Active Amphetamine Abuse in Total Hip Arthroplasty Carries Increased Risk for Postoperative Surgical and Medical Complications.

Background: The impact of amphetamine abuse on total hip arthroplasty (THA) outcomes has yet to be studied. As the rates of methamphetamine abuse continue to rise, understanding the risk profile of this population is imperative. This study aims to determine the risk of major surgical and medical complications for those with amphetamine abuse undergoing THA, with the hypothesis that amphetamine abuse carries increased risk. Methods: A retrospective review was performed with all-claims data files of a large national database querying International Classification of Disease, tenth revision, procedure codes identifying 333,038 primary THA, and 1027 with active amphetamine abuse. Medical and surgical complications including infection, dislocation, implant failure, periprosthetic fracture, and revision, as well as length of hospital stay and 90-day readmission rate, were identified. Univariate analysis compared rates of dependent outcomes. To account for independent variables, logistic regression was performed using age, Charlson comorbidity index, sex, obesity, tobacco use, and alcohol use. The results were presented as odds ratios (OR) and P values with significance set at <0.05. Results: Patients with active amphetamine abuse carried an increased risk of dislocation (OR 1.82, P ≤ .001), infection (OR 2.37, P ≤ .001), mechanical complications (OR 1.64, P ≤ .001), periprosthetic fracture (OR 1.53, P ≤ .05), revision (OR 1.70, P ≤ .001), 90-day readmission (OR 1.79, P ≤ .001), as well as medical complications (1.43, P = .02) compared to those without documented amphetamine abuse. Conclusions: Patients with amphetamine abuse are at increased risk of postoperative surgical and medical complications following THA. We recommend consideration of these risks prior to primary THA in this patient population.

Is Retention of the Acetabular Component at Revision Surgery a Long-Term Solution?

Background: Acetabular retention in revision total hip arthroplasty (THA) may be advantageous, yet long-term survival data is limited. Thus, we investigated long-term survivorship of retained acetabular components in revision THA with analysis of rerevision rate, instability risk, and clinical outcomes. Methods: We reviewed 98 hips with polyethylene wear and/or osteolysis that were revised with retained acetabular components. Acetabular inclination and anteversion were measured from prerevision radiographs. A retrospective chart review was performed, collecting outcomes of interest including Harris hip score, instability events, and rerevision surgery. Kaplan-Meier analysis was used to calculate the risk of revision over time. Predictors of survival including acetabular component position were analyzed by multiple logistic regression. Results: Average follow-up was 13 years (range, 5-24). Survivorship rates at 5, 10, 15, and 20 years were 89.7%, 81.6%, 70.8%, and 63.8%, respectively. There was improvement in average Harris hip score (61 to 76, P < .0001). There was a 9% rate of dislocation, and 6 hips (6%) were rerevised for recurrent instability. Overall, there were 23 (23%) rerevisions at an average of 6.1 years with the most common reasons being instability (6%) and aseptic loosening (6%). Use of conventional polyethylene was the only identified independent predictor of rerevision (P = .025). Conclusions: Retention of a well-fixed acetabular component in revision THA provides acceptable long-term outcomes with a 15-year survivorship of 71%. Instability and aseptic loosening were the most common reasons for rerevision. Surgeons may consider retaining the acetabular component at revision surgery if the implant is well-fixed and well-positioned.

Factors That Influence Orthopedic Women Residents' Selection of Adult Reconstruction.

BACKGROUND: Stereotypes may discourage women from going into the historically male-dominated field of Adult Reconstruction. Other factors such as interest, confidence, and a sense of belonging may influence subspecialty choice. The objective of this study was to survey orthopedic surgery residents regarding their perceptions about Adult Reconstruction. METHODS: A validated survey evaluating social determinants of behavior was adapted to assess orthopedic surgery residents' perceptions of Adult Reconstruction. The survey was electronically distributed to residents from 16 United States and Canadian Accreditation Council for Graduate Medical Education-accredited residency programs. There were 93 respondents including 39 women (42%) and 54 men (58%). Study data were collected and managed using an electronic data capture tool. Descriptive statistics were reported for all continuous variables. Percentiles and sample sizes were reported for categorical variables. RESULTS: Women and men reported similar interest in Adult Reconstruction (46% versus 41%, P = .60). Fewer women reported that they were encouraged to go into Adult Reconstruction by faculty (62% versus 85%, P = .001). Women and men reported similar confidence in their own ability to succeed in the subspecialty of Adult Reconstruction. However, when asked about the ability of other residents, both sexes rated men as having higher levels of confidence. Women and men perceived other residents and faculty felt "men are better Adult Reconstruction surgeons," but did not personally agree with this statement. CONCLUSION: Women and men residents expressed similar rates of interest and self-confidence in Adult Reconstruction, but there were social barriers including negative stereotypes that may prevent them from pursuing careers in Adult Reconstruction.

