Consensus Statement from India on the Renal Benefits of ARNi, SGLT-2i, and Bisoprolol in Chronic Kidney Disease.

Chronic kidney disease (CKD) is a major contributor to morbidity and mortality in India. CKD often coexists with heart failure (HF), diabetes, and hypertension. All these comorbidities are risk factors for renal impairment. HF and CKD are pathophysiologically intertwined, and the deterioration of one can worsen the prognosis of the other. There is a need for safe renal pharmacological therapies that target both CKD and HF and are also useful in hypertension and diabetes. Neurohormonal activation achieved through the activation of the sympathetic nervous system (SNS), the renin-angiotensin-aldosterone system (RAAS), and the natriuretic peptide system (NPS) is fundamental in the pathogenesis and progression of CKD and HF. Angiotensin receptor neprilysin inhibitor (ARNi), sodium-glucose cotransporter 2 inhibitors (SGLT-2i), and selective ß1-blocker (B1B) bisoprolol suppress this neurohormonal activation. They also have many other cardiorenal benefits across a wide range of CKD patients with or without concomitant HF, diabetes, or hypertension. This consensus statement from India explores the place of ARNi, SGLT-2i, and bisoprolol in the management of CKD patients with or without HF and other comorbidities.

Current Place of SGLT2i in the Management of Heart Failure: An Expert Opinion from India.

Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.

Validation of Impaction Grafting for Single-Level Transforaminal Lumbar Interbody Fusion-Technical Pearls and MicroCT Analysis.

STUDY DESIGN: Cadaveric study. BACKGROUND CONTEXT: Transforaminal lumbar interbody fusion (TLIF) represents a well-documented operative surgical technique utilized in the management of lumbar pathology requiring interbody arthrodesis. The microstructural properties of impaction grafting (IG) after TLIF has yet to be reported. PURPOSE: The current study was designed first, to quantify the degree, to which IG augmentation would increase intrabody final bone volume and bone graft surface contact area with the endplates; secondly to quantify the volumes of locally harvested bone and bone needed for maximal impaction. MATERIALS AND METHODS: Three cadaveric lumbosacral spine specimens were dissected into L1-L2, L3-L4, and L5-S1 motion segments for a total of 9 functional spinal units. Each interbody unit underwent a TLIF procedure with the implantation of an interbody spacer containing autogenous morselized bone. Microcomputed tomography scans were then performed to evaluate the final bone volume and bone surface contact area (BSCA). Subsequently, IG augmented TLIF procedure was carried and microcomputed tomography scans were repeated. RESULTS: IG augmentation of TLIF exhibited a 346% increase in final bone volume (TLIF: 0.30 ± 0.07 cm 3 ; IG-TLIF: 1.34 ± 0.42 cm 3 ; P < 0.05) and a 152% increase in BSCA (TLIF: 45.06 ± 15.47%; IG-TLIF: 68.28 ± 6.85%; P < 0.05) when compared with the nonimpacted TLIF treatment. In addition, the average amount of autogenous bone collected was 8.21±2.08 cm 3 , which sufficiently fulfilled the requirements for bone grafting (TLIF: 1.23 ± 0.40 cm 3 ; IG-TLIF 6.42 ± 1.20 cm 3 ). CONCLUSIONS: IG augmentation of TLIF significantly improved final bone volume in the disc space and BSCA with vertebral endplates in vitro. CLINICAL SIGNIFICANCE: Greater BSCA and final volume of bone graft reflect promisingly on their potential to increase fusion rates. Clinical studies will be needed to corroborate these findings.

Role of Bisoprolol in Heart Failure Management: A Consensus Statement from India.

In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective ß-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a ß-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.

Mobile shoppers' response to Covid-19 phobia, pessimism and smartphone addiction: Does social influence matter?

