Characteristics, comorbidities, and complications in multiple sclerosis (MS) and non-MS patients undergoing lumbar fusion for deformity.

Background: We compared the characteristics, comorbidities, and complications in spinal deformity patients with and without multiple sclerosis (MS) undergoing primary lumbar spine fusion. Methods: We used the Nationwide Inpatient Sample (NIS) from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes to create experimental MS (842 patients) and non-MS control (165,726 patients) cohorts undergoing primary lumbar spine fusion. Characteristics, comorbidities, and complications in spinal deformity patients with and without MS were evaluated using univariate and bivariate analysis. Results: MS spinal deformity patients undergoing primary lumbar spine fusion were younger, more likely to be female and more likely to undergo surgery at urban teaching hospitals. They also exhibited higher rates of depression and lower rates of diabetes without chronic complications, hypertension, and renal failure. However, no significant differences were found in mortality or total perioperative complication rates between MS and nonMS patients. Conclusion: We found that MS versus non-MS patients undergoing primary lumbar fusion for spinal deformity were younger, more likely to be female and had higher rates of depression but lower rates of diabetes, hypertension, and renal failure. Notably, both groups experienced comparable mortality and perioperative complication rates.

Clinical presentation of group B Streptococcus-infected diabetic foot ulcers.

OBJECTIVE: Group B Streptococcus (GBS) is a common pathogen in diabetic foot ulcers (DFUs), where it has been found to result in higher rates of soft tissue infection and amputation despite appropriate treatment. In this study, we aim to investigate clinical characteristics and prognosis of GBS DFU infections, especially those with tenosynovial involvement. We hypothesise that GBS-infected DFUs with tenosynovial involvement leads to an increased number of recurrent infections and unexpected returns to the operating room. METHOD: Data were retrospectively collected from GBS-infected DFU patients surgically treated by an orthopaedic foot and ankle surgeon over a four-year period. Demographics, comorbidities, initial laboratory values and culture results from infected bone samples were recorded. Clinical outcome was assessed by recurrent infection and unplanned reoperation(s) within 3 months following the initial surgery. RESULTS: In total, 72 patients were treated for GBS-infected DFUs. Intra-operative culture of infected bone identified GBS in 16 patients (22.2%). Significantly more black patients (p=0.017) were afflicted by GBS DFUs. Patients with GBS DFUs had higher initial haemoglobin A1C levels (p=0.019), and those with tenosynovial involvement were likely to require reoperation (p=0.036) and had a greater total number of surgeries (p=0.015) than those without. CONCLUSION: GBS-infected DFUs are more common in black patients and those with elevated haemoglobin A1Cs. GBS infections with tenosynovial involvement are particularly destructive and require aggressive treatment by surgeons.

Endotracheal Tube Cuff Overinflation Leading to Hypoxic Cardiac Arrest: A Case Report and Review of the Literature.

Endotracheal tube cuff overinflation has been shown to produce airway obstruction and subsequent ventilatory and hemodynamic compromise. Although rare, this complication is reversible and its prompt identification is paramount. We describe a case of a 68-year-old woman undergoing microlaryngoscopy and vocal cord lesion biopsy, who developed ventilatory failure and cardiac arrest following endotracheal tube overinflation intraoperatively. The patient was successfully resuscitated and was able to be ventilated after endotracheal tube replacement. We present a literature review and evidence-based management insights for endotracheal tube obstruction due to cuff overinflation.

Ultralong Follow-Up of Spinal Fusion for Adolescent Idiopathic Scoliosis: Harrington Instrumentation vs Uninstrumented Fusion.