Germline variant testing in serrated polyposis syndrome.

BACKGROUND AND AIM: Serrated polyposis syndrome (SPS) is now known to be the commonest polyposis syndrome. Previous analyses for germline variants have shown no consistent positive findings. To exclude other polyposis syndromes, 2019 British Society of Gastroenterology (BSG) guidelines advise gene panel testing if the patient is under 50 years, there are multiple affected individuals within a family, or there is dysplasia within any of the polyps. METHODS: A database of SPS patients was established at the Oxford University Hospitals NHS Foundation Trust. Patients were referred for genetic assessment based on personal and family history and patient preference. The majority were tested for a hereditary colorectal cancer panel including MUTYH, APC, PTEN, SMAD4, BMPR1A, STK11, NTLH1, POLD1, POLE, GREM1 (40-kb duplication), PMS2, and Lynch syndrome mismatch repair genes. RESULTS: One hundred and seventy-three patients were diagnosed with SPS based on World Health Organization 2019 criteria between February 2010 and December 2020. The mean age of diagnosis was 54.2 ± 16.8 years. Seventy-three patients underwent genetic testing and 15/73 (20.5%) were found to have germline variants, of which 7/73 (9.6%) had a pathogenic variant (MUTYH n = 2, SMAD4 n = 1, CHEK2 n = 2, POLD1 n = 1, and RNF43 n = 1). Only 60% (9/15) of these patients would have been recommended for gene panel testing according to current BSG guidelines. CONCLUSIONS: A total of 20.5% of SPS patients tested were affected by heterozygous germline variants, including previously unreported associations with CHEK2 and POLD1. This led to a change in management in seven patients (9.6%). Current recommendations may miss SPS associated with germline variants, which is more common than previously anticipated.

Effects of delayed postoperative void and preoperative urologic symptoms on delay in time of discharge for elective lumbar decompression surgery.

BACKGROUND CONTEXT: Almost half of all patients undergoing lumbar spine surgery have preoperative lower urinary tract symptoms (LUTS). These symptoms could affect postoperative voiding and subsequently length of stay. PURPOSE: To investigate the association between preoperative LUTS and time to first void and between time to first void and time to discharge among patients undergoing elective lumbar decompression surgery. STUDY DESIGN/SETTING: Retrospective analysis of prospectively collected data among patients at a single academic medical center. PATIENT SAMPLE: All patients ≥18 years of age undergoing elective lumbar decompression surgery between July 2017 and March 2020. OUTCOME MEASURES: The physiologic measure of a delayed time to first void was defined as an initial postoperative void of > 4 hours after anesthesia stop time. The outcome of prolonged time to discharge was defined as a stay of >24 hours after anesthesia stop time. METHODS: At their preoperative visit, patients completed the validated International Prostate Symptom Score (IPSS) (range, 0-35 points), which is applicable for LUTS assessment in both sexes. Clinically relevant LUTS are defined as an IPSS score of ≥8. Patients were followed from their preoperative visit to surgery admission discharge. Association of LUTS with time to first void and time to first void with admission discharge were estimated using risk ratios (RR) and 95% confidence intervals (CI) from a multivariable Poisson regression with a robust variance estimate adjusted for potential confounding variables including age, sex, IPSS, and intraoperative Foley catheter use. RESULTS: The analytic cohort included 170 patients with an average age of 57 years and 103 (61%) were men. Preoperative LUTS prevalence was 45%, and 111 (65%) of patients voided within 4 hours after surgery. For patients with preoperative LUTS, the unadjusted RR for a first void of >4 hours was 1.04 (95% CI: 0.82-1.32) (p=.77). Adjustment for age, sex, intraoperative Foley catheter use, revision surgery, previous spine surgery, single versus multiple levels, and lumbar location did not materially alter the risk: the multivariable RR was 1.04 (95% CI: 0.82-1.31) (p=.74). The unadjusted RR for a discharge of > 24 hours for patients with a time to first void of > 4 hours was 2.17 (95% CI: 1.51-3.10) (p<.001). After adjusting for age, sex, intraoperative Foley catheter use, IPSS, revision surgery, previous spine surgery, single versus multiple levels, and lumbar location, the multivariable RR was 1.72 (95% CI: 1.22-2.41) (p=.002). CONCLUSIONS: Regardless of preoperative LUTS status, an initial first void of >4 hours after surgery is associated with a longer time to discharge among patients undergoing elective lumbar decompression surgery. Future studies are needed to determine if encouraging early postoperative voiding results in timely discharge and shorter length of stay.

