Hospital Course and Complications of Subaxial Cervical Trauma Patients With Tetraplegia or Paraplegia: A Case Series and Literature Review.

STUDY DESIGN: A single-institution, retrospective cohort study. OBJECTIVE: The objective was to present demographic characteristics, mechanism of injuries, lengths of stay, intensive care unit (ICU) days, discharge locations, and causes of 90-day readmission for patients with subaxial spinal cord injuries resulting in paraplegia or tetraplegia. SUMMARY OF BACKGROUND DATA: Spinal cord injuries resulting in paraplegia or tetraplegia are rare injuries with debilitating outcomes. Numerous advances have occurred in caring for these patients, but patients still experience multiple complications. The severity of these injuries and numerous complications result in prolonged hospital stays and the need for extensive rehabilitation. METHODS: Twelve patients with subaxial spinal cord injury resulting in paraplegia or tetraplegia from a level 1 adult trauma center were reviewed. The primary outcomes included hospital length of stay, ICU days, intrahospital complications, 90-day readmission rates, and discharge location. We reviewed the literature for these outcomes in spinal cord injuries. RESULTS: For patients with subaxial spinal cord injuries resulting in paraplegia and tetraplegia, the average age was 36.0 years, and most were male [91.7% (11/12)]. The most common mechanism of injury was gunshot wounds[41.7% (5/12)]. Patients spent an average of 46.3 days in the hospital and 30.7 days in the ICU. Respiratory complications were the most common (9 patients). Fifty percent of patients (6/12) were discharged to the inpatient spinal cord rehab center, and 16.7% (2/12) expired while in the hospital. Two patients (20.0%) were readmitted within 90 days of discharge. CONCLUSIONS: Most patients with subaxial spinal cord injuries resulting in paraplegia or tetraplegia were young males with high-energy traumas. Many patients had intrahospital complications, and most were discharged to the hospital spinal rehab center. These findings likely stem from the severity of paraplegia and tetraplegia injuries and the need for rehabilitation.

Early Surgical Treatment of Thoracolumbar Fractures With Thoracolumbar Injury Classification and Severity Scores Less Than 4.

BACKGROUND: Thoracolumbar fractures (TLFs) are the most common spinal fractures seen in patients with trauma. The Thoracolumbar Injury Classification and Severity (TLICS) classification system is commonly used to help clinicians make more consistent and objective decisions in assessing the indications for surgical intervention in patients with thoracolumbar fractures. Patients with TLICS scores <4 are treated conservatively, but a percentage of them will have failed conservative treatment and require surgery at a later date. METHODS: All patients who received an orthopaedic consult between January 2016 and December 2020 were screened for inclusion and exclusion criteria. For patients meeting the study requirements, deidentified data were collected including demographics, diagnostics workup, and hospital course. Data analysis was conducted comparing length of stay, time between first consult and surgery, and time between surgery and discharge among each group. RESULTS: 1.4% of patients with a TLICS score <4 not treated surgically at initial hospital stay required surgery at a later date. Patients with a TLICS score <4 treated conservatively had a statistically significant shorter hospital stay compared with those treated surgically. However, when time between initial consult and surgery was factored into the total duration of hospital stay for those treated surgically, the duration was statistically equivalent to those treated nonsurgically. CONCLUSION: For patients with a TLICS score <4 with delayed mobilization after 3 days in the hospital or polytraumatic injuries, surgical stabilization at initial presentation can decrease the percentage of patients who fail conservative care and require delayed surgery. Patients treated surgically have a longer length of stay than those treated conservatively, but there is no difference in stay when time between consult and surgery was accounted for. In addition, initial surgery in patients with delayed mobilization can prevent long waits to surgery, while conservative measures are exhausted. LEVEL III EVIDENCE: Retrospective cohort study.

Practice patterns regarding post-discharge chemoprophylaxis for venous thromboembolism following bariatric surgery in the United States.

