CKD and Rapid Kidney Function Decline During the COVID-19 Pandemic.

Rationale & Objective: The direct and indirect effects of the coronavirus disease 2019 (COVID-19) pandemic on kidney function in the chronic kidney disease (CKD) population are not well understood. Study Design: Cohort study. Setting & Participants: Retrospective study of kidney function trajectories using deidentified administrative claims and laboratory data for Medicare Advantage and commercially insured enrollees with CKD stages G3-4 between 2018 and 2021. Predictors: COVID-19 infection. Outcome: Rapid kidney function decline defined as annual estimated glomerular filtration rate (eGFR) decline of ≥40%. Analytical Approach: Propensity score matching was used to identify individuals without COVID-19 infection matched 1:1 to a COVID-19 infected cohort and indexed on the date of diagnosing COVID-19 infection, age, sex, race or ethnicity, and Charlson comorbidity index score. Outpatient kidney function was compared during the prepandemic period (January 1, 2018, to February 29, 2020) with the pandemic period (March 1, 2020, to August 31, 2021). Two creatinine measurements, after the infection date and ≥60 days apart, were required to reduce correlation with acute infection. Results: Of 97,203 enrollees with CKD G3-4, 9% experienced a COVID-19 infection. Characteristics of 8,901 propensity matched enrollees include mean age 74 years, 58% women, 67% White, and 63% CKD G3a, 28% CKD G3b, and 9% CKD G4. Median overall annual eGFR change was -2.65 ml/min/1.73m2, with 76% of the cohort experiencing worsened eGFR in the pandemic period. Rapid kidney function decline was observed in 1.9% and 2.0% of enrollees in the prepandemic and pandemic periods, respectively. Rapid kidney function decline was observed in 2.5% of those with COVID-19 infection and 1.5% of those without COVID-19 infection (P < 0.05). Factors associated with increased odds of rapid kidney function decline during pandemic included Asian race, higher Charlson comorbidity index, advancing CKD stage, prepandemic rapid kidney function decline, and COVID-19 infection. Limitations: Retrospective study design with potential bias. Conclusions: COVID-19 infection increased odds of rapid kidney function decline during the pandemic. The downstream impact of pandemic-related eGFR decline on health outcomes, such as kidney failure or mortality, requires further study. Plain-Language Summary: We used a cohort of insured individuals with moderate-to-severe chronic kidney disease (CKD) to compare the rates of rapid kidney function decline in prepandemic and pandemic periods and to evaluate the impact of the coronavirus disease 19 (COVID-19) on kidney function decline. We found that overall rates of rapid kidney function decline did not change during the prepandemic and pandemic periods but were significantly higher in both periods among individuals with a COVID-19 infection. As CKD severity increased, rates of both rapid kidney function decline and COVID-19 increased. Advancing CKD, higher comorbid condition, Asian race, prepandemic rapid kidney function decline, and COVID-19 were all associated with higher odds of rapid kidney function decline in the pandemic. These findings suggest close monitoring is warranted for individuals with CKD and COVID-19.

Radial nerve myofibroma: a rare benign tumor with perineural infiltration. Illustrative case.

BACKGROUND: Myofibromas are benign mesenchymal tumors, classically presenting in infants and young children in the head and neck region. Perineural involvement, especially in peripheral nerves within the upper extremity, is extremely rare in myofibromas. OBSERVATIONS: The authors present the case of a 16-year-old male with a 4-month history of an enlarging forearm mass and rapidly progressive dense motor weakness in wrist, finger, and thumb extension. Preoperative imaging and fine needle biopsy confirmed the diagnosis of a benign isolated myofibroma. Given the dense paralysis, operative management was indicated, and intraoperative exploration showed extensive involvement of tumor within the radial nerve. The infiltrated nerve segment was excised along with the tumor, and the resulting 5-cm nerve gap was reconstructed using autologous cabled grafts. LESSONS: Perineural pseudoinvasion can be an extremely rare and atypical feature of nonmalignancies, resulting in dense motor weakness. Extensive nerve involvement may still necessitate nerve resection and reconstruction, despite the benign etiology of the lesion.

