Robust prediction of nonhome discharge following elective anterior cervical discectomy and fusion using explainable machine learning.

PURPOSE: Predict nonhome discharge (NHD) following elective anterior cervical discectomy and fusion (ACDF) using an explainable machine learning model. METHODS: 2227 patients undergoing elective ACDF from 2008 to 2019 were identified from a single institutional database. A machine learning model was trained on preoperative variables, including demographics, comorbidity indices, and levels fused. The validation technique was repeated stratified K-Fold cross validation with the area under the receiver operating curve (AUROC) statistic as the performance metric. Shapley Additive Explanation (SHAP) values were calculated to provide further explainability regarding the model's decision making. RESULTS: The preoperative model performed with an AUROC of 0.83 ± 0.05. SHAP scores revealed the most pertinent risk factors to be age, medicare insurance, and American Society of Anesthesiology (ASA) score. Interaction analysis demonstrated that female patients over 65 with greater fusion levels were more likely to undergo NHD. Likewise, ASA demonstrated positive interaction effects with female sex, levels fused and BMI. CONCLUSION: We validated an explainable machine learning model for the prediction of NHD using common preoperative variables. Adding transparency is a key step towards clinical application because it demonstrates that our model's "thinking" aligns with clinical reasoning. Interactive analysis demonstrated that those of age over 65, female sex, higher ASA score, and greater fusion levels were more predisposed to NHD. Age and ASA score were similar in their predictive ability. Machine learning may be used to predict NHD, and can assist surgeons with patient counseling or early discharge planning.

Management of humeral nonunions following failed surgical fixation.

INTRODUCTION: Management of humerus nonunions with previously failed fixation presents a complex problem. There are multiple revision fixation strategies, of which compression plating is a mainstay. The aim of this study was to assess the results of open reduction and direct compression plating without the need for autograft or allograft in the setting of revision humerus open reduction internal fixation. METHODS: This study is a retrospective analysis of 19 patients treated between 2008 and 2017 for humerus nonunions following failed fixation who were treated by a single surgeon using direct compression plating with bone graft substitutes. Patients were treated with neurolysis of the radial nerve, hardware removal, debridement of the nonunion site with shortening osteotomies, compression plating, and augmentation with bone graft substitutes. All patients were followed until radiographic and clinical union. RESULTS: Nineteen patients were identified for the study and 17 had adequate follow-up for final analysis. Humeral union was achieved in 16/17 (94.1%) patients with a mean time to union of 23 weeks. Two patients required a repeat compression plating with bone graft substitute to achieve union. The one patient with a nonunion radiographically reported minimal clinical symptoms and opted for no revision surgery. An association with the index procedure was seen, as three out of four of the patients who experienced radial nerve palsies after their index procedure subsequently experienced a radial nerve palsy after the procedure to repair their nonunion. All patient's all experienced a return of function in their radial nerve either back to baseline or improved from before the revision nonunion surgery. CONCLUSION: The use of humeral shortening osteotomy and compression plating without autograft or allograft is a viable option for management of humeral nonunions which avoids the morbidity associated with autograft harvest. The patients with radial nerve palsy after the index procedure are likely to have a transient radial nerve palsy as well after the revision surgery necessitating proper informed consent prior to the operation.

Skin closure with surgical staples in ankle fractures: a safe and reliable method.

PURPOSE: The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures. METHODS: Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication. RESULTS: The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups. CONCLUSION: The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.

Minocycline and Silver Dual-Loaded Polyphosphoester-Based Nanoparticles for Treatment of Resistant Pseudomonas aeruginosa.

