A patient journey audit tool (PJAT) to assess quality indicators in a nuclear medicine service.

PURPOSE: To develop a nuclear medicine specific patient journey audit tool (PJAT) to survey and audit patient journeys in a nuclear medicine department such as staff interaction with patients, equipment, quality of imaging and laboratory procedures, patient protection, infection control and radiation safety, with a view to optimising patient care and providing a high-quality nuclear medicine service. METHODS: The PJAT was developed specifically for use in nuclear medicine practices. Thirty-two questions were formulated in the PJAT to test the department's compliance to the Australian National Safety and Quality Health Service Standards, namely clinical governance, partnering with consumers, preventing and controlling health care infection, medication safety, comprehensive care, communicating for safety, blood management and recognising and responding to acute deterioration. The PJAT was also designed to test our department's adherence to diagnostic reference levels (DRL). A total of 60 patient journey audits were completed for patients presenting for nuclear medicine, positron emission tomography and bone mineral density procedures during a consecutive 4-week period to audit the range of procedures performed. A further 120 audits were captured for common procedures in nuclear medicine and positron emission tomography during the same period. Thus, a total of 180 audits were completed. A subset of 12 patients who presented for blood labelling procedures were audited to solely assess the blood management standard. RESULTS: The audits demonstrated over 85% compliance for the Australian national health standards. One hundred percent compliance was noted for critical aspects such as correct patient identification for the correct procedure prior to radiopharmaceutical administration, adherence to prescribed dose limits and distribution of the report within 24 h of completion of the imaging procedure. CONCLUSION: This PJAT can be applied in nuclear medicine departments to enhance quality programmes and patient care. Austin Health has collaborated with the IAEA to formulate the IAEA PJAT, which is now available globally for nuclear medicine departments to survey patient journeys.

The 50 most influential publications in clavicle fractures.

PURPOSE: Clavicle fractures are among the most common orthopedic fractures, and treatment methods, operative versus nonoperative, have been a point of contention. The purpose of this study was to evaluate the 50 most influential articles regarding clavicle fractures to better understand past focuses of research and to identify any gaps in knowledge. METHODS: A review of the most cited articles related to clavicle fractures was conducted using Web of Science database. A search was conducted in April 2022 by one trained researcher. Two independent researchers evaluated each article based on relevance to clavicle fracture. RESULTS: The mean number of citations was 179.1, ranging from 576 to 81 citations, and collectively cited 8954 times. The decade from 2000 to 2009 contributed the greatest portion of articles, with only a small portion coming from before 1980. The Journal of Bone and Joint Surgery-American Volume contributed the greatest number of articles (20%). The majority of the articles were therapeutic (n = 37) and focused on treatment and outcome (n = 32). Most of the clinically focused articles had a level of evidence of IV (n = 26). CONCLUSION: There is an increased influence of recent articles focused on clavicle fracture and management, due to the idea that conventional nonoperative treatment has a high rate of nonunion. Many of the most influential studies evaluate the outcomes of various treatments. Many of these studies, however, are lower levels of evidence, leaving a paucity of high level of evidence articles to support these conclusions. LEVEL OF EVIDENCE: V.

Human Papillomavirus Vaccination Trends and Disparities in the United States: Who Is Getting Left Behind?

BACKGROUND: United States guidelines recommend human papillomavirus (HPV) vaccination for males and females up to 26, with more recent extended coverage for those 27 to 45 years based on discussion with patients' clinician. This study seeks to assess trends and disparities of vaccination in the United States based on demographic characteristics. METHODS: Data were obtained from the National Health and Nutrition Examination Survey between 2007 and 2016. χ2 Analyses were used for statistical methods. RESULTS: Of 12,844 participants (median age, 22 years; range, 9-36 years), 2711 (21.3%) initiated HPV vaccination, of which 1358 (56.3%) completed the 3-dose vaccination series. Vaccination rates were higher in females compared with males (24.6% vs 13.0%; P < 0.001) and in Whites compared to Mexican Americans (22.6% vs 19.4%; P = 0.02). The uninsured had lower vaccination rates than private insurance and Medicaid (12.5% vs 22.4% vs 28.5%; P < 0.001). We divided the 10 year study into five separate periods (2007-2008, 2009-2010, 2011-2012, 2013-2014, and 2015-2016) to analyze trends. Vaccine initiation increased from 19.6% to 49.6% for 14-19-year olds (P < 0.001), 10.4% to 35.5% for females (P < 0.001), and 8.5% to 32.9% for Blacks (P < 0.001). Although on trend analyses, the vaccination rates with the highest proportional increase were found in those: older than 25 to 29 years (4.56-fold), Mexican Americans (4.56 fold), below high school education (2.32 fold), and low income group (2.90 fold) over time. CONCLUSIONS: The HPV vaccination rates in Mexican Americans increased nearly 5-fold over the last 10 years. However, their vaccination rates continue to lag behind Whites and Blacks.

