052 in years 1 to 5, respectively. Using real-world data, NYVEPRIA resulted in total annual cost savings of €8,620, €868,498, €868,498, €814,102, and €958,952 over years 1 to 5, respectively, leading to a cumulative 5-year cost savings of €3,518,669. Using data from clinical trials, NYVEPRIA resulted in total annual cost savings of €14,366, €1,447,496, €1,447,496, €1,356,836, and €1,598,253 over years 1 to 5, respectively, leading to a cumulative 5-year cost savings of €5,864,448.The introduction of a new pegfilgrastim biosimilar (NYVEPRIA) is potentially associated with substantial cost savings for the French healthcare system.

Study design Longitudinal cohort. Objective The aims of this study were to measure concordance between patients' and surgeons' preoperative expectations of lumbar surgery, and determine which member of the dyad more closely predicted fulfillment of expectations, defined as patient-reported status postoperatively. Summary of background data Concordant patient-surgeon expectations reflect effective communication and should foster better outcomes. Methods Preoperatively patients and surgeons completed identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function. Responses ranged from "complete improvement" to "do not have this expectation"; scores for each survey ranged from 0 to 100 (greatest expectations). Concordance between pairs of patient-surgeon scores was measured with the intraclass correlation coefficient (ICC). Postoperatively, fulfillment of expectations was measured from patient-reported amount of improvement received and was calculated as the proportion of patient-reported postoperative score relative to patient-reported preoperative score, and surgeon-reported preoperative score (range 0 [no expectations fulfilled] to >1.2 [expectations surpassed]). Clinical measures included patient-reported spine-related disability. Results For 402 patient-surgeon pairs, mean survey scores were 73 ± 19 (patients) and 57 ± 16 (surgeons); 84% of patients had higher scores than surgeons, mainly due to expecting complete improvement, whereas surgeons expected a lot/moderate/little improvement. The ICC for the entire sample was .31 (fair agreement); for subgroups, the greatest difference in ICC was for patients with more spine-related disability (ICC = .10, 95% confidence interval [CI]:0.00-0.23) versus less disability (ICC = .46, 95% CI: 0.34-0.56). 96% of patients were contacted ≥2.0 years postoperatively. Proportions of expectations fulfilled were 0.79 (0-3.00) (patients) and 1.01 (0-2.29) (surgeons). Thus patients were less likely to anticipate subsequent postoperative status (odds ratio [OR] 0.34, 95% CI 0.25-0.45) versus surgeons who were more likely to anticipate patient-reported postoperative status (OR 2.98, 95% CI: 2.22-4.00). Conclusion Concordance between patients' and surgeons' expectations was fair; due mostly to patients expecting complete improvement whereas surgeons expected a lot/moderate/little improvement. Compared to patients' expectations, surgeons' expectations more closely coincided with patient-reported fulfillment of expectations 2 years postoperatively.Level of Evidence: 1.

Study Design: Retrospective cohort study. Objectives: The identification of case types and institutional factors associated with reduced length of stay (LOS) is a key initial step to inform the creation of clinical care pathways that can assist hospitals to maximize the benefit of value-based payment models. The objective of this study was to identify preoperative, intraoperative, and postoperative factors associated with shorter than expected LOS after adult spinal deformity (ASD) surgery. Methods: A retrospective cohort study was performed of 82 patients with ASD who underwent ≥5 levels of fusion to the pelvis between 2013 and 2018. A LOS Results: A total of 35 patients were in group S (42.7%). Gender, age, body mass index, ASA (American Society of Anesthesiologists) class, and use of preoperative narcotics, revision surgery, day of admission, and surgical complications did not vary between the cohorts ( P > .05). Mild-moderate preoperative sagittal deformity (sagittal Schwab modifiers 0 or +), lower estimated blood loss (Conclusions: This study identifies the ASD “case phenotype,” intra-, and postoperative benchmarks associated with shorter LOS, providing targets for pathways designed to reduce LOS.

STUDY DESIGN Retrospective review of prospectively collected database. OBJECTIVE To delineate and visualize trajectories of the functional status in surgically-treated adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA Classifying long-term recovery following ASD surgery is not well defined. METHODS One thousand one hundred seventy-one surgically-treated patients with a minimum of 3-year follow-up were included. The group-based trajectory modeling (GBTM) was used to identify distinct trajectories of functional status over time, measured by Oswestry Disability Index (ODI). Patient profiles were then compared according to the observed functional patterns. RESULTS The GBTM identified four distinct functional patterns. The first group (10.0%) started with minimal disability (ODI: 15 ± 10) and ended up almost disability-free (low-low). The fourth group (21.5%) began with high ODI (66 ± 11) and improvement was minimal (high-high). Groups two (40.1%) and three (28.4%) had moderate disability (ODI: 39 ± 11 vs. 49 ± 11, P

Summary Background Tissue expanders can lead to bone deformity as well as bone resorption. Not all changes in the cranial bone can be completely normalised after tissue expander extraction. This study aimed to investigate the potential factors for persistent forehead deformities after tissue expansion. Patients and methods Cases of forehead tissue expansion performed from 2011 to 2015 were retrospectively reviewed. Demographic and clinical data were collected. Two plastic surgeons (Y.Q. and C.Q.) evaluated changes in the forehead by comparing preoperative and most recent postoperative photographs. The Fisher exact, chi-square and Student t tests, and univariate and multivariate logistic regression analyses were performed in this study. Results Sixty-seven patients underwent forehead expanded flap reconstructions and continuous follow-ups were done in the outpatient service. The mean duration of the follow-ups after expander removal was 33.86 months. Overall, 28 (41.8%) patients had forehead changes. Age, sex, indications for tissue expansion and follow-up time were not associated with forehead changes. There were significant differences in the total injection volume and expansion period between patients with forehead changes (41.8%) and those without (58.2%). No significant negative correlation was found between the duration of pressure bandage usage post-operatively and the occurrence of forehead changes. Conclusions Our recommendations for performing tissue expansion in the skull area are as follows: (1) always choose expanders with the largest base dimension; (2) perform tissue expansion as quickly as possible and (3) do not cause overexpansion. In addition, there was no proven benefit of using pressure bandages when skeletal changes occurred.

The kidney allocation system (KAS) is based on quality-based “longevity matching” strategies that provide only a momentary snapshot of expected outcomes at the time of transplantation. The purpose of our study was to define on a continuous timeline the relative and mutual interactions of donor and recipient characteristics on graft survival.Total 39,108 subjects who underwent kidney transplant between October 25, 1999 and January 1, 2007 were identified in the United Network for Organ Sharing dataset. Our primary outcome was graft survival. Time-dependent receiver operating characteristic (ROC) curves and area under time-dependent ROC curve (AUC) were used to compare the predictive ability of the two allocation systems.During the first year after transplantation, both donor and recipient models showed identical relevance. From the first to the sixth years, although the two ROC curves were nearly identical, the donor model outweighed the recipient model. Both models intersected again at the sixth year. From that time onward, the ROC curve for recipient characteristics model predominated over the ROC curve for donor characteristics model. The predictive value of the recipient model (AUC = 0.752) was greater than that of the donor model (AUC = 0.673)We hope that this model will provide additional guidance and risk stratification to further optimize organ allocation based on the dynamic interaction of both donor and recipient characteristics over time.