Pseudomonas aeruginosa has been detected in the lungs of ∼50% of patients with cystic fibrosis (CF), including 20% of adult CF patients. The majority of these adult patients harbor multi-drug resistant (MDR) strains, limiting the available treatment options. Silver has long been used as a broad-spectrum antimicrobial agent with a low incidence of resistance. Despite low toxicity, poor availability of silver cations mandates a high dosage to effectively eradicate infections. To address this shortcoming of silver, nanoparticles have been used as delivery devices to improve treatment outcomes. Furthermore, studies have demonstrated that synergistic combinations with careful dose calibrations and efficient delivery systems result in superior antimicrobial activity while avoiding potential side effects of both therapeutics. Here 4-epi-minocycline, a metabolite of minocycline, was identified as an active antimicrobial against P. aeruginosa using a high-throughput screen. The antimicrobial activities of 4-epi-minocycline, minocycline, and silver acetate against clinical isolates of P. aeruginosa obtained from CF patients were evaluated in vitro. Next, the synergistic activity of the silver/minocycline combination against P. aeruginosa isolates was investigated using checkerboard assays and identified with end-point colony forming unit determination assays. Finally, nanoparticles coloaded with minocycline and silver were evaluated in vitro for antimicrobial activity. The results demonstrated that both silver and minocycline are potent antimicrobials alone and that the combination allows a reduced dosage of both therapeutics to achieve the same antimicrobial effect. Furthermore, the proposed synergistic silver/minocycline combination can be coloaded into nanoparticles as a next-generation antibiotic to combat the threats presented by MDR pathogens.

Receptor-Mediated Attachment and Uptake of Hyaluronan Conjugates by Breast Cancer Cells.

Chemotherapy, a mainstay modality for cancer, is often hindered by systemic toxicity and side effects. With the emergence of nanomedicine, the development of drug therapy has shifted toward targeted therapy. Hyaluronan (HA) is an ideal molecule as a targeted delivery system because many carcinomas overexpress HA receptors. We have conjugated resveratrol, a natural polyphenol, and 3-(5-methoxy, 2-methyl-1H-indol-3-yl)-1-(4-pyridinyl)-2-propen-1-one (MOMIPP), a chalcone, to HA with the goal of enhancing drug bioavailability and targeting triple negative breast cancers. We demonstrate the ability of HA conjugates to accumulate in the tumor interstitium within 6 h after tail vein injections. In vitro, these conjugates interact with their target receptors, which are overexpressed by triple negative breast cancer cells under static and physiological flow. These interactions result in enhanced uptake and efficacy of the therapeutic, as demonstrated by a reduced IC50 over that of nonconjugated drugs. Thus, HA offers a platform to solubilize, target, and enhance the efficacy of chemotherapeutics.

Single-center experience in prostate fiducial marker placement: technique and midterm follow-up.

PURPOSE: To describe the technique, technical success, and complications of prostate fiducial marker implantation using transrectal ultrasound (US) guidance in patients undergoing image-guided radiation therapy. MATERIALS AND METHODS: A retrospective review was performed of patients who underwent fiducial marker placement from January 2010-April 2013. In each case, gold markers were placed in the prostate using transrectal US guidance. Computed tomography (CT) was performed after the procedure and evaluated to confirm correct placement. Technical success, complications, and development of symptoms during radiotherapy were reviewed. RESULTS: Transrectal US-guided fiducial marker placement was performed on 75 patients (mean age, 62 y; range, 48-79 y) with a mean Gleason score of 7.25 (range, 6-10). Fiducial marker placement was confirmed in the intended location of the prostate or prostate bed for 297 of 300 markers (99%) on follow-up CT imaging. Two markers were placed just outside the prostate capsule, and one marker was lost. Complications included sepsis (n = 1; 1.3%), self-limiting perirectal or intraprostatic hemorrhage (n = 3; 4%), nausea (n = 1; 1.3%), transient hypotension (n = 1; 1.3%), epididymitis (n = 1; 1.3%), and urinary tract infection (n = 1; 1.3%). Complications were seen more frequently in patients with high tumor grade (P = .001) and in patients who developed metastatic disease (P = .01). CONCLUSIONS: Transrectal US-guided implantation of fiducial markers is technically feasible, is well tolerated, and has a good safety profile.