BACKGROUND: There is no consensus regarding the optimal venous thromboembolism (VTE) prevention strategy following bariatric surgery. Post-discharge chemoprophylaxis is frequently recommended for high-risk patients with little supporting data. OBJECTIVES: To define practices related to post-discharge chemoprophylaxis in the United States. SETTING: United States. METHODS: From the Truven Health MarketScan Research database we identified patients age 18 to 64 years undergoing laparoscopic sleeve gastrectomy and gastric bypass (2009-2015). Use of post-discharge low-molecular-weight or unfractionated heparin, vitamin K antagonists, Factor Xa inhibitors, or direct thrombin inhibitors was determined, as was the occurrence of VTE events from discharge to 90 days. Patients with VTE during the index admission were excluded to focus on chemoprophylaxis after discharge (versus treatment). Multivariate logistic regression was used to evaluate the association between VTE and anticoagulant usage. RESULTS: Of 105,246 patients, .8% with VTE prior to discharge were excluded. The study cohort was 78.1% female, with a median age of 44 years. Hypercoagulable disorder was present in .9%. Post-discharge chemoprophylaxis rates were 11.3% and varied from state to state (.5%-37.4%). VTE rates varied from state to state (.4%-2.6%). VTE after discharge occurred in 1.3%. On multivariate analysis, hypercoagulable disorder (odds ratio [OR] 14.0; 95% confidence interval [CI] 11.6-16.9, P < .001), age ≥60 years (OR 2.3; 95% CI 1.0-5.3; P = .047), and male sex (female OR .8; 95% CI .7-.9, P < .001) increased the risk for VTE. Post-discharge chemoprophylaxis was associated with increased VTE risk (OR 2.1; 95% CI 1.8-2.4; P < .001). CONCLUSIONS: Post-discharge chemoprophylaxis following laparoscopic bariatric surgery is employed in 11.3% of patients. Variation in VTE rates and prophylaxis strategies exist nationally.

Very Early Versus Early Readmissions in General Surgery Patients.

BACKGROUND: Hospital readmission rates are an important quality metric. A readmission very soon after discharge may be related to a different cause than readmissions that occur later in the first 30 d. MATERIALS AND METHODS: The National Surgical Quality Improvement Program data sets from 2014 to 2015 were used to identify patients undergoing general surgery procedures. Demographics, comorbidities, and morbidity were analyzed. Stepwise regression was used to determine statistical predictors for any readmission. The final model variables were a combination of selected clinical variables and statistically significant variables. Multinomial logistic regression was then used with these variables to develop models for "very early" (days 0-3 after discharge) and "early" (days 4-30) readmissions. RESULTS: A total of 744,492 patients were included with 5.9% readmitted within 30 d and 1.5% readmitted within 3 d of discharge (26.1% of all readmissions). Significant risk factors for any readmission included ≥3 comorbidities, major surgery (operative time >1 h, length of stay greater >2 d), and American Society of Anesthesiologists class ≥3. When examining "very early" readmissions, the greatest risk factor was experiencing a severe complication (≥Grade III) before discharge. CONCLUSIONS: Readmissions within 3 d of discharge constitute a large portion of all 30 d readmissions. The greatest risk factor for "very early" readmission was a severe complication before discharge. Better understanding of the reason for this association is needed to develop effective prevention strategies.

The impact of preoperative anemia and malnutrition on outcomes in paraesophageal hernia repair.

BACKGROUND: Patients with a paraesophageal hernia may experience gastroesophageal reflux symptoms and/or obstructive symptoms such as dysphagia. Some patients with large and complex paraesophageal hernias unintentionally lose a significant amount of weight secondary to difficulty eating. A subset of patients will develop Cameron's erosions in the hernia, which contribute to anemia. Given the heterogeneous nature of patients who ultimately undergo paraesophageal hernia repair, we sought to determine if patients with anemia or malnutrition suffered from increased morbidity or mortality. METHODS: The American College of Surgeons National Surgical Quality Improvement Program datasets from 2011 to 2015 were queried to identify patients undergoing paraesophageal hernia repair. Malnutrition was defined as preoperative albumin < 3.5 g/dL. Preoperative anemia was defined as hematocrit less than 36% for females and 39% for males. Thirty-day postoperative outcomes were assessed. RESULTS: A total of 15,105 patients underwent paraesophageal hernia repair in the study interval. Of these patients, 7943 (52.6%) had a recorded preoperative albumin and 13.9% of these patients were malnourished. There were 13,139 (87%) patients with a documented preoperative hematocrit and 23.1% met criteria for anemia. Both anemia and malnutrition were associated with higher rates of complications, readmissions, reoperations, and mortality. This was confirmed on logistic regression. The average postoperative length of stay was longer in the malnourished (6.1 vs. 3.1 days when not malnourished, p < 0.0001) and anemic (4.1 vs. 2.8 days without anemia, p < 0.0001). CONCLUSION: Malnutrition and anemia are associated with increased morbidity and mortality in patients undergoing paraesophageal hernia repair, as well as a longer length of stay. This information can be used for risk assessment and perhaps preoperative optimization of these risk factors when clinically appropriate.

