Minimally invasive robot-assisted direct pars repair: illustrative cases.

BACKGROUND: Robot-assisted techniques are increasingly integrated into the field of spine surgery, with the potential benefits of increased accuracy and reduced radiation exposure. The objective of this study was to describe the technique of minimally invasive robot-assisted direct pars repair with 2 case illustrations. OBSERVATIONS: An 18-year-old male and a 42-year-old male, both with bilateral L5 spondylolysis, underwent successful minimally invasive L5 direct pars repairs with robotic assistance after conservative measures failed, and their cases are presented herein. LESSONS: A robot-assisted direct pars repair is a safe and effective technique for treating bilateral lumbar spondylolysis. The integration of robot-assisted techniques in spine surgery has the potential to improve outcomes, decrease surgical time, and reduce the amount of radiation exposure to operating room staff. https://thejns.org/doi/10.3171/CASE2415.

Utilizing visual symptoms to distinguish dry eye from glaucoma, cataract, and suspect glaucoma patients: a cross-sectional study.

BACKGROUND: The diagnosis of dry eye and other common ophthalmological conditions can be supported using patient reported symptoms, which is increasingly useful in contexts such as telemedicine. We aim to ascertain visual symptoms that differentiate dry eye from cataract, glaucoma, or glaucoma suspects. METHODS: Adults with dry eye, glaucoma, cataract, and suspected glaucoma (controls) completed a questionnaire to rate the frequency and severity of 28 visual symptoms. Univariate, followed by multivariable logistic regression with backward stepwise selection (p < 0.05), determined the individual symptoms and set of symptoms best distinguishing dry eye from each of the other conditions. RESULTS: Mean age of 353 patients (94 glaucoma suspect controls, 79 glaucoma, 84 cataract, and 96 dry eye) was 64.1 years (SD = 14.1); 67% were female and 68% White. Dry eye patients reported more frequent light sensitivity (OR = 15.0, 95% CI = 6.3-35.7) and spots in vision (OR = 2.8, 95% CI = 1.2-6.3) compared to glaucoma suspect controls. Compared to glaucoma patients, dry eye patients experienced more frequent light sensitivity (OR = 9.2, 95% CI = 2.0-41.7), but less frequent poor peripheral vision (OR = 0.2, 95% CI = 0.06-0.7), difference in vision between eyes (OR = 0.09, 95% CI = 0.01-0.7), and missing patches of vision (OR = 0.06, 95% CI = 0.009-0.3). Compared to cataract patients, dry eye patients reported more frequent spots in vision (OR = 4.5, 95% CI = 1.5-13.4) and vision variability across the week (OR = 4.7, 95% CI = 1.2-17.7) and were less likely to report worsening vision (OR = 0.1, 95% CI = 0.03-0.4) and blindness (OR = 0.1, 95% CI = 0.02-0.8). CONCLUSION: Visual symptoms may serve as a complementary tool to distinguish dry eye from various ocular conditions, though the symptoms that best distinguish dry eye differ across comparisons. Differentiating how patients visually perceive common eye diseases may be used in a variety of clinical settings to rule out specific conditions.

Optic Neuritis and Cranial Neuropathies Diagnosis Rates before Coronavirus Disease 2019, in the Initial Pandemic Phase, and Post-Vaccine Introduction.