Missing Care: the Initial Impact of the COVID-19 Pandemic on CKD Care Delivery.

BACKGROUND: Chronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD population is unknown. OBJECTIVE: To examine pandemic CKD care and identify factors associated with a high care deficit. DESIGN: Retrospective observational study PARTICIPANTS: 248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3-G4 CKD in 2018 MAIN MEASURES: Predicted (based on the pre-pandemic period of January 1, 2019-February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020-June 30, 2020), pre-vaccine (July 1, 2020-December 31, 2020), and late (January 2021-August 2021) periods and overall. KEY RESULTS: In-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9-20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8-43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall. CONCLUSIONS: The early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.

A data-based foundation for managing hypertension services.

OBJECTIVES: To understand primary care visits and medication utilization among older patients with hypertension to gauge opportunity for service redesign. STUDY DESIGN: Data came from 1,880,331 Medicare Advantage members with hypertension who had a primary care visit and a pharmacy claim for an antihypertensive, antidiabetic, or antilipemic medication. To determine activities associated with a primary care visit, we analyzed 43,258,454 medical claims, 245 procedure codes, and medication management associated with those visits. Models for predicting both hypertension visits and medication management were evaluated and applied. METHODS: Logistic regression was used to identify which features were predictive of a medication change or a provider visit. RESULTS: Almost 40% of visits were consultation only, not associated with a procedure, and 26.5% of individuals had no medication change in a year. For prescription changes, 75% were a return to a previously prescribed medication or a medication discontinuation. Twenty percent of the population accounted for 47.9% of visits. Type 2 diabetes and a prior medication change were the strongest predictors of a medication change. A previous medication change was also the strongest predictor of a subsequent provider visit. CONCLUSIONS: Our analysis suggests that a significant portion of care-consultation-only visits-may be relatively low value. Further, much of medication management may not require an office-based visit. Finally, utilization behavior of patients with hypertension and predictive models are likely to allow informed provisioning of new service models to specific population segments.

Contribution of the elevated thrombosis risk of males to the excess male mortality observed in COVID-19: an observational study.

BACKGROUND: The mortality rate of COVID-19 is elevated in males compared with females. OBJECTIVE: Determine the extent that the elevated thrombotic risk in males relative to females contributes to excess COVID-19 mortality in males. DESIGN: Observational study. SETTING: Data sourced from electronic medical records from over 200 US hospital systems. PARTICIPANTS: 60 877 patients aged 18 years and older hospitalised with COVID-19. EXPOSURE: Exposure variable: biological sex; key variable of interest: thrombosis. PRIMARY OUTCOME MEASURES: Primary outcome was COVID-19 mortality. We measured: (1) mortality rate of males relative to females, (2) rate of thrombotic diagnoses occurring during hospitalisation for COVID-19 in both sexes and (3) mortality rate when evidence of thrombosis was present. RESULTS: The COVID-19 mortality rate of males was 29.9% higher than that of females. Males had a 35.8% higher rate of receiving a thrombotic diagnosis compared with females. The mortality rate of all patients with a thrombotic diagnosis was 40.0%-over twice that of patients with COVID-19 without a thrombotic diagnosis (adjusted OR 2.50 (2.37 to 2.64), p<0.001). When defining thrombosis as either a documented thrombotic diagnosis or a D-dimer level ≥3.0 µg/mL, 16.4% of the excess mortality in male patients could be explained by increased thrombotic risk. CONCLUSIONS: Our findings suggest the higher COVID-19 mortality rate in males may be significantly accounted for by the elevated risk of thrombosis among males. Understanding the mechanisms that underlie increased male thrombotic risk may allow for the advancement of effective anticoagulation strategies that reduce COVID-19 mortality in males.

