Surgical Outcomes of Obese Patients With Adolescent Idiopathic Scoliosis From Endemic Areas of Obesity in the United States.

BACKGROUND: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). METHODS: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. RESULTS: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). CONCLUSION: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES. LEVEL OF EVIDENCE: Level III.

Long-term Results of Spine Stapling for AIS to Skeletal Maturity and Beyond.

BACKGROUND: We looked at long-term follow-up of spine stapling with Nitinol Staples. This was a cohort of all adolescent idiopathic scoliosis (AIS) patients with curves at high risk to progress based on curve magnitude, premenarchal status in all females, failure of brace treatment, and skeletal immaturity. METHODS: This is a single surgeon retrospective review of consecutive AIS patients treated with Nitinol staples for progressive scoliosis. Fourteen patients, 16 curves from 2005 to 2008 were eligible. Minimum curve for stapling was 30 degrees. Standard preoperative, intraoperative, and postoperative data were collected. All patients were followed for a minimum of 36 months and to skeletal maturity. Three groups were: improved (group 1), correction of any amount; minimal progression (group 2), progression ≤10 degrees; and failure (group 3), ≥10 degrees of progression. RESULTS: A total of 13 thoracic curves and 2 compensatory lumbar curves met the inclusion criteria (94%). Average follow-up was 61 months. The mean preoperative main thoracic curve was 35 degrees. All but 1 patients progressed at least 9 degrees in a brace prior to stapling. Females were all premenarchal, 10 patients were Risser 0 and 3 Risser 1. The average number of vertebrae stapled per curve was 6. Group 1 included 6 curves (40%). Group 2, 5 curves (33%). Group 3, 4 curves (27%). Three patients went on to uncomplicated fusion. Final curve measurement at the end of follow-up or before fusion (P=0.0037), curve progression (P≤0.001), and percentage of coronal correction on first postoperative standing radiograph (P=0.042) were the significant differences between groups 1+2 (successful) versus group 3 (failures). In total, 73% of this group either progressed ≤10 degrees or improved. CONCLUSIONS: This is the first study that follows AIS patients treated with spine stapling to skeletal maturity. Staples likely changed natural history in some of our patients. Initial percentage of correction on first standing postoperative PA x-rays was the only predictor of success. Stapling was safe without any long-term complications. LEVEL OF EVIDENCE: Level III-retrospective study.

Prospective Evaluation of a Noninvasive Hemoglobin Measurement System in Total Joint Arthroplasty.

We sought to prospectively determine the efficacy of a noninvasive hemoglobin measurement system compared to a traditional blood draw in patients undergoing total joint arthroplasty. One hundred consecutive patients had their hemoglobin level measured by blood draw and the noninvasive device, simultaneously. Results were analyzed for the entire group and further stratified based on race and perfusion index measured by the device. The financial implications and patient satisfaction were compared. Hemoglobin measurements in the entire group and the two sub-groups were similar between the noninvasive device and the traditional blood draw. The noninvasive system was preferred by 100% of patients. Additionally, cost savings per patient using the noninvasive system was $16.50. This correlated to an 86% savings per case over the standard blood draw. The noninvasive hemoglobin monitoring system offers comparable measurements to a standard blood draw, while improving patient satisfaction and lowering costs. (Journal of Surgical Orthopaedic Advances 29(2):94-98, 2020).

Preoperative Glycemic Control Predicts Perioperative Serum Glucose Levels in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Diabetic patients undergoing total joint arthroplasty (TJA) with postoperative hyperglycemia >200 mg/dL have increased the risk of prosthetic joint infection (PJI). We investigated the correlation between preoperative hemoglobin A1c (A1c) and postoperative hyperglycemia in diabetic patients undergoing TJA. METHODS: A retrospective review of 773 diabetic patients undergoing TJA was conducted. A Youden's J computational analysis determined the A1c where postoperative glucose levels >200 mg/dL were statistically more likely. Patients were then stratified into 3 groups: A1c <7%, A1c 7.0-8.0%, and A1c >8.0%. Outcomes included the highest postoperative in-hospital serum glucose level and PJI. RESULTS: We determined an A1c >7.45% resulted in a greater chance of postoperative hyperglycemia >200 mg/dL. Average postoperative serum glucose increased with A1c (A1c < 7 = 167 mg/dL, A1c 7.0-8.0 = 240 mg/dL, and A1c > 8 = 276 mg/dL, P < .0001). PJI did not statistically increase with A1c (2.25%, 1.99%, and 4.55%, respectively, P = .4319). CONCLUSION: Preoperative hemoglobin A1c levels correlate with postoperative glucose levels. We recommend using an A1c cutoff of 7.45% for patients undergoing TJA and suggest that caution should be exercised in patients with elevated A1c levels undergoing TJA.

