Lateral interbody fusion for adjacent segment disease: a narrative review.

Background and Objective: Adjacent segment disease (ASD) is a late complication of lumbar fusion characterized by persistent symptoms correlating to radiographic changes in the levels immediately above or below the prior fusion. Lateral interbody fusion (LIF) through a direct lateral approach is a minimally invasive and effective surgical treatment for ASD. Biomechanically, LIF for ASD provides significantly decreased motion in multiple planes. While hardware failure and injury to the lumbar plexus are potential complications, these risks may be outweighed by decreased blood loss, shorter operating room (OR) times, and possibly superior patient reported visual analog scale (VAS) scores compared to traditional posterior spinal fusion (PSF) alone. The purpose of this review is to summarize the history, uses, outcomes, and future directions of LIF for ASD. Methods: A review of national databases (PubMed and SCOPUS) was performed using literature from 1900 to 2022. Keywords included terms "LATERAL" and "LUMBAR" and "INTERBODY" and "FUSION" and "ADJACENT" and "SEGMENT" and "DISEASE". Studies that aimed to describe the biomechanical, clinical course and complications, radiological outcomes, biomechanical aspects, need for revision surgery, and/or patient reported outcomes of the XLIF/LIF technique were included. Key Content and Findings: This review includes a brief overview of the natural history of ASD and current approaches to address it. It then summarizes the main indications and utilization of LIF to address ASD, summarizing reported outcomes in regard to biomechanical, clinical, and radiographic outcomes. Conclusions: LIF has emerged as a minimally invasive and effective surgical treatment for ASD. This mini-review suggests that LIF provides a solid foundational biomechanical construct that has been paired with good patient-reported, clinical, and radiographic outcomes. While further research is required, current literature suggests that LIF for ASD results in fewer complications, decreased morbidity, and decreased need for subsequent surgery compared to other commonly utilized techniques.

Medical Malpractice Litigation Following Hindfoot Arthrodesis.

Given high patient expectations in the setting of complex surgeries, orthopedic surgeons are at risk of being subject to malpractice claims which can impose significant economic and psychological burden. This study investigates malpractice claims against orthopedic surgeons and podiatrists performing hindfoot arthrodesis and determine factors associated with plaintiff verdicts and settlements using the Westlaw legal database. The database was queried for all cases involving hindfoot arthrodesis using the terms "malpractice" and either "ankle fusion," "arthrodesis," "subtalar fusion," "tibiotalar fusion," "tibiotalocalcaneal fusion," "TTC fusion," or "tibiofibular fusion" from 1987 to 2023. Data regarding patient demographics, causes cited for litigation, case outcomes, and indemnity settlements were collected. Cases were excluded if the defendant was not an orthopedic surgeon or a podiatrist, the procedure involved was not a hindfoot arthrodesis, or if the patient was a minor. Forty-five cases of hindfoot arthrodesis met the inclusion criteria. The mean plaintiff age was 51.5 ± 13.8 years with 51.1% male. Thirty-three cases (73%) were in favor of the defendant, with an average inflation-adjusted payout of $853,863 (±456,179). The most alleged category of negligence was procedural/intraoperative error (75%) followed by postsurgical error (38%) and failure to inform (31%). The most common specific damages included functional/ROM limitation (49%), need for additional surgery (47%), continuing/worsened pain (27%), and nonunion/malunion (29%). Given the frequency of hindfoot arthrodesis performed, this study highlights the importance of effective communication with patients concerning potential postoperative complications, prognosis of their injury, and risks and benefits associated with each treatment modality.

Effect of L-Methylfolate Supplementation on Sleep for Patients with Reduced Methylenetetrahydrofolate Reductase Activity.