PURPOSE: To compare rates of diagnosis of neuro-ophthalmic conditions across the Coronavirus Disease 2019 (COVID-19) pandemic with pre-pandemic levels. DESIGN: Multicenter, retrospective, observational study. PARTICIPANTS: Patients seen for eye care between March 11, 2019, and December 31, 2021. METHODS: A multicenter electronic health record database, Sight Outcomes Research Collaborative (SOURCE), was queried for new diagnoses of neuro-ophthalmic conditions (cranial nerve [CN] III, IV, VI, and VII palsy; diplopia; and optic neuritis) and new diagnoses of other ophthalmic conditions from January 1, 2016, to December 31, 2021. Data were divided into 3 periods (pre-COVID, pre-COVID vaccine, and after introduction of COVID vaccine), with a 3-year look-back period. Logistic regressions were used to compare diagnosis rates across periods. Two-sample z-test was used to compare the log odds ratio (OR) of the diagnosis in each period with emergent ocular conditions: retinal detachment (RD) and acute angle-closure glaucoma (AACG). MAIN OUTCOME MEASURES: Diagnosis rate of neuro-ophthalmic conditions in each study period. RESULTS: A total of 323 261 unique patients (median age 59 years [interquartile range, 43-70], 58% female, 68% White) across 5 academic centers were included, with 180 009 patients seen in the pre-COVID period, 149 835 patients seen in the pre-COVID vaccine period, and 164 778 patients seen in the COVID vaccine period. Diagnosis rates of CN VII palsy, diplopia, glaucoma, and cataract decreased from the pre-COVID period to the pre-vaccine period. However, the optic neuritis diagnoses increased, in contrast to a decrease in RD diagnoses (P = 0.021). By comparing the diagnosis rates before and after widespread vaccination, all eye conditions evaluated were diagnosed at higher rates in the COVID vaccination period compared with pre-COVID and pre-vaccine periods. The log OR of neuro-ophthalmic diagnosis rates across every period comparison were largely similar to emergency conditions (RD and AACG, P > 0.05). However, the log OR of cataract and glaucoma diagnoses were different to RD or AACG (P < 0.05) in each period comparison. CONCLUSIONS: Neuro-ophthalmic diagnoses had a similar reduction in diagnosis rates as emergent eye conditions in the first part of the pandemic, except optic neuritis. After widespread COVID-19 vaccination, all ophthalmic diagnosis rates increased compared with pre-pandemic rates, and the increase in neuro-ophthalmic diagnosis rates did not exceed the increase in RD and AACG diagnosis rates. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

"We are still tired": staff and administrators' experiences during the COVID-19 pandemic within California residential care facilities for older adults.

BACKGROUND: Extensive research has been conducted on the impacts of the COVID-19 pandemic on long-term care workers in specialized care facilities. However, little is known about the impacts faced by facilities that provide generalized long-term support and care, such as residential care facilities for older adults (RCFs). This study describes the challenges experienced by staff and administrators of RCFs during the COVID-19 pandemic. METHODS: An electronic questionnaire collecting data using both closed- and open-ended questions on staff experiences was sent to 5,721 unique RCF administrator emails within the state of California between June-December 2021. Email addresses were obtained from the public database of RCFs available through the California Health and Human Services Open Data Portal. Descriptive statistics were calculated on quantitative data regarding staff preparedness training, access to resources, and administrators' confidence in meeting recommended guidelines during the pandemic. Inductive thematic analysis was conducted on qualitative data regarding the confidence levels in meeting pandemic guidelines and challenges faced related to staff stress and morale. RESULTS: A total of 150 RCF administrators across California (response rate of 2.6%) completed the survey. Over three-fourths of respondents indicated their facilities had a designated staff member to train other staff members on emergency preparedness plans and the most frequently used resources during the COVID-19 pandemic were the Department of Social Services Community Care Licensing Division (88.7%), the county health department (86.7%), and the Centers for Disease Control and Prevention (80.7%). Administrators felt least confident in their facilities' ability to maintain adequate staffing (52.0%), communication with nearby hospitals (62.1%) and communication with state and local public health officials (69.8%) during the pandemic. Three central themes emerged from the thematic analysis on staff stress and morale: (1) physical safety, mental and emotional impact of the COVID-19 pandemic; (2) staffing issues; and (3) challenges with guidelines in managing the ongoing pandemic. CONCLUSIONS: Findings from this research study can be used to actively target training resources for facility administrators and staff that have been identified as most frequently used and relevant for emergency preparedness in these understudied facilities. Additionally, developing a better understanding of the staffing stress and morale difficulties in RCFs can provide insight on how policymakers can assist these critical facilities in better preparing for future crises.

