Novel 3D magnetic resonance fingerprinting radiomics in adult brain tumors: a feasibility study.

OBJECTIVES: To test the feasibility of using 3D MRF maps with radiomics analysis and machine learning in the characterization of adult brain intra-axial neoplasms. METHODS: 3D MRF acquisition was performed on 78 patients with newly diagnosed brain tumors including 33 glioblastomas (grade IV), 6 grade III gliomas, 12 grade II gliomas, and 27 patients with brain metastases. Regions of enhancing tumor, non-enhancing tumor, and peritumoral edema were segmented and radiomics analysis with gray-level co-occurrence matrices and gray-level run-length matrices was performed. Statistical analysis was performed to identify features capable of differentiating tumors based on type, grade, and isocitrate dehydrogenase (IDH1) status. Receiver operating curve analysis was performed and the area under the curve (AUC) was calculated for tumor classification and grading. For gliomas, Kaplan-Meier analysis for overall survival was performed using MRF T1 features from enhancing tumor region. RESULTS: Multiple MRF T1 and T2 features from enhancing tumor region were capable of differentiating glioblastomas from brain metastases. Although no differences were identified between grade 2 and grade 3 gliomas, differentiation between grade 2 and grade 4 gliomas as well as between grade 3 and grade 4 gliomas was achieved. MRF radiomics features were also able to differentiate IDH1 mutant from the wild-type gliomas. Radiomics T1 features for enhancing tumor region in gliomas correlated to overall survival (p < 0.05). CONCLUSION: Radiomics analysis of 3D MRF maps allows differentiating glioblastomas from metastases and is capable of differentiating glioblastomas from metastases and characterizing gliomas based on grade, IDH1 status, and survival. KEY POINTS: • 3D MRF data analysis using radiomics offers novel tissue characterization of brain tumors. • 3D MRF with radiomics offers glioma characterization based on grade, IDH1 status, and overall patient survival.

Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality.

INTRODUCTION: Elderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied. METHODS: The 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR). RESULTS: A total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/µL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%. CONCLUSIONS: In elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.

Navigator utilization among African-American breast cancer patients at a Comprehensive Cancer Center.

Background: Patient navigation has been demonstrated to improve access to standard-of-care oncologic therapy. However, many patients - particularly those of African-American race - often do not have access to navigation upon receiving a diagnosis of cancer. As the most common cancer among African-American women is breast cancer, we sought to assess the rate of patient navigation among African-American breast cancer patients at our institution, which resides in a regional ZIP code comprised of 46% African-American residents. Materials and methods: African-American breast cancer patients who had been discussed at our weekly breast cancer multidisciplinary tumor board over a recent three-month period were assessed by a patient navigator representing the Navigator-Assisted Hypofractionation (NAVAH) program to determine their access to navigation in their cancer care. Responses were assessed from a breast cancer support group and culled to determine a baseline proportion of navigation utilization. Results: A total of 18 women of African-American race having been diagnosed with breast cancer were identified and assessed. Of these a total of 4 noted that they had received navigation, yielding a navigation utilization percentage of 22.2% among African-American breast cancer patients at our institution. Conclusion: The rate of navigation utilization among African-American breast cancer patients is poor. Despite our center residing in a region comprised of increased African-Americans, such predominance has not translated into optimizing navigation access for African-American breast cancer patients. This 22% rate of navigation utilization serves as a starting benchmark for initiatives such as the NAVAH program to provide tangible improvement in this patient population.

Radiomic analysis of magnetic resonance fingerprinting in adult brain tumors.