Temporal Patterns of High-Spend Subgroups Can Inform Service Strategy for Medicare Advantage Enrollees.

BACKGROUND: Most healthcare costs are concentrated in a small proportion of individuals with complex social, medical, behavioral, and clinical needs that are poorly met by a fee-for-service healthcare system. Efforts to reduce cost in the top decile have shown limited effectiveness. Understanding patient subgroups within the top decile is a first step toward designing more effective and targeted interventions. OBJECTIVE: Segment the top decile based on spending and clinical characteristics and examine the temporal movement of individuals in and out of the top decile. DESIGN: Retrospective claims data analysis. PARTICIPANTS: UnitedHealthcare Medicare Advantage (MA) enrollees (N = 1,504,091) continuously enrolled from 2016 to 2019. MAIN MEASURES: Medical (physician, inpatient, outpatient) and pharmacy claims for services submitted for third-party reimbursement under Medicare Advantage, available as International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and National Drug Codes (NDC) claims. KEY RESULTS: The top decile was segmented into three distinct subgroups characterized by different drivers of cost: (1) Catastrophic: acute events (acute myocardial infarction and hip/pelvic fracture), (2) persistent: medications, and (3) semi-persistent chronic conditions and frailty indicators. These groups show different patterns of spending across time. Each year, 79% of the catastrophic group dropped out of the top decile. In contrast, 68-70% of the persistent group and 36-37% of the semi-persistent group remained in the top decile year over year. These groups also show different 1-year mortality rates, which are highest among semi-persistent members at 17.5-18.5%, compared to 12% and 13-14% for catastrophic and persistent members, respectively. CONCLUSIONS: The top decile consists of subgroups with different needs and spending patterns. Interventions to reduce utilization and expenditures may show more effectiveness if they account for the different characteristics and care needs of these subgroups.

Objective Measures of Physical Distancing in the Hospital During the COVID-19 Pandemic.

During the COVID-19 pandemic, hospitals published physical-distancing guidance and created dedicated respiratory isolation units (RIUs) for patients with COVID-19. The degree to which such distancing occurred between clinicians and patients is unknown. In this study, heat sensors from an existing hospital hand-hygiene monitoring system objectively tracked room entries as a proxy for physical distancing in both RIUs and general medicine units before and during the pandemic. The RIUs saw a 60.6% reduction in entries per room per day (from 85.7 to 33.8). General medicine units that cared for patients under investigation for COVID-19 and other patients experienced a 14.7% reduction in entries per room per day (from 76.9 to 65.1). While gradual extinction was observed in both units as COVID-19 cases declined, the RIUs had a higher degree of physical distancing. Although the optimal level of physical distancing is unknown, sustaining physical distancing in the hospital may require re-education and real-time monitoring.

The impact of the COVID-19 pandemic on nighttime room entries and sleep disruptions for pediatric patients.

OBJECTIVES/BACKGROUND: Sleep is critical to recovery, but inpatient sleep is often disrupted. During the COVID-19 pandemic, social distancing efforts to minimize spread may have improved hospitalized children's sleep by decreasing unnecessary overnight disruptions. This study aimed to describe the impact of these efforts on pediatric inpatient sleep using objective and subjective metrics. METHODS: Sleep disruptions for pediatric inpatients admitted prior to and during the COVID-19 pandemic were compared. Hand hygiene sensors tracking room entries were utilized to measure objective overnight disruptions for 69 nights pre-pandemic and 154 pandemic nights. Caregiver surveys of overnight disruptions, sleep quantity, and caregiver mood were adopted from validated tools: the Karolinska Sleep Log, Potential Hospital Sleep Disruptions and Noises Questionnaire, and Visual Analog Mood Scale. RESULTS: Nighttime room entries initially decreased 36% (95% CI: 30%, 42%, p < 0.001), then returned towards baseline, mirroring the COVID-19 hospital census. However, surveyed caregivers (n_pre = 293, n_post = 154) reported more disrupted sleep (p < 0.001) due to tests (21% vs. 38%), anxiety (23% vs. 41%), and pain (23% vs. 48%). Caregivers also reported children slept 61 fewer minutes (95% CI: -12 min, -110 min, p < 0.001). Caregivers self-reported feeling more sad, weary, and worse overall (p < 0.001 for all). CONCLUSIONS: Despite a decrease in objective room entries during the pandemic, caregivers reported their children were disrupted more and slept less. Caregivers also self-reported worse mood. This highlights the effects of the COVID-19 pandemic on subjective experiences of hospitalized children and their caregivers. Future work targeting stress and anxiety could improve pediatric inpatient sleep.