Racial disparities in high-risk uterine cancer histologic subtypes: A United States Cancer Statistics study.

OBJECTIVE: Black women with uterine cancer on average have worse survival outcomes compared to White women, in part due to higher rates of aggressive, non-endometrioid subtypes. However, analyses of incidence trends by specific high-risk subtypes are lacking, including those with hysterectomy and active pregnancy correction. The objective of our study was to evaluate racial disparities in age-adjusted incidence of non-endometrioid uterine cancer in 720,984 patients. METHODS: Data were obtained from United States Cancer Statistics using SEER*Stat. We used the Behavioral Risk Factor Surveillance System to correct for hysterectomy and active pregnancy. Age-adjusted, corrected incidence of uterine cancer from 2001 to 2016 and annual percent change (APC) were calculated using Joinpoint regression. RESULTS: Of 720,984 patients, 560,131 (77.7%) were White, 72,328 (10.0%) were Black, 56,239 (7.8%) were Hispanic, and 22,963 (3.2%) were Asian/Pacific Islander. Age-adjusted incidence of uterine cancer increased from 40.8 (per 100,000) in 2001 to 42.9 in 2016 (APC = 0.5, p < 0.001). Black women had the highest overall incidence at 49.5 (APC = 2.3, p < 0.001). The incidence of non-endometrioid subtypes was higher in Black compared to White women, with the most pronounced differences seen in serous carcinoma (9.1 vs. 3.0), carcinosarcoma (6.1 vs. 1.8), and leiomyosarcoma (1.3 vs. 0.6). In particular, Black women aged 70-74 with serous carcinoma had the highest incidence (61.3) and the highest APC (7.3, p < 0.001). CONCLUSIONS: Black women have a two to four-fold higher incidence of high-risk uterine cancer subtypes, particularly serous carcinoma, carcinosarcoma, and leiomyosarcoma, compared to White women after correcting for hysterectomy and active pregnancy.

The Prevalence of Intimate Partner Violence and Association With Depression in University Students: Results of a Cross-Sectional Study.

The purpose of this cross-sectional study was to determine the prevalence of intimate partner violence (IPV) among university students, investigate the potential predictors of IPV in this population, and study the link between IPV and depression. The survey included sociodemographic, relationship quality, and depression-related questions. From 498 respondents, the prevalence of IPV was 4.8%, depression was 30.9%, and suicidal ideation was 20.3%. After adjusting for covariates and confounders, relationship satisfaction (odds ratio [OR], 0.201; 95% confidence interval [CI], 0.101-0.401; p < 0.001) and jealousy (OR, 0.270; 95% CI, 0.094-0.776; p = 0.015) were significant predictors of IPV. Relationship satisfaction predicted depressive disorders (OR, 0.504; 95% CI, 0.365-0.698; p < 0.001). IPV trended toward predicting the presence of a depressive disorder (OR, 0.436; 95% CI, 0.170-1.113; p = 0.083). Relationship satisfaction and jealousy predicted IPV. Although IPV did not predict depression, poor relationship satisfaction increased the odds of depression, implicating the influence of relationship satisfaction on both IPV and depression.

A novel quality assurance procedure for trajectory log validation using phantom-less real-time latency corrected EPID images.