Nuclear factor XIIIa staining (clone AC-1A1 mouse monoclonal) is a sensitive and specific marker to discriminate sebaceous proliferations from other cutaneous clear cell neoplasms.

Sebaceous carcinoma is a rare but serious malignancy that may be difficult to diagnose when poorly differentiated. Other epithelial tumors with clear cell change may mimic sebaceous carcinoma. Few useful or specific immunohistochemical markers for sebaceous differentiation are available. Nuclear staining with factor XIIIa (clone AC-1A1) was recently found to be a highly sensitive marker of sebaceous differentiation. We evaluated nuclear factor XIIIa (AC-1A1) staining in sebaceous neoplasms vs. other cutaneous clear cell tumors. We stained 27 sebaceous proliferations: sebaceous hyperplasia (7), sebaceous adenoma (8), sebaceoma (5), sebaceous carcinoma (7). We also stained 67 tumors with clear cell change: basal cell carcinoma (8), squamous cell carcinoma (8), hidradenoma (7), desmoplastic trichilemmoma (2), trichilemmoma (10), trichilemmal carcinoma (3), clear cell acanthoma (9), atypical fibroxanthoma (1), syringoma (8), trichoepithelioma (1), metastatic renal cell carcinoma (2), and nevi with balloon cell change (8). Nuclear factor XIIIa (AC-1A1) staining was present in 100% of sebaceous proliferations; 96% displayed strong staining. Non-sebaceous clear cell tumors were negative or only weakly positive with factor XIIIa (AC-1A1) in 95.5%; only 4.5% showed strong staining. This suggests that strong nuclear factor XIIIa (AC-1A1) staining is a sensitive and specific marker of sebaceous neoplasms vs. other clear cell tumors.

Nuclear factor XIIIa staining (clone AC-1A1 mouse monoclonal) is a highly sensitive marker of sebaceous differentiation in normal and neoplastic sebocytes.

BACKGROUND: Sebaceous proliferations are common and may be confused with other cutaneous neoplasms. Few useful or specific immunohistochemical markers for sebaceous differentiation are available. We incidentally observed strong factor XIIIa (Ventana clone AC-1A1 on Ventana Benchmark Ultra stainer) nuclear staining in normal sebaceous glands and hypothesized that this might be a useful marker in sebaceous proliferations. METHODS: Immunohistochemistry for factor XIIIa (AC-1A1) was performed on seven sebaceous hyperplasias, eight sebaceous adenomas, five sebaceomas, seven sebaceous carcinomas. RESULTS: Strong nuclear factor XIIIa (AC-1A1) staining was present in 100% of normal sebaceous glands, 100% of sebaceous hyperplasia, adenoma and carcinoma, and 80% of sebaceoma. Moderately or poorly differentiated squamous cell carcinomas (SCCs) (n = 26) were also stained for factor XIIIa (AC-1A1); two showed focal strong staining (8%), but the remainder showed only weak or negative staining (92%). In contrast, factor XIIIa clones from Abcam, Cambridge, MA, USA (EP3372) and Vector Laboratories, Burlingame, CA, USA (E980.1) were negative in sebocyte nuclei. CONCLUSIONS: We report the novel finding of consistent nuclear factor XIIIa (AC-1A1) staining in normal, hyperplastic and neoplastic sebocytes. Factor XIIIa (AC-1A1) is a highly sensitive marker of sebaceous differentiation. It may have potential clinical utility as a specific marker to distinguish sebaceous carcinoma from poorly differentiated SCC.