Because of the Covid-19 pandemic, there has been a variety of changes identified in customers' shopping behaviours, and development of new practices as a response to the crisis. The purpose of this research is to examine the effects of Covid-19 phobia, and news exposure on individuals' psychological states, and their resulting mobile shopping behaviour. Relying upon the Activate, Belief and Consequences (ABC) model of the Cognitive-Behaviour Theory, this research applies the partial least square structural modelling (PLS-SEM) methodology for analysing the data from 302 mobile shoppers from India. The results confirm that Covid-19 phobia and Covid-19 news exposure are substantial determinants of consumers' smartphone addictive use and pessimism, which in turn affect mobile shopping frequency. Additionally, social influence is found to play a vital role in moderating mobile shopping frequency for individuals, who experience smartphone addiction. The current study is a pioneering effort to examine the influence of Covid-19-induced phobia on consumers' psychological states and their subsequent impact on their mobile shopping frequency. The study provides several contributions to theory and practice within the areas of technology use and mobile shopping in particular.

Blockchain for SME Clusters: An Ideation using the Framework of Ostrom Commons Governance.

Small and medium-sized enterprises (SMEs) organize themselves into clusters by sharing a set of limited resources to achieve the holistic success of the cluster. However, these SMEs often face conflicts and deadlock situations that hinder the fundamental operational dynamics of the cluster due to varied reasons, including lack of trust and transparency in interactions, lack of common consensus, and lack of accountability and non-repudiation. Blockchain technology brings trust, transparency, and traceability to systems, as demonstrated by previous research and practice. In this paper, we explore the role of blockchain technology in building a trustworthy yet collaborative environment in SME clusters through the principles of community self-governance based on the work of Nobel Laureate Elinor Ostrom. We develop and present a blockchain commons governance framework for the three main dimensions i.e., interaction, autonomy, and control, based on the theoretical premise of equivalence mapping and qualitative analysis. This paper examines the role of blockchain technology to act as a guiding mechanism and support the smooth functioning of SMEs for their holistic good. The study focuses on sustainability and improving productivity of SMEs operating in clusters under public and private partnership. This is the first study to address the operational challenges faced by SEMs in clusters by highlighting the dimensions of blockchain commons governance dimensions.

Femoral nerve neuromonitoring for lateral lumbar interbody fusion surgery.

BACKGROUND CONTEXT: The transpsoas lateral lumbar interbody fusion (LLIF) technique is an effective alternative to traditional anterior and posterior approaches to the lumbar spine; however, nerve injuries are the most reported postoperative complication. Commonly used strategies to avoid nerve injury (eg, limiting retraction duration) have not been effective in detecting or preventing femoral nerve injuries. PURPOSE: To evaluate the efficacy of emerging intraoperative femoral nerve monitoring techniques and the importance of employing prompt surgical countermeasures when degraded femoral nerve function is detected. STUDY DESIGN/SETTING: We present the results from a retrospective analysis of a multi-center study conducted over the course of 3 years. PATIENT SAMPLE: One hundred and seventy-two lateral lumbar interbody fusion procedures were reviewed. OUTCOME MEASURES: Intraoperative femoral nerve monitoring data was correlated to immediate postoperative neurologic examinations. METHODS: Femoral nerve evoked potentials (FNEP) including saphenous nerve somatosensory evoked potentials (snSSEP) and motor evoked potentials with quadriceps recordings were used to detect evidence of degraded femoral nerve function during the time of surgical retraction. RESULTS: In 89% (n=153) of the surgeries, there were no surgeon alerts as the FNEP response amplitudes remained relatively unchanged throughout the surgery (negative group). The positive group included 11% of the cases (n=19) where the surgeon was alerted to a deterioration of the FNEP amplitudes during surgical retraction. Prompt surgical countermeasures to an FNEP alert included loosening, adjusting, or removing surgical retraction, and/or requesting an increase in blood pressure from the anesthesiologist. All the cases where prompt surgical countermeasures were employed resulted in recovery of the degraded FNEP amplitudes and no postoperative femoral nerve injuries. In two cases, the surgeons were given verbal alerts of degraded FNEPs but did not employ prompt surgical countermeasures. In both cases, the degraded FNEP amplitudes did not recover by the time of surgical closure, and both patients exhibited postoperative signs of sensorimotor femoral nerve injury including anterior thigh numbness and weakened knee extension. CONCLUSIONS: Multimodal femoral nerve monitoring can provide surgeons with a timely alert to hyperacute femoral nerve conduction failure, enabling prompt surgical countermeasures to be employed that can mitigate or avoid femoral nerve injury. Our data also suggests that the common strategy of limiting retraction duration may not be effective in preventing iatrogenic femoral nerve injuries.