The use of trajectory log files for routine patient quality assurance is gaining acceptance. Such use requires the validation of the trajectory log itself. However, the accurate localization of a multileaf collimator (MLC) leaf while it is in motion remains a challenging task. We propose an efficient phantom-less technique using the EPID to verify the dynamic MLC positions with high accuracy. Measurements were made on four Varian TrueBeams equipped with M120 MLCs. Two machines were equipped with the S1000 EPID; two were equipped with the S1200 EPID. All EPIDs were geometrically corrected prior to measurements. Dosimetry mode EPID measurements were captured by a frame grabber card directly linked to the linac. All leaf position measurements were corrected both temporally and geometrically. The readout latency of each panel, as a function of pixel row, was determined using a 40 × 1.0 cm2 sliding window (SW) field moving at 2.5 cm/s orthogonal to the row readout direction. The latency of each panel type was determined by averaging the results of two panels of the same type. Geometric correction was achieved by computing leaf positions with respect to the projected isocenter position as a function of gantry angle. This was determined by averaging the central axis position of fields at two collimator positions of 90° and 270°. The radiological to physical leaf end position was determined by comparison of the measured gap with that determined using a feeler gauge. The radiological to physical leaf position difference was found to be 0.1 mm. With geometric and latency correction, the proposed method was found to be improve the ability to detect dynamic MLC positions from 1.0 to 0.2 mm for all leaves. Latency and panel residual geometric error correction improve EPID-based MLC position measurement. These improvements provide for the first time a trajectory log QA procedure.

Predictors and Outcomes of Paramedian Incisional Hernia After Anterior Spine Exposure.

BACKGROUND: Anterior exposures for lumbar spine surgery are increasingly common for treating various spinal pathologies. A retroperitoneal approach via a paramedian incision has grown rapidly in popularity, but little is known about the risk of incisional hernia development with this technique. We sought to assess the incidence of paramedian incisional hernia development and identify risk factors that are associated with occurrence. MATERIALS AND METHODS: We conducted a retrospective review of all patients who underwent anterior lumbar spine exposure by a paramedian approach between 2012 and 2017 at a single, tertiary medical center. The primary outcome was the development of postoperative paramedian incisional hernia. RESULTS: Of the 735 patients included in the study, 445 (60.5%) were women, and the mean (standard deviation) age of all patients was 60 y (12.4). Nearly all (97.4%) paramedian approaches were performed with a vascular surgeon present. Median follow-up time was 10 mo (interquartile range 3.5-19.9). Postoperative paramedian hernia developed in 20 patients (2.7%), of which 14 underwent repair. The mean (standard deviation) size of the hernia was 13.5 cm (5.5); 9 of 14 (64%) were repaired with synthetic mesh, whereas 3 of 14 (21%) required bowel resection. On multivariate analysis, risk factors associated with hernia development were male gender (0.045), higher American Society of Anesthesiologists class (0.039), history of abdominal surgery (P = 0.013), and postoperative intensive care unit admission (P = 0.02). CONCLUSIONS: A paramedian approach for anterior lumbar spine exposure resulted in a low rate of incisional hernia with minimal morbidity. Surgeons involved in these collaborative procedures should consider the risk factors that predispose patients to develop these hernias.

Depression Severity and Depression Stigma Among Students: A Survey of Universities in Five Countries.

In the university setting, mental disorders have come under greater scrutiny and more attention has been given toward addressing the social stigmas associated with mental illness in an effort to promote mental well-being and improve mental health care delivery on-campus. Depression has been previously linked to a reduction in quality of life, suicidal ideation, and poor academic performance. However, few studies have directly compared the burden of depression or stigmatized views between multiple universities. As a result, this cross-sectional study of university students from five countries was performed to determine the burden of depressive disorders, the stigmatizations of beliefs related to depression, and international variation. A questionnaire consisting of a sociodemographic survey, Patient Health Questionnaire-9 (PHQ-9), and Depression Stigma Scale (DSS) was distributed via multiple routes to undergraduate and graduate students at institutions in the United States, Taiwan, United Arab Emirates, Egypt, and Czech Republic. The point prevalence of depression was determined by using the algorithm scoring method of the PHQ-9. Depression severity was determined according to the summed-item scoring method of the PHQ-9. The degree of stigmatization of beliefs was determined by continuous scores on the DSS subscales for personal and perceived stigma. Differences in depression severity, personal stigma, and perceived stigma were determined according to analysis of variance and further studied using post hoc Tukey's tests. Responses were collected from students in the United States (n = 593), United Arab Emirates (n = 134), Taiwan (n = 217), Egypt (n = 105), and Czech Republic (n = 238). Of 1287 responses, 30.7% (n = 396) screened positive for a depressive disorder: 18.0% (n = 232) for major depressive disorder and 12.7% (n = 164) for another depressive disorder. Depression severity differed internationally (p < 0.001). Emirati students significantly exhibited most depression followed by Czech, American, and Taiwanese students (all ps < 0.001). There was also a difference between students of different countries in terms of personal stigma (p < 0.001), with Emirati students holding more stigmatized personal views than Czech, American, Egyptian, and Taiwanese students (all ps < 0.001). Students similarly demonstrated differences in terms of personal stigma (p < 0.001). Egyptian students exhibited the most perceived stigma followed by Emirati, Taiwanese, American, and Czech students (all ps < 0.001). These findings suggest a high point prevalence of depression among university students and differences in the severity of depression, which has implications for the delivery of mental health care in this population. There were significant differences in terms of personal and perceived stigma between university students, indicating resource allocation for university-based campaigns to reduce depression stigma may need to be tailored to the population. After implementation of stigma reduction programs, future follow-up surveys can be done to compare degrees of stigma before and after the intervention.