Assessment of Prevalence, Clinical Characteristics, and Risk Factors Associated With "Low Flow State" Using Cardiac Magnetic Resonance.

Objective: To assess prevalence, clinical characteristics, and risk factors associated with low flow state (LFS) in a multiethnic population with normal left ventricular ejection fraction (LVEF). Patients and Methods: The study included 4398 asymptomatic participants undergoing cardiac magnetic resonance from July 17, 2000, to August 29, 2002. Left ventricular (LV) mass, volume, and myocardial contraction fraction were assessed. Low flow state was defined as stroke volume index (SVi of <35 mL/m2). Clinical characteristics, cardiac risk factors, and cardiac magnetic resonance findings were compared between LFS and normal flow state (NFS) groups (NFS: SVi of ≥35 mL/m2). Results: There were significant differences in the prevalence of LFS in different ethnic groups. Individuals with LFS were older (66±9.6 vs 61±10 years; P<.0001). The prevalence of LFS was 19% in the group aged older than 70 years. The logistic multivariable regression analysis found that age was independently associated with LFS. The LFS group had significantly higher prevalence of diabetes (30% vs 24%; P=.001), LV mass-volume ratio (1.13±0.22 vs 0.91±0.15; P<.0001), inflammatory markers, a lower LV mass index (59±10 vs 65±11 kg/m2; P<.001), lower myocardial contraction fraction (58.1±10.6% vs 75.7±13%; P<.001), and a lower left atrial size index (32.2±4.6 vs 36.7±5.9 mm/m2; P<.0001) than NFS. Conclusion: Low flow state may be considered an under-recognized clinical entity associated with increasing age, multiple risk factors, increased inflammatory markers, a lower LV mass index, and suboptimal myocardial performance despite the presence of normal LVEF and absence of valvular disease.

Outcomes in non-ST-segment elevation myocardial infarction complicated by in-hospital cardiac arrest based on management strategy.

BACKGROUND: There are limited data on in-hospital cardiac arrest (IHCA) complicating non-ST-segment-elevation myocardial infarction (NSTEMI) based on management strategy. METHODS: We used National Inpatient Sample (2000-2017) to identify adults with NSTEMI (not undergoing coronary artery bypass grafting) and concomitant IHCA. The cohort was stratified based on use of early (hospital day 0) or delayed (≥hospital day 1) coronary angiography (CAG), percutaneous coronary intervention (PCI), and medical management. Outcomes included incidence of IHCA, in-hospital mortality, adverse events, length of stay, and hospitalization costs. RESULTS: Of 6,583,662 NSTEMI admissions, 375,873 (5.7 %) underwent early CAG, 1,133,143 (17.2 %) received delayed CAG, 2,326,391 (35.3 %) underwent PCI, and 2,748,255 (41.7 %) admissions were managed medically. The medical management cohort was older, predominantly female, and with higher comorbidities. Overall, 63,085 (1.0 %) admissions had IHCA, and incidence of IHCA was highest in the medical management group (1.4 % vs 1.1 % vs 0.7 % vs 0.6 %, p < 0.001) compared to early CAG, delayed CAG and PCI groups, respectively. In adjusted analysis, early CAG (adjusted OR [aOR] 0.67 [95 % confidence interval {CI} 0.65-0.69]; p < 0.001), delayed CAG (aOR 0.49 [95 % CI 0.48-0.50]; p < 0.001), and PCI (aOR 0.42 [95 % CI 0.41-0.43]; p < 0.001) were associated with lower incidence of IHCA compared to medical management. Compared to medical management, early CAG (adjusted OR 0.53, CI: 0.49-0.58), delayed CAG (adjusted OR 0.34, CI: 0.32-0.36) and PCI (adjusted OR 0.19, CI: 0.18-0.20) were associated with lower in-hospital mortality (all p < 0.001). CONCLUSION: Early CAG and PCI in NSTEMI was associated with lower incidence of IHCA and lower mortality among NSTEMI-IHCA admissions.