Covid-19 pandemic and consumer-employee-organization wellbeing: A dynamic capability theory approach.

The consumers, employees, and organizations have been deeply impacted by Covid-19 pandemic. The present study offers a detailed coping mechanism for organizations based on the extant literature and content analysis of responses of senior management executives. The study is based on semi-structured long interviews with senior executives from various industries. Various measures have been identified for firms as a coping strategy for crisis management and customer well-being. Covid-19 has changed the way individuals live. This study suggests that firms should come forward for well-being of their employees in this new normal. One of the major shifts due to pandemic is in consumer behavior and their consumption habits. Pandemic made consumers go for digitization, think for hygiene, sustainability, and local products. And firms should keep the changed consumer behavior in mind while manufacturing the products. Furthermore, present study suggests that firms can create a positive image of their company by doing CSR activities for society's well-being.

Percutaneous image-guided cryoablation of spinal metastases: A systematic review.

Percutaneous cryoablation (PCA) is a minimally invasive technique that has been recently used to treat spinal metastases with a paucity of data currently available in the literature. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective or retrospective studies concerning metastatic spinal neoplasms treated with current generation PCA systems and with available data on safety and clinical outcomes were included. In the 8 included studies (7 retrospective, 1 prospective), a total of 148 patients (females = 63%) underwent spinal PCA. Tumors were located in the cervical (3/109 [2.8%], thoracic (74/109 [68.8%], lumbar (37/109 [33.9%], and sacrococcygeal (17/109 [15.6%] regions. Overall, 187 metastatic spinal lesions were treated. Thermo-protective measures (e.g., carbo-/hydro-dissection, thermocouples) were used in 115/187 [61.5%] procedures. For metastatic spinal tumors, the pooled mean difference (MD) in pain scores from baseline on the 0-10 numeric rating scale was 5.03 (95% confidence interval [CI]: 4.24 to 5.82) at a 1-month follow-up and 4.61 (95% CI: 3.27 to 5.95) at the last reported follow-up (range 24-40 weeks in 3/4 studies). Local tumor control rates ranged widely from 60% to 100% at varying follow-ups. Grade I-II complications were reported in 9/148 [6.1%] patients and grade III-V complications were reported in 3/148 [2.0%]) patients. PCA, as a stand-alone or adjunct modality, may be a viable therapy in appropriately selected patients with painful spinal metastases who were traditionally managed with open surgery and/or radiation therapy.

Assessment of the impact of heart failure on household economic well-being: a protocol.

Background: Heart failure (HF), which is an emerging public health issue, adversely affects the strained health system in India. The adverse impact of HF on the economic well-being has been narrated in various anecdotal reports from India, with affected individuals and their dependents pushed into the vicious cycle of poverty. There is limited research quantifying how HF impacts the economic well-being of households from low- and middle-income countries. Methods: We describe the methods of a detailed economic impact assessment of HF at the household level in India. The study will be initiated across 20 hospitals in India, which are part of the National heart Failure Registry (NHFR). The selected centres represent different regions in India, stratified based on the prevailing stages of epidemiological transition levels (ETLs). We will collect data from 1800 patients with acute decompensated HF and within 6-15 months follow-up from the time of initial admission. The data that we intend to collect will consist of a) household healthcare expenditure including out-of-pocket expenditure, b) financing mechanisms used by households and (c) the impoverishing effects of health expenditures including distress financing and catastrophic health expenditure. Trained staff at each centre will collect data by using a validated and structured interview schedule. The study will have 80% power to detect an 8% difference in the proportion of households experiencing catastrophic health expenditures between two ETL groups.  After considering a non-response rate of 5%, the target sample size is approximately 600 patients from each group and the total sample size is 1800 patients. Potential Impact: Our study will provide information on catastrophic health spending, distress financing and household expenditure in heart failure patients. Our findings will help policy makers in understanding the micro-economic impact of HF in India and aid in allocation of appropriate resources for prevention and control of HF.

Patients Undergoing 3-Level-or-Greater Decompression-Only Surgery for Lumbar Spinal Stenosis Have Similar Outcomes to Those Undergoing Single-Level Surgery at 2 Years.