The adoption of oncology biosimilars has been slow in the USA, which may be attributed in part to stakeholder perceptions and lack of operational guidance that supports favorable access to biosimilars. Our objective was to understand the real-world implementation experiences with oncology biosimilars of US payers and healthcare professionals (HCPs) as their experience with biosimilars has evolved. In-depth qualitative interviews with payers (n = 20) and HCPs (n = 17 physicians, n = 3 practice managers) were conducted. Payers included managed care organizations (MCOs), integrated delivery networks, and pharmacy benefit managers (PBMs). Physicians were affiliated with a healthcare network or were community based, specialized in hematology/oncology, and had prescribed oncology biosimilars. Audio transcripts of the interviews were coded using MaxQDA software to enable descriptive analysis of the qualitative data. Over 80.0% of physicians perceived the efficacy and safety of biosimilars to be highly comparable to that of originators. Up to 87.5% of physicians reported using biosimilars in > 50% of their treatment-naive patients and were comfortable using biosimilars in all approved indications. To encourage utilization, 75.0% of MCOs/PBMs preferred biosimilars over originators in treatment-naive patients and implementation via step therapy. Physician involvement in choosing biosimilars was minimal, which was largely dependent on practice protocols or insurance preferences. The major factor influencing payers’ coverage decisions and biosimilar adoption was potential cost savings. US payers and physicians who have experience with biosimilars have favorable views of oncology biosimilars, particularly for treatment-naive patients. A framework for integrating biosimilars into oncology practice is developing, primarily driven by insurance coverage, contracting, and cost benefits.

BACKGROUND The improvement of nasolabial folds by either lateral superficial musculoaponeurotic system rhytidectomy or minimal access cranial suspension lift alone is commonly performed, but patient satisfaction is often limited in East Asians. An innovative technique, termed the cable-stayed face lift, which combines the strengths of lateral superficial musculoaponeurotic system rhytidectomy and minimal access cranial suspension lift, was developed for improved results. METHODS Between 2016 and 2019, 20 cable-stayed face lifts were performed in a single hospital. Two plastic surgeons independently evaluated postsurgery outcomes using a five-point Likert scale, where 5 = excellent, 4 = good, 3 = fair, 2 = no change, and 1 = worse. Patient satisfaction was assessed by relevant items from the FACE-Q questionnaire. RESULTS Twenty patients with a mean age of 51 years underwent face-lift surgery. The mean follow-up ± SD was 11.3 ± 9.8 months. The five-point Likert scale score evaluated by surgeons was 3.65 ± 1.08. Patient-perceived age visual analogue scale (7.8 ± 4.4) exhibited a difference between preoperative actual age and postoperative apparent age. Patients demonstrated high satisfaction with outcome (67.5 ± 16.2) and satisfaction with lower face and jawline (76.2 ± 14.9). No major complication, hematoma, or seroma was observed. CONCLUSION The authors' approach-cable-stayed face lift-offers a good alternative to provide a more effective effacement of nasolabial folds, by lifting the nasolabial folds with parallel vector and lower face and neck with the vertical vector. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Aim: To describe treatment patterns and patient and provider characteristics associated with the recently introduced biosimilar rituximab-pvvr. Methods: This retrospective analysis included adult patients with one or more claims for rituximab-pvvr, with an index date of 23 January 2020 and a study period covering 1 January 2019–31 July 2020. Results: Of 249 patients included, the most common rituximab-pvvr indications were non-Hodgkin’s lymphoma (77.5%) and chronic lymphocytic leukemia (11.2%). Some patients with non-Hodgkin’s lymphoma (42.5%) and chronic lymphocytic leukemia (39.3%) switched to rituximab-pvvr from the reference product or another rituximab biosimilar. Most patients were aged ≥65 years (63.5%) and were male (54.6%). Most (59.0%) rituximab-pvvr prescribers practiced in the south of the USA. Conclusion: Utilization occurred in approved and extrapolated indications. These preliminary findings suggest switching between reference product and rituximab biosimilars; rituximab-pvvr combination regimens are being adopted in real-world oncology practice.

Study design Systematic review. Objective To determine the difference in postoperative sagittal alignment when single level cervical radiculopathy or myelopathy is treated with an anterior cervical discectomy and fusion (ACDF) using a structural graft and plate, a stand-alone ACDF, or a total disc arthroplasty (TDR). We also wanted to determine if postoperative sagittal alignment impacted clinical outcomes in this patient population. Summary of background data Although there are several accepted techniques for interbody reconstruction during single level anterior cervical surgery, little is known on the impact of any of them on segmental and regional sagittal alignment. Methods A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines of the PubMed, Embase, and Cochrane databases. Only studies which contained pre and postoperative C2-7 Cobb angles as well as Neck Disability Index (NDI) scores following single level traditional ACDF with plate and cage, stand-alone ACDF, or TDR with at least 1 year follow up were included. Results There were 12 publications that fulfilled the inclusion criteria with a total of 658 patients. Cluster regression analysis showed no difference between treatment arms at each respective time-point or in the overall change in NDI from preoperative to postoperative (P = 0.88). Cluster regression analysis showed no difference between treatment arms at each respective time point or in the overall change in lordosis from pre-op to post-op (P = 0.93). Conclusion This review provides evidence that while NDI scores improved across all devices, there was no significant difference in NDI improvement or C2-7 Cobb angle change between single level traditional ACDF, stand-alone ACDF, or TDR. Although TDR has not been considered a lordosis producing operation, our investigation shows it does not differ significantly in sagittal profile from other cervical fusion techniques. Moreover, we show that the NDI score improved, regardless of device implanted. Level of evidence 1.

Physical function is a critical aspect of patient outcomes. NDI is a widely validated outcome measure in cervical spine disease, yet to what extent its individual domains predict changes in physical function remains unknown.To examine the impact of individual NDI domains on changes in physical function in patients undergoing cervical spine surgery.Prospective Cohort Study.Adult patients undergoing cervical spine surgery, excluding those undergoing surgery for instability due to trauma.Absolute change in outcome measures (Patient Reported Outcomes Measurement Information System [PROMIS] Physical Function [PF], Short Form 36 [SF-36] Physical Component Score [PCS], and Neck Disability Index [NDI]) from pre- to postoperatively, correlation of NDI individual domains with PROMIS PF and SF-36 PCS (preoperatively, postoperatively, and change from pre- to postoperatively).Patients undergoing cervical spine surgery between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires (NDI, SF-36 PCS, and PROMIS PF) preoperatively and at 6 months postoperatively. Patient demographics, including age, body mass index, Charlson Comorbidity Index, and underlying diagnoses were collected. Comparisons between NDI scores preoperatively versus postoperatively were conducted using Wilcoxon signed rank sum test. Correlations of NDI individual items and PROMIS/SF-36 were assessed using Pearson correlation. A stepwise linear regression analysis was performed to identify NDI items that are independently predictive of PROMIS PF and SF-36 PCS.A total of 137 patients were included in the study, with mean age 56.9 years (range 24.4-84.9). Each of the NDI domains as well as PROMIS PF and SF-36 PCS demonstrated significant improvement following cervical spine surgery (p.001). Changes in all NDI domains demonstrated significant negative correlation with changes in PROMIS PF, with recreation (R=-0.537, p.001), work (R=-0.514, p.001), and pain intensity (R=-0.488, p.001) having the greatest negative correlation. Changes in all NDI domains demonstrated significant negative correlation with changes in SF-36 PCS, with recreation (R=-0.451, p.001), work (R=-0.443, p.001), lifting (R=-0.373, p.001), and driving (R=-0.373, p.001) having the greatest negative correlation. For PROMIS PF, the NDI domains that were independently associated with changes in PF were work (R=-0.092, p=.001), pain intensity (R=-0.089, p=.003), and recreation (R=-0.067, p=.004). For SF-36 PCS, the NDI items that were independently associated with changes in PCS were work (R=-0.269, p=.003) and recreation (R=-0.215, p=.002).All NDI domains improve significantly after cervical spine surgery and demonstrate significant correlation with changes in PROMIS PF and SF-36 PCS. The work, recreation, and pain intensity domains were the only independent predictors of physical function changes postoperatively. Considering physical function, our findings highlight the importance of presenting changes in individual NDI domains in addition to the total score.