Medication management for complex patients in primary care: application of a remote, asynchronous clinical pharmacist model.

Purpose: Drug therapy problems impact about one-third of US adults, and these issues are likely to continue to worsen as the population of aging Americans increases. The objective of this study is to assess the feasibility of a remotely delivered Comprehensive Medication Management (CMM) for primary practice patients who are polypharmatic and at high risk for drug therapy problems.Methods: Using medical and prescription claims data, a list of Medicare Advantage beneficiaries at high risk for drug therapy problems was identified. Participants were enrolled in a 6-month CMM program from February - November 2020. In the program, their existing drug therapy was assessed by a pharmacist, Drug therapy problems were identified and resolved. A Collaborative Practice Agreement allowed the pharmacists to make prescription changes as needed.Results: Eighty-three percent (202) of contacted individuals agreed to participate in the study. All participants were on five medications or more, and 71% were on more than eight. A clinical pharmacist found that 86% of participants had a drug therapy problem according to classification criteria. Seventy-nine percent of all drug therapy problems identified were resolved upon completion of the study.Conclusion: The findings of this study suggest that engagement of a remote clinical pharmacist can contribute to efficient resolution of most drug therapy problems identified in a primary care population. A service model using remote pharmacist services may be an effective means of improving team-based primary care medication management for this population.

Rationale, Methodological Quality, and Reporting of Cluster-Randomized Controlled Trials in Critical Care Medicine: A Systematic Review.

OBJECTIVE: Compared with individual-patient randomized controlled trials, cluster randomized controlled trials have unique methodological and ethical considerations. We evaluated the rationale, methodological quality, and reporting of cluster randomized controlled trials in critical care studies. DATA SOURCES: Systematic searches of Medline, Embase, and Cochrane Central Register were performed. STUDY SELECTION: We included all cluster randomized controlled trials conducted in adult, pediatric, or neonatal critical care units from January 2005 to September 2019. DATA EXTRACTION: Two reviewers independently screened citations, reviewed full texts, protocols, and supplements of potentially eligible studies, abstracted data, and assessed methodology of included studies. DATA SYNTHESIS: From 1,902 citations, 59 cluster randomized controlled trials met criteria. Most focused on quality improvement (24, 41%), antimicrobial therapy (9, 15%), or infection control (9, 15%) interventions. Designs included parallel-group (25, 42%), crossover (21, 36%), and stepped-wedge (13, 22%). Concealment of allocation was reported in 21 studies (36%). Thirteen studies (22%) reported at least one method of blinding. The median total sample size was 1,660 patients (interquartile range, 813-4,295); the median number of clusters was 12 (interquartile range, 5-24); and the median patients per cluster was 141 (interquartile range, 54-452). Sample size calculations were reported in 90% of trials, but only 54% met Consolidated Standards of Reporting Trials guidance for sample size reporting. Twenty-seven of the studies (46%) identified a fixed number of available clusters prior to trial commencement, and only nine (15%) prespecified both the number of clusters and patients required to detect the expected effect size. Overall, 36 trials (68%) achieved the total prespecified sample size. When analyzing data, 44 studies (75%) appropriately adjusted for clustering when analyzing the primary outcome. Only 12 (20%) reported an intracluster coefficient (median 0.047 [interquartile range, 0.01-0.13]). CONCLUSIONS: Cluster randomized controlled trials in critical care typically involve a small and fixed number of relatively large clusters. The reporting of key methodological aspects of these trials is often inadequate.