Patients With Symptomatic Sequelae of Slipped Capital Femoral Epiphysis Have Advanced Cartilage Wear at the Time of Surgical Intervention.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a common hip problem in children. The resulting deformity can cause impingement similar to cam-type idiopathic femoroacetabular impingement (FAI). Although there are similarities between FAI and SCFE, deformity patterns, severity, and time of onset of symptoms varies, which may impact management. The purpose of this study was to describe patterns of articular cartilage damage in patients undergoing surgical hip dislocation for sequelae of SCFE in comparison to patients undergoing arthroscopic surgery for primary FAI. METHODS: Patients were identified who underwent surgical treatment for hip pain due to primary FAI (cam type) or sequelae of SCFE. Clinical data and radiographic measurements were recorded. Cartilage was assessed intraoperatively. Severity was classified using the modified Beck classification, while location was classified into 6 sectors. Statistical analysis was performed to test for differences in demographic and radiographic characteristics between the SCFE and FAI patients. χ2 or Fisher exact tests were used to evaluate trends in patterns of acetabular and femoral cartilage wear between SCFE and FAI groups. RESULTS: The SCFE group had 28 hips compared with 304 in the FAI group. SCFE patients were younger (19 vs. 32, P<0.001), had higher body mass index (30±5.9 vs. 24±4.8, P<0.001), and were more often male (61% vs. 27%, P<0.001). Deformity severity based on α-angle was higher in the SCFE group [AP 74 vs. 55 (P=0.001) and Dunn 72 vs. 58 (P<0.001)]. There were no significant differences with regards to lateral center edge angle, anterior center edge angle, or Tonnis angle. In both groups the most common locations for cartilage lesions in both groups were the anterior peripheral and superolateral peripheral regions with fewer but more widely distributed femoral head lesions. The SCFE group had higher rates of femoral head and superolateral central cartilage lesions compared with the FAI group. There was no statistical difference between high-grade femoral or acetabular cartilage lesions between groups. CONCLUSIONS: Patients with SCFE were younger at the time of surgery and presented with more severe deformity based on radiographic α-angle compared to patients with FAI. Our results suggest higher prevalence of femoral head lesions and more diffuse cartilage injury in patients with SCFE. This study can be used to support early surgical intervention in patients with symptomatic sequelae of SCFE due to risk of premature joint damage. LEVEL OF EVIDENCE: Level III-prognostic study.

Suspected Metal Allergy and Femoral Loosening After Total Knee Arthroplasty: A Diagnostic Dilemma.

Metal sensitivity is increasingly prevalent and is associated with negative outcomes after total knee arthroplasty (TKA). Currently, there is no consensus on diagnostic criteria for TKA failure from immune reaction. We present a patient who had pain and aseptic effusion 2 years after TKA. Radiographs were concerning femoral loosening. Lymphocyte transformation testing showed nickel sensitivity. During revision surgery, the femoral component was loose. The histologic aseptic lymphocyte-dominated vasculitis-associated lesion score was 4 with elevated CD4+ lymphocytes, consistent with sensitization. Nickel-free revision implants were used. One year after surgery, the patient is symptom-free. This case has features suggestive of an immune reaction, with femoral loosening, and is illustrative of the diagnostic dilemma. Using a hypoallergenic knee eliminates future concern for nickel sensitivity.