Patients With Chronic Obstructive Pulmonary Disease Are at Higher Risk for Pneumonia, Septic Shock, and Blood Transfusions After Total Shoulder Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been associated with several complications after surgery, including pneumonia, myocardial infarction, septic shock, and mortality. To the authors' knowledge, there has been no work analyzing the impact of COPD on complications after total shoulder arthroplasty (TSA). Although previous work has elucidated the complications COPD has on TKA and THA, extrapolating the results of lower extremity arthroplasty to TSA may prove to be inaccurate. Compared with lower extremity arthroplasty, TSA is a relatively new procedure that has only recently gained popularity. Therefore, this study seeks to elucidate COPD's effects on complications in TSA specifically so that postoperative care can be tailored for these patient populations. Assessing these patients may enable surgeons to implement preoperative precautionary measures to prevent serious adverse events in these patients. QUESTIONS/PURPOSES: What serious postoperative complications are patients with COPD at risk for within the 30-day postoperative period after TSA? METHODS: The American College of Surgeons National Surgical Quality Improvement Program® (ACS-NSQIP) database was queried to identify 14,494 patients who had undergone TSA between 2005 and 2016, excluding patients who had undergone hemiarthroplasties of the shoulder and revision shoulder arthroplasties. The ACS-NSQIP database was utilized in this study for the comprehensive preoperative and postoperative medical histories it provides for each patient for 274 characteristics. Among the 14,494 patients undergoing TSA, 931 (6%) patients who had a history of COPD were identified, and the two cohorts-COPD and non-COPD-were analyzed for differences in their demographic factors, comorbidities, and acute complications occurring within 30 days of their procedure. Univariate analyses were utilized to assess differences in the prevalence of demographic features, comorbidities, and perioperative/postoperative outcomes after surgery. Multivariate regression analyses were used to assess COPD as an independent risk factor associated with complications. RESULTS: COPD is an independent risk factor for three complications after TSA: pneumonia (odds ratio [OR], 2.793; 95% confidence interval [CI], 1.426-5.471; p = 0.003), bleeding resulting in transfusion (OR, 1.577; 95% CI, 1.155-2.154; p = 0.004), and septic shock (OR, 9.259; 95% CI, 2.140-40.057; p = 0.003). CONCLUSIONS: In light of the increased risk of these serious complications, surgeons should have a lower threshold of suspicion for infection in patients with COPD after TSA so that adequate measures can be taken before developing severe infectious complications including pneumonia and septic shock. Surgeons may also consider administering tranexamic acid in patients with COPD undergoing TSA to reduce the amount of blood transfusions necessary. Future work through randomized control trials analyzing (1) the effectiveness of more aggressive infection prophylaxis in decreasing the risk of pneumonia/septic shock; and (2) the use of tranexamic acid in decreasing blood transfusion requirements in patients with COPD undergoing TSA is warranted. LEVEL OF EVIDENCE: Level III, therapeutic study.

Surgical complications associated with congestive heart failure in elderly patients following primary hip hemiarthroplasty for femoral neck fractures.