BACKGROUND: Stability following multilevel decompressive laminectomy without fusion has been debated using in vitro biomechanical and radiographic models. However, there is a lack of information regarding clinical outcomes for these patients. The aim of the present study was to determine the association between clinical outcomes and number of levels decompressed via laminectomy for treatment of lumbar spinal stenosis. METHODS: We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy between 2009 and 2015 by senior orthopedic spine surgeons for lumbar spinal stenosis. Patients were divided into 2 groups based on the number of decompression levels: single level or 3 or more levels. Patient-reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey scores, and Veterans Rand 12-Item Health Mental and Physical Survey scores. RESULTS: Overall, 138 consecutive patients were assessed, of which 106 underwent a single-level and 32 underwent a 3-or-more-level laminectomy. Average follow-up was 24.2 months. There were no significant differences in the preoperative VAS back, VAS leg, or ODI scores between the single-level laminectomy and 3-or-more-level laminectomy groups. Both groups of patients experienced significant improvements in these clinical outcomes postoperatively with no clinically significant difference in the degree of improvement. Reoperation rates were low and similar between the 2 groups. CONCLUSIONS: Patients undergoing decompression of 3 or more levels present with similar postoperative outcomes to those who undergo a single-level decompression for lumbar spinal stenosis. Under specific clinical and radiographic criteria, a multilevel decompression of 3 or more levels may be a safe and effective procedure with acceptable outcomes at 2 years after surgery. LEVEL OF EVIDENCE: 3.

Stressors and coping strategies of migrant workers diagnosed with COVID-19 in Singapore: a qualitative study.

INTRODUCTION: The health, psychological and socioeconomic vulnerabilities of low-wage migrant workers have been magnified in the COVID-19 pandemic, especially in high-income receiving countries such as Singapore. We aimed to understand migrant worker concerns and coping strategies during the COVID-19 pandemic to address these during the crisis and inform on comprehensive support needed after the crisis. METHODS: In-depth semi-structured interviews were carried out with migrant workers diagnosed with COVID-19. The participants were recruited from a COVID-19 mass quarantine facility in Singapore through a purposive sampling approach. Interviews were transcribed verbatim and thematic analysis performed to derive themes in their collective experience during the crisis. RESULTS: Three theme categories were derived from 27 interviews: migrant worker concerns during COVID-19, coping during COVID-19 and priorities after COVID-19. Major stressors in the crisis included the inability to continue providing for their families when work is disrupted, their susceptibility to infection in crowded dormitories, the shock of receiving the COVID-19 diagnosis while asymptomatic, as well as the isolating conditions of the quarantine environment. The workers coped by keeping in contact with their families, accessing healthcare, keeping updated with the news and continuing to practise their faith and religion. They looked forward to a return to normalcy after the crisis with keeping healthy and having access to healthcare as new priorities. CONCLUSION: We identified coping strategies employed by the workers in quarantine, many of which were made possible through the considered design of care and service delivery in mass quarantine facilities in Singapore. These can be adopted in the set-up of other mass quarantine facilities around the world to support the health and mental well-being of those quarantined. Our findings highlight the importance of targeted policy intervention for migrant workers, in areas such as housing and working environments, equitable access to healthcare, and social protection during and after this crisis.

Reviving tourism industry post-COVID-19: A resilience-based framework.

The COVID-19 pandemic struck the tourism industry severely. Based on the review of 35 papers that studied the tourism industry in the wake of the pandemic, we propose a resilience-based framework for reviving the global tourism industry post-COVID-19. Our framework outlines four prominent factors for building resilience in the industry: government response, technology innovation, local belongingness, and consumer and employee confidence. We argue that using such inclusive resilience; the tourism industry may transform into a new global economic order characterized by sustainable tourism, society's well-being, climate action, and the involvement of local communities. We also offer directions for future research in the area.

Five decades of research on foreign direct investment by MNEs: An overview and research agenda.

Despite the significance attached to foreign direct investment (FDI) by Multinational enterprises (MNEs), there are is no comprehensive review of the FDI literature. Moreover, those that have been published, focus on subsets of FDI. This review systematically examines the empirical as well as theoretical research on FDI through an analysis of 500 articles published during the last five decades. Theoretical models, methods, context, and contributions to scholarship were reviewed. We strive to highlight the key theories, paradigms, and articles and provide directions for future research. We conclude that FDI has evolved as the most significant area of international business.