Biopsy Sampling in Upper Gastrointestinal Endoscopy: A Survey from 10 Tertiary Referral Centres Across Europe.

BACKGROUND: Guidelines give robust recommendations on which biopsies should be taken when there is endoscopic suggestion of gastric inflammation. Adherence to these guidelines often seems arbitrary. This study aimed to give an overview on current practice in tertiary referral centres across Europe. METHODS: Data were collected at 10 tertiary referral centres. Demographic data, the indication for each procedure, endoscopic findings, and the number and sampling site of biopsies were recorded. Findings were compared between centres, and factors influencing the decision to take biopsies were explored. RESULTS: Biopsies were taken in 56.6% of 9,425 procedures, with significant variation between centres (p < 0.001). Gastric biopsies were taken in 43.8% of all procedures. Sampling location varied with the procedure indication (p < 0.001) without consistent pattern across the centres. Fewer biopsies were taken in centres which routinely applied the updated Sydney classification for gastritis assessment (46.0%), compared to centres where this was done only upon request (75.3%, p < 0.001). This was the same for centres stratifying patients according to the OLGA system (51.8 vs. 73.0%, p < 0.001). More biopsies were taken in centres following the MAPS guidelines on stomach surveillance (68.1 vs. 37.1%, p < 0.001). Biopsy sampling was more likely in younger patients in 8 centres (p < 0.05), but this was not true for the whole cohort (p = 0.537). The percentage of procedures with biopsies correlated directly with additional costs charged in case of biopsies (r = 0.709, p = 0.022). CONCLUSION: Adherence to guideline recommendations for biopsy sampling at gastroscopy was inconsistent across the participating centres. Our data suggest that centre-specific policies are applied instead.

Lectins in Cervical Screening.

Cervical screening in low-resource settings remains an unmet need. Lectins are naturally occurring sugar-binding glycoproteins whose binding patterns change as cancer develops. Lectins discriminate between dysplasia and normal tissue in several precancerous conditions. We explored whether lectins could be developed for cervical screening via visual inspection. Discovery work comprised lectin histochemistry using a panel of candidate lectins on fixed-human cervix tissue (high-grade cervical intraepithelial neoplasia (CIN3, n = 20) or normal (n = 20)), followed by validation in a separate cohort (30 normal, 25 CIN1, 25 CIN3). Lectin binding was assessed visually according to staining intensity. To validate findings macroscopically, near-infra red fluorescence imaging was conducted on freshly-resected cervix (1 normal, 7 CIN3), incubated with topically applied fluorescently-labelled lectin. Fluorescence signal was compared for biopsies and whole specimens according to regions of interest, identified by the overlay of histopathology grids. Lectin histochemistry identified two lectins-wheat germ agglutinin (WGA) and Helix pomatia agglutinin (HPA)-with significantly decreased binding to CIN3 versus normal in both discovery and validation cohorts. Findings at the macroscopic level confirmed weaker WGA binding (lower signal intensity) in CIN3 vs. normal for biopsies (p = 0.0308) and within whole specimens (p = 0.0312). Our findings confirm proof-of-principle and indicate that WGA could potentially be developed further as a probe for high-grade cervical disease.

Blue Light Imaging and Linked Color Imaging for the Characterization of Mucosal Changes in Chronic Gastritis: A Clinicians View and Brief Technical Report.