BACKGROUND: Harrington instrumentation for adolescent idiopathic scoliosis (AIS) was revolutionary and allowed patients to mobilize faster as compared with patients treated with uninstrumented fusion. However, Harrington instrumentation provided correction of the deformity in 1 plane, resulting in limited sagittal plane control. Patients who received these 2 surgeries are aging, and to date, ultralong follow-up of these patients has not been reported. OBJECTIVE: The purpose of this study was to evaluate long-term patient-reported outcomes and radiographic parameters after Harrington nonsegmental distraction instrumentation vs uninstrumented fusion in the treatment of AIS. METHODS: Fourteen adult patients with AIS who were previously instrumented (n = 7) or uninstrumented (n = 7) were identified. Recent x-ray image measurements such as pelvic incidence (PI), sagittal vertical axis (SVA), pelvic tilt (PT), lumbar lordosis (LL), and pelvic incidence minus lumbar lordosis (PI-LL) were used to analyze deformities. Scoliosis Research Society-7 (SRS-7), Neck Disability Index (NDI), and Oswestry Disability Index (ODI) were used to evaluate patient-reported outcomes. Complications and rates of revision surgery were also evaluated. RESULTS: The mean age was 67.1 ± 5 years in the instrumented group and 64.1 ± 9 years in the uninstrumented group. There were no significant differences between instrumented and uninstrumented in SRS-7 (23.4 ± 2.9 vs 23.6 ± 2.6, P = 0.93), NDI (5.7 ± 4.5 vs 10.6 ± 4.5, P = 0.08), and ODI (9.7 ± 13.7 vs 9.4 ± 8.7, P = 0.99). Radiographic measurements of instrumented vs uninstrumented resulted in comparable PT (24.0 ± 7.9 vs 30.5 ± 4.7, P = 0.09), PI (61.3 ± 16.9 vs 67.2 ± 9.5, P = 0.47), LL (34.9 ± 14.4 vs 42.8 ± 11.0, P = 0.29), PI-LL (26.4 ± 25.1 vs 24.3 ± 10.4, P = 0.43), and SVA (38.1 ± 30.1 vs 52.3 ± 21.6, P = 0.37). There were 2 patients in the instrumented group who developed adjacent segment disease that required operative intervention compared with none in the uninstrumented group (P = 0.46). CONCLUSION: In long-term follow-up of instrumented and uninstrumented fusion, patients had similar patient-reported outcomes and radiographic parameters, although the instrumented cohort had higher rates of adjacent segment disease.

PROMIS Scores Should Not be Used in Isolation to Measure Outcomes in Lumbar Stenosis Patients.

STUDY DESIGN: Retrospective cross-sectional analysis. OBJECTIVE: The aim of this study was to establish the strength of relationship between the Patient-reported Outcomes Measurement Information System (PROMIS) Adult Depression (AD), Physical Function (PF), and Pain Interference (PI) with the Swiss Spinal Stenosis Questionnaire (SSSQ) in assessing lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: In 2009, there were >35,000 surgeries for LSS, which amounted to $1.65 billion in health care cost. By 2021, there will be >2.4 million people in the United States with symptomatic LSS. There is an increasing emphasis on patient-reported outcomes (PROs) to define value in medicine. Therefore, it would be beneficial to compare PROMIS, a universal PRO, against the SSSQ, the "criterion standard" for assessing LSS. METHODS: Eighty-two patients with LSS completing the PROMIS and SSSQ were enrolled. Per existing institutional protocol, PROMIS AD, PF, and PI were completed at every clinic visit. Linear regression analysis was then performed to evaluate how well the SSSQ and PROMIS scores correlated to each other. RESULTS: When linear regression was performed for pre-treatment values, the R2 value for the SSSQ PF versus PROMIS PF was 0.14 (P = 0.0008), whereas the R2 value for the SSSQ symptom severity versus PROMIS PI was 0.03 (P = 0.13). The R2 value for the combined SSSQ physical function and symptom severity versus PROMIS AD was 0.07 (P = 0.02). When post-treatment SSSQ satisfaction scores were correlated to postoperative PROMIS AD, PI, and PF scores, the R2 values for a good linear fit were 0.13, 0.25, and 0.18 respectively (P values: 0.01, 0.003, and 0.003). CONCLUSION: Pre-treatment PROMIS scores do not adequately capture the disease-specific impact of spinal stenosis, but postoperative PROMIS scores better reflect outcomes after surgery for LSS. PROMIS scores should not be used in isolation to assess outcomes in patients with LSS.Level of Evidence: 4.