STUDY DESIGN This was a prospective cohort study. OBJECTIVE The objective of this study was to establish minimal clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds for Patient-Reported Outcomes Measurement Information System (PROMIS) in cervical spine pathology. SUMMARY OF BACKGROUND DATA PROMIS enables improved psychometric properties with reduced questionnaire burden through computer adaptive testing. Despite studies showing good correlation with "legacy" outcome measures, literature on the clinical significance of changes in PROMIS scores is scarce. MATERIALS AND METHODS Adult patients undergoing cervical spine surgery at a single institution between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires [Short Form-36 (SF-36), Neck Disability Index (NDI), Visual Analogue Scale Arm/Neck, and PROMIS Pain Interference (PI) and Physical Function (PF)] preoperatively and at 6 months postoperatively. MCID was calculated using distribution-based and SCB using anchor-based methods. The SF-36 Health Transition Item was utilized as an anchor with the cutoff values chosen using receiver operating characteristic curve analysis. RESULTS There were 139 patients meeting inclusion criteria, with a mean age of 56.4 years and diagnoses of myelopathy (n=36), radiculopathy (n=48) and myeloradiculopathy (n=49). There were significant improvements in PROMIS PF, PROMIS PI, NDI, and SF-36 preoperatively to postoperatively (P

Study Design: Case series/systematic review. Objectives: To report on patients undergoing posterior cervical fusion for symptomatic pseudarthrosis following anterior cervical discectomy and fusion (ACDF), and to assess outcomes reporting in the literature. Methods: Patients undergoing posterior instrumented fusion for pseudarthrosis after primary ACDF from 2013 to 2018 by a single surgeon were reviewed consecutively. Neck Disability Index (NDI) and visual analogue scale (VAS) arm/neck were recorded at preoperative, 6-month, and 1-year time points. A systematic review of the literature was performed, and outcomes reporting was recorded. Results: NDI scores were 54.4 (SD 19.1), 36.6 (SD 18.1), and 41.2 (SD 19.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months ( P = .004). VAS neck scores were 8.1 (SD 1.3), 5.0 (SD 2.9), and 5.8 (SD 2.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months ( P = .038). VAS arm scores were 5.1 (SD 4.1), 3.5 (SD 3.2), and 3.6 (SD 2.7) at preoperative, 6-month, and 1-year time points, respectively, with improvement although these did not reach statistical significance ( P = .145). The most common subjective outcomes reported in the literature were general symptoms assessments (43%), ordinal scales (43%), and VAS neck (19%) scales, with the majority of studies (67%) documenting one measure. Conclusions: Patient-reported outcomes demonstrate clinically meaningful improvement within the first 6 months after posterior fusion for pseudarthrosis. Studies demonstrate substantial variability and no standardization in outcomes reporting, limiting the ability to compare results across interventions and pathologies. Standardized reporting will enable comparisons to inform patients and physicians on the optimal approach to treat this difficult problem.

STUDY DESIGN Retrospective database analysis. OBJECTIVE To identify preoperative risk factors for emergency department (ED) visit and unplanned hospital readmission after primary anterior cervical discectomy and fusion (ACDF) at 30 and 90 days. SUMMARY OF BACKGROUND DATA Limited data exist to identify factors associated with ED visit or readmission after primary ACDF within the first 3 months following surgery. METHODS Patients undergoing ACDF from 2005 to 2012 were identified in the Statewide Planning and Research Cooperative System database. Multivariable regression models were created based on patient-level and surgical characteristics to identify independent risk factors for hospital revisit. RESULTS Of 41,813 patients identified, 2514 (6.0%) returned to the ED within 30 days of discharge. Risk factors included age 1, length of stay (LOS) greater than 1 day (OR 1.23), and fusion of > 2 levels (OR 1.17). Four thousand six hundred nine (11.0%) patients returned to the ED within 90 days. Risk factors mirrored those at 30 days. Patients having private insurance or those discharged to rehab were less likely to present to the ED. One thousand three hundred ninety-four (3.3%) patients were readmitted by 30 days. Risk factors included male sex, Medicare, or Medicaid insurance (OR 1.71 and 1.79 respectively), Charlson comorbidity index > 1, discharge to a skilled nursing facility (OR 2.90), infectious/pathologic (OR 3.296), or traumatic (OR 1.409) surgical indication, LOS > 1 day (OR 1.66), or in-hospital complication. 2223 (5.3%) patients were readmitted by 90 days. Risk factors mirrored those at 30 days. No differences in readmission were seen based on race or number of levels fused. Patients aged 18 to 34 were less likely to be readmitted versus patients older than 35. CONCLUSION Insurance status, comorbidities, and LOS consistently predicted an unplanned hospital visit at 30 and 90 days. Although nondegenerative surgical indications and in-hospital complications did not predict ED visits, these factors increased the risk for readmission. LEVEL OF EVIDENCE 3.

Study design Prospective cohort study. Objective To examine preoperative urinary cross-linked n-telopeptide (uNTx) and assess for association with fusion rates in patients undergoing single and multi-level anterior cervical decompression and fusion (ACDF). Summary of background data Although high rates of fusion have been reported for ACDF, the risk of pseudarthrosis remains substantial. An established marker of bone turnover, uNTx may prove useful as a predictor of fusion. Methods Patients undergoing primary ACDF with allograft/plating technique from 2015 to 2017 by a single surgeon were consecutively enrolled and preoperative uNTx was collected. Patients undergoing revision, with creatinine >1.2, and with improperly-collected uNTx were excluded. Demographics, laboratory values, and fusion status were assessed at 6 months, 1 year, and 2 years postoperatively. Results Of the 97 patients enrolled, 69 met inclusion criteria. Of included cases, 41%, 33%, 18%, and 8% underwent 1-, 2-, 3-, and 4-level ACDF, respectively. Overall, fusion rates were 37.3%, 70.9%, and 95.3% at 6 months, 1 year, and 2 years, respectively. uNTx was higher in the fusion group (31.1 vs. 22.2, P = 0.001) at 6 months and 1 year (30.0 vs. 21.0, P = 0.006), with no difference at 2 years. No differences were identified in the proportion of smokers, immunomodulatory agents, corpectomies, or fusion levels between groups. Multivariate regression analysis demonstrated that uNTx is an independent predictor of fusion (odds ratio, OR, 1.124, P = 0.003). Both groups experienced improvements in NDI and VAS neck pain at 6 months with no significant differences noted between groups. Of 16 patients with pseudarthrosis at 1 year, 2 underwent posterior cervical fusion for symptoms. Conclusion Preoperative uNTx was greater in patients with successful ACDF fusion compared with patients with pseudarthrosis at 6 months and 1 year. A negative correlation was found between preoperative uNTx and motion on dynamic imaging. These results suggest that uNTx could serve to identify patients at risk for pseudarthrosis after ACDF. Level of evidence 3.

Retrospective review of prospective multicenter database.To identify an optimal set of factors predicting the risk of proximal junctional failure (PJF) while taking the time dependency of PJF and those factors into account.Surgical correction of adult spinal deformity (ASD) can be complex and therefore, may come with high revision rates due to PJF.Seven hundred sixty-three operative ASD patients with a minimum of 1-year follow-up were included. PJF was defined as any type of proximal junctional kyphosis (PJK) requiring revision surgery. Time-dependent ROC curves were estimated with corresponding Cox proportional hazard models. The predictive abilities of demographic, surgical, radiographic parameters, and their possible combinations were assessed sequentially. The area under the curve (AUC) was used to evaluate models' performance.PJF occurred in 42 patients (6%), with a median time to revision of approximately 1 year. Larger preoperative pelvic tilt (PT) (hazard ratio [HR]=1.044, P = 0.034) significantly increased the risk of PJF. With respect to changes in the radiographic parameters at 6-week postsurgery, larger differences in pelvic incidence-lumbar lordosis (PI-LL) mismatch (HR = 0.924, P = 0.002) decreased risk of PJF. The combination of demographic, surgical, and radiographic parameters has the best predictive ability for the occurrence of PJF (AUC = 0.863), followed by demographic along with radiographic parameters (AUC = 0.859). Both models' predictive ability was preserved over time.Over correction increased the risk of PJF. Radiographic along with demographic parameters have shown the approximately equivalent predictive ability for PJF over time as with the addition of surgical parameters. Radiographic rather than surgical factors may be of particular importance in predicting the development of PJF over time. These results set the groundwork for risk stratification and corresponding prophylactic interventions for patients undergoing ASD surgery.4.