BACKGROUND: Blue light imaging (BLI) and linked color imaging (LCI) are new imaging modalities for the endoscopic evaluation of mucosal changes within the digestive tract. There is little experience with these modalities in the characterization of chronic gastritis (CG) intestinal metaplasia (IM) and atrophy in the stomach. AIMS AND METHODS: In a single-center observational pilot study, we correlated endoscopic findings with histology in selected patients. RESULTS: Findings from 29 patients were included in the analysis. Six patients had macroscopically normal gastric mucosa at endoscopy, and this was confirmed histologically in 5 of them. At endoscopy, 15 patients had the presence of IM in the antrum predicted, and this was confirmed histologically in 11 (73%). In the corpus, we predicted the presence of IM in 14 patients, and this was confirmed in 11 (78%) at histology. Eleven patients had the endoscopic suspicion of atrophy in antrum, which was confirmed in 9 patients (82%). In total, 14 patients had endoscopic suspicion of atrophy in corpus mucosa at endoscopy, but only 10 were confirmed in histology (71%). The concordance of endoscopic classification and histology was 93% for antrum and 88% for corpus. The positive predictive value and negative predictive value for IM were 0.74 and 0.83 and for atrophy 0.63 and 0.97, respectively. CONCLUSIONS: LCI and BLI are helpful in characterization of mucosal changes in CG. The ability to rule out premalignant conditions by endoscopy only reflects the clinical use and harbors significant clinical implications.

The Rationale and Efficacy of Primary and Secondary Prevention in Adenocarcinomas of the Upper Gastrointestinal Tract.

While the primary risk factor for oesophageal adenocarcinoma (OAC) and its precursor lesion Barrett's oesophagus (BO) is gastro-oesophageal reflux, the infection with Helicobacter pylori (H. pylori) is the dominant risk factor for gastric cancer. Reduction of reflux by dietary measures and proton pump inhibitors has some merits in OAC prevention, and the chemopreventive effect of Aspirin and statins is being widely investigated; however, improved outcome in OAC occurs primarily as the result of secondary prevention. Early detection of neoplastic lesions in Barrett's metaplasia can be achieved by surveillance endoscopies. Novel endoscopic imaging modalities carry similar importance as the endoscopic treatment techniques as without detection of early lesions, therapy cannot be applied. Minimally invasive approaches are currently being investigated to identify patients with BO who are at particular risk of neoplastic progression. While dietary factors also play an important role in the prevention of gastric cancer and chemoprevention seems to be promising, the most beneficial effect has been shown for the eradication of H. pylori infection, which results in at least a one third reduction of gastric cancer risk. This effect can be further improved if the eradication takes place prior to the development of pre-neoplastic gastric conditions such as mucosal atrophy or intestinal metaplasia (IM). The definition of the "point of no return", after which eradication is less effective, is of high importance, although H. pylori eradication can still be beneficial even at more advance stages of mucosal changes. For this reason, patients with advanced atrophy and IM should undergo endoscopic surveillance in the same way as patients with BO. There is also need for development of non-invasive tests to identify patients at high risk of progression to gastric cancer to improve outcome of these surveillance approaches.

Lower Urinary Tract Symptoms and Urinary Bother Are Common in Patients Undergoing Elective Cervical Spine Surgery.