Clinical utilization of species-specific immunoassays for identification of Staphylococcus aureus and Streptococcus agalactiae in orthopedic infections.

Staphylococcus aureus and Streptococcus agalactiae (Group B streptococcus, GBS) are common causes of deep musculoskeletal infections (MSKI) and result in significant patient morbidity and cost to the healthcare system. One of the major challenges with MSKI is the lack of faithful diagnostics to correctly identify the primary pathogen, as standard culture-based assays are prone to false positives in the case of polymicrobial infections, and false negatives due to limitations in sample acquisition and antibiotic use before presentation. To improve upon our current diagnostic methods for MSKI, we developed a multiplex immunoassay for antigen-specific IgGs in serum (Luminex), and medium enriched for newly synthesized antibodies (MENSA) for anti-S. aureus and GBS generated from cultured peripheral blood mononuclear cells (PBMCs) of orthopedic infection patients undergoing surgical treatment. Samples were obtained from 110 MSKI patients: 80 diabetic foot ulcer, 21 periprosthetic joint infection, 5 septic arthritis, 2 spine, 1 hand, and 1 fracture-related infection (FRI). Anti-S. aureus and anti-GBS antibody titers were compared to culture results to assess their concordance in identifying the pathogens. Immunoassay, particularly MENSA, showed high diagnostic potential for monomicrobial S. aureus and GBS orthopedic infections (AUC > 0.95). MENSA also demonstrated diagnostic potential for GBS polymicrobial orthopedic infection and for GBS DFU (AUC > 0.83 for both). Serum showed high diagnostic potential for S. aureus PJI (AUC > 0.95). Taken together, these findings support the development of species-specific immunoassays for the identification of causal pathogens in active MSKI, especially in conjunction with standard culture.

Volume-outcome relationship in halo vest utilization for C2 fractures.

BACKGROUND CONTEXT: The prevalence of C2 fractures has increased in recent years. The treatment of these fractures include halo-vest immobilization (HVI), rigid cervical collar, or spinal fusion. There is controversy regarding the management of these fractures with different institutions having their own protocols based on individualized experience. The volume-outcome relationship of HVI use for C2 fractures has not been studied. Evaluation of such relationships are important as they suggest that patients may benefit from referral to and treatment at high-volume institutions. PURPOSE: To evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State. STUDY DESIGN: Retrospective analysis of a statewide database. PATIENT SAMPLE: We queried the New York Statewide Planning and Research Cooperative System database for the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 805.02 (closed fracture of second cervical vertebra) and procedure code 029.4 (insertion or replacement of skull tongs or halo traction device) to identify all patients who received HVI for a fracture of the second cervical vertebra between the years 2001 and 2014. Those who had isolated C2 fractures were selected. OUTCOME MEASURES: Outcomes of interest included resource utilization characteristics (hospitalization charges and length of stay), perioperative complications, comorbidities, 30-day mortality, any readmission, and any future cervical fusion surgery. METHODS: The 2001 to 2014 Statewide Planning and Research Cooperative System database was used to identify patients with C2 fractures who received HVI. Our key independent variable was institution volume modeled as high- (>25 halos/year), medium-, (10-25 halos/year), or low-volume (<10 halos/year) based on the total number of HVI procedures reported by hospitals during the study period. We compared outcomes with respect to hospital volume. We also compared patients by age groups: <40, 40 to 60, 60 to 80, and >80. Multivariate logistic regressions were performed for the binary variables any complication and any readmission while controlling for covariates hospital volume, age, sex, race, insurance status, and Elixhauser comorbidity mean. Statistical significance was set at a value of p<.05 for all analyses. RESULTS: In all, 625 patients with C2 fractures managed with HVI were included. Most patients were male (53%) and Caucasian (76%) with a mean age of 57. Patients at high-volume hospitals were younger (52 vs. 59 and 60 for medium- and low-volume, respectively; p<.01) and had fewer future readmissions (40% vs. 54% and 84% for medium- and low-volume, respectively; p<.01). On multivariable analysis, those with private insurance and worker's compensation had lower likelihood of future readmission compared to Medicaid patients. Patients >80 had higher rates of major in-hospital complications (52% vs. 40%, 18%, and 19% for groups 60-79, 40-59, and <40, respectively; p<.01), mortality (14% vs. 5%, 1%, and 1% for groups 60-79, 40-59, and <40, respectively; p<.01), and readmissions after the initial HVI (62% vs. 50%, 54%, and 37% for groups 60-79, 40-59, and <40, respectively; p<.01). The annual rate of HVI use for C2 fractures decreased significantly from 2001 to 2014 (0.32 to 0.06 HVI procedures per 100,000 people; p<.01) with the rate of decline being less pronounced in high-volume institutions (70% decrease vs. 85% and 90% for medium- and low-volume, respectively). CONCLUSIONS: Halo vest utilization for C2 fractures in New York State has been declining over the past decade, with the decline being less pronounced in high-volume hospitals. Our hospital volume analysis suggests that HVI use in high-volume institutions is associated with a lower rate of future readmissions. This finding suggests that patients with C2 fractures may benefit from treatment at high-volume institutions. Further research to help improve referral of appropriate patients and increase access to such institutions is warranted.