Association Between Age-stratified Cohorts and Perioperative Complications and 30-day and 90-day Readmission in Patients Undergoing Single-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To assess perioperative complication rates and readmission rates after ACDF in a patient population of advanced age. SUMMARY OF BACKGROUND DATA: Readmission rates after ACDF are important markers of surgical quality and, with recent shifts in reimbursement schedules, they are rapidly gaining weight in the determination of surgeon and hospital reimbursement. METHODS: Patients 18 years of age and older who underwent elective single-level ACDF were identified in the National Readmissions Database (NRD) and stratified into 4 cohorts: 18-39 ("young"), 40-64 ("middle"), 65-74 ("senior"), and 75+ ("elderly") years of age. For each cohort, the perioperative complications, frequency of those complications, and number of patients with at least 1 readmission within 30 and 90 days of discharge were analyzed. χ 2 tests were used to calculate likelihood of complications and readmissions. RESULTS: There were 1174 "elderly" patients in 2016, 1072 in 2017, and 1010 in 2018 who underwent ACDF. Their rate of any complication was 8.95%, 11.00%, and 13.47%, respectively ( P <0.0001), with dysphagia and acute posthemorrhagic anemia being the most common across all 3 years. They experienced complications at a greater frequency than their younger counterparts (15.80%, P <0.0001; 16.98%, P <0.0001; 21.68%, P <0.0001). They also required 30-day and 90-day readmission more frequently ( P <0.0001). CONCLUSION: It has been well-established that advanced patient age brings greater risk of perioperative complications in ACDF surgery. What remains unsettled is the characterization of this age-complication relationship within specific age cohorts and how these complications inform patient hospital course. Our study provides an updated analysis of age-specific complications and readmission rates in ACDF patients. Orthopedic surgeons may account for the rise in complication and readmission rates in this population with the corresponding reduction in length and stay and consider this relationship before discharging elderly ACDF patients.

Antimicrobial activity of a natural compound and analogs against multi-drug-resistant Gram-positive pathogens.

The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has sparked global concern due to the dwindling availability of effective antibiotics. To increase our treatment options, researchers have investigated naturally occurring antimicrobial compounds and have identified MC21-A (C58), which has potent antimicrobial activity against MRSA. Recently, we have devised total synthesis schemes for C58 and its chloro-analog, C59. Here, we report that both compounds eradicate 90% of the 39 MRSA isolates tested [MIC90 and minimum bactericidal concentration (MBC90)] at lower or comparable concentrations compared to several standard-of-care (SoC) antimicrobials including daptomycin, vancomycin, and linezolid. Furthermore, a stable, water-soluble sodium salt of C59, C59Na, demonstrates antimicrobial activity comparable to C59. C59, unlike vancomycin, kills stationary-phase MRSA in a dose-dependent manner and completely eradicates MRSA biofilms. In contrast to vancomycin, exposing MRSA to sub-MIC concentrations of C59 does not result in the emergence of spontaneous resistance. Similarly, in a multi-step study, C59 demonstrates a low propensity of resistance acquisition when compared to SoC antimicrobials, such as linezolid and clindamycin. Our findings suggest C58, C59, and C59Na are non-toxic to mammalian cells at concentrations that exert antimicrobial activity; the lethal dose at median cell viability (LD50) is at least fivefold higher than the MBC90 in the two mammalian cell lines tested. A morphological examination of the effects of C59 on a MRSA isolate suggests the inhibition of the cell division process as a mechanism of action. Our results demonstrate the potential of this naturally occurring compound and its analogs as non-toxic next-generation antimicrobials to combat MRSA infections. IMPORTANCE: The rapid emergence of methicillin-resistant Staphylococcus aureus (MRSA) isolates has precipitated a critical need for novel antibiotics. We have developed a one-pot synthesis method for naturally occurring compounds such as MC21-A (C58) and its chloro-analog, C59. Our findings demonstrate that these compounds kill MRSA isolates at lower or comparable concentrations to standard-of-care (SoC) antimicrobials. C59 eradicates MRSA cells in biofilms, which are notoriously difficult to treat with SoC antibiotics. Additionally, the lack of resistance development observed with C59 treatment is a significant advantage when compared to currently available antibiotics. Furthermore, these compounds are non-toxic to mammalian cell lines at effective concentrations. Our findings indicate the potential of these compounds to treat MRSA infections and underscore the importance of exploring natural products for novel antibiotics. Further investigation will be essential to fully realize the therapeutic potential of these next-generation antimicrobials to address the critical issue of antimicrobial resistance.