Achieving Smart Photochromics Using Water-Processable, High-Contrast, Oxygen-Sensing, and Photoactuating Thiazolothiazole-Embedded Polymer Films.

Water-soluble dipyridinium thiazolo[5,4-d]thiazole (TTz) compounds are incorporated into inexpensive poly(vinyl alcohol) (PVA)/borax films and exhibit fast (<1 s), high-contrast photochromism, photofluorochromism, and oxygen sensing. Under illumination, the films change from clear/yellow TTz2+ to purple TTz•+ and then blue TTz0. The contrast and speed of the photochromism are dependent on the polymer matrix redox properties and the concentration of TTz2+. The photoreduced films exhibit strong, near-infrared light (1000-1500 nm) absorbances in addition to visible color changes. Spectroscopic ellipsometry was used to establish the complex dielectric function for the TTz2+ and TTz0 states. Incorporating non-photochromic dyes yields yellow-to-green and pink-to-purple photochromism. Additionally, when illuminated, reversible photoactuation occurs, causing mechanical contraction in the TTz-embedded films. The blue film returns to its colorless state via exposure to O2, making the films able to sense oxygen and leak direction for smart packaging. These films show potential for use in self-tinting smart windows, eyeglasses, displays, erasable memory devices, fiber optic communication, and oxygen sensing.

Prediction of 2-year clinical outcome trajectories in patients undergoing anterior cervical discectomy and fusion for spondylotic radiculopathy.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes. METHODS: In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models. RESULTS: The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%-23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health-related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome. CONCLUSIONS: Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%-23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.

Blurry Vision as a Presentation of Waldenström's Macroglobulinemia: A Case Report With Review of Current Management.

A patient was diagnosed with Waldenström's macroglobulinemia (WM) after the initial findings of anemia and ophthalmological findings of retinal hemorrhage. Upon further workup, the patient was found to have an IgM predominant monoclonal gammopathy on serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP). This highlights the need for open communication between different specialties, streamlining rapid and accurate diagnosis. Also highlighted are the unique pathophysiological changes involved in the development of WM. A patient's primary complaint was blurry vision. After the patient was noted to have a monoclonal gammopathy on SPEP, bone marrow biopsy was performed. The bone marrow biopsy findings were consistent with lymphoplasmacytic lymphoma (LPL). The patient received plasmapheresis and chemotherapy. The disease course is described. The patient saw rapid improvement in all lab abnormalities after the beginning of the appropriate therapy of plasmapheresis and chemotherapy. Remission is common with WM. Regular follow-up with this patient is important.

Post-Traumatic Bio-Behavioral Rehabilitation of Adult Female Victims.

OBJECTIVE: To determine if low resting basal AM cortisol and flat diurnal cortisol slope that has been reported in female abuse victims, which is dysregulated in the same way in female violent perpetrators, could be corrected and if healthier diurnal cortisol patterns are associated with less aggression in adult female victims. DESIGN AND METHODS: A non-experimental, naturalistic study evaluated if bio-behavioral rehabilitation could occur for females living in a Delaware homeless mission and participating in their programs. Basal salivary cortisol (AM, PM & slope), aggression, neurological conditions, general health, alcohol use, having been a victim of abuse, religion, spirituality and forgiveness were evaluated over one month between 2018 and 2019. RESULTS: T tests revealed significant improvement in mean cortisol (AM, PM & slope), aggression, emotional/ behavioral dyscontrol, and health over one month while participating in the mission's programs. Paired t-tests however were only significant for aggression and health. Healthier cortisol was significantly correlated with greater time since last alcohol, greater time since last abuse, less aggression, better health and greater religion, spirituality and forgiveness. CONCLUSION: Community programs could be cost effective methods of post-traumatic bio-behavioral rehabilitation. Forgiveness may play a critical role for abuse victims. A larger sample and more settings are needed, although these findings are promising.