INTRODUCTION: Although there are reports of the impact of congestive heart failure (CHF) on total knee arthroplasty and total hip arthroplasty, there is a lack of literature analyzing CHF in hip hemiarthroplasty (HHA) procedures. The main objective of this study was to evaluate the effect of CHF on risks for complications following HHA for the treatment of FNF. METHODS: The ACS-NSQIP database was queried for all patients who had undergone HHA from 2005 to 2016. Patients were propensity-matched without replacement in a 1:1 manner based on age and gender. Pearson's Chi squared tests and Fischer's exact tests were utilized to compare differences in demographics, comorbidities, and complication rates. Multivariate logistic regression analyses were used to assess the impact of CHF as an independent risk factor for postoperative complications. RESULTS: A propensity-matched cohort of 537 (4.24%) non-CHF patients was generated in order to analyze differences between the two cohorts. CHF was found to be a significant independent risk factor for pneumonia (p = 0.003), progressive renal insufficiency (p = 0.040), myocardial infarctions (p = 0.050), extended length of stay (≥ 5 days) (p < 0.001), and mortality (p < 0.001). CONCLUSION: This study has established CHF as an independent risk factor for various postoperative complications following HHA for the treatment of FNF. Although orthopedic surgeons may decline to perform elective procedures on CHF patients, FNFs require urgent surgical intervention. Therefore, it is important to be aware of various increased risks of certain complications in this subset patient population.

The practice of mediation to resolve clinical, bioethical, and medical malpractice disputes.

Mediation is a voluntary process whereby a neutral and impartial third party-t-he mediator--is present to facilitate communication and negotiation between the disputing parties so that amicable settlements can be agreed. Being confidential and non-adversarial in nature, the mediation process and skills are particularly applicable in clinical practice to facilitate challenging communications following adverse events, to assist bioethical decision making and to resolve disputes. Mediation is also a more effective and efficient means of dispute resolution in medical malpractice claims when compared with civil litigation. Health care mediation teams should be set up at individual facilities to provide education and consultation services to frontline staff and patients. At a community level, the Government, the mediation community, and the health care professionals should join forces to promote mediation as a means to settle medical malpractice claims outside of the courtroom.

Radiomodulating Properties of Superparamagnetic Iron Oxide Nanoparticle (SPION) Agent Ferumoxytol on Human Monocytes: Implications for MRI-Guided Liver Radiotherapy.

Superparamagnetic iron oxide nanoparticles (SPION) have attracted great attention not only for therapeutic applications but also as an alternative magnetic resonance imaging (MRI) contrast agent that helps visualize liver tumors during MRI-guided stereotactic body radiotherapy (SBRT). SPION can provide functional imaging of liver parenchyma based upon its uptake by the hepatic resident macrophages or Kupffer cells with a relative enhancement of malignant tumors that lack Kupffer cells. However, the radiomodulating properties of SPION on liver macrophages are not known. Utilizing human monocytic THP-1 undifferentiated and differentiated cells, we characterized the effect of ferumoxytol (Feraheme®), a carbohydrate-coated ultrasmall SPION agent at clinically relevant concentration and therapeutically relevant doses of gamma radiation on cultured cells in vitro. We showed that ferumoxytol affected both monocytes and macrophages, increased the resistance of monocytes to radiation-induced cell death and inhibition of cell activity, and supported the anti-inflammatory phenotype of human macrophages under radiation. Its effect on human cells depended on the duration of SPION uptake and was radiation dose-dependent. The results of this pilot study support a strong mechanism-based optimization of SPION-enhanced MRI-guided liver SBRT for primary and metastatic liver tumors, especially in patients with liver cirrhosis awaiting a liver transplant.

Traumatic Irreducible Pediatric Radial Head Dislocations: A Unique Case and Review of the Literature.

Background: Irreducible radial head dislocations are uncommon injuries and blocks to reduction typically result from interposed soft tissue. We report the case of a pediatric patient who sustained an irreducible radial head dislocation with a concomitant posterior elbow dislocation and coronoid process fracture. To the author's knowledge, irreducible radial head dislocations presenting as part of a terrible triad like constellation of injuries have not been previously reported. A case-based review of the literature was also performed. Case Description: A 7-year-old male presents to our pediatric hospital as a transfer from an outside hospital after sustaining a posterolateral radial head and posterior elbow dislocation secondary to a fall. CT imaging and 3D reconstruction revealed a Type 1 coronoid process fracture. At our institution, closed attempts at reduction in the operating room under fluoroscopy with general anesthesia were also unsuccessful. Open reduction of the radial head and repair of the soft tissue structures was ultimately required to stabilize the patient's elbow injury. Conclusion: Irreducible pediatric radial head dislocations are rare and inherently unstable injuries. To the authors' knowledge, there are no prior reports of irreducible radial head dislocations that present in a terrible triad like fashion with a coronoid process fracture and posterior elbow dislocation. In the present report, successful treatment of this injury required open reduction and soft tissue repair. Level of Evidence: IV.