PURPOSE: This is a radiomics study investigating the ability of texture analysis of MRF maps to improve differentiation between intra-axial adult brain tumors and to predict survival in the glioblastoma cohort. METHODS: Magnetic resonance fingerprinting (MRF) acquisition was performed on 31 patients across 3 groups: 17 glioblastomas, 6 low-grade gliomas, and 8 metastases. Using regions of interest for the solid tumor and peritumoral white matter on T1 and T2 maps, second-order texture features were calculated from gray-level co-occurrence matrices and gray-level run length matrices. Selected features were compared across the three tumor groups using Wilcoxon rank-sum test. Receiver operating characteristic curve analysis was performed for each feature. Kaplan-Meier method was used for survival analysis with log rank tests. RESULTS: Low-grade gliomas and glioblastomas had significantly higher run percentage, run entropy, and information measure of correlation 1 on T1 than metastases (p < 0.017). The best separation of all three tumor types was seen utilizing inverse difference normalized and homogeneity values for peritumoral white matter in both T1 and T2 maps (p < 0.017). In solid tumor T2 maps, lower values in entropy and higher values of maximum probability and high-gray run emphasis were associated with longer survival in glioblastoma patients (p < 0.05). Several texture features were associated with longer survival in glioblastoma patients on peritumoral white matter T1 maps (p < 0.05). CONCLUSION: Texture analysis of MRF-derived maps can improve our ability to differentiate common adult brain tumors by characterizing tumor heterogeneity, and may have a role in predicting outcomes in patients with glioblastoma.

High Dietary Intake of Specific Fatty Acids Increases Risk of Flares in Patients With Ulcerative Colitis in Remission During Treatment With Aminosalicylates.

BACKGROUND & AIMS: Dietary factors may have a significant role in relapse of disease among patients with ulcerative colitis (UC). However, the relationship between diet and UC is inadequately understood. We analyzed data from the diet's role in exacerbations of mesalamine maintenance study to determine whether dietary factors affect the risk of disease flares in patients with UC. METHODS: We performed a prospective, multicenter, observational study of 412 patients, from 25 sites, with UC in remission during monotherapy with an aminosalicylate. Patients completed a validated food frequency questionnaire at enrollment and were followed for 12 months. We analyzed the relationship between diet and disease remission or flare for groups of macronutrients and micronutrients, and food groups previously associated with an increased risk of flare. RESULTS: Forty-five patients (11%) had a UC relapse within 1 year of study enrollment. When analyzed in tertiles, increasing intake of multiple fatty acids was associated with increasing odds of relapse. In multivariable logistic regression analysis, only myristic acid (odds ratio, 3.01; 95% confidence interval, 1.17-7.74) maintained this dose-response relationship. Other foods previously implicated in flares of UC, such as processed meat, alcohol, and foods high in sulfur, were not associated with an increased risk of flare. CONCLUSIONS: In a prospective study of more than 400 patients with UC undergoing treatment with aminosalicylates, we associated high dietary intake of specific fatty acids, including myristic acid (commonly found in palm oil, coconut oil, and dairy fats) with an increased risk of flare. These findings can help design interventional studies to evaluate dietary factors in UC.

Success of Ultra-low Dose Radiation Therapy for Primary Cutaneous B-cell Lymphoma.

OBJECTIVES: Primary cutaneous B-cell lymphoma (PCBCL) is a relatively rare disease, associated with 5-year overall survival of nearly 95% when treated with external beam radiation therapy (EBRT) alone. However, standard EBRT doses yield acute skin toxicity in more than 70% of patients and grade 3 to 4 acute skin toxicity in nearly 10% of patients. Consequently, the PCBCL treatment paradigm is shifting towards lower EBRT doses. This study evaluates our early experience with ultra-low dose EBRT (total dose of 4 Gy in 2 fractions) for PCBCL. METHODS: Four biopsy-confirmed PCBCL lesions (1 anterior thigh and 3 chest) in 2 male patients were treated with 2 Gy×2 fraction EBRT using electrons through a clinical setup. The anterior thigh lesion was treated using a clamshell to protect the scrotum from scatter dose. Treatment was achieved using 9 MeV electrons to the 85% isodose line using no bolus, with follow-up every 4 months and potential retreatment if no visible response at 8 to 9 months. RESULTS: All lesions demonstrated a response to EBRT by 4 months, visibly manifesting as flattening with changes in pigmentation. At the last follow-up (20, 20, 16.5, and 4 mo, respectively), all lesions had flattened with no evidence of local recurrence and no skin toxicity. CONCLUSIONS: Treatment of PCBCL with ultra-low dose EBRT to 4 Gy total dose in 2 fractions provides durable local control with zero skin toxicity. These results are encouraging for both the success of treatment and the potential to use similarly low doses for retreatment should patients exhibit local recurrence.

