Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO. METHODS: We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA). RESULTS: 5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2. CONCLUSION: Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.

Complete Spinal Cord Injury Secondary to Serratia marcescens Spinal Epidural Abscess: A Report of Significant Neurological Improvement After a Delayed Presentation.

The exact time at which neurological deficits secondary to a spinal cord injury (SCI) become permanent is unknown. However, urgent decompression within 24 hours of insult is advocated to maximize the return of function. Despite previous literature showing poor neurological recovery with intervention after 24-72 hours, multiple cases have since shown noteworthy clinical improvement following significant delays in presentation. We report the case of a 55-year-old incarcerated male who presented to our hospital with a four-week history of a complete (American Spinal Injury Association (ASIA) A) SCI after a prison altercation. The patient exhibited profound deficits of over one-month duration, and magnetic resonance imaging (MRI) revealed an epidural abscess at T7-T8 with severe cord compression and another epidural abscess at L4-L5. This prompted immediate IV antibiotic therapy. A full neurological examination at hospital admission showed a complete absence of sensation, motor, rectal tone, and rectal function below T8, indicating a grade ASIA A SCI. Blood cultures grew Serratia marcescens. After thorough deliberation, considering over a month of complete neurological deficits, it was decided that surgical intervention would be unlikely to improve the patient's clinical status. Nonetheless, after only 24 hours of IV antibiotic administration, the patient progressed from an ASIA A to B, with a return of 100% accurate, although dull, sensation below T8. Within one week, his abscesses diminished on follow-up MRI, yet T7-T8 remained under significant pressure with no further clinical improvements. Due to his unexpected improvement to an ASIA B, which then plateaued at this level, surgery was again discussed in an attempt to maximize recovery. The patient wished to proceed, even given low chances of a meaningful recovery. He subsequently underwent evacuation and decompression. Two weeks postoperatively, the patient advanced from an ASIA B to C; he remained so until discharge 46 days after presentation and 30 days after surgical decompression. This case is noteworthy within the literature due to two compelling features. Firstly, it represents a significantly delayed presentation of a complete SCI with unexpected, meaningful, and swift improvement after medication and surgical intervention. Secondly, it is one of the few documented cases of Serratia marcescens spinal epidural abscess (SEA).

Creating Consensus in the Definition of Spinopelvic Mobility.

INTRODUCTION: The term "spinopelvic mobility" is most often applied to motion within the spinopelvic segment. It has also been used to describe changes in pelvic tilt between various functional positions, which is influenced by motion at the hip, knee, ankle and spinopelvic segment. In the interest of establishing a consistent language for spinopelvic mobility, we sought to clarify and simplify its definition to create consensus, improve communication, and increase consistency with research into the hip-spine relationship. METHODS: A literature search was performed using the Medline (PubMed) library to identify all existing articles pertaining to spinopelvic mobility. We reported on the varying definitions of spinopelvic mobility including how different radiographic imaging techniques are used to define mobility. RESULTS: The search term "spinopelvic mobility" returned a total of 72 articles. The frequency and context for the varying definitions of mobility were reported. 41 papers used standing and upright relaxed-seated radiographs without the use of extreme positioning, and 17 papers discussed the use of extreme positioning to define spinopelvic mobility. DISCUSSION: Our review suggests that the definitions of spinopelvic mobility is not consistent in the majority of published literature. We suggest descriptions of spinopelvic mobility independently consider spinal motion, hip motion, and pelvic position, while recognizing and describing their interdependence.

Characterization of aerosolized particles from nanoclay-enabled composites during manipulation processes.

Manufacturing, processing, use, and disposal of nanoclay-enabled composites potentially lead to the release of nanoclay particles from the polymer matrix in which they are embedded; however, exposures to airborne particles are poorly understood. The present study was conducted to characterize airborne particles released during sanding of nanoclay-enabled thermoplastic composites. Two types of nanoclay, Cloisite® 25A and Cloisite® 93A, were dispersed in polypropylene at 0%, 1%, and 4% loading by weight. Zirconium aluminum oxide (P100/P180 grits) and silicon carbide (P120/P320 grits) sandpapers were used to abrade composites in controlled experiments followed by real-time and offline particle analyses. Overall, sanding the virgin polypropylene with zirconium aluminum oxide sandpaper released more particles compared to silicon carbide sandpaper, with the later exhibiting similar or lower concentrations than that of polypropylene. Thus, a further investigation was performed for the samples collected using the zirconium aluminum oxide sandpaper. The 1% 25A, 1% 93A, and 4% 93A composites generated substantially higher particle number concentrations (1.3-2.6 times) and respirable mass concentrations (1.2-2.3 times) relative to the virgin polypropylene, while the 4% 25A composite produced comparable results, regardless of sandpaper type. It was observed that the majority of the inhalable particles were originated from composite materials with a significant number of protrusions of nanoclay (18-59%). These findings indicate that the percent loading and dispersion of nanoclay in the polypropylene modified the mechanical properties and thus, along with sandpaper type, affected the number of particles released during sanding, implicating the cause of potential adverse health effects.