In vivo gene delivery with L-tyrosine polyphosphate nanoparticles.

The concept of gene therapy is promising; however, the perceived risks and side effects associated with this technology have severely dampened the researchers' enthusiasm. Thus, the development of a nonviral gene vector without immunological effects and with high transfection efficiency is necessary. Currently, most nonviral vectors have failed to achieve the in vivo transfection efficiencies of viral vectors due to their toxicity, rapid clearance, and/or inappropriate release rates. Although our previous studies have successfully demonstrated the controlled-release of plasmid DNA (pDNA) polyplexes encapsulated into nanoparticles formulated with l-tyrosine polyphosphate (LTP-pDNA nanoparticles), the in vivo transfection capabilities and immunogenicity of this delivery system have yet to be examined. Thus, we evaluate LTP-pDNA nanoparticles in an in vivo setting via injection into rodent uterine tissue. Our results demonstrate through X-gal staining and immunohistochemistry of uterine tissue that transfection has successfully occurred after a nine-day incubation. In contrast, the results for the control nanoparticles show results similar to those of shams. Furthermore, reverse transcriptase polymerase chain reaction (RT-PCR) from the injected tissues confirms the transfection in vivo. To examine the immunogenicity, the l-tyrosine polyphosphate (LTP) nanoparticles have been evaluated in a mouse model. No significant differences in the activation of the innate immune system are observed. These data provide the first report for the potential use of controlled-release nanoparticles formulated from an amino acid based polymer as an in vivo nonviral vector for gene therapy.

Educating Radiology Stakeholders on Relevant Health Issues and Terminology Regarding LGBTQIA+ Patients in 2023.

RATIONALE AND OBJECTIVES: Over 20% of the Lesbian, Gay, Bisexual, Queer or Questioning, Intersex, Asexual or Ally, and more (LGBTQIA+) community reports experiencing discrimination upon accessing health care, causing many to defer access to care and resulting in poorer outcomes. While members of this community routinely undergo imaging studies, little formal education exists within the field of radiology to review the unique health care needs of this population and the specific relevance to imaging, in addition to actionable methods to promote inclusion. MATERIALS AND METHODS: A 1-hour educational conference was held for a cohort of radiology resident physicians at our institution, in which topics including LGBTQIA+ health care disparities, clinical nuances relevant to the field of radiology, and actionable suggestions that both academic and private-practice centers can adopt to foster inclusion were presented. All attendees were required to complete a 12-question, multiple-choice preconference and postconference examination. RESULTS: Median prelecture and postlecture quiz scores for four first-year radiology residents were 29% and 75%, for two second-year radiology residents were 29% and 63%, for two third-year radiology residents were 17% and 71%, and for three fourth-year radiology residents were 42% and 80%. CONCLUSION: Multiple areas of opportunity to foster LGBTQIA+ inclusion at the provider and administration levels currently exist throughout the field of radiology. A radiology-focused education module regarding clinical nuances, health care inequities, and ways to foster an inclusive environment with the LGBTQIA+ community is an effective way to promote learner knowledge.

Synergistic Antimicrobial Effects of Ibuprofen Combined with Standard-of-Care Antibiotics against Cystic Fibrosis Pathogens.