Validation of Spanish-Language Surveys Utilized for the Navigator-Assisted Hypofractionation (NAVAH) Program to Aid Hispanic-American Breast Cancer Patients.

OBJECTIVES: Cancer accounts for 22% of all mortality and is the leading cause of death among Hispanic and/or Latinx patients in the United States. The disparities in access to radiation therapy (RT), mortality rates, and treatment outcomes among Hispanic-American breast cancer patients compared with other populations highlight the urgent need for targeted interventions. The Navigator-Assisted Hypofractionation (NAVAH) program, with its innovative patient navigation approach and culturally sensitive survey, aims to better identify the specific barriers faced by this population. This study is a report of the NAVAH program experience piloting a Spanish-language culturally sensitive survey in Hispanic-American volunteers. METHODS: Hispanic-American volunteers with fluency in Spanish were recruited to participate in survey conduction, identified from local networks. Survey information was assessed by topic category, and survey responses were amalgamated into a representative score for each category. Survey categories include acceptability (comfort and prejudice among interactions with the system), accessibility (transportation, distance to care, and health care literacy), accommodation (access to the internet, navigating transportation), affordability (financial considerations, employment, and level of education), and availability (access to a medical center, coordinating care, and overall quality of care). RESULTS: A total of 6 volunteers meeting inclusion criteria completed the survey; 4 in person and 2 by telephone. The median survey completion time was 12 minutes 38 seconds. Respondents noted satisfaction and trust in their interactions with medical providers; however, responses in the acceptability category highlighted a high perception of disparities in the medical system, including a high prevalence of racial and ethnic prejudice and a high prevalence of treatment differences between high-income and low-income patients in clinical settings. CONCLUSIONS: In the first Spanish-language survey of its kind, our findings indicate that this survey design is feasible in the Hispanic-American population. Implementation of this survey in breast cancer patients will provide more definitive and comprehensive answers regarding other categories in the survey, including financial challenges during treatment, access to accommodations, and perception of treatment during cancer care. The investigation involving patients actively receiving breast cancer RT is currently underway.

Ehlers-Danlos Syndrome is Associated with Increased Rates of Adjacent Segment Disease Following TLIF: A Propensity Matched Study.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a collection of connective tissue disorders which are often associated with tissue laxity and disc degeneration. However, the implications of EDS on the risk of adjacent segment disease (ASD) after transforaminal lumbar interbody fusion (TLIF) are not well described. The objective of this study is to compare the rates of ASD among patients with EDS and those without EDS. METHODS: Patients who underwent 1-3 level TLIF for degenerative disc disease between 2010-2022 were identified using the PearlDiver Mariner all-claims insurance database. Patients with all types of EDS were included. Patients undergoing surgery for tumors, trauma, or infection were excluded. 1:1 propensity matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with ASD in a linear regression model. The primary outcome measure was the development of ASD. The secondary outcomes were the development of pseudoarthrosis, medical complications, and surgical complications. RESULTS: Propensity matching resulted in 2 equal groups of 85 patients who did or did not have EDS and underwent 1-3 level TLIF. Patients without EDS were less likely to experience ASD (RR 0.18, 95% CI 0.09-0.35, P < 0.001). There was no significant difference between the 2 patient groups with regards to a diagnosis of pseudoarthrosis, and there was no significant difference for all-cause medical and surgical complications between the 2 patient groups. CONCLUSIONS: After propensity matching to control for confounding variables, the findings of this study suggest that EDS may be associated with an increased risk of ASD following TLIF. Future studies are needed to corroborate these findings.

