Long-term survivability of surgical and nonsurgical management of spinal epidural abscess.

BACKGROUND CONTEXT: Spinal epidural abscess (SEA) is a rare and life-threatening infection within the epidural space with significant functional impairment and morbidity. Active debate remains over whether to operate for SEAs, with limited existing data comparing the long-term survivability after surgical versus nonsurgical management. PURPOSE: This study aims to determine the long-term survival of patients who underwent surgical and nonsurgical management for SEA. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: A total of 250 consecutive SEA patients. OUTCOME MEASURES: Survival and mortality rates, complications. METHODS: All patients treated at a tertiary medical center for a primary SEA from January 2000 to June 2020 are identified. Data collection is by retrospective chart review. Cox proportional hazards regression models are used for all survival analyses while controlling for potential confounding variables and with multiple testing corrections. RESULTS: A total of 35 out of 250 patients died with an overall all-cause mortality of 14%. More than half of all deaths occurred within 90 days after treatment. The 90-day, 3-year, and 5-year survival rates are 92.8%, 89.2%, and 86.4%, respectively. Among surgery patients, the all-cause mortality was 13.07%, compared to 16.22% for medically-managed patients. Surgical treatment (decompression, fusion, debridement) significantly reduced the risk of death by 62.4% compared to medical therapy (p=.03), but surgery patients experienced a significantly longer mean length of stay (p=.01). Risk factors of short-term mortality included hypoalbuminemia (<3.5 g/dL), American Society of Anesthesiologists (ASA) 4+, and cardiac arrest. Risk factors of long-term mortality were immunocompromised state, elevated WBC count >12,000, sepsis, septic shock, ASA 4+, and cardiac arrest (p<.05). In terms of complications, surgically-managed patients experienced a higher proportion of deep vein thrombosis (p<.05). CONCLUSIONS: The overall long-term survivability of SEA treatment is relatively high at (86% at 5-year) in this study. The following SEA mortality risk factors were identified: hypoalbuminemia (short-term), immunocompromised state (long-term), leukocytosis (long-term), sepsis and septic shock (long-term), ASA 4+ and cardiac arrest (overall). For primary SEA patients, surgical management may reduce mortality risk compared to nonsurgical management.

Development of a Needs Assessment for Low-income Seniors in Cleveland Ohio: A student-driven Interprofessional Approach.

BACKGROUND AND OBJECTIVE: Older persons with low socioeconomic status in the United States have different and unique health needs compared to younger persons. As part of a student-led, interprofessional partnership, we performed a needs assessment of community dwelling older persons with low socioeconomic status in an urban location within Ohio, USA. METHODS: Three entities participated in the needs assessment: a student-run health clinic, a Federally Qualified Health Center, and an apartment complex of the study population. Health professional students from medical, dental, nursing, social work, nutrition, and physician assistant programs led the needs assessment process. The process consisted of multiple phases, which included preliminary literature review, survey development, data collection, and analysis. The final survey was multidisciplinary, with six content areas covered in 37 items. RESULTS: One hundred nineteen survey responses were received, and multiple areas of need were identified including food insecurity, dental care access, and mental health. 93% of participants had at least one unmet health need and 39% of respondents met our classification for high need. The needs of the local study population had key differences from previously published data in more generalized populations of older community-dwelling individuals in the United States, notably lower utilization of dental care (43% vs. 66%), increased prevalence of possible food insecurity (30% vs. 17%), and increased use of age-appropriate preventive cancer screening services. CONCLUSIONS: Multiple areas of need were successfully identified through a student-led interprofessional needs assessment. Future student teams can address the identified needs, again through interprofessional collaborations. This process may have unique benefits to help build robust community-academic partnerships, while fostering interprofessional collaborative opportunities among healthcare students.

Risk Factors of Emergency Department Utilization After Outpatient Surgery for Sports-Related Injuries.

INTRODUCTION: The purpose of this study was to identify the most common reasons for and risk factors associated with postoperative emergency department (ED) utilization after orthopaedic procedures for sports-related injuries. METHODS: Using the 2014 to 2016 New York and Florida State Databases from the Healthcare Cost and Utilization Project, outpatient procedures for sports-related injuries were identified. Patient records were tracked across care settings within each state to determine the rate and reasons of postoperative ED utilization within 90 days after the index surgery. Multiple logistic regression models were used to identify risk factors associated with ED visits at 0 to 7 days, 8 to 30 days, 31 to 90 days postoperatively. RESULTS: A total of 28,192 surgery visits for sports-related injuries were identified, with knee arthroscopy with partial meniscectomy (18.48%) and arthroscopic anterior cruciate ligament reconstruction (17.04%) as the two most common procedures treating sports injuries. The overall postoperative ED utilization rates were 1.6% (0 to 7 days postoperative), 1.3% (8 to 30 days) and 2.1% (31 to 90 days). The main cause of ED visits was markedly different during each postoperative period: mainly musculoskeletal pain (36.3%) during 0 to 7 days, either musculoskeletal pain (17%) or injury (16.6%) during 8 to 30 days, and injury (24.2%) during 31 to 90 days. Sports with the highest ED utilization in descending order were basketball, football, ice/snow sports, walking/running, cycling, and soccer. Relative to open procedures, arthroscopic procedures were 0.71 times as likely to result in a postoperative ED visit. Independent predictors of ED utilization up to 90 days postoperatively included renal failure, chronic pulmonary disease, psychosis, diabetes, and alcohol abuse. DISCUSSION: Rate of ED utilization after outpatient surgery for sports-related injuries is low (<2.2%), with postoperative musculoskeletal pain and reinjury as the two most common causes, highlighting the importance of postoperative pain management and injury prevention. Arthroscopic procedures showed markedly lower ED utilization compared with open surgery, although not indicative of overall superiority. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Patient Preferences and Perceptions of Provider Diversity in Orthopaedic Surgery.

