Perioperative Nutritional Supplementation Decreases Wound Healing Complications Following Elective Lumbar Spine Surgery: A Randomized Controlled Trial.

BACKGROUND: The prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50% and is associated with higher rates of surgical site infections, medical complications, longer lengths of stay, and mortality. PURPOSE: To determine if perioperative nutritional intervention decreases wound healing complications in patients undergoing lumbar spine surgery. STUDY DESIGN/SETTING: A prospective randomized controlled trial. MATERIALS AND METHODS: Patients aged 55+ undergoing elective primary lumbar surgery were included. Patients with a preoperative albumin<3.5 g/dL were defined as malnourished. Intervention group received nutritional supplementation (protein shake) twice daily from postoperative day 0 to two weeks postdischarge. Control group was instructed to continue regular daily diets. Primary outcomes included minor in-hospital complications (wound drainage, electrolyte abnormalities, hypotension, ileus, deep venous thrombus) and wound healing complications within 90 days. Secondary outcomes included 90-day emergency room visits, readmissions, and return to the operating room. Baseline data were compared between groups using means comparison tests. Multivariable analysis evaluated association of outcomes with nutritional supplementation. Subanalysis of malnourished patients assessed effects of nutritional supplementation on outcomes. RESULTS: One hundred three patients were included. Thirty-seven (35.9%) were considered malnourished preoperatively. Forty-six (44.7%) received nutritional intervention and 57 (55.3%) served as controls. Adjusted analysis found patients receiving supplementation had lower rates of in-hospital minor complications (2.1% vs. 23.2%, P <0.01), and perioperative wound healing complications (3.4% vs. 17.9%, P <0.05). Subgroup analysis of 37 malnourished patients demonstrated that malnourished patients who received perioperative nutritional supplementation had lower rates of minor complications during admission (0.0% vs. 34.4%, P =0.01) and return to the operating room within 90 days (0.0% vs. 12.4%, P =0.04). CONCLUSIONS: Over one third of patients undergoing lumbar surgery were malnourished. Nutritional supplementation during the two-week perioperative period decreased rates of minor complications during admission and wound complications within 90 days. Malnourished patients receiving supplementation less often returned to the operating room. To our knowledge, this is the first study to investigate the effects of perioperative nutritional intervention on wound healing complications for patients undergoing elective lumbar spine surgery. LEVEL OF EVIDENCE: I.

Clinical and Quality of Life Benefits for End-Stage Workers' Compensation Chronic Pain Claimants following H-Wave® Device Stimulation: A Retrospective Observational Study with Mean 2-Year Follow-Up.

Previously promising short-term H-Wave® device stimulation (HWDS) outcomes prompted this retrospective cohort study of the longer-term effects on legacy workers' compensation chronic pain claimants. A detailed chart-review of 157 consecutive claimants undergoing a 30-day HWDS trial (single pain management practice) from February 2018 to November 2019 compiled data on pain, restoration of function, quality of life (QoL), and polypharmacy reduction into a summary spreadsheet for an independent statistical analysis. Non-beneficial trials in 64 (40.8%) ended HWDS use, while 19 (12.1%) trial success charts lacked adequate data for assessing critical outcomes. Of the 74 final treatment study group charts, missing data points were removed for a statistical analysis. Pain chronicity was 7.8 years with 21.6 ± 12.2 months mean follow-up. Mean pain reduction was 35%, with 89% reporting functional improvement. Opioid consumption decreased in 48.8% of users and 41.5% completely stopped; polypharmacy decreased in 36.8% and 24.4% stopped. Zero adverse events were reported and those who still worked usually continued working. An overall positive experience occurred in 66.2% (p < 0.0001), while longer chronicity portended the risk of trial or treatment failure. Positive outcomes in reducing pain, opioid/polypharmacy, and anxiety/depression, while improving function/QoL, occurred in these challenging chronic pain injury claimants. Level of evidence: III.

Job-Related Performance and Quality of Life Benefits in First Responders Given Access to H-Wave® Device Stimulation: A Retrospective Cohort Study.