A systematic review of endometrial cancer clinical research in Africa.

BACKGROUND: Women in Africa are experiencing a rising burden of endometrial cancer. Research and investment to improve treatment and outcomes are critically needed. We systematically reviewed and characterized endometrial cancer-related research within a clinically relevant context to help organize and assess existing endometrial cancer research in Africa. METHODS: According to PRISMA guidelines, we searched online databases for published endometrial cancer articles from African countries from January 1, 2011, to July 20, 2021. Based on our inclusion and exclusion criteria, independent reviewers documented the study design, country/region, human development index, focus of research, type of interventions performed, and histologic and molecular type to illustrate the breadth of research coverage in each region. RESULTS: A total of 18 research articles were included. With an average Human Development Index (HDI) in Africa of 0.536, the average HDI of the represented countries in this study was 0.709. The majority (88.9%) of prospective endometrial cancer research articles in Africa were from North Africa, with Egypt encompassing 83.3% of the papers. Most of these studies focused on endometrial cancer diagnosis. Research on the treatment of endometrial cancer is still emerging (33% of papers). Of all included articles, only 11.1% represented Sub-Saharan Africa, where the majority population of black Africans reside. CONCLUSIONS: Endometrial cancer research in Africa is extremely limited, with the majority being concentrated in African countries with higher HDIs. As the incidence of endometrial cancer rises in Sub-Saharan Africa, there is a pressing need for more prospective clinical research to tackle the growing disease burden and improve outcomes.

Cannabis Use is Associated With Higher Rates of Pseudarthrosis Following TLIF: A Multi-Institutional Matched-Cohort Study.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To compare the rates of pseudarthrosis in patients undergoing 1 to 3 level transforaminal lumbar interbody fusion (TLIF) procedures between cannabis users and noncannabis users. SUMMARY OF BACKGROUND DATA: Recreational use of cannabis is common, though it remains poorly studied and legally ambiguous in the United States. Patients with back pain may turn to adjunctive use of cannabis to manage their pain. However, the implications of cannabis use on the achievement of bony fusion are not well-characterized. METHODS: Patients who underwent 1 to 3 level TLIF for degenerative disc disease or degenerative spondylolisthesis between 2010 and 2022 were identified using the PearlDiver Mariner all-claims insurance database. Cannabis users were identified with ICD 10 code F12.90. Patients undergoing surgery for nondegenerative pathologies such as tumors, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with pseudarthrosis in a linear regression model. The primary outcome measure was development of pseudarthrosis within 24 months after 1 to 3 level TLIF. The secondary outcomes were the development of all-cause surgical complications as well as all-cause medical complications. RESULTS: A 1:1 exact matching resulted in two equal groups of 1593 patients who did or did not use cannabis and underwent 1 to 3 level TLIF. Patients who used cannabis were 80% more likely to experience pseudarthrosis compared with patients who do not [relative risk (RR): 1.816, 95% CI: 1.291-2.556, P <0.001]. Similarly, cannabis use was associated with significantly higher rates of all-cause surgical complications (RR: 2.350, 95% CI: 1.399-3.947, P =0.001) and all-cause medical complications (RR: 1.934, 95% CI: 1.516-2.467, P <0.001). CONCLUSION: After 1:1 exact matching to control for confounding variables, the findings of this study suggest that cannabis use is associated with higher rates of pseudarthrosis, as well as higher rates of all-cause surgical and all-cause medical complications. Further studies are needed to corroborate our findings.

Underrepresented Minority Composition of Invited Panelists at the 2021 ASTRO Annual Meeting.