OBJECTIVEThe purpose of this meta-analysis was to evaluate the impact of perioperative antiepileptic drug (AED) prophylaxis on short- and long-term seizure incidence among patients undergoing brain tumor surgery. It is the first meta-analysis to focus exclusively on perioperative AED prophylaxis among patients undergoing brain tumor surgery.METHODSThe authors searched PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, and the System for Information on Gray Literature in Europe for records related to perioperative AED prophylaxis for patients with brain tumors. Risk of bias in the included studies was assessed using the Cochrane risk of bias tool. Incidence rates for early seizures (within the first postoperative week) and total seizures were estimated based on data from randomized controlled trials. A Mantel-Haenszel random-effects model was used to analyze pooled relative risk (RR) of early seizures (within the first postoperative week) and total seizures associated with perioperative AED prophylaxis versus control.RESULTSFour RCTs involving 352 patients met the criteria of inclusion. The results demonstrated that perioperative AED prophylaxis for patients undergoing brain tumor surgery provides a statistically significant reduction in risk of early postoperative seizures compared with control (RR = 0.352, 95% confidence interval 0.130–0.949, p = 0.039). AED prophylaxis had no statistically significant effect on the total (combined short- and long-term) incidence of seizures.CONCLUSIONSThis meta-analysis demonstrates for the first time that perioperative AED prophylaxis for brain tumor surgery provides a statistically significant reduction in early postoperative seizure risk.

BACKGROUND CONTEXT Quantitative computed tomography (QCT) of the lumbar spine is used as an alternative to dual-energy X-ray absorptiometry in assessing bone mineral density (BMD). The average BMD of L1-L2 is the standard reportable metric used for diagnostic purposes according to current recommendations. The density of L1 and L2 has also been proposed as a reference value for the remaining lumbosacral vertebrae and is commonly used as a surrogate marker for overall bone health. Since regional BMD differences within the spine have been proposed, it is unclear if the L1-L2 average correlates with the remainder of the lumbosacral spine. PURPOSE The aim of this study was to determine possible BMD variations throughout the lumbosacral spine in patients undergoing lumbar fusion and to assess the correlation between the clinically used L1-L2 average and the remaining lumbosacral vertebral levels. STUDY DESIGN/SETTING This is a retrospective case series. PATIENT SAMPLE Patients undergoing posterior lumbar spinal fusion from 2014 to 2017 at a single, academic institution with available preoperative CT imaging were included in this study. OUTCOME MEASURES The outcome measure was BMD measured by QCT. METHODS Standard QCT measurements at the L1 and L2 vertebra and additional experimental measurements of L3, L4, L5, and S1 were performed. Subjects with missing preoperative lumbar spine CT imaging were excluded. The correlations between the L1-L2 average and the other vertebral bodies of the lumbosacral spine (L3, L4, L5, S1) were evaluated. RESULTS In total, 296 consecutive patients (55.4% female, mean age of 63.1 years) with available preoperative CT were included. The vertebral BMD values showed a gradual decrease from L1 to L3 and increase from L4 to S1 (L1=118.8 mg/cm3, L2=116.6 mg/cm3, L3=112.5 mg/cm3, L4=122.4 mg/cm3, L5=135.3 mg/cm3, S1=157.4 mg/cm3). There was strong correlation between the L1-L2 average and the average of the other lumbosacral vertebrae (L3-S1) with a Pearson's correlation coefficient (r=0.85). We also analyzed the correlation between the L1-L2 average and each individual lumbosacral vertebra. Similar relationships were observed (r value, 0.67–0.87), with the strongest correlation between the L1-L2 average and L3 (r=0.87). CONCLUSIONS Our data demonstrate regional BMD differences throughout the lumbosacral spine. Nevertheless, there is high correlation between the clinically used L1-L2 average and the BMD values in the other lumbosacral vertebrae. We, therefore, conclude the standard clinically used L1-L2 BMD average is a useful bone quantity measure of the entire lumbosacral spine in patients undergoing lumbar spinal fusion.

Background Context Sacral fractures are a rare but potentially devastating complication. Long-fusion constructs, including the sacrum, that do not extend to the pelvis may result in sacral fractures. Besides established risk factors including gender, age, and number of levels fused, body mass index (BMI), pelvic parameters, and bone mineral density (BMD) have also been proposed as potential risk factors for postoperative sacral fractures. The literature supporting this, however, is limited. Purpose The aim of the present study was to assess whether preoperative pelvic parameters, BMI, or BMD of patients with sacral fracture are different compared with age, gender, and fusion level-matched non-fracture controls. Study Design/Setting This is a case-control study. Patient Sample Patients undergoing posterior instrumented fusion at a single academic institution between 2002 and 2016 were included in the study. Outcome Measures The outcome measure was occurrence of a postoperative sacral fracture. Methods Patients with sacral fractures after posterior instrumented spinal fusion, including the sacrum, were retrospectively identified and matched 2:1 with non-fracture controls based on gender, age, and number of levels fused. Patients with concurrent spinopelvic fixation or missing preoperative computed tomography (CT) imaging were excluded. Preoperative sagittal balance was assessed using lateral radiographs. Quantitative computed tomography (QCT) assessment included standard measurements at L1/L2 and additional experimental measurements of the S1 body and sacral ala. Results Twenty-one patients with sacral fracture were matched to non-fracture controls. The majority of the patients with sacral fracture was female (76.2%) and of advanced age (mean 66.4 years). Fracture and control groups were well matched with respect to gender, age, and number of levels fused. Standard measurements at L1/L2 showed no significant difference in BMD between the fracture and the control groups (109.9 mg/cm3 vs. 116.4 mg/cm3, p=.414). Similarly, there was no significant BMD differences between the groups using the experimental measurements of the S1 body (183.6 mg/cm3 vs. 176.2 mg/cm3, p=.567) and the sacral ala (8.9 mg/cm3 vs. 4.8 mg/cm3, p=.616). Mean preoperative pelvic incidence-lumbar lordosis mismatch and pelvic tilt were not significantly different between the groups. Univariate conditional logistic regression analysis revealed that the odds of experiencing a sacral fracture was approximately six times higher for obese patients compared with normal or underweight patients. After controlling for BMI in multivariate conditional logistic regression models, BMD was still not significantly associated with the odds of experiencing sacral fractures. Conclusions To our knowledge, this is the first study to assess the association of preoperative BMD measured by QCT, pelvic parameters, and BMI with postoperative sacral fractures in a large patient cohort. Interestingly, our data do not show any difference in preoperative pelvic parameters and BMD between the groups. This is in line with previous reports that indicate only a few patients with sacral fracture after fusion surgery have clear evidence of osteoporosis. Bone mineral density as a measure of bone quantity, rather than bone quality, may not be as important in these fractures as previously thought. Obesity, however, was associated with higher odds of experiencing postoperative sacral fractures. The present study thereby challenges the widespread concept that obesity is a protective factor against fractures in the elderly. In summary, our results suggest that BMI and gender, more than pelvic parameters and BMD, are risk factors for postoperative sacral fractures.

