Preoperative Cervical Epidural Steroid Injections: Utilization and Postoperative Complications in ACDF, PCDF, and Decompression.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Identify factors associated with cervical epidural steroid injection (CESI) receipt before anterior cervical discectomy and fusion (ACDF), posterior cervical decompression and fusion (PCDF), or decompression; evaluate the association between CESI receipt and 90-day postoperative complications; and determine characteristics of CESI associated with complications. SUMMARY OF BACKGROUND DATA: Previous literature has suggested that a preoperative CESI may increase the risk of postoperative complications. However, these studies were limited in the procedures and complications they evaluated. METHODS: The IBM MarketScan database was queried for patients aged 18 years or older who underwent ACDF, PCDF, or cervical decompression for disc herniation, stenosis, radiculopathy, myelopathy, and/or spondylosis without myelopathy between January 1, 2014 and September 30, 2020. CESI receipt within 12 months preoperatively, injection characteristics, and postoperative complications were extracted. Multivariable logistic regression models were used to investigate associations between patient characteristics and receipt of CESI, receipt of a CESI and each 90-day postoperative complication, and CESI characteristics and each 90-day complication. RESULTS: Among the unique patients who underwent each procedure, 20,371 ACDF patients (30.93%), 1259 (22.24%) PCDF patients, and 3349 (36.30%) decompression patients received a preoperative CESI. In all 3 cohorts, increasing age, increasing comorbidity burden, smoker status, and diagnosis of myelopathy were associated with decreased odds of preoperative CESI receipt, while female sex and diagnosis of radiculopathy and spondylosis without myelopathy were associated with increased odds. There were no meaningful between-group comparisons or significant associations between preoperative CESI receipt and any 90-day postoperative complications in multivariable models (all P>0.05). CONCLUSIONS: This study elucidated the main determinants of CESI receipt and found no differences in the odds of developing 90-day postoperative complications, but did identify differential outcomes with regard to some injection characteristics. LEVEL OF EVIDENCE: Level III.

Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care?

INTRODUCTION: Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care. METHODS: A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0-100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0-94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant. RESULTS: Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs. $5,974, p < 0.0001), as well as within 90 days after surgery ($12,700 vs. $10,462, p < 0.0001). CONCLUSIONS: Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care. LEVEL OF EVIDENCE: III.

Safety and Efficacy of a Single-Stage versus Two-Stage Intramedullary Nailing for Synchronous Impending or Pathologic Fractures of Bilateral Femur for Oncologic Indications: A Systematic Review.

Although intramedullary nail (IMN) fixation is the standard of care for most impending and/or complete pathologic fractures of the femur, the optimal timing/sequence of the IMN in cases of synchronous bilateral femoral disease in advanced cancer is not well established. Thus, we compared the outcomes of single-stage (SS) vs. two-stage (TS) IMN of the bilateral femur with a systematic review of the literature on this topic. Bilateral SS and TS IMN cases were identified from 14 studies extracted from four databases according to PRISMA guidelines. Safety (complications, reoperations, mortality, survival, blood loss, and transfusion) and efficacy (length of stay [LOS], time to start rehabilitation and adjuvant therapy, functional scores, and cost) were compared between the groups. A total of 156 IMNs in 78 patients (36 SS and 42 TS) were analyzed. There were one surgical (infection in TS requiring reoperation; p = 0.860) and fifteen medical complications (five in SS, ten in TS; p = 0.045), with SS being associated with lower rates of total and medical complications. Survival, intraoperative mortality, and postoperative same-admission mortality were similar. No cases of implant failure were reported. Data on LOS, rehabilitation, and adjuvant therapy were scarcely reported, although one study favored SS over TS. No study compared cost or functional scores. Our study is the largest and most comprehensive of its kind in supporting the safety and efficacy of a SS bilateral femur IMN approach in these select patients. Further investigations with higher levels of evidence are warranted to optimize treatment protocols for this clinical scenario.