Purpose: The American Society for Radiation Oncology (ASTRO) Annual Meeting is one of the primary venues for radiation oncologists to present new research, network, and share innovations. In this brief report, we describe the racial representation of invited physician speakers at the Annual Meeting relative to the specialty. Methods and Materials: The program list of all invited educational sessions and panel speakers in the ASTRO annual meetings from 2021 was accessed via the ASTRO website. Race was determined by a combination of facial recognition and Internet investigation. Speakers and panels were divided by race and specialty. Underrepresented in medicine (URiM) was defined as Black race and/or Hispanic ethnicity. Results: We identified 182 cumulative speaking panels at the 2021 ASTRO annual meeting and 960 individuals who filled these panels. The majority of speakers were of White race (57%), followed by Asian race (34.2%). URiM speakers made up approximately 8.6% of speakers and were mostly congregated in diversity, equity, and inclusion in health care (DEI) panels. A total of 15.6% of panels were White-only, and 14.8% of panels had at least 1 URiM member. URiM race speakers were mostly congregated in DEI panels, comprising 44.9% of DEI speaker positions and 4.1% of non-DEI speaker positions; this difference reached statistical significance (P < .0001). Conclusions: The proportion of underrepresented minorities receiving panel invitations at ASTRO remains minimal and is virtually nonexistent outside of DEI-related panels. Targeted efforts to increase URiM representation will be needed to make tangible progress on this issue, just as they have yielded progress on increasing gender diversity in panel invitations.

Do Obese Patients Lose Weight After Lumbar Spine Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: Obesity is a major health care concern in the United States and is associated with high rates of postoperative complications after spine surgery. Obese patients assert that weight reduction is not possible unless spine surgery first relieves their pain and concomitant immobility. We describe the post-spine surgery effects on patient weight, with an emphasis on obesity. METHODS: PubMed, EMBASE, Scopus, Web of Science, and Cochrane databases were systematically searched according to the PRISMA guidelines. The search included indexed terms and text words from database inception to the date of the search (15 April 2022). Studies chosen for inclusion had to have data reporting on pre- and postoperative patient weight after spine surgery. Data and estimates were pooled using the Mantel-Haenszel method for random-effects meta-analysis. RESULTS: Eight articles encompassing 7 retrospective and 1 prospective cohort were identified. A random effects model analysis demonstrated that overweight and obese patients (body mass index [BMI], >25 kg/m2) had increased odds of clinically significant weight loss after lumbar spine surgery compared with non-obese patients (odds ratio, 1.63; 95% confidence interval, 1.43-1.86, P < 0.0001). There was no significant difference in the raw weight change between BMI categories (mean difference, -0.67 kg, 95% confidence interval, -4.71 to 3.37 kg, P = 0.7463). CONCLUSIONS: Compared with non-obese patients (BMI, <25 kg/m2), overweight and obese patients have higher odds of clinically significant weight loss after lumbar spine surgery. No difference in pre-operative and post-operative weight was found, although statistical power was lacking in this analysis. Randomized controlled trials and additional prospective cohorts are needed to further validate these findings.

Laminectomy With Fusion is Associated With Greater Functional Improvement Compared With Laminectomy Alone for the Treatment of Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and Meta-analysis. OBJECTIVE: To compare outcomes and complications profile of laminectomy alone versus laminectomy and fusion for the treatment of degenerative lumbar spondylolisthesis (DLS). SUMMARY OF BACKGROUND DATA: Degenerative lumbar spondylolisthesis is a common cause of back pain and functional impairment. DLS is associated with high monetary (up to $100 billion annually in the US) and nonmonetary societal and personal costs. While nonoperative management remains the first-line treatment for DLS, decompressive laminectomy with or without fusion is indicated for the treatment-resistant disease. METHODS: We systematically searched PubMed and EMBASE for RCTs and cohort studies from inception through April 14, 2022. Data were pooled using random-effects meta-analysis. The risk of bias was assessed using the Joanna Briggs Institute risk of bias tool. We generated odds ratio and standard mean difference estimates for select parameters. RESULTS: A total of 23 manuscripts were included (n=90,996 patients). Complication rates were higher in patients undergoing laminectomy and fusion compared with laminectomy alone (OR: 1.55, P <0.001). Rates of reoperation were similar between both groups (OR: 0.67, P =0.10). Laminectomy with fusion was associated with a longer duration of surgery (Standard Mean Difference: 2.60, P =0.04) and a longer hospital stay (2.16, P =0.01). Compared with laminectomy alone, the extent of functional improvement in pain and disability was superior in the laminectomy and fusion cohort. Laminectomy with fusion had a greater mean change in ODI (-0.38, P <0.01) compared with laminectomy alone. Laminectomy with fusion was associated with a greater mean change in NRS leg score (-0.11, P =0.04) and NRS back score (-0.45, P <0.01). CONCLUSION: Compared with laminectomy alone, laminectomy with fusion is associated with greater postoperative improvement in pain and disability, albeit with a longer duration of surgery and hospital stay.