Current chronic pain treatments primarily target symptoms and are often associated with harmful side-effects and complications, while safer non-invasive electrotherapies like H-Wave® device stimulation (HWDS) have been less explored. The goal of this study is to evaluate first responder-reported effects of HWDS on job-related and quality-of-life measures. This is a retrospective cohort study where first responders were surveyed following voluntary use of HWDS regarding participant experience, frequency of use, job-related performance, and quality-of-life. Responses were analyzed using means comparison tests, while bivariate analysis assessed responses associated with HWDS usage. Overall, 92.9% of first responder HWDS users (26/28) reported a positive experience (p < 0.0001), with 82.1% citing pain reduction (p = 0.0013), while 78.6% indicated it would be beneficial to have future device access (p = 0.0046). Participants using H-Wave® were at least six times more likely to report higher rates of benefit (100% vs. 0%, p = 0.022), including pain reduction (91.3% vs. 8.7%, p = 0.021) and improved range-of-motion (93.3% vs. 69.2%, p = 0.044). Spending more time with family was associated with better job performance following frequent HWDS use (50% vs. 8.3%, p = 0.032). Repetitive first responder H-Wave® use, with minimal side effects and easy utilization, resulted in significant pain reduction, improvements in job performance and range-of-motion, and increased time spent with family, resulting in overall positive experiences and health benefits. Level of Evidence: III.

H-Wave® Device Stimulation: A Critical Review.

Pain treatments have historically centered on drugs, but an "opioid crisis" has necessitated new standards of care, with a paradigm shift towards multi-modal pain management emphasizing early movement, non-narcotics, and various adjunctive therapies. Electrotherapies remain understudied and most lack high-quality clinical trials, despite a desperate need for effective adjunctive options. A systematic search of human clinical studies on H-Wave® device stimulation (HWDS) was conducted as well as a comprehensive review of articles articulating possible HWDS mechanisms of action. Studies unrelated to H-Wave were excluded. Data synthesis summarizes outcomes and study designs, categorized as pre-clinical or clinical. Pre-clinical studies demonstrated that HWDS utilizes a biphasic waveform to induce non-fatiguing muscle contractions which positively affect nerve function, blood and lymph flow. Multiple clinical studies have reported significant benefits for diabetic and non-specific neuropathic pain, where function also improved, and pain medication usage substantially dropped. In conclusion, low- to moderate-quality HWDS studies have reported reduced pain, restored functionality, and lower medication use in a variety of disorders, although higher-quality research is needed to verify condition-specific applicability. HWDS has enough reasonable evidence to be considered as an adjunctive component of non-opioid multi-modal pain management, given its excellent safety profile and relative low cost. Level of Evidence: III.

The impact of postoperative neurologic complications on recovery kinetics in cervical deformity surgery.

OBJECTIVE: The objective of the study is to investigate which neurologic complications affect clinical outcomes the most following cervical deformity (CD) surgery. METHODS: CD patients (C2-C7 Cobb >10°, CL >10°, cSVA >4 cm or chin-brow vertical angle >25°) >18 years with follow-up surgical and health-related quality of life (HRQL) data were included. Descriptive analyses assessed demographics. Neurologic complications assessed were C5 motor deficit, central neurodeficit, nerve root motor deficits, nerve sensory deficits, radiculopathy, and spinal cord deficits. Neurologic complications were classified as major or minor, then: intraoperative, before discharge, before 30 days, before 90 days, and after 90 days. HRQL outcomes were assessed at 3 months, 6 months, and 1 year. Integrated health state (IHS) for the neck disability index (NDI), EQ5D, and modified Japanese Orthopaedic Association (mJOA) were assessed using all follow-up time points. A subanalysis assessed IHS outcomes for patients with 2Y follow-up. RESULTS: 153 operative CD patients were included. Baseline characteristics: 61 years old, 63% female, body mass index 29.7, operative time 531.6 ± 275.5, estimated blood loss 924.2 ± 729.5, 49% posterior approach, 18% anterior approach, 33% combined. 18% of patients experienced a total of 28 neurologic complications in the postoperative period (15 major). There were 7 radiculopathy, 6 motor deficits, 6 sensory deficits, 5 C5 motor deficits, 2 central neurodeficits, and 2 spinal cord deficits. 11.2% of patients experienced neurologic complications before 30 days (7 major) and 15% before 90 days (12 major). 12% of neurocomplication patients went on to have revision surgery within 6 months and 18% within 2 years. Neurologic complication patients had worse mJOA IHS scores at 1Y but no significant differences between NDI and EQ5D (0.003 vs. 0.873, 0.458). When assessing individual complications, central neurologic deficits and spinal cord deficit patients had the worst outcomes at 1Y (2.6 and 1.8 times worse NDI scores, P = 0.04, no improvement in EQ5D, 8% decrease in EQ5D). Patients with sensory deficits had the best NDI and EQ5D outcomes at 1Y (31% decrease in NDI, 8% increase in EQ5D). In a subanalysis, neurologic patients trended toward worse NDI and mJOA IHS outcomes (P = 0.263, 0.163). CONCLUSIONS: 18% of patients undergoing CD surgery experienced a neurologic complication, with 15% within 3 months. Patients who experienced any neurologic complication had worse mJOA recovery kinetics by 1 year and trended toward worse recovery at 2 years. Of the neurologic complications, central neurologic deficits and spinal cord deficits were the most detrimental.