Web-based patient portal access in an orthopedic adult reconstruction patient population.

BACKGROUND: We surveyed patients in an adult reconstruction practice as to their use of the Web-based portal provided by our electronic health record, seeking to reveal patterns of use and helpfulness. METHODS: A total of 150 completed surveys were received. The survey queried demographics, the number of clinic visits, Internet access, portal activation, portal use frequency, and portal information questions and how patients answered them. Helpfulness was rated from 1 (not helpful) to 5 (very helpful). Statistical analysis included bivariate analysis and logistic regression, with odds ratio (OR) and 95% confidence interval (CI) reported. RESULTS: The mean age was 67.6 years. Most were females (n = 97, 65.1%). Most (68.7%) patients used the portal. Younger age (OR, 0.94; CI, 0.90-0.99) and access to Internet (OR, 31.8; CI, 8.5-119.4) predicted portal use (P < .005), whereas gender and number of clinic visits did not (P > .373). Of all, 47.5% of patients were unclear about online chart information. Older age indicated being unclear of portal information (68.5 vs 66, P = .0002). Of those who clarified doubts regarding information (n = 67), 23 used the Internet (34.3%), 32 (47.7%) called the physician, and 12 (17.9%) asked a friend and/or family member. Most (90.3%) patients felt the portal was helpful in gathering health information. CONCLUSIONS: Age and Internet access affected portal usage; ability to understand chart information decreased with age. Most patients used the Internet or a family member to clarify doubts regarding portal information. The use of portal data resulted in 32 extra communications to the physician.

Sex Differences in Poisonings Among Older Adults: An Analysis of the Toxicology Investigators Consortium (ToxIC) Registry, 2010 to 2016.

PURPOSE: Adults aged >65 years are susceptible to intentional and unintentional poisoning, with contributing factors that include polypharmacy, comorbidity, susceptibility to medication error, and gaps in research. Although toxicologists are often tasked with managing and preventing poisoning among older adults, little is known about sex differences in these poisonings. The aim of this study was to review sex differences in poisonings among older adults managed at the bedside by medical toxicologists. METHODS: All case subjects aged >65 years in the Toxicology Investigators Consortium (ToxIC) registry between January 2010 and December 2016 were reviewed. Data included reasons for exposure and consultation, exposure agents and routes, presenting clinical findings, and treatment provided. Cases missing age, sex, or primary reason for toxicology consultation data were excluded. We used χ2 tests to assess differences in distribution of study variables according to participant sex. FINDINGS: Among 51,441 total registry cases, 542 (1.05%) were excluded because of missing data. Among the remaining 50,899 cases, 2930 (5.8%) were included for age >65 years; 52.3% of older adults were female. Race was missing or unknown for 49.2% of cases. Adverse drug reactions were more commonly encountered in female subjects than in their male counterparts (9.6% vs 6.4%; P = 0.001). No statistically significant sex differences were observed for total numbers of intentional, unintentional pharmaceutical, and nonpharmaceutical exposures. The most common medications involved were cardiovascular (16.8%) and analgesics/opioids (14.8%). Female subjects were more likely than male subjects to be evaluated by a toxicologist for cardiovascular medications (18.7% vs 14.7%; P = 0.004) and analgesics/opioids (17.6% vs 11.8%; P < 0.001). Male subjects were more likely than female subjects to be evaluated for ethanol toxicity (7.4% vs 1%; P < 0.001) and for envenomations (4.2% vs 1.8%; P < 0.001). The most common route of exposure was oral ingestion (81.3%). Signs/symptoms were noted in 54.8% of cases, with the most common abnormal vital sign being bradycardia (17.2%). Pharmacologic support was the most common intervention and was more common in male subjects than in female subjects (17.7% vs 12.3%; P < 0.001). Deaths were reported in 38 female subjects (2.45%) and 46 male subjects (3.34%); there was no statistically significant difference in death rate according to sex (P = 0.148). IMPLICATIONS: Older female adults were more commonly evaluated by a medical toxicologist for an adverse drug reaction than older male adults. Female patients were more likely than male patients to be evaluated for poisoning related to analgesic/opioids and cardiovascular medications, and older male patients more frequently received pharmacologic support than older female patients. No significant sex differences were observed in numbers of toxicology consultations for intentional, unintentional pharmaceutical, and nonpharmaceutical exposures.