BACKGROUND: Lower urinary tract symptoms (LUTS) and urinary bother have been reported in adults undergoing surgery and have been associated with urinary tract infections, longer hospital stays, increased surgical costs, and decreased patient satisfaction. Previous reports indicate that up to one in two patients with lumbar spine pathology have moderate-to-severe LUTS, but little is known about LUTS in patients with cervical spine conditions. QUESTIONS/PURPOSES: (1) What is the prevalence of moderate-to-severe LUTS and clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (2) Does the presence of myelopathy affect frequency of moderate-to-severe LUTS or clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (3) Do MRI findings of spinal cord injury or compression correlate with presence and severity of LUTS? METHODS: We performed a cross-sectional study using clinical data collected from adult patients undergoing elective cervical spine surgery. Over an approximately 30-month period, we approached all patients who were evaluated in the preoperative clinic before undergoing elective cervical spine surgery. Of the 257 approached, 242 participated (94%). Study participants ranged in age from 34 to 83 years with a mean age of 58 years (SD 12). There were 108 males (45%) and 134 females (55%). A validated questionnaire, the International Prostate Symptom Score (IPSS), was used to identify LUTS. The IPSS score ranges from 0 to 35 points with LUTS presence defined as a score of ≥ 8 and LUTS severity categorized as mild (IPSS 0-7), moderate (IPSS 8-19), or severe (IPSS 20-35). Quality of life resulting from urinary bother is scored 0 to 6 with scores ≥ 4 considered clinically relevant urinary bother. Patients were grouped into a myelopathy group and a nonmyelopathy group based on diagnosis as assigned by the operating surgeon. MRIs were analyzed by one spine surgeon to identify the presence of cord signal, number of levels with cord compression (mm), and a calculated compression ratio score with cord compression and with compression ratio among patients with myelopathy. RESULTS: The prevalence of moderate LUTS in our patient sample was 40% (97 of 242; 95% confidence interval [CI], 34%-47%). The prevalence of severe LUTS in our patient sample was 8% (19 of 242; 95% CI, 5%-12%). Clinically relevant urinary bother was reported in 18% of patients (41 of 228; 95% CI, 13%-24%). After adjustment for age and sex, the odds of moderate-to-severe LUTS among patients with myelopathy was greater than that observed in patients without myelopathy (adjusted odds ratio, 2.0; p = 0.015). The prevalence of clinically relevant urinary bother was higher in patients with myelopathy (30% [26 of 88]) compared with those with no myelopathy (11% [15 of 140]; p < 0.001). With the numbers available, among patients with myelopathy, there was no difference in distribution of LUTS symptom severity or IPSS score according to cord signal presence (50% [23 of 46]) and absence (65% [31 of 48]; p = 0.153), number of levels with compression (70% [seven of 10 with four levels]; 59% [13 of 22 with three levels]; 51% [19 of 37] with two levels; and 60% [15 of 25] with one level; p = 0.730), millimeters of cord compression (r = 0.02; p = 0.854), or compression ratio (r = 0.09; p = 0.413). CONCLUSIONS: Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe LUTS. This is more than double the prevalence that has been reported in a community-dwelling adult population. These symptoms can impair quality of life, lead to surgical complications (urinary retention or incontinence), and may be mistaken for cauda equina, prompting potentially unnecessary imaging and studies. Given that urinary bother is reported less frequently than LUTS, patients may be less likely to seek care for urinary symptoms before undergoing surgery. Therefore, it is important to increase provider awareness of the high prevalence of LUTS. LEVEL OF EVIDENCE: Level III, prognostic study.

Developmental Dysplasia of the Hip.

Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH.

Hip Arthroscopy Complicated by a Deep Vein Thrombosis in a Patient with May-Thurner Syndrome: A Case Report.

CASE: A 20-year-old woman underwent hip arthroscopy with a labral repair, a femoral neck osteoplasty, and acetabular rim trimming. Six weeks after surgery, she presented with leg pain and edema, and was found to have an extensive deep vein thrombosis (DVT). Additional imaging studies revealed apparent extrinsic compression of the left common iliac vein, a vascular anatomic variant consistent with May-Thurner syndrome (MTS). CONCLUSION: Thromboembolic events in patients undergoing low-risk procedures should raise concern for additional risk factors, including MTS. Identifying this variant in patients is important to prevent future thrombotic complications.

Prevalence of Preoperative Lower Urinary Tract Symptoms in Patients Undergoing Elective Lumbar Spine Surgery.

STUDY DESIGN: Cross-sectional cohort study. OBJECTIVE: To determine the prevalence of moderate-to-severe lower urinary tract symptoms (LUTS) in patients undergoing elective lumbar spine surgery, and to describe associations between prevalence, severity of symptoms, demographic variables, and spine pathology. SUMMARY OF BACKGROUND DATA: The prevalence of LUTS is unknown in patients with lumbar spine disease. Furthermore, the extent of LUTS severity and the relationship between spine pathology and LUTS is not well documented. METHODS: We used the validated International Prostate Symptom Score (IPSS) to assess LUTS severity among elective lumbar spine surgery patients from October 2015 to April 2017 at a single academic institution. Moderate-to-severe LUTS was defined as IPSS score of 8 or more. The IPSS also includes a question to assess urinary bother, for which a score of 4 or more indicates clinically significant bother. Prevalence estimates and 95% confidence intervals were computed in the sample overall, and according to sex, age, and lumbar spine diagnosis. RESULTS: IPSS data were obtained from 373 patients (97% of those eligible) undergoing elective lumbar spine surgery. Moderate-to-severe urinary symptoms were reported by 46% of these patients, and by 51% of women and 42% of men. Prevalence of moderate-to-severe urinary symptoms increased with age, rising from 38% in patients younger than 40 years to 57% in patients 70 years or older. LUTS prevalence according to spondylolisthesis, stenosis, scoliosis, and herniated nucleus pulposus diagnostic groups were 51%, 50%, 50%, and 31%, respectively. Clinically significant urinary bother was reported by 14% overall, 10% of men, and 18% of women, and prevalence also increased with age. CONCLUSION: Moderate-to-severe LUTS were highly prevalent in this sample. Urinary symptoms are more prevalent with increasing age, in women, and in patients with stenosis, spondylolisthesis, and scoliosis. Proportionally, fewer patients reported clinically significant urinary bother, which may impact patient reporting and physician identification of urinary symptoms. LEVEL OF EVIDENCE: 3.