YouTube as an Information Source for Lumbar Disc Herniations: A Systematic Review.

OBJECTIVE: The Internet is a source of health information for patients. Quality of information available to patients is varied and uncontrolled. Physicians should be familiar with the overall quality of the information. This review provides an evaluation of YouTube's current patient accessible health information on the topic of lumbar disc herniation (LDH). METHODS: YouTube was queried using 3 different search strings: (1) "disc herniation", (2) "lumbar disc herniation", or (3) "lower back disc herniation". Video duplicates, non-English, or those that contained no audio or were not relevant to LDH were excluded. The first 50 videos per search string were evaluated. Two reviewers independently assessed videos. Parameters included duration, upload date, number of views, number of likes, views per day, and likes per day. A scoring system was used to grade the videos for their performance on diagnosis and treatment of LDH. RESULTS: The first 50 videos produced a total number of hits of 50,500, 29,100, and 22,100, respectively. Strong agreement, assessed using intraclass correlation coefficient (ICC), was demonstrated between readers for both diagnostic scores (ICC 0.921, 95% CI 0.866-0.953) and treatment scores (ICC 0.916, 95% CI 0.855-0.951). Educational Physician videos had significantly greater diagnostic and treatment scores compared to non-physician videos (9.54 vs. 7.05, P = 0.048, and 6.53 vs. 5.3, P = 0.004). CONCLUSIONS: YouTube videos pertaining to LDH were found to have low overall quality. Physicians should be cognizant about information sources readily available to patients as they may influence patient expectations and preconceptions.

Clinical Outcomes of Bariatric Surgery Before Spinal Fusion: A Systematic Review.

INTRODUCTION: Morbidly obese patients are at increased risk for intraoperative and postoperative complications following spinal fusion. Preoperative weight loss can improve clinical outcomes. The present systematic literature review is aimed to evaluate the hypothesis that bariatric surgery before spinal fusion surgery is associated with higher rates of complications and revisions. METHODS: Three databases were queried for literature pertaining to bariatric surgery prior to spinal fusion. A 2-author screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Methodologic index for non-randomized studies criteria was used to objectively assess the methodologic quality of the studies reviewed. Retrospective cohort studies in which the patients underwent bariatric surgery were included. RESULTS: Four retrospective cohort studies consisting of a total of 180,090 patients were included. Length of stay was significantly shorter for the bariatric surgery (BS) group patients than the control (C) groups patients (P = 0.009). There were no significant differences in 1-year mortality rate (P = 1.0), readmission rate (P = 0.86), overall postoperative complications (P = 0.83), and postoperative infections (P = 0.97) between the BS and C groups. CONCLUSIONS: There were no consistent differences in rates of postoperative complications, infections, hospital readmission, and mortality between obese patients with bariatric surgery prior to spinal fusion and control group patients. The present study does not support the hypothesis that bariatric surgery before spinal fusion contributes to a higher rate of postoperative complications in patients undergoing spinal fusion.

Risk Factors for Surgical Site Infections After Single-Level Anterior Lumbar Interbody Fusion.