Extracorporeal Membrane Oxygenation Physiological Factors Influence Pulse Oximetry and Arterial Oxygen Saturation Discrepancies.

BACKGROUND: Cannulation strategy, vasopressors, and hemolysis are important physiological factors that influence hemodynamics in extracorporeal membrane oxygenation (ECMO). We hypothesized these factors influence the discrepancy between oxygen saturation measured by pulse oximetry (Spo2) and arterial blood gas (Sao2) in patients on ECMO. METHODS: We retrospectively analyzed adults (aged ≥18 years) on venoarterial or venovenous ECMO at a tertiary academic ECMO center. Spo2-Sao2 pairs with oxygen saturation ≥70% and measured within 10 minutes were included. Occult hypoxemia was defined as Sao2 ≤88% with a time-matched Spo2 ≥92%. Adjusted linear mixed-effects modeling was used to assess the Spo2-Sao2 discrepancy with preselected demographics and time-matched laboratory variables. Vasopressor use was quantified by vasopressor dose equivalences. RESULTS: Of 139 venoarterial-ECMO and 88 venovenous-ECMO patients, we examined 20,053 Spo2-Sao2 pairs. The Spo2-Sao2 discrepancy was greater in venovenous-ECMO (1.15%) vs venoarterial-ECMO (-0.35%, P < .001). Overall, 81 patients (35%) experienced occult hypoxemia during ECMO. Occult hypoxemia was more common in venovenous-ECMO (65%) than in venoarterial-ECMO (17%, P < .001). In linear mixed-effects modeling, Spo2 underestimated Sao2 by 9.48% in central vs peripheral venoarterial-ECMO (95% CI, -17.1% to -1.79%; P = .02). Higher vasopressor dose equivalences significantly worsened the Spo2-Sao2 discrepancy (P < .001). In linear mixed-effects modeling, Spo2 overestimated Sao2 by 25.43% in single lumen-cannulated vs double lumen-cannulated venovenous-ECMO (95% CI, 5.27%-45.6%; P = .03). Higher vasopressor dose equivalences and lactate dehydrogenase levels significantly worsened the Spo2-Sao2 discrepancy (P < .001). CONCLUSIONS: Venovenous-ECMO patients are at higher risk for occult hypoxemia compared with venoarterial-ECMO. A higher vasopressor requirement and different cannulation strategies (central venoarterial-ECMO; single-lumen venovenous-ECMO) were significant factors for clinically significant Spo2-Sao2 discrepancy in both ECMO modes.

Trends on Near-Infrared Spectroscopy Associated With Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation.

We aimed to determine the association between cerebral regional oxygen saturation (rSO 2 ) trends from cerebral near-infrared spectroscopy (cNIRS) and acute brain injury (ABI) in adult venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. ABI was defined as intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, or brain death during ECMO. rSO 2 values were collected from left and right cerebral oximetry sensors every hour from ECMO cannulation. Cerebral desaturation was defined as consecutive hours of rSO 2 < 40%. rSO 2 asymmetry was determined by (a) averaging left/right rSO 2 difference over the entire ECMO run; (b) consecutive hours of rSO 2 asymmetry. Sixty-nine VA-ECMO patients (mean age 56 years, 65% male) underwent cNIRS. Eighteen (26%) experienced ABI. When the mean rSO 2 asymmetry was >8% there was significantly increased odds of ABI (aOR = 39.4; 95% CI = 4.1-381.4). Concurrent rSO 2 < 40% and rSO 2 asymmetry >10% for >10 consecutive hours (asymmetric desaturation) was also significantly associated with ABI (aOR = 5.2; 95% CI = 1.2-22.2), but neither criterion alone were. Mean rSO 2 asymmetry>8% exhibited 39% sensitivity and 98% specificity for detecting ABI, with an area under the curve (AUC) of 0.86, and asymmetric desaturation had 33% sensitivity and 88% specificity, with an AUC of 0.72. These trends on NIRS monitoring may help detect ABI in VA-ECMO patients.

