RESUMO
Background: Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing population of patients with kidney dysfunction, there is a scarcity of literature focusing on kidney dysfunction as a risk-factor for post-operative ACDF complications. The purpose is to evaluate the differential impact of kidney dysfunction on perioperative outcomes including surgical and medical complications, extended length of hospital stay (LOS), and death within 30 days following ACDF. Patient Sample: This was a retrospective cohort study of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who had undergone an elective ACDF procedure between 2011-2021 using Current Procedural Terminology code 22551. Patients were categorized into five cohorts based on eGFR according to the "Kidney Disease: Improving Global Outcomes" Classification: values of: ≥ 90(reference cohort), 60-89 (G2), 30-59 (G3), 15-29 (G4), and <15 (G5). One-way ANOVA for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the five groups. Multivariable logistic regression analysis assessed the effect of kidney dysfunction on post-operative surgical outcomes. Significance was defined as p<.05. Results: About 75,508 ACDF patients were included, of who 57,480 were G1, 15,186 were G2, 2,192 were G3, 312 were G4, and 338 were G5. G4 and G5 independently increased the risk of medical complications (OR: 1.893, 95% CI [1.296-2.705]; OR: 2.241, 95% CI [1.222-3.964]) and blood transfusion. Only G5 independently increased the risk for extended LOS (OR: 2.410, 95% CI [1.281-4.371], p=.005). Conclusion: High grade CKD is an independent risk factor for medical complications, extended hospital LOS, and blood transfusions following ACDF, underscoring the importance of risk stratification to optimize perioperative management and reduce the burden of complications and healthcare costs. Conversely, low grade CKD does not increase the risk of complications in ACDF.
RESUMO
BACKGROUND CONTEXT: Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing diabetic patient population, there is a paucity of literature focusing on insulin-dependence as a risk-factor for post-operative ACDF complications. PURPOSE: To evaluate the differential impact of insulin dependence on perioperative outcomes including total length of stay, surgical, and medical complications within thirty days following ACDF. STUDY DESIGN/SETTING: A retrospective cohort, large multicenter database study. PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551. OUTCOME MEASURES: Perioperative surgical and medical complications. METHODS: The study population was divided into 3 groups 1) insulin-dependent diabetes mellitus (IDDM), 2) non-insulin-dependent diabetes mellitus (NIDDM), and 3) no diabetes mellitus (non-DM). One-way analysis of variance for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the 3 groups. Multivariable logistic regression analysis assessed the effect of diabetes mellitus status on post-operative medical and surgical outcomes. RESULTS: A total of 85,758 ACDF procedures were identified between 2011 and 2021, of which 5,178 were IDDM, 9,652 were NIDDM, and 70,982 were non-DM. The rates of surgical and medical complication varied between the 3 groups. IDDM patients had the highest rates of at least one medical complication (6.1%). Only IDDM increased the risk for medical complications (OR: 1.320, 95% CI [1.144-1.518]) and extended hospital length of stay (LOS) (OR: 1.244, 95% CI [1.071-1.441]) following a multivariate logistic regression analysis. CONCLUSION: Patients with IDDM were at an increased risk for postoperative medical complications and extended hospital LOS. Personalized postoperative management, guided by risk assessment is indicated for this population. These findings can be used to improve risk stratification and informed consent for DM patients who are insulin dependent.
RESUMO
BACKGROUND: Current management of acute inhalational carbon monoxide (CO) toxicity includes hyperbaric or normobaric O2 therapy. However, efficacy has not been established. The purpose of this study was to establish therapeutic proof of concept for a novel injectable antidote consisting of the combination of hydroxocobalamin and ascorbic acid into a reduced form (B12r) as demonstrated by clinically significant increase (>500 ppm) in CO2 production, reduced carboxyhemoglobin (COHgb) half-life (COHgb t1/2), and increased cerebral O2 delivery and attenuation of CO-induced microglial damage in a preclinical rodent model of CO toxicity. METHODS: B12r-mediated conversion of CO to CO2 and COHgb t1/2 in human blood were measured by gas analysis and Raman resonance spectroscopy. Rats were exposed to either air or CO and then injected with saline or B12r. Cognitive assessment was tested in a Morris water maze. Brain oxygenation was measured with Licox. Brain histology was assessed by fluorescent antibody markers and cell counts. RESULTS: B12r resulted in significant CO2 production (1,170 ppm), compared with controls. COHgb t1/2 was reduced from 33 minutes (normal saline) to 17.5 (p < 0.001). In rat models, severe CO-induced brain hypoxia (PbtO2, 18 mm Hg) was followed by significant reduction in τ25 to 12 minutes for B12r rats versus 40 minutes for normal saline-treated rats (p < 0.0001). There was major attenuation of CO-induced microglial damage, although cognitive performance differences were minimal. CONCLUSION: Our preclinical data suggest that the novel synergism of hydroxocobalamin with ascorbic acid has the potential to extract CO through conversion to CO2, independently of high-flow or high-pressure O2. This resulted in a clinically significant off-gassing of CO2 at levels five to eight times greater than those of controls, a clinically significant reduction in COHgb half-life, and evidence of increased brain oxygenation and amelioration of myoglial damage in rat models. Reduced hydroxocobalamin has major potential as an injectable antidote for CO toxicity.