Trade credit research before and after the global financial crisis of 2008 - A bibliometric overview.

This study presents an overview of the state-of-the-art in trade credit research by examining 1191 publications between 1955 and 2019. Applying bibliometrics and econometrics, the study compares the extant research across the three sub-domains of banking and finance, production and operations, and accounting. Findings suggest that the financial emergency in the global market had resulted in a watershed moment in trade credit research. About 69 % of the literature was found to have emerged after the global economic crisis of 2008. A network analysis grouped the trade credit articles into four major and four minor clusters. The banking and financing cluster exhibited the highest growth followed by the production and operation cluster while the perspectives of accounting are yet to gain traction. Conversely, reputation of the publishing hub, empirical studies, and the production and operational dimensions of the research positively and significantly influence citations. Alongside a thorough introspection, the study also provides new areas to direct the course of future research.

Rigid-Plating and Cortico-Cancellous Allograft Are Effective for 3-Level Anterior Cervical Discectomy and Fusion: Radiographic and Clinical Outcomes.

OBJECTIVE: To determine the risk factors associated with radiographic changes and clinical outcomes following 3-level anterior cervical discectomy and fusion (ACDF) using rigidplate constructs and cortico-cancellous allograft. ACDF has demonstrated efficacy for treatment of multilevel degenerative cervical conditions, but current data exists in small heterogeneous forms. METHODS: A retrospective review included 98 patients with primary 3-level ACDF surgery at one institution from 2008 to 2013 with minimum 1-year follow-up. Cervical sagittal vertical axis (SVA), segmental height, fusion, and lordosis radiographs were measured preoperatively and at 2 postoperative periods. RESULTS: Rates of asymptomatic pseudarthroses and total reoperations were 18% and 4%, respectively. Results demonstrated immediate improvements in cervical lordosis (5.5°, p < 0.01) and segmental height (5.0-mm increase, p < 0.01) with little changes in the cervical SVA (3.2-mm increase, p < 0.01). The segmental height decreased from immediate postoperative period to final follow-up (1.7-mm decrease, p < 0.01). Older age was protective against radiolucent lines (p < 0.05). Patient-reported outcomes significantly improved following surgery (p < 0.01). Current smoking status and diagnosis of diabetes mellitus had no impact on radiographic or clinical outcomes. Risk factors were not identified for the 5 reoperations (4%). CONCLUSION: Three-level ACDF with rigid-plating and cortico-cancellous allograft is an effective procedure for degenerative diseases of the cervical spine without the application of additional adjuncts or combined anteriorposterior cervical surgeries. Significant improvements in cervical lordosis, segmental height, and segmental alignment can be achieved with little change in cervical SVA and a low rate of reoperations over short-term follow-up. Similarly, patient-reported outcomes show significant improvements.

Clinical Presentation and Outcomes of Patients With a Lumbar Far Lateral Herniated Nucleus Pulposus as Compared to Those With a Central or Paracentral Herniation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Examine pre- and postoperative outcomes between patients presenting with a central/paracentral versus a far lateral herniated nucleus pulposus (HNP) and assess whether significantly worse postoperative outcomes, assessed via patient self-reported survey, are associated with far lateral disc herniations. METHODS: We performed a retrospective cohort analysis of patients who underwent primary lumbar decompression between January 2008 and December 2015. Groups were divided based on herniation type, central/paracentral or far lateral. Patients with 3 months, or longer, of follow-up were included. Variables analyzed included demographics, American Society of Anesthesiologists (ASA) Score, Charleston Comorbidity Index (CCI), Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and Veterans RAND 12-Item Mental and Physical Survey (VR-12) scores. RESULTS: A total of 100 patients met the inclusion criteria. Postoperative ODI scores for central/paracentral HNP were significantly lower compared to far lateral HNP. Patients with a far lateral disc herniation presented with significantly lower preoperative SF-12 and VR-12 scores. The improvement in ODI score from preoperative to final was significantly lower in the patients presenting with a far lateral HNP. CONCLUSIONS: Although patients with far lateral HNP present with worse preoperative outcome scores, they can expect similar symptom improvement to central or paracentral herniations following discectomy. This information can be used for future surgeons when weighing conservative versus surgical treatment of far lateral herniations.