Lumbar Arthroplasty Is Associated With a Lower Incidence of Adjacent Segment Disease Compared With ALIF: A Propensity-matched Analysis.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The objective of this study was to compare the rate of adjacent segment disease (ASD) between lumbar disk arthroplasty (LDA) and anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA: LDA and ALIF are alternative surgical approaches used to treat lumbar degenerative disk disease. However, there is a paucity of studies comparing the risk of ASD after these procedures. METHODS: Patients who underwent 1- to 2-level LDA or ALIF between 2010 and 2022 were identified in the PearlDiver Mariner insurance all-claims database. Exclusion criteria included the history of prior lumbar spine surgery or surgery for tumors, trauma, or infection. 1:1 propensity matching was performed using demographic factors, medical comorbidities, and surgical factors, which were significantly associated with ASD. RESULTS: 1:1 propensity matching created two equal groups of 1625 patients without baseline differences who underwent LDA or ALIF. LDA was significantly associated with a lower risk of ASD (relative risk: 0.932, 95% CI, 0.899-0.967, P <0.001) and need for revision within 30 days (relative risk: 0.235, 95% CI, 0.079-0.698, P =0.007). There were no differences in all-cause surgical and medical complications between both groups. CONCLUSIONS: After risk adjustment for demographic and clinical characteristics, the results suggest that LDA is associated with a lower risk of ASD compared with ALIF. LDA was also associated with lower hospital cost and shorter length of stay.

Preoperative HbA1c and Postoperative Outcomes in Spine Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To perform a systematic review and meta-analysis of previous studies on HbA1c in preoperative risk stratification in patients undergoing spinal procedures and provide an overview of the consensus recommendations. SUMMARY OF BACKGROUND DATA: Diabetes mellitus (DM) and hyperglycemia have been shown to be independent risk factors for increased surgical complications. Glycated Hemoglobin A1C (HbA1c), a surrogate for long term glycemic control, is an important preoperative parameter that may be optimized to reduce surgical complications and improve patient-reported outcomes. However, comprehensive systematic reviews on preoperative HbA1c and postoperative outcomes in spine surgery have been limited. METHODS: We systematically searched PubMed, EMBASE, Scopus, and Web-of-Science for English-language studies from inception through April 5 th , 2022, including references of eligible articles. The search was conducted according to PRISMA guidelines. Only studies in patients undergoing spine surgery with preoperative HbA1c values and postoperative outcomes available were included. RESULTS: A total of 22 articles (18 retrospective cohort studies, 4 prospective observational studies) were identified with level of evidence III or greater. The majority of studies (n=17) found that elevated preoperative HbA1c was associated with inferior outcomes or increased risk of complications. Random-effect meta-analysis demonstrated that patients with preoperative HbA1c >8.0% had increased risk(s) of postoperative complications (RR: 1.85, 95% CI: [1.48, 2.31], P <0.01) and that patients with surgical site infection (SSI) had higher preoperative HbA1c (Mean Difference: 1.49%, 95% CI: [0.11, 2.88], P =0.03). CONCLUSION: The findings of this study suggest that HbA1c >8.0% is associated with an increased risk of complications. HbA1c was higher by 1.49% on average among patients with SSI when compared to patients who did not experience SSI. These results suggest that elevated HbA1c is associated with less favorable outcomes following spine surgery. LEVEL OF EVIDENCE: IV.