Neutropenic Enterocolitis: New Insights Into a Deadly Entity.

Neutropenic enterocolitis (NE) is a deadly ileocecal-based disease seen in patients with a recent history of chemotherapy. As histology is not included in the current diagnostic criteria, the pathologic features of NE are poorly understood. We undertook a multi-institutional study of NE, and report helpful clinical clues, such as immunosuppression (n=20/20), recent chemotherapy (n=17/18), neutropenia (n=16/18) gastrointestinal symptoms (n=19/19), abnormal imaging studies of the cecum/right colon (n=11/14), and positive microbiological studies (n=13/15). Fever (n=9/15) and sepsis (n=8/16) were also common. Pathologically, the cecum/right colon was always involved (n=17/17), but findings were identified in other bowel segments as well. NE lesions consisted of patchy necrosis (n=18/20), infiltrating organisms (n=17/20), hemorrhage (n=15/20), ulcer (n=15/19), edema (n=15/20), and depletion of inflammatory cells (n=15/20). Seventy-nine percent (n=15/19) of patients with histologically confirmed NE died: 47% (n=7/15) of these deaths were attributed to NE and the remainder to the patients' underlying conditions. Importantly, we observed a clinical diagnostic discordancy rate of 35% (n=9/26): 15% (n=3/20) of histologically confirmed NE were clinically unsuspected, and 26% (n=6/23) of clinically suspected NE represented a different disease process. Alternative diagnoses included unspecified colitis, infection, graft-versus-host disease, relapsed malignancy, mycophenolate injury, appendicitis, and ischemia. The causes of death in patients with NE mimics included unrecognized appendicitis and unrecognized graft-versus-host disease. To improve diagnostic accuracy, we propose that histology be required for a diagnosis of "definitive NE," with other clinically suspicious cases reported as "suspicious for NE" until all other possible diagnoses have been reasonably excluded.

Short communication: mucocutaneous leishmaniasis in HIV-related immune reconstitution syndrome.

Immune reconstitution inflammatory syndrome (IRIS) is an immuno-pathologic reaction to quiescent opportunistic microbial pathogens upon restoration of underlying immune defects. Here we report a Honduran patient with HIV/AIDS who developed a facial rash worsening on antiretroviral therapy and increasing CD4 count. Culture and PCR analysis from the skin biopsy identified Leishmania panamensis, which was effectively treated with long-term liposomal amphotericin B. This is the first report of mucocutaneous leishmaniasis (MCL)-associated IRIS due to L. panamensis.

Idiopathic Hypereosinophilic Syndrome With Cutaneous Manifestations and Flame Figures: A Spectrum of Eosinophilic Dermatoses Whose Features Overlap With Wells' Syndrome.

IMPORTANCE: Wells syndrome (WS) (eosinophilic cellulitis) is an uncommon eosinophilic dermatitis that has been rarely described in association with, but distinct from, hypereosinophilic syndrome (HES). OBSERVATIONS: We report a case of an eosinophilic dermatosis with flame figures in association with idiopathic HES, manifested by inflammatory myocarditis, asthma, and peripheral blood eosinophilia. CONCLUSIONS AND RELEVANCE: The diagnoses of WS and HES, rather than being distinct findings, may represent 2 entities on a spectrum of hypereosinophilic diseases. The diagnosis of WS should be made with caution and should prompt a thorough investigation that includes a work-up for a systemic eosinophilic disorder.

Grover disease (transient acantholytic dermatosis) in acute myeloid leukemia on FDG PET/CT.

A 48-year-old man with a newly diagnosed acute myeloid leukemia developed purpuric rash on day 6 after chemotherapy. Skin biopsy on day 8 demonstrated Grover disease. Triamcinolone treatment started on day 10 with subjective improvement on day 15. Initial FDG PET/CT on day 12 demonstrated rarely seen diffuse skin uptake that was interpreted as technical artifact and repeated on day 16. Accurately reviewing both PET and CT imaging would prevent confusion between diffuse cutaneous hypermetabolic activity and a technical artifact. Grover disease usually affects the trunk and may be related to the elimination of chemotherapy agents by sweating.