Comparing Bleeding and Thrombotic Rates in Spine Surgery: An Analysis of 119 888 Patients.

STUDY DESIGN: Retrospective, database review. OBJECTIVES: Examine the utilization rate of postoperative deep vein thrombosis (DVT) prophylaxis and compare the incidence and severity of bleeding and thrombotic complications in elective spine surgery patients. METHODS: We utilized PearlDiver, a national orthopedics claims database. All patients who underwent elective spine surgery from 2007 to 2017 were included. Patients were stratified by the presence of DVT prophylaxis drug codes, then by comorbidities for postoperative bleeding/thrombosis. The severity of all bleeding and thrombotic complications in each cohort was studied, including the incidence of complications requiring operative washout, diagnosis of pulmonary embolism, intensive care unit admission, and mortality. RESULTS: A total of 119 888 patients were included. The majority of patients (118 720, >99%) were not administered postoperative DVT chemoprophylaxis while a minority of patients (1168) were. The overall rates of bleeding and thrombotic complications within the population not receiving DVT prophylaxis were 1.96% and 2.45%, respectively (P < .001). The incidence of surgical intervention for a wound washout was 0.62% compared with 1.05% for pulmonary embolism (P < .001). Intensive care unit admission rates related to a wound washout procedure or pulmonary embolism also significantly differed (0.07% vs 0.34%, P < .001). There were no observed differences in mortality. When controlling for patient comorbidity, patients with atrial fibrillation, cancer, or a prior history of thrombotic complications experienced the greatest increased risks of postoperative thrombosis. CONCLUSIONS: DVT prophylaxis is not routinely utilized following elective spine procedures. We report that there exist specific populations which may receive benefit from these practices, although further study is necessary to determine optimal prevention strategies for both thrombotic and bleeding complications in spine surgery.

Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring.

BACKGROUND: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS: Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.

Bioethanol Production from UK Seaweeds: Investigating Variable Pre-treatment and Enzyme Hydrolysis Parameters.

This study describes the method development for bioethanol production from three species of seaweed. Laminaria digitata, Ulva lactuca and for the first time Dilsea carnosa were used as representatives of brown, green and red species of seaweed, respectively. Acid thermo-chemical and entirely aqueous (water) based pre-treatments were evaluated, using a range of sulphuric acid concentrations (0.125-2.5 M) and solids loading contents (5-25 % [w/v]; biomass: reactant) and different reaction times (5-30 min), with the aim of maximising the release of glucose following enzyme hydrolysis. A pre-treatment step for each of the three seaweeds was required and pre-treatment conditions were found to be specific to each seaweed species. Dilsea carnosa and U. lactuca were more suited with an aqueous (water-based) pre-treatment (yielding 125.0 and 360.0 mg of glucose/g of pre-treated seaweed, respectively), yet interestingly non pre-treated D. carnosa yielded 106.4 g g-1 glucose. Laminaria digitata required a dilute acid thermo-chemical pre-treatment in order to liberate maximal glucose yields (218.9 mg glucose/g pre-treated seaweed). Fermentations with S. cerevisiae NCYC2592 of the generated hydrolysates gave ethanol yields of 5.4 g L-1, 7.8 g L-1 and 3.2 g L-1 from D. carnosa, U. lactuca and L. digitata, respectively. This study highlighted that entirely aqueous based pre-treatments are effective for seaweed biomass, yet bioethanol production alone may not make such bio-processes economically viable at large scale.