A scoring system to predict postoperative medical complications in high-risk patients undergoing elective thoracic and lumbar arthrodesis.

BACKGROUND CONTEXT: Various surgical factors affect the incidence of postoperative medical complications following elective spinal arthrodesis. Because of the inter-relatedness of these factors, it is difficult for clinicians to accurately risk-stratify individual patients. PURPOSE: Our goal was to develop a scoring system that predicts the rate of major medical complications in patients with significant preoperative medical comorbidities, as a function of the four perioperative parameters that are most closely associated with the invasiveness of the surgical intervention. STUDY DESIGN/SETTING: This study used level 2, Prognostic Retrospective Study. PATIENT SAMPLE: The patient sample consisted of 281 patients with American Society of Anesthesiologists (ASA) scores of 3-4 who underwent elective thoracic, lumbar, or thoracolumbar fusion surgeries from 2007 to 2011. OUTCOME MEASURES: Physiologic risk factors, number of levels fused, complications, operative time, intraoperative fluids, and estimate blood loss were the outcome measures of this study. METHODS: Risk factors were recorded, and patients who suffered major medical complications within the 30-day postoperative period were identified. We used chi-square tests to identify factors that affect the medical complication rate. These factors were ranked and scored by quartiles. The quartile scores were combined to form a single composite score. We determined the major medical complication rate for each composite score, and divided the cohort into quartiles again based on score. A Pearson linear regression analysis was used to compare the incidence of complications to the score. RESULTS: The number of fused levels, operative time, volume of intraoperative fluids, and estimated blood loss influenced the complication rate of patients with ASA scores of 3-4. The quartile ranking of each of the four predictive factors was added, and the sum became the composite score. This score predicted the complication rate in a linear fashion ranging from 7.6% for the lowest risk group to 34.7% for the highest group (r=0.998, p<.001). CONCLUSIONS: Taken together, the four factors, though not independent of one another, proved to be strongly predictive of the major medical complication rate. This score can be used to guide medical management of thoracic and lumbar spinal arthrodesis patients with preexisting medical comorbidities.

MMP2 and MMP7 at the invasive front of gastric cancer are not associated with mTOR expression.

BACKGROUND: Regulation of MMP expression by activation of mTOR signalling has been demonstrated for several tumor types, but has thus far not been confirmed in gastric cancer. FINDINGS: The study compromised 128 patients who underwent gastric resection for cancer (66.4 % male; 86 intestinal, 42 diffuse type). Immunohistochemical staining of MMPs was performed to analyse the topographical pattern of MMP expression at the tumor center and the invasive front, respectively. MMP2 showed higher expression at the invasive front compared to the tumor center, whereas MMP7 staining scores were higher in the tumor center, and there was no difference for MMP9. The expression of p-mTOR was higher in the tumor center than at the invasive front, with a similar trend for mTOR. For intestinal type gastric cancer there was a weak correlation of MMP9 with expression of mTOR in the tumor center. Otherwise, there was no correlation of the MMPs with mTOR. By treatment of MKN45 gastric cancer cells with rapamycin, a reduction of p-mTOR in the Western blot was achieved; however, expression of MMPs remained unaffected. CONCLUSIONS: Expression of MMP2 and MMP7 in gastric cancer is not associated with mTOR, MMP9 expression might be related to mTOR signalling in a subset of tumors.