Escalation strategies, management, and outcomes of acute myocardial infarction-cardiogenic shock patients receiving percutaneous left ventricular support.

BACKGROUND: There are limited national-level data on the contemporary practices of mechanical circulatory support (MCS) use in acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS: We utilized the Healthcare Cost and Utilization Project-National/Nationwide Inpatient Sample data (2005-2017) to identify adult admissions (>18 years) with AMI-CS. MCS devices were classified as intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD), or extracorporeal membrane oxygenation (ECMO). We evaluated trends in the initial device used (IABP alone, pLVAD alone or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in-hospital mortality and device escalation. RESULTS: Among 327,283 AMI-CS admissions, 131,435 (40.2%) had an MCS device placed with available information on timing of placement. IABP, pLVAD, and ≥2 MCS devices were used as initial device in 120,928 (92.0%), 8202 (6.2%), and 2305 (1.7%) admissions, respectively. Most admissions were maintained on the initial MCS device with 1%-1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). Urban, medium, and large-sized hospitals and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in-hospital mortality (adjusted odds ratio: 1.56, 95% confidence interval:  1.38-1.75; p < 0.001). Admissions receiving durable LVAD/heart transplantation increased over time in those initiated on pLVAD and ≥2 MCS devices, resulting in lower in-hospital mortality. CONCLUSIONS: In this 13-year study, escalation of MCS in AMI-CS was associated with higher in-hospital mortality suggestive of higher acuity of illness. The increase in number of durable LVAD/heart transplantations alludes to the role of MCS as successful bridge strategies.

Racial and ethnical discrepancy in hypoxemia detection in patients on extracorporeal membrane oxygenation.

Objective: To determine whether there is racial/ethnical discrepancy between pulse oximetry (SpO2) and oxygen saturation (SaO2) in patients receiving extracorporeal membrane oxygenation (ECMO). Methods: This was a retrospective observational study at a tertiary academic ECMO center with adults (>18 years) on venoarterial (VA) or venovenous (VV) ECMO. Datapoints were excluded if oxygen saturation ≤70% or SpO2-SaO2 pairs were not measured within 10 minutes. The primary outcome was the presence of a SpO2-SaO2 discrepancy between different races/ethnicities. Bland-Altman analyses and linear mixed-effects modeling, adjusting for prespecified covariates, were used to assess the SpO2-SaO2 discrepancy between races/ethnicities. Occult hypoxemia was defined as SaO2 <88% with a time-matched SpO2 ≥92%. Results: Of 139 patients receiving VA-ECMO and 57 patients receiving VV-ECMO, we examined 16,252 SpO2-SaO2 pairs. The SpO2-SaO2 discrepancy was greater in VV-ECMO (1.4%) versus VA-ECMO (0.15%). In VA-ECMO, SpO2 overestimated SaO2 in Asian (0.2%), Black (0.94%), and Hispanic (0.03%) patients and underestimated SaO2 in White (-0.06%) and nonspecified race (-0.80%) patients. The proportion of SpO2-SaO2 measurements considered occult hypoxemia was 70% from Black compared to 27% from White patients (P < .0001). In VV-ECMO, SpO2 overestimated SaO2 in Asian (1.0%), Black (2.9%), Hispanic (1.1%), and White (0.50%) patients and underestimated SaO2 in nonspecified race patients (-0.53%). In linear mixed-effects modeling, SpO2 overestimated SaO2 by 0.19% in Black patients (95% confidence interval, 0.045%-0.33%, P = .023). The proportion of SpO2-SaO2 measurements considered occult hypoxemia was 66% from Black compared with 16% from White patients (P < .0001). Conclusions: SpO2 overestimates SaO2 in Asian, Black, and Hispanic versus White patients, and this discrepancy was greater in VV-ECMO versus VA-ECMO, suggesting the need for physiological studies.