Energy absorbed by longitudinally splitting a tibialis anterior allograft: implications for double-bundle anterior cruciate ligament reconstruction.

PURPOSE: Split tibialis anterior (TA) allografts have been proposed as a source for double-bundle anterior cruciate ligament reconstruction. We sought to determine whether longitudinally splitting a TA tendon leads to a change in the mechanical properties of the tendon. METHODS: Seven cadaveric matched pairs of TA tendons were procured. One member of each pair was longitudinally pierced in its midportion and then bluntly split, creating 2 longitudinally divided grafts. The other member of the pair remained intact. Each tendon was then frozen into thermoelectrically cooled clamps and loaded to failure on an MTS machine (MTS Systems, Eden Prairie, MN) at a displacement of 1 mm/s. The area under the force-versus-displacement curve was calculated as an indicator of energy absorbed by the tendon before failure. The energy absorbed by the intact tendon was then compared with the summed energy absorbed by the 2 specimens obtained by splitting the sibling specimen. RESULTS: Energy absorbed by the intact tendon was 10,300 +/- 3,433 Nmm, whereas total energy absorbed by the 2 longitudinally split tendons was 10,530 +/- 2,095 Nmm (P = .78). CONCLUSIONS: Longitudinal splitting of a TA allograft by the technique described does not significantly affect the graft's ability to absorb energy. CLINICAL RELEVANCE: The splitting technique described can safely be used to create 2 grafts if surgeons wish to use a TA graft for a double-bundle anterior cruciate ligament reconstruction or for reconstruction by use of fixation devices requiring 2 looped tendon grafts.

Restoration of regenerative osteoblastogenesis in aged mice: modulation of TNF.

Skeletal changes accompanying aging are associated with both increased risk of fractures and impaired fracture healing, which, in turn, is due to compromised bone regeneration potential. These changes are associated with increased serum levels of selected proinflammatory cytokines, e.g., tumor necrosis factor alpha (TNF-alpha). We have used a unique model of bone regeneration to demonstrate (1) that aged-related deficits in direct bone formation can be restored to young mice by treatment with TNF blockers and (2) that the cyclin-dependent kinase inhibitor p21 is a candidate for mediation of the osteoinhibitory effects of TNF. It has been hypothesized recently that TNF antagonists may represent novel anabolic agents, and we believe that the data presented here represent a successful test of this hypothesis.

Instructions about nicotine dose influence acute responses to nasal spray.

Effects of substance use are typically assumed to be related to pharmacological actions. However, beliefs about the drug content of a substance may strongly influence subjective and reinforcing responses to that substance (i.e., "placebo" effects). We examined the subjective and reinforcing effects of a nasal spray containing no nicotine as a function of instructions about the nicotine content of the spray (Told Nicotine vs. Told No Nicotine). Smokers (n=49) not interested in quitting smoking abstained overnight prior to a single session in which they were randomly assigned to one of three groups, involving one of the two instructional sets or a group that got no spray. Following dose instructions, subjects in the two spray groups were administered one set of four sprays from the spray bottle and then rated them intermittently on items related to "reward" (e.g., "liking", amount they would pay for more) and other effects. At the same time points, they also rated mood, craving, and withdrawal, and had heart rate and blood pressure measured. Reinforcement was then determined by the number of ad libitum sprays they self-administered during a 20-min period. The no-spray group simply rested quietly during the session, while measures were assessed at the same time points as subjects in the other two groups. Those in the Told Nicotine group reported greater spray ratings of "how much nicotine," "liking," "satisfying," "buzz/head rush," and "similar to smoking" compared with the Told No Nicotine group. Craving decreased more for those Told Nicotine versus those Told No Nicotine, but also decreased more for those Told No Nicotine compared with the no spray group. There were no significant differences in amount they would pay for more sprays, withdrawal, mood, cardiovascular responses, or in spray self-administration. These results show that instructions about the nicotine content of a novel delivery device (nasal spray) can influence self-reported spray ratings and reduce craving but are limited with respect to effects on other measures of drug response.