Complete Acid-Based Hydrolysis Assay for Carbohydrate Quantification in Seaweed: A Species-Specific Optimized Approach.

Accurate quantification of the carbohydrate content of biomass is crucial for many bio-refining processes. The most commonly followed protocol is typically a modification of the NREL-based assay (specifically designed for carbohydrate analysis from lignocellulosic biomass). However, this NREL protocol was revealed to be excessively thermochemically harsh for seaweed biomass. This can result in erroneously low total sugar quantification as the reaction severity can degrade a proportion of the liberated sugars to decomposition products such as furans. Here we describe an optimization of the total acid hydrolysis protocol for accurate quantification of the carbohydrate content of seaweeds. Different species of seaweed can be accurately evaluated for their carbohydrate contents by following this optimized method.

Benchmarks of Duration and Magnitude of Opioid Consumption After Common Spinal Procedures: A Database Analysis of 47,823 Patients.

STUDY DESIGN: A retrospective cohort study performed in a nationwide insurance claims database. OBJECTIVE: This study aimed to examine duration and magnitude of postoperative opioid prescriptions following common spinal procedures. SUMMARY OF BACKGROUND DATA: Postoperative opioid prescription practices vary widely among providers and procedures and standards of care are not well-established. Previous work does not adequately quantify both duration and magnitude of opioid prescription. METHODS: Forty seven thousand eight hundred twenty three patients with record of any of four common spinal procedures in a nationwide insurance claims database were stratified by preoperative opioid use into three categories: "opioid naive," "sporadic user," or "chronic user," defined as 0, 1, or 2+ prescriptions filled in the 6 months preceding surgery. Those with record of subsequent surgery or readmission were excluded. Duration of opioid use was defined as the time between the index surgery and the last record of filling an opioid prescription. Magnitude of opioid use was defined as milligram morphine equivalents (MME) filled by 30 days post-op, converted to 5 mg oxycodone pills for interpretation. RESULTS: Opioid naive patients were less likely than chronic opioid users to fill any opioid prescription after surgery (63-68% naive vs. 91-95% chronic, P < 0.001), and when they did, their prescriptions were smaller in magnitude (76-91 pills naive vs. 127-152 pills chronic). One year after surgery, 15% to 18% of opioid naive and 50% to 64% of chronic opioid users continued filling prescriptions. CONCLUSION: Opioid naive patients use less postoperative opioids, and for a shorter period of time, than chronic users. This study serves as a normative benchmark for examining postoperative opioid use, which can assist providers in identifying patients with opioid dependence. Importantly, this work calls out the high risk of opioid exposure, as 15% to 18% of opioid naive patients continued filling opioid prescriptions 1 year after surgery. LEVEL OF EVIDENCE: 3.

Benchmarks of Duration and Magnitude of Opioid Consumption After Total Hip and Knee Arthroplasty: A Database Analysis of 69,368 Patients.

BACKGROUND: Opioid prescribing after orthopedic surgeries varies widely, and there is little consensus establishing proper standards of care. This retrospective cohort study examines opioid prescribing trends following total hip (THA) and knee (TKA) arthroplasty and evaluates preoperative opioid use as a predictor of duration and magnitude of postoperative opioid use. METHODS: Patients who underwent THA or TKA in a nationwide insurance database were stratified by preoperative opioid use. Naive, sporadic, and chronic users were defined as 0, 1, or 2+ prescriptions filled 6 months before surgery. Patients were excluded for readmission or subsequent surgery. Duration of opioid use was defined as time between the procedure and the last opioid prescription record, and magnitude of opioid use was defined as quantity of pills filled by 30 days postop. RESULTS: Naive patients were less likely than chronic users to fill any opioid prescription after surgery (THA: 61.5% naive vs 90.4% chronic, TKA: 72.0% naive vs 95.9% chronic), and they obtained fewer pills (THA: 73 pills naive vs 126 pills chronic, TKA: 86 pills naive vs 126 pills chronic, 5-mg oxycodone equivalent). Between 10% (THA) and 13% (TKA) of naive and between 47% (THA) and 62% (TKA) of chronic users continued opioid use at 1 year postop. CONCLUSION: Chronic users obtain more opioids postoperatively and continue filling prescriptions for longer than naive patients. This work benchmarks norms regarding opioid use and furthermore these data highlight the powerful effect of opioid exposure during surgery as 10%-13% of naive patients continued opioids at 1 year postop.