Cystic fibrosis (CF) is a common life-shortening genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Lungs of CF patients are often colonized or infected with microorganisms requiring frequent courses of antibiotics. Antibiotic-resistant bacterial infections have been a growing concern in CF patients. Chronic bacterial infections and concomitant airway inflammation damage the lungs, ultimately leading to respiratory failure. Several clinical trials have demonstrated that high-dose ibuprofen reduces the rate of pulmonary function decline in CF patients. This beneficial effect has been attributed to the anti-inflammatory properties of ibuprofen. Previously, we have confirmed that high-dose ibuprofen demonstrates antimicrobial activity against P. aeruginosa both in vitro and in vivo. However, no study has examined the antimicrobial effect of combining ibuprofen with standard-of-care antimicrobials. Here, we evaluated the possible synergistic activity of combinations of common nonsteroidal anti-inflammatory drugs (NSAIDs), namely, ibuprofen, naproxen, and aspirin, with commonly used antibiotics for CF patients. The drug combinations were screened against different CF clinical isolates. Antibiotics that demonstrated increased efficacy in the presence of ibuprofen were further tested for potential synergistic effects between these NSAIDS and antimicrobials. Finally, a survival analysis of a P. aeruginosa murine infection model was used to demonstrate the efficacy of the most potent combination identified in in vitro screening. Our results suggest that combinations of ibuprofen with commonly used antibiotics demonstrate synergistic antimicrobial activity against drug-resistant, clinical bacterial strains in vitro. The efficacy of the combination of ceftazidime and ibuprofen against resistant P. aeruginosa was demonstrated in an in vivo pneumonia model.

Sleep Disturbance Trends in the Short-Term Postoperative Period for Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Patients undergoing total joint arthroplasty (TJA) often experience preoperative/postoperative sleep disturbances. Although sleep quality generally improves > 6 months after surgery, patterns of sleep in the short-term postoperative period are poorly understood. This study sought to (1) characterize sleep disturbance patterns over the 3-month postoperative period and (2) investigate clinical and sociodemographic factors associated with 3-month changes in sleep. METHODS: This retrospective analysis of prospectively collected data included 104 primary elective TJA patients. Patients were administered the PROMIS Sleep Disturbance questionnaire preoperatively and at 2 weeks, 6 weeks, and 3 months postoperatively. Median sleep scores were compared between time points using Wilcoxon signed-rank tests, stratified by preoperative sleep impairment. A multivariable logistic regression model identified factors associated with 3-month clinically improved sleep. RESULTS: The percentage of patients reporting sleep within normal limits increased over time: 54.8% preoperatively and 58.0%, 62.5%, and 71.8% at 2 weeks, 6 weeks, and 3 months post-TJA, respectively. Patients with normal preoperative sleep experienced a transient 4.7-point worsening of sleep at 2 weeks ( P = 0.003). For patients with moderate/severe preoperative sleep impairment, sleep significantly improved by 5.4 points at 2 weeks ( P = 0.002), with improvement sustained at 3 months. In multivariable analysis, patients undergoing total hip arthroplasty (versus knee; OR: 3.47, 95% CI: 1.06 to 11.32, P = 0.039) and those with worse preoperative sleep scores (OR: 1.13, 95% CI: 1.04 to 1.23, P = 0.003) were more likely to achieve clinically improved sleep from preoperatively to 3 months postoperatively. DISCUSSION: Patients experience differing patterns in postoperative sleep changes based on preoperative sleep disturbance. Hip arthroplasty patients are also more likely to experience clinically improved sleep by 3 months compared with knee arthroplasty patients. These results may be used to counsel patients on postoperative expectations and identify patients at greater risk of impaired postoperative sleep. STUDY DESIGN: Retrospective analysis of prospectively collected data.

Risk of Infection After Total Knee or Hip Arthroplasty After Receipt of Multiple Corticosteroid or Hyaluronic Acid Injections.