Dropped Head Syndrome: An Update on Etiology and Surgical Management.

¼ Dropped head syndrome is a group of disorders with diverse etiologies involving different anatomical components of the neck, ultimately resulting in a debilitating, flexible, anterior curvature of the cervical spine. ¼ Causes of dropped head syndrome include myasthenia gravis, amyotrophic lateral sclerosis, Parkinson disease, radiation therapy, and cumulative age-related changes. Idiopathic cases have also been reported. ¼ Nonoperative treatment of dropped head syndrome includes orthotic bracing and physical therapy. ¼ Surgical treatment of dropped head syndrome consists of cervical spine fusion to correct the deformity. ¼ The limited data available examining the clinical and radiographic outcomes of surgical intervention indicate a higher rate of complications with the majority having favorable outcomes in the long term.

X-ray crystal structures, density functional theory and docking on deacetylase enzyme for antiproliferative activity of hispolon derivatives on HCT116 colon cancer.

The antiproliferative action of hispolon derivatives is stronger than that of related curcumin against several tumor cell lines. Hispolon size, smaller than curcumin, fits better than curcumin into the active site of HDAC6, an enzyme involved in deacetylation of lysine residues. HDACs are considered potential targets for tumor drug discovery and hydroxamates are known inhibitors of HDACs. One of them, SAHA (Vorinostat) is used in clinical studies. Investigations into possible mechanisms for hispolon derivatives active against the HCT116 colon tumor cell line are done after examining the structural results obtained from hispolon X-ray crystal structures as well as performing associated computational docking and Density Functional Theory techniques on HDAC6. These studies show preference for the HDAC6 active site by chelating the Zn center, in contrast with other ineffective hispolon derivatives, that establish only a single bond to the metal center. Structure activity relationships make clear that hydrogenation of the hispolon bridge also leads to single bond (non chelate) hispolon-Zn binding, and consistently nullifies the antiproliferative action against HCT116 tumor.

Crystallographic and spectroscopic characterization of 5-chloro-pyridine-2,3-di-amine.

The two ortho-amino groups of the title compound, C5H6ClN3, twist out of the plane of the mol-ecule to minimize intra-molecular inter-action between the amino hydrogen atoms. In the crystal, the amino groups and the pyridine N atom engage in inter-molecular hydrogen bonding. The mol-ecules pack into spiral hydrogen-bonded columns with offset face-to-face π-stacking.