INTRODUCTION: Clinicians have limited options outside controlled substances to address sleep disturbance, which left untreated can negatively affect patient outcomes in cardiovascular health, mental health, immunologic function, and more. For some, genetic factors may influence sleep disturbances. L-methylfolate, the active form of folate, plays a critical role in regulation of monoamine neurotransmitters known to have significant impact on sleep regulation: dopamine, serotonin, norepinephrine. Single nucleotide polymorphisms of the enzyme methylene-tetrahydrofolate-reductase are common and can impact monoamine production. The goal of this study was to evaluate effects of L-methylfolate supplementation on sleep in a cohort with reduced methylene tetrahydrofolate reductase (MTHFR) activity. METHODS: A retrospective cohort of patients being treated with L-methylfolate in a concierge medical clinic setting was studied. Patients presenting with sleep complaints were evaluated using the Patient-Reported Outcomes Measurement Information System at baseline. Patients with known MTHFR polymorphisms at either C667T and/or A1298C were recommended 5 mg of L-methylfolate daily and were reevaluated at 2 wks, at 4 wks, and at 8 wks of supplementation. Statistical comparisons were made utilizing ANOVA and T-test comparisons. RESULTS: Ten were included in the final cohort: six male and four female, average age 43 ± 16 years. Beginning at wk 2, average sleep disturbance improved significantly by -6.94 points (p = 0.005) and by 8 wks, all patients had improvement with a -14.34 change in disturbance from baseline (p = 0.001). CONCLUSION: Improvement in sleep disturbance was seen in both low and intermediate function phenotypes. L-methylfolate may be useful for improving sleep in patients with MTHFR polymorphism.

Impact of Nicotine Replacement Therapy on Breast Surgery Outcomes.

BACKGROUND: Smoking cessation therapy, including nicotine replacement therapy (NRT), is used perioperatively to assist patients to reduce their tobacco smoke intake and consequently decrease their risk of smoking-associated complications. There are, however, theoretical concerns that nicotine-induced peripheral vasoconstriction could impair wound healing. This study investigated the effect of NRT on postoperative outcomes in patients undergoing breast surgery. METHODS: A retrospective chart review of patients undergoing breast surgery within the Yale New Haven Health System from the years 2014 to 2020 was performed. Documented smoking status within 6 months before surgery, use or prescription of NRT, type of surgery, and surgical complications of infection, wound dehiscence, tissue necrosis, hematoma, seroma, fat necrosis, and return to operating room within 30 days were recorded. Demographic and complication data were compared between patients with NRT usage and those without using t-tests and chi-square analyses. Multivariable logistic regression models were created to predict the effect of NRT usage on the occurrence of any complication. RESULTS: A total of 613 breast procedures met inclusion criteria, of which 105 (17.2%) had documented NRT use. The NRT cohort and the non-NRT cohort were well balanced with respect to demographics and procedural variables. Upon multivariable modeling for risk of any surgical complication, NRT was not a significant predictor (odds ratio [OR]: 1.199, p = 0.607 and OR: 0.974, p = 0.912, respectively), whereas procedure type, increased body mass index, and increased age were. CONCLUSION: NRT use was not associated with an increased risk of postoperative complications compared with not using NRT as part of smoking cessation therapy prior to operation.

The Use of Medical Chaperones During Physical Examinations: The Perceptions of Adolescents and Their Caregivers.

PURPOSE: A medical chaperone serves as a witness for a patient and health care practitioner during a medical examination. We sought to better understand the preferences of parents and children toward the use of chaperones during pediatric physical examinations. METHODS: This cross-sectional study surveyed patients aged 8 to 18 years and their parents presenting primarily to the emergency department as well as primary care ambulatory clinic and inpatient units. Participants were asked which individuals (patient alone, parent, or medical chaperone) should be present for each aspect of the child's physical examination. RESULTS: The survey was completed by 121 patients (mean age 14 years, 58.5% girls) and 122 parents (mean age 42 years, 82.8% women) in a variety of clinical settings (17 in inpatient, 17 in outpatient clinic, and 87 emergency department admissions). Significant differences existed between male and female patients regarding preferred presence for every body part being examined ( P ≤ 0.002). Female patients preferred to have a same-sex parent in the room, particularly for examination of the breasts, genitalia, or rectum and when the examination was performed by a male provider. Male patients preferred to be alone or with either parent for any body part being examined, regardless of provider sex. CONCLUSIONS: Adolescents have significant differences in who they prefer to be in the room for the physical examination based on patient and provider sex in settings where they are unfamiliar with the health care examiner. Few patients and parents preferred a medical chaperone; most preferred a parent to be in the room. Patient and parent considerations should be prioritized when creating policies for the use of medical chaperones.