Abstract Background: Anterior lumbar interbody fusion (ALIF) has become an increasingly popular and effective treatment modality for various conditions of the lumbar spine. However, complications after this procedure can be costly. Surgical site infections (SSIs) are one of these types of complications. The present study identifies independent risk factors for SSI after single-level ALIF to identify high-risk patients better. Patients and Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify single-level ALIF patients from 2005 to 2016. Multilevel fusions and non-anterior approach procedures were excluded. Mann-Pearson χ2 tests analyzed categorical variables, whereas one-way analysis of variance (ANOVA) and independent t-tests analyzed differences in mean values of continuous variables. Risk factors for SSI were identified via a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated utilizing the predicted probabilities. Results: A total of 10,017 patients met inclusion criteria; 80 (0.80%) had developed SSI and 9,937 (99.20%) had not. On multivariable logistic regression models, class 3 obesity (p = 0.014), dialysis (p = 0.025), long-term steroid use (p = 0.010), and wound classification 4 (dirty/infected) (p = 0.002) all independently increased the risk for SSI in single-level ALIF. The area under the receiver operating characteristic curve (AUROC; C-statistic) was 0.728 (p < 0.001), indicating relatively strong reliability of the final model. Conclusions: Several independent risk factors including obesity, dialysis, long-term steroid use, and dirty wound classification all increased risk for SSI after single-level ALIF. By identifying these high-risk patients, surgeons and patients can have more informed pre-operative discussions. In addition, identifying and optimizing these patients prior to operative intervention may help to minimize infection risk.

Hip hemiarthroplasty for the treatment of femoral neck fractures in dialysis patients.

OBJECTIVES: This study sought to delineate the postoperative outcomes in dialysis patients undergoing hip hemiarthroplasty (HHA) for the treatment of femoral neck fractures (FNF) in order to better optimise pre- and postoperative management and minimise short-term morbidity and mortality rates. METHODS: 16,955 patients who had undergone HHA for femoral neck fractures from 2005 to 2018 were isolated from a multi-institutional surgical registry, of which 343 (2.0%) were on dialysis and 16,612 (98.0%) were not. The cohorts were identified/analysed for differences in their comorbidities, demographic factors, and 30-day postoperative complications using Fischer's exact tests and Mann-Whitney U-tests. Coarsened exact matching (CEM) was implemented in order to control for baseline difference in demographics and comorbidities. Multivariate logistic regression analyses were used to assess the impact of dialysis as an independent risk factor for various complications, including reoperations, readmissions, and mortality. RESULTS: Upon CEM-matching (L1-statistic <0.001), weighted multivariate logistic regression analyses demonstrated dialysis to be an independent risk factor for minor complications (OR 3.051, p < 0.001), pneumonia (OR 3.943, p < 0.001), urinary tract infections (UTIs) (OR 2.684, p < 0.001), major complications (OR 1.892, p < 0.001), unplanned intubation (OR 2.555, p = 0.047), cardiac arrest (OR 11.897, p < 0.001), deep vein thrombosis (DVT), (OR 2.610, p = 0.049), and mortality (OR 2.960, p < 0.001). CONCLUSIONS: Dialysis independently increased the risk for unplanned intubation, cardiac arrest, blood transfusions, pneumonia, DVT, and mortality. In communicating postoperative expectations, surgeons should aim to clarify the patients' preferences and potential resuscitation designations prior to surgical intervention due to the increased risk of serious complications. A lower threshold of suspicion for DVT in this population is reasonable. Identifying high-risk patient populations that may experience increased rates of complications, with the ensuing financial expenditures, due to medical complexity rather than subpar management may help providers avoid penalties in caring for these patients.

Risk Factors for Blood Transfusions in Elective Single-Level Anterior Lumbar Interbody Fusion for Degenerative Conditions.