Complicated Abdominal Wall Hernias in the Elderly: Time Is Life and Comorbidities Matter.

BACKGROUND: Abdominal wall hernias represent a common problem that can present as surgical emergencies with increased morbidity and mortality. The data examining outcomes in elderly patients with hernia emergencies is scant. METHODS: The 2007-2017 ACS-NSQIP database was queried. Patients ≥65 years old with a diagnosis of acute complicated abdominal wall hernia were included. Univariable and multivariable analyses were used to identify independent predictors of 30-day mortality and surgical site infection (SSI). RESULTS: Main predictors of 30-day mortality were admission from nursing home or chronic care facility (OR = 1.62, 95% CI: 1.10-2.38, P = .014), transfer from outside ED (OR = 1.81, 95% CI: 1.31-2.51, P < .001), days from admission to operation (OR = 1.05, 95% CI: 1.02-1.08, P = .002), recent significant weight loss (OR = 1.95, 95% CI: 1.12-3.37, P = .018), pre-operative septic shock (OR = 4.13, 95% CI: 2.44-6.99, P < .001), ventilator dependence (OR = 2.50, 95% CI: 1.29-4.81, P = .006), and ASA status. When compared to open repair, laparoscopic repair emerged as protective against SSI (OR = .34, 95% CI: .17-.66, P = .001). Bowel resection (OR = 2.15, 95% CI: 1.63-2.84, P < .001) and increasing wound class were risk factors for SSI. CONCLUSION: In the elderly patient presenting with an acute complicated abdominal wall hernia, time to surgery is crucial for survival, and comorbidities influence outcome. Laparoscopy is an option in management due to its decreased risk of surgical site infection without increased mortality, whenever patient factors are favorable for this approach.

TLIF is Associated With Lower Rates of Adjacent Segment Disease and Complications Compared to ALIF: A Matched-Cohort Analysis.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To compare the rate of adjacent segment disease (ASD) in patients undergoing anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) for the treatment of degenerative stenosis and spondylolisthesis. SUMMARY OF BACKGROUND DATA: ALIF and TLIF are frequently used to treat Lumbar stenosis and spondylolisthesis. While both approaches have distinct advantages, it is unclear whether there are any differences in rates of ASD and postoperative complications. METHODS: A retrospective cohort study of patients who underwent index 1-3 levels ALIF or TLIF between 2010 and 2022, using the PearlDiver Mariner Database, an all-claims insurance database (120 million patients). Patients with a history of prior lumbar surgery and those undergoing surgery for cancer, trauma, or infection were excluded. Exact 1:1 matching was performed using demographic factors, medical comorbidities, and surgical factors found to be significantly associated with ASD in a linear regression model. The primary outcome was a new diagnosis of ASD within 36 months of index surgery, and secondary outcomes were all-cause medical and surgical complications. RESULTS: Exact 1:1 matching resulted in 2 equal groups of 106,451 patients undergoing TLIF and ALIF. The TLIF approach was associated with a lower risk of ASD (RR 0.58, 95% CI 0.56-0.59, P < 0.001) and all-cause medical complications (RR 0.94, 95% CI 0.91-0.98, P =0.002). All-cause surgical complications were not significantly different between both groups. CONCLUSION: After 1:1 exact matching to control for confounding variables, this study suggests that for patients with symptomatic degenerative stenosis and spondylolisthesis, a TLIF procedure (compared to ALIF) is associated with a decreased risk of developing ASD within 36 months of index surgery. Future prospective studies are needed to corroborate these findings. LEVEL OF EVIDENCE: Level-3.

Delayed fascial closure in nontrauma abdominal emergencies: A nationwide analysis.