Retrospective review of prospective multicenter database.To investigate the determinants of patient satisfaction with respect to changes in functional limitations 2 years after spinal deformity surgery.For operatively treated adult spine deformity (ASD), patient satisfaction has become an important component of evaluating quality of care.A total of 430 operative patients with ASD with 2-year follow-up were analyzed. Patient satisfaction was assessed using the Scoliosis Research Society 22-item. Latent class analysis was performed to assign individuals to classes based on the changes in pre- and 2-year postoperative functions, assessed using the Oswestry Disability Index (ODI). An ordered logistic regression was conducted to assess the association of class membership and satisfaction.Latent class analysis identified four classes. The worsened-condition class (WC: 1.4%) consisted of patients who were likely to experience worsened function, particularly in lifting and pain intensity. The remained-same class (RS: 13.0%) included patients who remained the same, because the majority reported approximately no change in walking, standing, and sitting. The mild-improved class (mild-I: 40.2%) included patients with mildly enhanced conditions, specifically, in standing, social life, and employment. The most-improved class (most-I: 45.3%) included patients with great improvement after surgery mainly in standing, followed by social life and employment. The odds of being satisfied were significantly increased by 3.91- (P 0.001) and 16.99-fold (P 0.001), comparing patients in mild-I and most-I to the RS/WC class, respectively, after controlling for confounders.Improvement in standing, social life, and employment are the most important determinants of patient satisfaction postsurgery. Reduced pain intensity and enhanced walking ability also help to elevate patient satisfaction. However, lifting, personal care, sitting, sleeping, and travelling may be of less importance. Examining the heterogeneity of patient-reported outcome in patients with ASD allows the identification of classes with different patient characteristics and satisfaction, and thus, help to guide tailored provision of care.4.

Background Neurocognitive impairment (NCI) and frailty are more prevalent among persons with human immunodeficiency virus (HIV, PWH) compared to those without HIV. Frailty and NCI often overlap with one another. Whether frailty precedes declines in neurocognitive function among PWH or vice versa has not been well established. Methods AIDS Clinical Trials Group (ACTG) A5322 is an observational cohort study of older PWH. Participants undergo annual assessments for NCI and frailty. ACTG A5322 participants who developed NCI as indexed by tests of impaired executive functioning and processing speed during the first 3 years were compared to persons who maintained normal cognitive function; those who demonstrated resolution of NCI were compared to those who had persistent NCI. Participants were similarly compared by frailty trajectory. We fit multinomial logistic regression models to assess associations between baseline covariates (including NCI) and frailty, and associations between baseline covariates (including frailty) and NCI. Results In total, 929 participants were included with a median age of 51 years (interquartile range [IQR] 46–56). At study entry, 16% had NCI, and 6% were frail. Over 3 years, 6% of participants developed NCI; 5% developed frailty. NCI was associated with development of frailty (odds ratio [OR] = 2.06; 95% confidence interval [CI] = .94, 4.48; P = .07). Further adjustment for confounding strengthened this association (OR = 2.79; 95% CI = 1.21, 6.43; P = .02). Baseline frailty however was not associated with NCI development. Conclusions NCI was associated with increased risk of frailty, but frailty was not associated with development of NCI. These findings suggest that the presence of NCI in PWH should prompt monitoring for the development of frailty and interventions to prevent frailty in this population.

BACKGROUND Deceased donor kidneys with acute kidney injury (AKI) and donation after circulatory death (DCD) kidneys are viable sources of organs. The outcomes of renal transplantation from DCD donors with AKI are not known. METHODS A retrospective review of deceased donor renal transplants performed from 2006 to 2016 was conducted using the United Network for Organ Sharing dataset. Donors were stratified by DCD or brain dead status and by AKI stage. Recipients were followed until graft failure or the end of study. Cox regression was used to adjust for donor, recipient, and transplant covariates known to affect the incidence of delayed graft function and graft survival. RESULTS A total of 135 644 patients were included in the study. The odds of delayed graft function among DCD recipients were significantly higher across all donor AKI stages. The unadjusted risk of overall and death-censored graft failure were similar between the 2 groups. After adjusting for covariates, there was a significant increase in the risk of overall graft failure in recipients of DCD allografts from donors with stage 2 AKI. There was also a higher risk of death-censored graft failure among stage 1 and 2 AKI DCD recipients. CONCLUSIONS DCD renal allografts from donors experiencing stage 1 and 2 AKI have a higher adjusted risk of death-censored graft failure than AKI stage-matched donation after brain death renal allografts. Their use, however, is still associated with improved outcomes compared with waitlist mortality.

To compare the pregnancy outcome of emergency cerclage performed in twin and singleton pregnancies. A retrospective trial was carried out in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China, from January 2013 to December 2018. A total of 89 women with acute cervical incompetence underwent the emergency cerclage. Main outcome measures were gestational age at delivery and the fetal outcome. There were 31 twin and 58 singleton pregnancies that underwent emergency cerclage. In singleton pregnancies, gestational age at delivery (31.57 ± 6.11 vs 28.81 ± 4.34, p = 0.016), and prolongation of pregnancy (8.69 ± 6.13 vs 5.41 ± 3.72, p

OBJECTIVEOsteoporosis is a metabolic bone disease that increases the risk for fragility fractures. Screening and diagnosis can be achieved by measuring bone mineral density (BMD) using quantitative CT tomography (QCT) in the lumbar spine. QCT-derived BMD measurements can be used to diagnose osteopenia or osteoporosis based on American College of Radiology (ACR) thresholds. Many reports exist regarding the disease prevalence in asymptomatic and disease-specific populations; however, osteoporosis/osteopenia prevalence rates in lumbar spine fusion patients without fracture have not been reported. The purpose of this study was to define osteoporosis and osteopenia prevalence in lumbar fusion patients using QCT.METHODSA retrospective review of prospective data was performed. All patients undergoing lumbar fusion surgery who had preoperative fine-cut CT scans were eligible. QCT-derived BMD measurements were performed at L1 and L2. The L1–2 average BMD was used to classify patients as having normal findings, osteopenia, or osteoporosis based on ACR criteria. Disease prevalence was calculated. Subgroup analyses based on age, sex, ethnicity, and history of abnormal BMD were performed. Differences between categorical groups were calculated with Fisher’s exact test.RESULTSOverall, 296 consecutive patients (55.4% female) were studied. The mean age was 63 years (range 21–89 years). There were 248 (83.8%) patients with ages ≥ 50 years. No previous clinical history of abnormal BMD was seen in 212 (71.6%) patients. Osteopenia was present in 129 (43.6%) patients and osteoporosis in 44 (14.9%). There were no prevalence differences between sex or race. Patients ≥ 50 years of age had a significantly higher frequency of osteopenia/osteoporosis than those who were < 50 years of age.CONCLUSIONSIn 296 consecutive patients undergoing lumbar fusion surgery, the prevalence of osteoporosis was 14.9% and that for osteopenia was 43.6% diagnosed by QCT. This is the first report of osteoporosis disease prevalence in lumbar fusion patients without vertebral fragility fractures diagnosed by QCT.

Acute kidney injury (AKI) is a serious complication in the intensive care unit (ICU), which may increase the mortality of critically ill patients. The red blood cell distribution width (RDW) has proved useful as a predictor of short-term prognosis in critically ill patients with AKI. However, it remains unknown whether RDW has a prognostic value of long-term all-cause mortality in these patients. The data of 18279 critically ill patients with AKI at first-time hospital admission were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The tertiles of the RDW values were used to divide subjects into three groups, namely RDW

BACKGROUND: Renal anemia is a severe complication of chronic kidney disease (CKD) and may worsen its prognosis. Roxadustat is the only oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI) that has been proved effective to treat renal anemia. However, effects of roxadustat on non-dialysis-dependent CKD (NDD-CKD) have yet to be supported by evidence-based medicine. METHODS: Based on the databases of PubMed, EMBASE and Web of Science by 12 April 2019 (CRD42019133225), a meta-analysis of randomized controlled trials (RCTs) on roxadustat for treatment of NDD-CKD was conducted. Primary outcomes were parameters of hemoglobin (Hb) and Hb response. Secondary outcomes were hepcidin, ferritin, total iron binding capacity (TIBC), transferrin saturation (TAST), incidences of diarrhea, adverse events (AEs) and severe adverse events (SAEs). The risk of bias and the quality of evidence were assessed, respectively. Both continuous and binary variables were analyzed by the random effects models. Sensitivity analyses were performed when a significant heterogeneity was observed (P50%). RESULTS: Finally, three studies with a total of 214 subjects in the roxadustat group and 80 subjects in the placebo group were enrolled. An increase of Hb [weighted mean difference (WMD) =1.22, 95% CI: 0.95 to 1.49, P