The Impact of Social Determinants of Health on Pressure Injury Progression: A Retrospective Chart and Scoping Review.

OBJECTIVE: To understand the effects of nutrition security and social determinants of health (SDOHs) on pressure injury (PI) progression through a scoping review and retrospective review of patients reporting to New England's largest healthcare system. METHODS: Authors performed a scoping review for full-text, original articles reporting outcomes data specific to PIs in patients with socially informed nutrition insecurity. Investigators also performed a retrospective review of all patients from 2012 to 2021 to search for patients with PI documentation and International Classification of Diseases, Tenth Revision Z codes related to the SDOHs. RESULTS: A full-text review of 2,323 articles from 1965 to 2020 failed to locate any eligible studies. Investigators identified 1,044 patients who met the inclusion criteria; 50.7% were men, 74.3% were White, and 13.3% had evidence of detrimental SDOHs. The average PI duration was 12.13 days (interquartile range, 6 days). Multivariate regression analysis revealed that PI duration was longer in men, Black patients, and patients with evidence of detrimental SDOHs compared with their converse counterparts (P < .0001). The presence of detrimental SDOHs independently predicted an increased duration of disease by 13.07 days (95% CI, 8.99-17.15; t = 6.29, P < .0001). CONCLUSIONS: A patient's SDOH history has a significant and considerably stronger correlation with disease progression than predictors that are traditionally studied such as sex, race, or body mass index. These findings are novel, as highlighted by the absence of data uncovered in the literature. These data carry relevance for plastic surgeons wishing to prevent early recurrence following operative closure of PI-related wounds.

The effect of COVID-19 on the pressure injury reporting gap.

Responsibilities placed on nurses increased during the COVID-19 pandemic. Hospital-acquired PI monitoring was deferred in favor of more critical patient needs. It was hypothesized that a counterintuitive dip in HAPI reporting would be observed despite maximum hospital capacity across much of the United States. The electronic medical records of patients treated in the YNHH System between December 2017 and February 2021 were retrospectively reviewed to identify patients with HAPIs, defined as PIs not documented upon admission but subsequently present during the patient's hospital stay. Paired t test revealed a significantly lower number of reported incidents mid-pandemic than during the prepandemic baseline months (P <.0001). The data in this report show interdisciplinary clinician-led teams must continue to monitor for HAPIs and congruous conditions to minimize reporting gaps and progression in PI severity despite COVID-19 pandemic-related conditions and additional related responsibilities.

The Identification and Management of Small Intestinal Bacterial Overgrowth: A Functional Medicine Approach.

Small intestinal bacterial overgrowth (SIBO) can exist in common conditions such as irritable bowel syndrome, obesity, cirrhosis, and Parkinson. Using the functional medicine matrix broadens the lens of how to evaluate SIBO. Assessing the predisposing factors, triggers, and contributors of SIBO enables the provider to better understand possible management strategies. Applying the functional medicine 5R program, remove, replenish, repair, reinoculate, and rebalance includes conventional treatment of SIBO and expands the provider's toolbox on different modalities to restore gut function.

Evaluation of intramuscular olanzapine and ziprasidone in the medically ill.