BACKGROUND: Initially used in trauma management, delayed abdominal closure endeavors to decrease operative time during the index operation while still being lifesaving. Its use in emergency general surgery is increasing, but the data evaluating its outcome are sparse. We aimed to study the association between delayed abdominal closure, mortality, morbidity, and length of stay in an emergency surgery cohort. METHODS: The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was examined for patients undergoing emergency laparotomy. The patients were classified by the timing of abdominal wall closure: delayed fascial closure versus immediate fascial closure. Propensity score matching was performed based on preoperative covariates, wound classification, and performance of bowel resection. The outcomes were then compared by univariable analysis. RESULTS: After matching, both the delayed fascial closure and immediate fascial closure groups consisted of 3,354 patients each. Median age was 65 years, and 52.6% were female. The delayed fascial closure group had a higher in-hospital mortality (35.3% vs 25.0%, P < .001), a higher 30-day mortality (38.6% vs 29.0%, P < .001), a higher proportion of acute kidney injury (9.5% vs 6.6%, P < .001), a lower proportion of postoperative sepsis (11.8% vs 15.6%, P < .001), and a lower proportion of surgical site infection (3.4% vs 7.0%, P < .001). CONCLUSION: Compared with immediate fascial closure, delayed fascial closure is associated with an increased mortality in the patients matched based on comorbidities and surgical site contamination. In emergency general surgery, delaying abdominal closure may not have the presumed overarching benefits, and its indications must be further defined in this population.

Morbidity and Mortality After Burr Hole Craniostomy Versus Craniotomy for Chronic Subdural Hematoma Evacuation: A Single-Center Experience.

BACKGROUND: Chronic subdural hematomas (cSDHs) are common neurosurgical pathological entities and typically occur after trauma in elderly patients. The 2 most commonly used strategies for treatment have included burr hole drainage and craniotomy with decompression. However, the choice of these procedures has remained controversial and has been primarily determined by surgeon preference. We designed a matched-cohort analysis to compare these 2 procedures and identify the risk factors associated with the postoperative outcomes. Thus, we compared the rates of reoperation and mortality for patients who had undergone craniotomy versus burr hole evacuation for cSDH. METHODS: A retrospective review examining the data from 299 consecutive patients with cSHDs from 2002 to 2015 was performed. We compared the following endpoints between the 2 procedures: 30-day mortality, discharge to a skilled nursing facility, and the need for reoperation. We also compared the potential risk factors in the patients with different primary outcomes. RESULTS: Patients undergoing craniotomy had a decreased need for reoperation compared with patients treated with burr hole evacuation (7.5% vs. 15.7%; P = 0.044). Older age was associated with both increased disposition to a nursing facility and increased 30-day mortality in both groups. Increased 30-day mortality was associated with aspirin usage in patients who had undergone craniotomy and with warfarin (Coumadin) in patients who had undergone burr hole evacuation. CONCLUSIONS: Our study identified an increased need for reoperation for patients treated with burr hole evacuation compared with those undergoing craniotomy. Older age and low Glasgow coma scale scores were associated with worse outcomes in both groups. Certain methods of anticoagulation were also associated with worse outcomes, which varied between the 2 groups. We recommend that surgeons individualize the choice of procedure according to the specific patient characteristics with consideration of these findings.

Synthesis and characterization of a redox-active ion channel supporting cation flux in lipid bilayers.

The synthesis, cation binding and transmembrane conductive properties of a novel synthetic ion channel containing a redox-active ferrocene unit are described. Fluorescence spectroscopy was used to demonstrate that the channel supports multiple ion coordination and association constants for 1:1 and 1:2 (channel:cation) coordination for both Na(+) and K(+) were evaluated. Experiments using a black lipid membrane preparation revealed that this compound functioned effectively as an ion channel for both Na(+) and K(+). Concomitant (23)Na NMR spectroscopy studies supported this finding and revealed a Na(+) flux, at least 5 times higher than ion transport rates by monensin. Furthermore, oxidation of the redox-active centre (Fe(2+) to Fe(3+)) effectively inhibited ion transport.