BACKGROUND: Few studies have assessed the relationship between the quantity of preoperative corticosteroid injections (CSIs) or hyaluronic acid injections (HAIs) and postoperative infection risk after total knee or hip arthroplasty (TKA, THA). We aimed to (1) determine whether the number of injections administered before TKA/THA procedures is associated with postoperative infections and (2) establish whether infection risk varies by injection type. METHODS: This retrospective cohort study included 230,487 THAs and 371,511 TKAs from the 2017 to 2018 Medicare Limited Data Set. The quantity of CSI or HAI, defined as receiving either CSI or HAI ≤2 years before TKA/THA, was identified and categorized as 0, 1, 2, or >2. The primary outcome was 90-day postoperative infection. Multivariable regression models measured the association between the number of injections and 90-day postoperative infection. Odds ratios and 95% confidence intervals were reported. RESULTS: The percentage of THA patients receiving 1, 2, and >2 preoperative CSIs was 6.1%, 1.6%, and 0.8%, respectively. Receiving >2 CSIs within 2 years before THA was associated with higher odds of 90-day postoperative infection (odds ratios = 1.74, 95% CI = 1.11 to 2.74, P = 0.02). The percentage of TKA patients receiving 1, 2, and >2 CSIs was 3.0%, 1.2%, and 1.1%, respectively. For HAIs in TKA patients, percentage receiving injections was 98.3%, 0.6%, 0.2%, and 0.9%, respectively. Quantity of CSIs or HAIs administered was not associated with postoperative infection among TKA patients. CONCLUSION: Patients receiving >2 injections before THA had higher odds of 90-day postoperative infection. This finding was not observed in TKA patients. These results suggest that the use of >2 injections within 2 years of THA should be avoided.

The Interactions between L-tyrosine based nanoparticles decorated with folic acid and cervical cancer cells under physiological flow.

Many anticancer drugs have been established clinically, but their efficacy can be compromised by nonspecific toxicity and an inability to reach the desired cancerous intracellular spaces. In order to address these issues, researchers have explored the use of folic acid as a targeted moiety to increase specificity of chemotherapeutic drugs. To expand upon such research, we have conjugated folic acid to functionalized poly(ethylene glycol) and subsequently decorated the surface of l-tyrosine polyphosphate (LTP) nanoparticles. These nanoparticles possess the appropriate size (100-500 nm) for internalization as shown by scanning electron microscopy and dynamic light scattering. Under simulated physiological flow, LTP nanoparticles decorated with folic acid (targeted nanoparticles) show a 10-fold greater attachment to HeLa, a cervical cancer cell line, compared to control nanoparticles and to human dermal fibroblasts. The attachment of these targeted nanoparticles progresses at a linear rate, and the strength of this nanoparticle attachment is shown to withstand shear stresses of 3.0 dyn/cm(2). These interactions of the targeted nanoparticles to HeLa are likely a result of a receptor-ligand binding, as a competition study with free folic acid inhibits the nanoparticle attachment. Finally, the targeted nanoparticles encapsulated with a silver based drug show increased efficacy in comparison to nondecorated (plain) nanoparticles and drug alone against HeLa cells. Thus, targeted nanoparticles are a promising delivery platform for developing anticancer therapies that overexpress the folate receptors (FRs).

Trends in the Charges and Utilization of Computer-Assisted Navigation in Cervical and Thoracolumbar Spinal Surgery.

STUDY DESIGN: Retrospective national database study. PURPOSE: This study is conducted to assess the trends in the charges and usage of computer-assisted navigation in cervical and thoracolumbar spinal surgery. OVERVIEW OF LITERATURE: This study is the first of its kind to use a nationwide dataset to analyze trends of computer-assisted navigation in spinal surgery over a recent time period in terms of use in the field as well as the cost of the technology. METHODS: Relevant data from the National Readmission Database in 2015-2018 were analyzed, and the computer-assisted procedures of cervical and thoracolumbar spinal surgery were identified using International Classification of Diseases 9th and 10th revision codes. Patient demographics, surgical data, readmissions, and total charges were examined. Comorbidity burden was calculated using the Charlson and Elixhauser comorbidity index. Complication rates were determined on the basis of diagnosis codes. RESULTS: A total of 48,116 cervical cases and 27,093 thoracolumbar cases were identified using computer-assisted navigation. No major differences in sex, age, or comorbidities over time were found. The utilization of computer-assisted navigation for cervical and thoracolumbar spinal fusion cases increased from 2015 to 2018 and normalized to their respective years' total cases (Pearson correlation coefficient=0.756, p =0.049; Pearson correlation coefficient=0.9895, p =0.010). Total charges for cervical and thoracolumbar cases increased over time (Pearson correlation coefficient=0.758, p =0.242; Pearson correlation coefficient=0.766, p =0.234). CONCLUSIONS: The use of computer-assisted navigation in spinal surgery increased significantly from 2015 to 2018. The average cost grossly increased from 2015 to 2018, and it was higher than the average cost of nonnavigated spinal surgery. With the increased utilization and standardization of computer-assisted navigation in spinal surgeries, the cost of care of more patients might potentially increase. As a result, further studies should be conducted to determine whether the use of computer-assisted navigation is efficient in terms of cost and improvement of care.