INTRODUCTION: Despite the paucity of studies evaluating short-acting parenteral second-generation antipsychotics in the medically ill, their use in this population has increased. The purpose of this study was to characterize the use of IM olanzapine and ziprasidone in the medically ill at an academic medical center. METHODS: This is a retrospective medical record review of all patients who received IM olanzapine or ziprasidone on nonpsychiatric inpatient units at a large academic medical center from August 1, 2015 to July 31, 2017. The primary endpoint characterized the indication for use. Secondary endpoints included safety, effectiveness, and prescribing patterns. RESULTS: After exclusion criteria, a total of 100 patients were included in this study, predominantly white males with a mean age of 56 years. Seventy-four percent of patients received IM ziprasidone and 26% received IM olanzapine. The most common indications for use were agitation of nonpsychotic origin (40%) and delirium (33%). Patients received IM olanzapine and ziprasidone when their use was contraindicated (26.9% vs 9.5%, respectively). DISCUSSION: Intramuscular second-generation antipsychotics are increasingly being used in the medically ill for delirium and agitation. Our study confirms these were the most common indications for IM second-generation antipsychotic use in this population. Additionally, their use appeared to be well-tolerated, and no patient developed Torsades de Pointes even when combined with other agents that putatively increase QTc. Given the retrospective, single-center, nonrandomized design of this study, the safety and effectiveness of these parenteral second-generation antipsychotics in common causes of acute agitation should continue to be further evaluated.

Translesion synthesis inhibitors as a new class of cancer chemotherapeutics.

Introduction: Translesion synthesis (TLS) is a DNA damage tolerance mechanism that replaces the replicative DNA polymerase with a specialized, low-fidelity TLS DNA polymerase that can copy past DNA lesions during active replication. Recent studies have demonstrated a primary role for TLS in replicating past DNA lesions induced by first-line genotoxic agents, resulting in decreased efficacy and acquired chemoresistance. With this in mind, targeting TLS as a combination strategy with first-line genotoxic agents has emerged as a promising approach to develop a new class of anti-cancer adjuvant agents. Areas covered: In this review, we provide a brief background on TLS and its role in cancer. We also discuss the identification and development of inhibitors that target various TLS DNA polymerases or key protein-protein interactions (PPIs) in the TLS machinery. Expert opinion: TLS inhibitors have demonstrated initial promise; however, their continued study is essential to more fully understand the clinical potential of this emerging class of anti-cancer chemotherapeutics. It will be important to determine whether a specific protein involved in TLS is an optimal target. In addition, an expanded understanding of what current genotoxic chemotherapies synergize with TLS inhibitors will guide the clinical strategies for devising combination therapies.

Serum lidocaine levels and cutaneous side effects after application of 23% lidocaine 7% tetracaine ointment to the face.

BACKGROUND: Few published studies have analyzed serum lidocaine levels and individual patient characteristics affecting metabolism after application of compounded topical anesthetics. OBJECTIVE: To measure serum lidocaine levels during and cutaneous side effects after standardized application of 23% lidocaine/7% tetracaine compounded anesthetic to the face of healthy volunteers. METHODS AND MATERIALS: Fifty-two volunteers were enrolled, and compounded 23% lidocaine/7% tetracaine ointment was applied to their faces for 2 hours. Lidocaine levels were determined every 30 minutes during application and for 2 hours after removal. Follow-up telephone calls 3 days later assessed cutaneous side effects. RESULTS: Median peak lidocaine level was 1.15 µg/mL, and the highest peak lidocaine level in an individual was 3.4 µg/mL. Higher serum lidocaine levels were found in men (p < .01), nonwhite volunteers (p = .02), and those with larger facial surface area (p = .04). Age and body mass index did not affect lidocaine levels. Irritant contact dermatitis was common, resulting in hyperpigmentation in some patients. CONCLUSION: Facial surface area, male sex, and nonwhite ethnicity were associated with higher serum lidocaine levels after topical application of lidocaine. Compounded anesthetics containing lidocaine should be used with caution under the direct supervision of a physician.