OBJECTIVES To determine the relationship between glycemic status and cognitive performance in men living with HIV (MLWH) and without HIV infection. DESIGN A prospective HIV/AIDS cohort study in four US cities between 1999 and 2016. METHODS Glycemic status was categorized as normal glucose, impaired fasting glucose, controlled diabetes mellitus and uncontrolled diabetes mellitus at each semiannual visit. Cognitive performance was evaluated using nine neuropsychological tests which measure attention, constructional ability, verbal learning, executive functioning, memory and psychomotor speed. Linear mixed models were used to assess the association between glycemic status and cognition. RESULTS Overall, 900 MLWH and 1149 men without HIV were included. MLWH had significantly more person-visits with impaired fasting glucose (52.1 vs. 47.9%) and controlled diabetes mellitus (58.2 vs. 41.8%) than men without HIV (P

Background Vertebral fracture (VF) is the most common osteoporotic fracture in postmenopausal women, although most VFs are subclinical. Prevalent VFs are a significant predictor of subsequent fracture and therefore, identification of VF improves the identification of those with high fracture risk. The aim of present study was to systematically review the literature that assessed the prevalence of VF in asymptomatic postmenopausal women, using Vertebral Fracture Assessment (VFA) by dual-energy X-ray absorptiometry. Method Medline, Web of Science and Cochrane databases were searched between Jan 1st, 2000 and Jan 31st, 2018, for publications in English that reported the prevalence of VFA-detected VF in asymptomatic postmenopausal women. We also searched for reports, conference papers and grey literature. Reviewers screened studies for eligibility and extracted data for included studies. Random effects meta-analyses were performed to calculate the prevalence of VF. The presence of publication bias was assessed using funnel plots by precision and Egger's Test of the Intercept. Results A total of 1777 articles were identified, 94 studies were fully reviewed and 28 studies (n = 25,418) met the inclusion criteria and were analyzed. More than two thirds of the studies were cross-sectional and the sample size varied widely across the studies (from 63 to 5156). The mean age ranged from 59.5 to 86.2 years old. The prevalence of osteoporosis and osteopenia varied between 6–57.0% and 25.1–58.9%, respectively. However, among women who had prevalent VFs, up to 43% had osteopenia and as many as 32% had normal bone density. The weighted pooled prevalence of VFA-detected VF in asymptomatic women was 28% (95% CI: 23%–32%). Conclusion VFA is able to identify prevalent VF in asymptomatic postmenopausal women. The use of VFA identified an average of 28% of asymptomatic women with VFs, many of whom did not have a diagnosis of osteoporosis. Implementation of VFA as a routine screening tool may detect high risk women. Detection of VF might lead to pharmacological treatment in individuals who may not otherwise be treated.

STUDY DESIGN Prospective Cohort Study OBJECTIVE.: The aim of this study was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) against existing patient-reported outcomes in the cervical spine. SUMMARY OF BACKGROUND DATA Current patient-reported outcomes in cervical spine have substantial limitations. PROMIS offers the potential for improved psychometric properties with reduced questionnaire burden. METHODS Adult patients undergoing cervical spine surgery at a single institution between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires (36-Item Short Form Health Survey [SF-36], Neck Disability Index (NDI), Visual Analog Scale arm/neck, and PROMIS pain Interference [PI], physical Function [PF], and Upper Extremity [UE]) preoperatively and at 6 months postoperatively. Demographic data, diagnosis, and procedural data were recorded. Validation of the instruments was completed with a Rasch Model as well as measurement of coverage, efficiency, test-retest reliability, responsiveness, and convergent validity. RESULTS Of 197 patients who completed the preoperative survey, 164 were eligible for 6-month follow-up and 139 completed 6-month postoperative surveys. The most common diagnoses were radiculopathy (37.6%), myeloradiculopathy (30.5%), and myelopathy (28.4%). All studied instruments had acceptable fit to a Rasch model. PROMIS computer adaptive testings (CATs) demonstrated improved average time to completion for PI (39 seconds), PF (47 seconds), and UE (54 seconds), compared to NDI (117 s) and SF-36 PCS (175 seconds). Responsiveness for PROMIS CATs was similar to NDI and SF-36, test-retest reliability was lower for PI (intraclass correlation: 0.68), PF (0.70), and UE (0.59), compared to NDI (0.86) and PCS (0.85). For convergent validity, PI was strongly correlated to NDI and PF to SF-36 PCS. There were no significant floor or ceiling effects for the PROMIS domains, although UE had preoperative clustering (n = 18) at a high score (56.4) and PI had postoperative clustering (n = 27) at a low score (38.7). CONCLUSION PROMIS CATs demonstrate several advantages, including efficiency and responsiveness, while demonstrating good convergent validity with legacy instruments. Nevertheless, CATs had lower test-retest reliability and had significant clustering at higher levels of function for the PI and UE CATs. These limitations must be considered before broad adoption of CATs in cervical spine patients. LEVEL OF EVIDENCE 3.

The rate of cervical spinal fusion has been increasing significantly. However, there is a paucity of literature describing trends based on surgical approach using complete population databases. We investigated the approach-based trends in epidemiology, indications, and in-hospital outcomes of cervical spinal fusion.New York's Statewide Planning and Research Cooperative System database was queried to identify patients who underwent primary subaxial cervical fusion from 1997 to 2012. Demographic and clinical information was obtained. Subgroup analyses were performed based on surgical approach: anterior (A), posterior (P), and circumferential (C).A total of 87,045 cervical fusions were included. Over the study period, the population-adjusted annual fusion rate increased from 23.7 to 50.6 per 100,000 population (P0.001). A fusion was most common (85.2%), followed by P (12.3%), and C (2.5%). Mean ages were 49.8 ± 11.9, 59.9 ± 15.2, and 55.1 ± 14.5 years (P0.001), respectively. Although rates remained steady among younger patients, they increased for older patients. Overall, degenerative conditions were the predominant indications for surgery and increased in rate over time. The mean length of stay was: A, 3.1 ± 10.5; P, 9.1 ± 14.1; and C, 14.1 ± 22.5 days (P0.001). Rates of in-hospital complications were A, 3.0%; P, 10.5%; and C, 18.9% (P0.001), and mortality was A, 0.3%, P, 1.8%, and C, 2.5% (P0.001).The rate of subaxial spinal fusions increased 114% from 1997 to 2012 in New York State. Rates remained stable in younger patients but increased in the older population. Preoperative indications and postoperative courses differed significantly among the various approaches, with patients undergoing anterior fusion having better short-term outcomes.

Background/Aims: Dysbiosis of the intestinal microbiota may accelerate the progression of chronic kidney disease (CKD) by increasing the levels of urea toxins. In recent years, probiotics have been recognized to maintain the physiological balance of the intestinal microbiota. In this study, we aim to assess the therapeutic effects of probiotics on CKD patients with and without dialysis via meta-analysis. Methods: We conducted a meta-analysis of randomized controlled trials (RCTs) by searching the databases of Pubmed, EMBASE and Cochrane Library (No. CRD42018093080). Studies on probiotics for treatment of CKD adults lasting for at least 4 weeks were selected. The primary outcomes were the levels of urea toxins, and the second outcomes were the levels of interleukin (IL)-6, C-reactive protein (CRP) and hemoglobin (Hb). The risk of bias was assessed by Cochrane Collaboration’ tool, and the quality of evidence was appraised with the Grading of Recommendation Assessment. Means and standard deviations were analyzed by random effects analysis. Stratified analysis was done and sensitivity analysis was performed when appropriate. Results: Totally, eight studies with 261 patients at CKD stage 3 to 5 with and without dialysis were included. We found a decrease of p-cresyl sulfate (PCS) of 3 studies with 125 subjects (P = 0.01, SMD -0.57, 95% CI, -0.99 to -0.14, I2 = 25%) and an increase of IL-6 in 3 studies with 134 subjects (P = 0.03, 95% CI, SMD 0.37, 0.03 to 0.72, I2 = 0%) in the probiotics groups. Analysis of serum creatinine (P = 0.47), blood urine nitrogen (P = 0.73), CRP (P = 0.55) and Hb (P = 0.49) yielded insignificant difference. Conclusion: Limited number of studies and small sample size are limitations of our study. Probiotics supplementation may reduce the levels of PCS and elevate the levels of IL-6 whereby protecting the intestinal epithelial barrier of patients with CKD.