Playing nice: improving the professional climate between physicians and midwives in the Calgary area.

BACKGROUND: Anecdotal reports in the Calgary area indicate a lack of integration of midwives into the mainstream obstetrical community and strained relationships between obstetrical care providers. Finding ways to cultivate positive working relationships is essential for ensuring excellent patient care standards. In this study we sought to identify barriers to an effective working relationship between physicians (both obstetricians and family physicians) and midwives, and to find ways to improve the quality of professional interactions and promote team-based pregnancy care. METHODS: We conducted a mail survey within the former Calgary Health Region that included questions about professional interaction, philosophy regarding childbirth, and relationships between obstetrical practitioners. Participants included family physicians (FPs), midwives (MWs), and obstetricians (OBs) who were identified from publicly available lists. RESULTS: The overall response rate was 80% (144/180). Eligible responses were received from 56 FPs (89% female, 45% in practice < 10 years), 25 MWs (100% female, 68% < 10 years), and 37 OBs (60% female, 49% < 10 years). Responses in agreement with selected survey statements were as follows: childbirth is a dangerous process (36% FPs, 1% MWs, 57% OBs); there are many unnecessary Caesarean sections performed (23% FPs, 76% MWs, 27% OBs); MWs are well-trained professionals (68% FPs, 100% MWs, 30% OBs); residents would benefit from learning from midwives (61% FPs, 100% MWs, 38% OBs); and working relationships could be improved (89% FPs, 100% MWs, 97% OBs). CONCLUSION: Relationships between physicians and midwives are sometimes strained. Potential solutions include increased integration in learning, joint attendance at meetings and rounds, and increased opportunities for collaboration.

Contexte : Des signalements empiriques issus de la région de Calgary indiquent un manque d'intégration des sages-femmes au sein de la communauté obstétricale générale et des relations tendues entre les fournisseurs de soins obstétricaux. Il s'avère essentiel de trouver des façons de cultiver des relations de travail positives pour assurer l'excellence des soins offerts aux patientes. Dans le cadre de cette étude, nous avons cherché à identifier les obstacles à la mise en œuvre d'une relation de travail efficace entre les médecins (tant les obstétriciens que les médecins de famille) et les sages-femmes, et à trouver des façons d'améliorer la qualité des interactions professionnelles et de promouvoir l'offre de soins de maternité en équipe. Méthodes : Nous avons mené, au sein de l'ancienne Calgary Health Region, une enquête postale qui comprenait des questions au sujet de l'interaction professionnelle, de la philosophie en matière d'accouchement et des relations entre les fournisseurs de soins obstétricaux. Parmi les participants, on trouvait des médecins de famille (MF), des sages-femmes (SF) et des obstétriciens (OB) ayant été identifiés à partir des listes publiquement disponibles. Résultats : Le taux de réponse global a été de 80 % (144/180). Des réponses admissibles ont été obtenues de la part de 56 MF (femmes : 89 %, pratique < 10 ans : 45 %), de 25 SF (femmes : 100 %, pratique < 10 ans : 68 %) et de 37 OB (femmes : 60 %, pratique < 10 ans : 49 %). Les réponses indiquant l'accord du répondant pour ce qui est de certaines des affirmations de l'enquête se déclinaient comme suit : « L'accouchement est un processus dangereux ¼ (36 % des MF, 1 % des SF, 57 % des OB); « De nombreuses césariennes sont menées inutilement ¼ (23 % des MF, 76 % des SF, 27 % des OB); « Les sages-femmes sont des professionnelles bien formées ¼ (68 % des MF, 100 % des SF, 30 % des OB); « Les résidents tireraient avantage d'une participation à une séance de formation menée par des sages-femmes ¼ (61 % des MF, 100 % des SF, 38 % des OB); et « Les relations de travail pourraient être améliorées ¼ (89 % des MF, 100 % des SF, 97 % des OB). Conclusion : Les relations entre les médecins et les sages-femmes sont parfois tendues. Parmi les solutions possibles, on trouve une intégration accrue dans le cadre de l'apprentissage, la participation à des réunions et à des rondes communes, et l'augmentation du nombre d'occasions de collaborer.