Cages in ACDF are Associated With a Higher Nonunion Rate Than Allograft: A Stratified Comparative Analysis of 6130 Patients.

STUDY DESIGN: A retrospective database review. OBJECTIVE: The purpose of this study was to analyze the rate of nonunion in patients treated with structural allograft and intervertebral cages in anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Existing literature consists primarily of single-center studies with inconsistent findings. METHODS: We performed a retrospective analysis of 6130 patients registered in the PearlDiver national database through Humana Insurance from 2007 to 2016. All ACDF patients with anterior plating who were active in the database for at least 1 year were included in the study. Patients with a fracture history within 1 year of intervention, past arthrodesis of hand, foot, or ankle, or a planned posterior approach were excluded from the study. Patients were stratified by number of levels treated, tobacco use, and diabetic condition. Nonunion rates of structural allograft and intervertebral cage groups after 1 year were compared using Chi-squared analyses. RESULTS: Four thousand sixty-three patients were included in the allograft group, while 2067 were included in the cage group. Overall nonunion rates were significantly higher in the cage group (5.32%) than in allograft group (1.97%) (P < 0.01). When controlling for confounders, increased rates of nonunion were consistently observed in the cage group, achieving statistical significance in 25 of the 26 analyses. CONCLUSION: The increased rate of nonunion associated with intervertebral cages may suggest the superiority of allograft over cages in ACDF. LEVEL OF EVIDENCE: 3.

Bioethanol Production from Brewers Spent Grains Using a Fungal Consolidated Bioprocessing (CBP) Approach.

Production of bioethanol from brewers spent grains (BSG) using consolidated bioprocessing (CBP) is reported. Each CBP system consists of a primary filamentous fungal species, which secretes the enzymes required to deconstruct biomass, paired with a secondary yeast species to ferment liberated sugars to ethanol. Interestingly, although several pairings of fungi were investigated, the sake fermentation system (A. oryzae and S. cerevisiae NCYC479) was found to yield the highest concentrations of ethanol (37 g/L of ethanol within 10 days). On this basis, 1 t of BSG (dry weight) would yield 94 kg of ethanol using 36 hL of water in the process. QRT-PCR analysis of selected carbohydrate degrading (CAZy) genes expressed by A. oryzae in the BSG sake system showed that hemicellulose was deconstructed first, followed by cellulose. One drawback of the CBP approach is lower ethanol productivity rates; however, it requires low energy and water inputs, and hence is worthy of further investigation and optimisation.

Mashing with unmalted sorghum using a novel low temperature enzyme system: Impacts of sorghum grain composition and microstructure.

Brewing lager beers from unmalted sorghum traditionally requires the use of high temperature mashing and exogenous enzymes to ensure adequate starch conversion. Here, a novel low-temperature mashing system is compared to a more traditional mash in terms of the wort quality produced (laboratory scale) from five unmalted sorghums (2 brewing and 3 non-brewing varieties). The low temperature mash generated worts of comparable quality to those resulting from a traditional energy intensive mash protocol. Furthermore, its performance was less dependant on sorghum raw material quality, such that it may facilitate the use of what were previously considered non-brewing varieties. Whilst brewing sorghums were of lower protein content, protein per se did not correlate with mashing performance. Rather, it was the way in which protein was structured (particularly the strength of protein-starch interactions) which most influenced brewing performance. RVA profile was the easiest way of identifying this characteristic as potentially problematic.