Background: ALIF (anterior lumbar interbody fusion) and other spinal fusion surgeries are among the most common orthopaedic procedures requiring blood transfusions. However, blood transfusions have been associated with various complications, including adverse reactions and infections. The present study aims to identify independent risk factors for blood transfusions in patients undergoing single-level ALIF specifically to better identify high risk patients and optimize perioperative management. Methods: All patients who had undergone single-level ALIF patients for the treatment of degenerative spinal conditions, excluding traumatic, pathologic, and infectious etiologies, were identified by querying a multi-institutional surgical registry from 2005 to 2018. Multi-level fusions, PLIF/TLIF, and posterior procedures were also excluded. Mann-Whitney-U-Tests were used to analyze continuous variables, while Fisher's-Exact-Tests/Bonferroni-Corrected-Tests were used for categorical variables. Multivariate logistic regression analysis with alternating backward stepwise elimination and forward entry was implemented to identify significant predictors for blood transfusions within 72 hours after incision. The predicted probabilities were used in post-regression diagnostics to generate a Receiver Operating Characteristic (ROC) curve to assess model performance. Results: 4,792 single-level ALIF patients met inclusion criteria - 183 (3.82%) had received blood transfusions within 72 hours after incision and 4,609 (96.18%) had not. Age ≥60 years (OR 1.954, p<0.001), preoperative transfusions (OR 33.758, p=0.023), extended operative times (≥197.0 minutes; 75th percentile) (OR 4.645, p<0.001), ASA≥3 (OR 1.395, p<0.001) and preoperative hematocrit levels (Hct) 30.00-37.99 (OR 1.562, p=0.016) and Hct <30.00 (OR 6.334, p<0.001) were shown to be significant independent risk factors for perioperative blood transfusions. The area under the ROC curve (AUROC; C-statistic) was 0.759 (p<0.001), indicating relatively strong discriminatory ability/predictability of the final model. Conclusion: Several independent risk factors including age ≥60 years, preoperative blood transfusions and extended operative times increased risk for blood transfusion following single-level ALIF. The present study aims to help surgeons identify high-risk patients to better communicate postoperative expectations and optimize patients to reduce the risk of transfusions and secondary complications. Level of Evidence: III.

Online Adaptive MRI-Guided Stereotactic Body Radiotherapy for Pancreatic and Other Intra-Abdominal Cancers.

A 1.5T MRI combined with a linear accelerator (Unity®, Elekta; Stockholm, Sweden) is a device that shows promise in MRI-guided stereotactic body radiation treatment (SBRT). Previous studies utilized the manufacturer's pre-set MRI sequences (i.e., T2 Weighted (T2W)), which limited the visualization of pancreatic and intra-abdominal tumors and organs at risk (OAR). Here, a T1 Weighted (T1W) sequence was utilized to improve the visualization of tumors and OAR for online adapted-to-position (ATP) and adapted-to-shape (ATS) during MRI-guided SBRT. Twenty-six patients, 19 with pancreatic and 7 with intra-abdominal cancers, underwent CT and MRI simulations for SBRT planning before being treated with multi-fractionated MRI-guided SBRT. The boundary of tumors and OAR was more clearly seen on T1W image sets, resulting in fast and accurate contouring during online ATP/ATS planning. Plan quality in 26 patients was dependent on OAR proximity to the target tumor and achieved 96 ± 5% and 92 ± 9% in gross tumor volume D90% and planning target volume D90%. We utilized T1W imaging (about 120 s) to shorten imaging time by 67% compared to T2W imaging (about 360 s) and improve tumor visualization, minimizing target/OAR delineation uncertainty and the treatment margin for sparing OAR. The average time-consumption of MRI-guided SBRT for the first 21 patients was 55 ± 15 min for ATP and 79 ± 20 min for ATS.

A target definition based on electroanatomic maps for stereotactic arrhythmia radioablation.

PURPOSE: Identifying the target region is critical for successfully treating ventricular tachycardia (VT) with single fraction stereotactic arrhythmia radioablation (STAR). We report the feasibility of target definition based on direct co-registration of electroanatomic maps (EAM) and radioablation planning images. MATERIALS AND METHODS: The EAM consists of 3D cardiac anatomy representation with electrical activity at endocardium and is acquired by a cardiac electrophysiologist (CEP) during electrophysiology study. The CEP generates an EAM using a 3D cardiac mapping system anticipating radioablation planning. Our in-house software read these non-DICOM EAMs, registered them to a planning image set, and converted them to DICOM structure files. The EAM based target volume was finalized based on a consensus of CEPs, radiation oncologists and medical physicists, then expanded to ITV and PTV. The simulation, planning, and treatment is performed with a standard STAR technique: a single fraction of 25 Gy using volumetric-modulated arc therapy or dynamic conformal arc therapy depending on the target shape. RESULTS: Seven patients with refractory VT were treated by defining the target based on registering EAMs on the planning images. Dice similarity indices between reference map and reference contours after registration were 0.814 ± 0.053 and 0.575 ± 0.199 for LV and LA/RV, respectively. CONCLUSIONS: The quality of the transferred EAMs on the MR/CT images was sufficient to localize the treatment region. Five of 7 patients demonstrated a dramatic reduction in VT events after 6 weeks. Longer follow-up is required to determine the true safety and efficacy of this therapy using EAM-based direct registration method.