The modified frailty index (mFI) is emerging as a leading measure for preoperative risk assessment using routinely available medical record data. Our objective was to determine if mFI predicts morbidity and mortality in the diverse national cohort of patients undergoing neurosurgery for intracranial neoplasms. We identified patients in the National Surgical Quality Improvement Program who underwent oncologic neurosurgery procedures between 2008 and 2012. The mFI, ranging from 0 to 1, was calculated as the proportion of 11 possible risk factors present. We assessed the associations between mFI and 30-day mortality, neurologic and medical complications, prolonged length of stay, and unfavorable discharge in univariate and multivariable analyses and compare the index to established risk stratification techniques. A total of 9149 patients were identified. Mortality, severe medical complications, prolonged length of stay, and unfavorable discharge increased incrementally with increasing levels of frailty. Severe neurologic complications were highest in those with low frailty. In multivariable logistic regression analysis, increased frailty increased the odds of all adverse outcomes, including neurologic complications. The mFI increased the ability to predict all outcomes beyond available indices and was the most reliable predictor of neurologic complications. The mFI can be calculated from routinely collected medical record data and is predictive of 30-day adverse outcomes in a wide variety of neurosurgical oncology patients. The index may be a useful component of preoperative risk assessment with implications for shared decision-making, perioperative planning, and risk adjusted outcomes measurement in national quality registries.

Plant-parasitic nematodes (PPNs) cause serious crop losses worldwide. In this study, we investigated the nematicidal factors and the modes and mechanisms of action involved in nematode control by Paenibacillus polymyxa KM2501-1. Treatment of the second-stage juveniles (J2) juveniles of PPN Meloidogyne incognita with the biological control agent KM2501-1 resulted in a mortality of 87.66% in vitro and reduced symptoms on tomato by up to 82.61% under greenhouse conditions. We isolated 11 volatile organic compounds (VOCs) from strain KM2501-1, of which 8 had contact nematicidal activity, 6 had fumigant activity, and 5 acted as stable chemotactic agents to M. incognita. The VOCs provided a comprehensive strategy against PPNs that included “honey-trap”, fumigant, attractant and repellent modes. Furfural acetone and 2-decanol functioned as “honey-traps” attracting M. incognita and then killing it by contact or fumigation. Two other VOCs, 2-nonanone and 2-decanone, as well as strain KM2501-1 itself, destroyed the integrity of the intestine and pharynx. Collectively our results indicate that VOCs produced by P. polymyxa KM2501-1 act through diverse mechanisms to control M. incognita. Moreover, the novel “honey-trap” mode of VOC–nematode interaction revealed in this study extends our understanding of the strategies exploited by nematicidal biocontrol agents.

Background There is growing recognition that perioperative complication rates are similar between hospitals, but mortality rates are lower at high-volume centers. This may be due to differences in the ability to rescue patients from major complications. Objective To examine the relationship between hospital caseload and failure to rescue from complications following resection of intracranial neoplasms. Methods We identified adults in the Nationwide Inpatient Sample diagnosed with glioma, meningioma, brain metastasis, or acoustic neuroma, who underwent surgical resection between 1998 and 2010. We stratified hospitals by low, intermediate, and high surgical volume tertiles and calculated failure to rescue rates (mortality in patients after a major complication). Results A total of 550 054 patients were analyzed. Overall risk-adjusted complication rates were comparable between low- and medium-volume centers, and slightly lower at high-volume centers (15.3% [15.2, 15.5] vs 15.7% [15.5, 15.9] vs 14.3% [14.1, 14.6]). Risk-adjusted mortality decreased with increasing hospital surgical volume (10.3% [10.2, 10.5] vs 9.0% [8.9, 9.1] vs 7.1% [7.0, 7.2]). The overall risk-adjusted failure to rescue rate also decreased with increasing surgical volume (26.9% [26.3, 27.4] vs 24.8% [24.3, 25.3] vs 20.9% [20.5, 21.5]). Conclusion While complication rates were similar between high-volume and low-volume hospitals following craniotomy for tumor, mortality rates were substantially lower at high-volume centers. This appears to be due to the ability of high-volume hospitals to rescue patients from major perioperative complications.

ImportanceThough it has been a common practice to use sharp needles to administer local anesthesia for upper blepharoplasty, the evidence for their benefit is lacking. ObjectiveTo evaluate whether ...

Objective: The aim of the study was to examine alcohol use in African American women’s social networks.Design: This was a longitudinal study of African American women and their social networks in Baltimore, MD. Data were collected through face-to-face interviews at a community-based research clinic. Alcohol consumption frequency was assessed by a single question ‘How often do you drink alcohol?’ with a four-point ordinal rating scale ‘never,’ ‘monthly or less,’ ‘2–4 times a month’ and ‘>2 times a week.’ A longitudinal ordinal logistic model was conducted to use 317 African American women’s alcohol consumption frequency as a predictor of their social networks’ alcohol consumption frequency.Results: Results show that African American women’s alcohol consumption frequency was a statistically significant predictor of their social network members’ alcohol consumption frequency.Conclusion: Findings suggest the merit of social network-based approaches to address alcohol use among urban minority populations.

Nurses are often first to identify and manage a patient leaving against medical advice (AMA), and so they are critical contributors to the development of strategies to address this problem. We studied AMA discharge in order to help develop useful interventions. We performed a cross-sectional analysis of 55,938 discharges from a single urban hospital for the years 2002-2003 and 2012-2013. AMA discharge rates were higher for HIV-infected patients than for patients with alcohol-related disorders or sickle cell anemia in both time periods, even after adjustment for age, race, sex, insurance status, and household income. For HIV infection, 25% of AMA discharges occurred in patients with multiple AMA discharges and 30-day readmission rates were higher after an AMA discharge: odds ratio 1.57 (95% confidence interval 1.01 to 2.43, p = .046). Team-based and nursing interventions that incorporate the treatment-based values and preferences of HIV-infected patients with prior AMA discharges may improve linkage to care and reduce readmissions.