Temperature Outcomes without heater cooler units in adult patients supported with extracorporeal membrane oxygenation: A retrospective cohort study.

INTRODUCTION: Heater-cooler units (HCUs) are frequently incorporated into extracorporeal membrane oxygenation (ECMO) circuits to help maintain patient normothermia. However, these devices may be associated with increased cost and infection risk. This study describes our institution's experience managing adult ECMO patients without the routine use of in-circuit HCUs. METHODS: We performed a retrospective analysis of adult patients treated with veno-venous (VV) or veno-arterial (VA) ECMO at our institution. The primary outcomes were rates of HCU use and the relative duration of the ECMO treatment course in which patients maintained normothermia (36-37.5°C), with and without HCUs. Secondary outcomes of mortality and ECMO-related complications were planned across HCU and non-HCU groups; exploratory analyses were performed across a 75% "ECMO time in normothermia" threshold. RESULTS: Among a cohort of 71 patients, zero (0%) were managed with in-circuit HCUs. A majority of ECMO patient-hours were spent in the normothermic range. Median and mean percentages of ECMO normothermia time were 75% (IQR 49%-81%) and 62% (SD ± 27%). Twenty-nine patients (40%) met the threshold of 75% ECMO normothermia time, as used to evaluate secondary outcomes. At this threshold, mortality risk was significantly higher among the non-normothermic cohort; other ECMO-related complications did not vary significantly. CONCLUSIONS: In the absence of HCU use, the majority of ECMO patient-hours were spent in normothermia. However, only a minority of patients achieved normothermia for at least 75% of their ECMO course. In-circuit HCUs may be required to maintain high percentages of normothermic time in adult EMCO patients.

Intramedullary Nailing with and without the Use of Bone Cement for Impending and Pathologic Fractures of the Humerus in Multiple Myeloma and Metastatic Disease.

Although intramedullary nailing (IMN) is considered the standard of care for the surgical management of most femur metastatic diseases, the optimal treatment of metastatic humeral impending and/or pathologic fractures is still debatable. Moreover, the use of cemented humeral nails has not been thoroughly studied, and only a few small series have compared their results with uncemented nails. The purpose of this study was to compare the (1) survivorship, (2) functional outcomes, and (3) perioperative complications in patients receiving cemented versus uncemented humerus IMN for impending or complete pathologic fractures resulting from metastatic disease or multiple myeloma. We retrospectively reviewed 100 IMNs in 82 patients, of which 53 were cemented and 47 were uncemented. With a mean survival of 10 months (Cemented: 8.3 months vs. Uncemented: 11.6 months, p = 0.34), the mean Musculoskeletal Tumor Society (MSTS) scores increased from 42.4% preoperatively (Cemented: 40.2% vs. Uncemented: 66.7%, p = 0.01) to 89.2% at 3 months postoperatively (Cemented: 89.8% vs. Uncemented: 90.9%, p = 0.72) for the overall group (p < 0.001). Both cohorts yielded comparable complication rates (overall [22.6% vs. 19.1%)], surgical ([11.3% vs. 4.3%], and medical [13.2% vs. 14.9%], all p > 0.05), but estimated blood loss was significantly higher in the cemented group (203 mL vs. 126 mL, p = 0.003). Thus, intramedullary nailing, with and without cement augmentation in select patients, is a relatively safe and effective therapeutic modality for metastatic humeral disease with similar clinical outcomes and acceptable complication rates. While controlling for possible selection bias, larger-scale, higher-level studies are warranted to validate our results.