Congenital Etiology Is an Independent Risk Factor for Complications in Adolescents Undergoing Corrective Scoliosis Surgery: Comparison of In-hospital Comorbidities Using Nationwide KID's Inpatient Database.

BACKGROUND: Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS: A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS: In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P<0.001), had fewer comorbidities (P<0.001), and sustained similar complication incidence. In the 10 and over age analysis, CS patients similarly had shorter fusions, but greater comorbidities, and significantly more complications (odds ratio, 1.6; confidence interval, 1.4-1.8). CONCLUSIONS: CS patients have higher in-hospital complication rates. With more comorbidities, these patients have increased risk of sustaining procedure-related complications such as shock, infection, and Adult Respiratory Distress Syndrome. These data help to counsel patients and their families before spinal fusion. LEVEL OF EVIDENCE: Level III-retrospective review of a prospectively collected database.

Incidence of Congenital Spinal Abnormalities Among Pediatric Patients and Their Association With Scoliosis and Systemic Anomalies.

BACKGROUND: Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies. METHODS: A retrospective cohort analysis on Health care Cost and Utilization Project's Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. OUTCOME MEASURES: Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies. Frequencies of congenital spine anomalies were estimated using KID hospital-and-year-adjusted weights. Poisson distribution in contingency tables tabulated concurrence of other congenital anomalies, grouped by body system. RESULTS: Of 12,039,432 patients, rates per 100,000 cases were: 9.1 hemivertebra, 4.3 Klippel-Fiel, 56.3 Chiari malformation, 52.6 tethered cord, 83.4 spina bifida, 1.2 absence of vertebra, and 6.2 diastematomyelia. Diastematomyelia had the highest concurrence of other anomalies: 70.1% of diastematomyelia patients had at least one other congenital anomaly. Next, 63.2% of hemivertebra, and 35.2% of Klippel-Fiel patients had concurrent anomalies. Of the other systems deformities cooccuring, cardiac system had the highest concurrent incidence (6.5% overall). In light of VACTERL's definition of a patient being diagnosed with at least 3 VACTERL anomalies, hemivertebra patients had the highest cooccurrence of ≥3 anomalies (31.3%). With detailed analysis of hemivertebra patients, secundum ASD (14.49%), atresia of large intestine (10.2%), renal agenesis (7.43%) frequently cooccured. CONCLUSIONS: Congenital abnormalities of the spine are associated with serious systemic anomalies that may have delayed presentations. These patients continue to be at a very high, and maybe higher than previously thought, risk for comorbidities that can cause devastating perioperative complications if not detected preoperatively, and full MRI workups should be considered in all patients with spinal abnormalities. LEVEL OF EVIDENCE: Level III.

Comparing Allografts to Autografts for Maintenance of Cervical Sagittal Parameters and Clinical Outcomes Following Anterior Cervical Discectomy and Fusion With Anterior Cervical Plating.

OBJECTIVE: Current literature has not shown if using either allograft or autograft differentially affects postoperative cervical sagittal parameters. The goal of this study was to compare sagittal alignment and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with allograft versus autograft. METHODS: A retrospective cohort analysis of patients who underwent single-level ACDF was conducted. Preoperative, immediate postoperative, and final follow-up radiographic assessments were conducted and included: change in C2-7 lordosis, T1 slope, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, and proximal and distal adjacent segment degeneration (ASD). Patient-reported outcomes were obtained using the Neck Disability Index and visual analogue scale scores for neck and arm. RESULTS: A total of 404 patients were assessed; 353 using allograft and 51 using autograft. No significant differences existed in demographics. Cervical lordosis improved in both groups without significant changes in SVA. Autograft group had a significantly greater amount of lordosis at the proximal segment on immediate postoperative radiographs and less overall cervical lordosis at final follow-up. Sagittal parameters were similar at each time point without significant changes between the 3-time points. No significant differences existed in radiographic ASD or reoperation rates. Fusion rates exceeded 96% in both groups. No significant differences existed between preoperative, postoperative, or change in patient-reported outcomes between the 2 groups. CONCLUSION: Sagittal alignment is maintained following ACDF when using either allograft or autograft. Radiographic evidence of ASD is present in both groups; however, this was not considered clinically significant, given low rates of pseudarthrosis or reoperation. No significant differences exist between groups in terms of patient-reported outcomes.