BACKGROUND CONTEXT Recent studies have shown teriparatide therapy reduces the risk of proximal junctional kyphosis/failure (PJK/PJF) and subsequent revision after corrective surgery for adult spinal deformity (ASD). However, teriparatide usually costs more than other anti-osteoporotic treatments and its cost effectiveness for the prevention of these unfavorable sequelae is unclear. PURPOSE The aim of this study is to investigate the cost effectiveness of preoperative teriparatide therapy for ASD patients utilizing a Markov model of ASD corrective surgery. STUDY DESIGN/SETTING An economic decision-analysis based on a Markov model simulation. PATIENT SAMPLE A thorectical cohort of patients with adult spinal deformity patients who undergo corrective surgery. OUTCOME MEASURES Cost/QALY and the rates of patients who successfully achieved fusion without any correction loss due to PJK/PJF. METHODS A Markov model of ASD surgery was created incorporating the incidences of PJK/PJF and revision rates due to PJK/PJF in the surgically treated ASD patient with or without 12-month teriparatide treatment, revision rates for non-PJK causes, recurrence rates of PJK/PJF, postoperative mortality, and pre-/postoperative quality-adjusted life-years (QALYs), obtained from previously published literature. The effectiveness was measured in cost/QALY and the rates of patients who successfully achieved fusion without any correction loss due to PJK/PJF in each group. RESULTS The Markov model simulation showed that the 10-year cumulative cost was higher in the teriparatide group ($131,000 vs $83,000). The percentage of patients without correction loss at 10 years after surgery was also higher in the teriparatide group (86.9% vs 76.7%). The 10-year average QALYs of each group were 0.59 in the no teriparatide group and 0.61 in the teriparatide group. The cost-effectiveness of 12-month teriparatide therapy measured in cost/QALY was $213,000/QALY, which was almost twice as high as the commonly used cost-effectiveness threshold ($100,000/QALY). Teriparatide therapy can be considered as cost-effective only if teriparatide therapy less than 6 months is as effective as 12 months of treatment for PJK/PJF prevention, or teriparatide is administrated only for high-risk patients whose 24-month PJK/PJF incidence rate exceeds approximately 40% without teriparatide ($94000/QALY). CONCLUSIONS The results of our Markov model simulation suggest that teriparatide therapy is associated with lower correction loss, but is not a cost-effective option if it is routinely administered in all ASD patients regardless of bone status. Careful selection of high-risk patients for teriparatide therapy is warranted as a more cost-effective measure. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Laparoscopy is being increasingly applied to pediatric inguinal hernia repair. In younger children, however, open repair remains preferred due to concerns related to anesthesia and technical challenges. We sought to assess outcomes after laparoscopic and open inguinal hernia repair in children less than or equal to 3 years. A prospective, single-blind, parallel group randomized controlled trial was conducted at three clinical sites. Children ≤3 years of age with reducible unilateral or bilateral inguinal hernias were randomized to laparoscopic herniorrhaphy (LH) or open herniorrhaphy (OH). The primary outcome was the number of acetaminophen doses. Secondary outcomes included operative time, complications, and parent/caregiver satisfaction scores. Forty-one patients were randomized to unilateral OH (n = 10), unilateral LH (n = 17), bilateral OH (n = 5) and bilateral LH (n = 9). Acetaminophen doses, LOS, complications, and parent/caregiver scores did not differ among groups. Laparoscopic unilateral hernia repair demonstrated shorter operative time, a consistent finding for overall laparoscopic repair in univariate (p = 0.003) and multivariate (p = 0.010) analysis. No cases of testicular atrophy were documented at 2 (SD = 2.7) years. Children ≤3 years of age in our cohort safely underwent LH with similar pain scores, complications, and recurrence as OH. Parents and caregivers report high satisfaction with both techniques.

Evidence supporting routine postoperative antiepileptic drug (AED) prophylaxis following oncologic neurosurgery is limited, and actual practice patterns are largely unknown beyond survey data. To describe patterns and predictors of postoperative AED prophylaxis following intracranial tumor surgery. The MarketScan Database was used to analyze pharmacy claims data and clinical characteristics in a national sample over a 5-year period. Among 5895 patients in the cohort, levetiracetam was the most widely used AED for prophylaxis (78.5%) followed by phenytoin (20.5%). Prophylaxis was common but highly variable for patients who underwent open resection of supratentorial intraparenchymal tumors (62.5%, reference) or meningiomas (61.9%). In multivariate analysis, biopsies were less likely to receive prophylaxis (44.8%, OR 0.47, 95% CI 0.33–0.67), and there was near consensus against prophylaxis for infratentorial (9.7%, OR 0.07, CI 0.05–0.09) and transsphenoidal procedures (0.4%, OR 0.003, CI 0.001–0.010). Primary malignancies (52.1%, reference) and secondary metastases (42.2%) were more likely to receive prophylaxis than benign tumors (23.0%, OR 0.63, CI 0.48–0.83), as were patients discharged with home services and patients in the Northeast. There was a large spike in duration of AED use at approximately 30 days. Use of seizure prophylaxis following intracranial biopsies and supratentorial resections is highly variable, consistent with a lack of guidelines or consensus. Current practice patterns do not support a clear standard of care and may be driven in part by geographic variation, availability of post-discharge services, and electronic prescribing defaults rather than evidence. Given uncertainty regarding effectiveness, indications, and appropriate duration of AED prophylaxis, well-powered trials are needed.

STUDY DESIGN Single-center retrospective study. OBJECTIVE Investigate how differing degrees of pelvic incidence (PI) modulate the recruitment of pelvic tilt (PT) in response to similar amounts of sagittal malalignment as measured by T1-Pelvic Angle (TPA). SUMMARY OF BACKGROUND DATA Past research has shown that some patients do not recruit PT in response to sagittal malalignment. Given the anatomic relationship between PI and PT, we sought to determine whether differing PI is associated with variable recruitment of PT. METHODS Single-center retrospective study of 2077 patients undergoing full body radiographs and TPA>10°. Five groups of patients (Very Low, Low, Average, High, and Very High PI) were defined utilizing PI ranges on a Gaussian distribution. Linear regression (LR) evaluated correlation of TPA to PT within each PI group. Multivariate LR evaluated whether correlation between TPA and PT differed between each PI group. RESULTS Mean PT increased with increasing levels of PI (P

Gait speed declines at a faster rate in persons with HIV (PWH) than in the general population but the risk factors associated with this decline are not well understood. In the AIDS Clinical Trials Group (ACTG) A5322 (HAILO, HIV Infection, Aging, and Immune Function Long-term Observational Study), an observational cohort study of PWH ≥40 years of age, those who developed slow gait during the first 3 years of follow-up were compared with persons who maintained normal speed. Associations with demographic and clinical covariates were assessed using multivariable logistic regression. Of 929 participants, 81% were men, 31% Black, and 20% Hispanic. Median age was 51 years [interquartile range (IQR) = 46-56]. At study entry, 92% had plasma HIV RNA

Background Post-operative ileus (POI) is common and can be associated with significant morbidity. Questions/Purposes We aimed to identify the incidence of and risk factors associated with severe post-operative ileus (SPOI) after elective orthopedic surgery. Methods We conducted a retrospective case–control study of patients undergoing elective orthopedic procedures at a single musculoskeletal specialty hospital. SPOI cases matched 1:2 to non-POI controls. International Classification of Diseases, Ninth Revision (ICD-9), codes were used to identify patients who were coded as having an episode of POI. After chart review, a subset was classified as clinical SPOI cases, based on set criteria. Regression models were constructed to identify variables associated with SPOI. Results Of 273 POI cases, 77 (28.2%) were classified as SPOI. Overall rates of SPOI were 2.74/1000 orthopedic discharges, with SPOI most common in spine surgeries (9.07/1000 spine procedure discharges). Hypothesis-generating multivariable conditional logistic regression suggested that, for hip and knee cases, not being on a full diet by post-operative day (POD) 2 posed an increased risk of SPOI. For spine cases, not being on a full diet on POD 2 and longer surgery times were associated with risk of SPOI. Conclusions In this retrospective case–control study, patients undergoing elective orthopedic procedures who had not progressed to full diet by POD 2 and spine patients with longer operative times were most at risk for SPOI. These data can be used clinically by peri-operative physicians to stratify patients according to risk.

This paper investigates a Yagi antenna with circular polarization (CP) at the end-fire direction based on normal-mode helix. It consists of a right-handed center-fed helical dipole and two parasitic helixes with the same direction of rotation. The parameters of the driven helix are optimized to realize circular polarization and quasi-uniform radiation in the plane normal to the helix axis. The coupling between the driven and parasitic helixes is utilized to achieve a unidirectional radiation. It is found that an end-fire beam with CP is obtained by carefully choosing the parameters of the parasitic helix and the spacing between them. Simulation results show that the final optimized antenna achieves a gain of 6.4 dBic and front-to-back ratio of 8.1 dB at 1 GHz.