Multi-Level Posterior Cervical Foraminotomy Associated With Increased Post-operative Infection Rates and Overall Re-Operation Relative to Anterior Cervical Discectomy With Fusion or Cervical Disc Arthroplasty.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Cervical radiculopathy meeting operative criteria has traditionally been managed using anterior cervical discectomy and fusion (ACDF). However, cervical disc arthroplasty (CDA) and posterior cervical foraminotomy (PCF) are also reasonable options. This study aimed to assess differences in postoperative outcomes among patients undergoing multi-level ACDF, CDA, or PCF comparing medical/surgical complications and healthcare utilization parameters. METHODS: Patients who underwent multi-level ACDF, CDA, or PCF between 2012 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Patients were stratified based on procedure type and propensity score matched to resolve baseline differences. ANOVA was performed to identify differences in medical complications, surgical complications, and healthcare utilization metrics. RESULTS: A total of 31 344 patients who underwent an eligible procedure were identified (ACDF: n = 28 089, CDA: n = 1748, PCF: n = 1507), and 684 patients remained in each group following propensity score matching. Patients undergoing multi-level PCF were found to experience longer lengths of hospital stay (PCF: 1.67 ± 1.61 days, ACDF: 1.50 ± 1.32 days, CDA: 1.27 ± 1.05 days, P < .001), higher rates of reoperation (PCF: 3.2%, ACDF: 1.0%, CDA: .4%, P = .020), superficial infection (PCF: 1.3%, ACDF: .3%, CDA: .1%, P = .008) and deep infection (PCF: 1.2%, ACDF: 0%, CDA: 0%, P < .001). There were no outcome differences between multi-level ACDF and CDA. CONCLUSIONS: Patients undergoing multi-level PCF were at increased risk for longer hospital stay, re-operation, and infection relative to those undergoing ACDF and CDA. Future research should aim to uncover the precise mechanisms underlying these complications, as well as analyze long term outcomes. LEVEL OF EVIDENCE: III.

Binary organization of epidermal basal domains highlights robustness to environmental exposure.

Adulte interfollicular epidermis (IFE) renewal is likely orchestrated by physiological demands of its complex tissue architecture comprising spatial and cellular heterogeneity. Mouse tail and back skin display two kinds of basal IFE spatial domains that regenerate at different rates. Here, we elucidate the molecular and cellular states of basal IFE domains by marker expression and single-cell transcriptomics in mouse and human skin. We uncover two paths of basal cell differentiation that in part reflect the IFE spatial domain organization. We unravel previously unrecognized similarities between mouse tail IFE basal domains defined as scales and interscales versus human rete ridges and inter-ridges, respectively. Furthermore, our basal IFE transcriptomics and gene targeting in mice provide evidence supporting a physiological role of IFE domains in adaptation to differential UV exposure. We identify Sox6 as a novel UV-induced and interscale/inter-ridge preferred basal IFE-domain transcription factor, important for IFE proliferation and survival. The spatial, cellular, and molecular organization of IFE basal domains underscores skin adaptation to environmental exposure and its unusual robustness in adult homeostasis.

Comparative Evaluation of Tube First Versus Video Laryngoscope First Techniques in a Normal and Simulated Difficult Airway Model: A Randomized Controlled Trial.

In patients with difficult airways, there can be difficulty with advancing the endotracheal tube into the airway even with a good view of the glottis using video laryngoscopy. The purpose of this study was to determine if the time required to intubate an airway and the number of gaze changes by the laryngoscopist could be decreased by using a novel video laryngoscope technique. Sixteen experienced Certified Registered Nurse Anesthetists were recruited to intubate a manikin with a normal or difficult airway using both the laryngoscope first technique and a new endotracheal tube first technique (4 intubations total) in a randomized sequence. The data were analyzed with the Mann-Whitney (U) test to compare the differences between the normal and difficult airway conditions. Although no significant difference was noted in the time to intubation between intubation techniques, the number of gaze changes was found to be significantly fewer in the tube first technique (P=.0009). A steep learning curve, associated with the accommodation of the manikin, was demonstrated by a decrease in time and gaze changes with subsequent intubations. Incorporating the endotracheal tube first technique into an education curriculum could increase patient safety by decreasing the time to secure a difficult airway.