Comparison of total joint arthroplasty care patterns prior to the Covid-19 pandemic and after resumption of elective surgery during the Covid-19 Outbreak: A retrospective, large urban academic center study.

BACKGROUND: After the suspension of elective surgeries was lifted in June 2020 in New York State, challenges remained regarding coordination of total joint arthroplasty (TJA) cases. Using the experience from a high-volume health system in New York City, we aimed to describe patterns of care after resumption of elective TJA. METHODS: We retrospectively assessed 7,699 TJAs performed before and during the COVID-19 pandemic. Perioperative characteristics and clinical outcomes were compared between TJAs based on time period of performance: 1) pre-pandemic (PP, June 8th-December 8th, 2019), 2) initial period post-resumption of elective surgeries (IR, June 8th-September 8th, 2020), and 3) later period post-resumption (LR, September 9th-December 8th, 2020). RESULTS: LOS > 2 days (83%, 67%, 70% for PP, IR, LR periods respectively) and discharge rates to post-acute care (PAC) facilities were lower during the pandemic periods (ORIR vs. PP: 0.48, 95% CI: 0.40-0.59, p < 0.001; ORLR vs. PP: 0.63, 95% CI: 0.53-0.75, p < 0.001). Compared to the pre-pandemic period, the risk for 30-day readmission was lower during the IR period (OR: 0.62, 95% CI: 0.40-0.98, p = 0.041) and similar during the LR period (OR: 0.96, 95% CI: 0.65-1.41, p = 0.832). CONCLUSIONS: Despite decreased LOS and discharge to PAC for TJAs performed during the pandemic, 30-day readmissions did not increase. Given the increased costs and lack of superior functional outcomes associated with discharge to PAC, these findings suggest that discharge to PAC facilities need not return to pre-pandemic levels.

The Impact of Computer-Assisted Navigation on Charges and Readmission in Patients Undergoing Posterior Cervical Fusion Surgery.

STUDY DESIGN: Retrospective cohort study of 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database (NRD). OBJECTIVE: The aim was to evaluate cost and outcomes associated with navigation use on posterior cervical fusion (PCF) surgery patients. SUMMARY OF BACKGROUND DATA: Computer-assisted navigation systems demonstrate comparable outcomes with hardware placement and procedural speed compared with traditional techniques. Innovations in technology continue to improve surgeons' performance in complicated procedures, causing need to analyze the impact on patient care. METHODS: The 2016 NRD was queried for patients with PCF surgery ICD-10 codes. Cost and readmission rates were compared with and without navigation. Nonelective cases and patients below 18 years of age were excluded. Univariate analysis on demographics, surgical data, and total charges was performed. Lastly, multivariate analysis was performed to assess navigation's impact on cost and postoperative outcomes. RESULTS: A total of 11,834 patients were identified, with 137 (1.2%) patients undergoing surgery with navigation and 11,697 (98.8%) patients without. Average total charge was $131,939.47 and $141,270.1 for the non-navigation and navigation cohorts, respectively ( P =0.349). Thirty-day and 90-day readmission rates were not significantly lower in patients who received navigation versus those that did not ( P =0.087). This remained insignificant after adjusting for several variables, age above 65, sex, medicare status, mental health history, and comorbidities. The model adjusting for demographic and comorbidities maintained insignificant results of navigation being associated with decreased 30-day and 90-day readmissions ( P =0.079). CONCLUSIONS: Navigation use in PCF surgery was not associated with increased cost, and patients operated on with navigation did not significantly have increased routine discharge or decreased 90-day readmission. As a result, future studies must continue to evaluate the cost-benefit of navigation use for cervical fusion surgery. LEVEL OF EVIDENCE: Level III.