BACKGROUND: Orthopaedic surgery in the U.S. historically has been among the least demographically diverse specialties in medicine. Currently, limited data exist on how patients perceive diversity within the field and what patients look for when choosing an orthopaedic surgeon. The purpose of this study was to identify specific patient preferences for surgeon demographics and understand patient perceptions of racial and gender diversity in orthopaedic surgery. METHODS: Nonconsecutive patients from orthopaedic clinics affiliated with a U.S. academic health system voluntarily completed a 39-item questionnaire that surveyed basic demographic information, perception of diversity, racial and gender preferences during surgeon selection, and perception of health-care inequalities. Bivariate analyses were used to test the association between patient-surgeon demographic variables and ratings of diversity. Multiple regression models were used to identify independent predictors of overall perceived diversity ratings. RESULTS: A total of 349 patients (80.6% White, 17.9% Black, and 1.5% other) were analyzed. Black patients were more likely to experience difficulty relating to their surgeon than White patients (11.48% versus 2.29%; odds ratio [OR], 5.62; 95% confidence interval [CI], 1.55 to 21.1; p = 0.004). Moreover, Black patients were more likely to perceive racial bias from their surgeon than White patients (5.17% versus 0.37%; OR, 14.44; 95% CI, 1.14 to 766.29; p = 0.02). While the level of racial diversity perceived by White patients (2.57 of 10) was significantly higher than that perceived by Black patients (2.10 of 10) (p = 0.001), the absolute difference between these 2 figures was small, suggesting that both groups perceived racial diversity in orthopaedics to be low. White and Black patients differed in their importance ranking of a surgeon's race (p < 0.0001): Black patients ranked a surgeon's race with higher importance (mean, 3.49 of 10) when selecting a surgeon compared with White patients (1.45 of 10). Both male and female patients gave relatively low importance rankings for a surgeon's gender (mean, 1.58 of 10 and 2.15 of 10, respectively, p = 0.02). CONCLUSIONS: Patients in this study did not perceive orthopaedic surgery as a diverse field (overall diversity rating, <3 of 10). There were significant racial and gender differences in patients' preferences for specific physician characteristics when choosing an orthopaedic surgeon, which may help explain some instances of perceived racial bias and difficulty relating to their orthopaedic surgeon.

The Impact of the Addition of a Physical Therapy Assistant to the Treatment Team for Management of Neck Pain: A Retrospective Analysis of Outpatient Physical Therapy Clinics.

Introduction The impact of physical therapy assistants (PTAs) on patient outcomes, mostly in the acute and subacute setting, is well known in the literature. However, no study to date has examined the impact of using PTAs as part of a treatment team in the outpatient setting for common musculoskeletal conditions. The purpose of this study is to determine if physical therapy team composition, either physical therapists (PTs) only or a team consisting of PTs and PTAs, has a significant impact on patient outcomes in adult patients with musculoskeletal neck pain to help investigate an ideal practice pattern for outpatient physical therapy. Methods This is a retrospective cohort study analyzing the impact of physical therapy treatment team composition (PTs only, or team consisting of PTs and PTAs) on pain, active range-of-motion (AROM), and disability outcomes via the Neck Disability Index (NDI) in the conservative treatment of neck pain. All patients were treated with usual physical therapy care. Inclusion criteria involved patients with a diagnosis of neck pain (M48.2), older than 18 years old, a physical therapy evaluation procedure code (97161, 97162, 97163), and at least two visits per bout of physical therapy. Primary outcome measures were pain, bilateral rotation AROM, disability, and number of visits.  Results Included patients (n=195) had an average age of 60.8 years ± 16.1 years with an average number of total physical therapy visits of 7.4 visits ± 4.3 visits (range, 2 visits - 22 visits) with 120 patients (61.5%) treated by a PT only (PT-only group) and 75 patients (38.5%) treated by a team consisting of a PT and a PTA (PTA group). The PT-only group had significantly fewer visits than the PTA group (p<0.001). The PT-only group had a pain improvement of 2.1 points ± 2.3 points whereas the PTA group had a pain improvement of 2.2 points ± 2.4 points with no significant difference between the two groups (p=0.573). The PT-only group (n=46 patients) had an average rotation AROM improvement of 20.0 ± 17.4 degrees whereas the PTA group (n=40 patients) had an average rotation AROM improvement of 16.8 degrees ± 23.0 degrees with no significant difference between the level of rotation AROM improvement between the two groups (p=0.408). Furthermore, there was also no significant difference in the amount of NDI improvement seen in both groups (p=0.594). Conclusion There was no significant difference in patient outcomes for pain, AROM, and disability when PTAs were added to the physical therapy treatment team in the conservative management of neck pain in the outpatient setting. However, patients treated with a treatment team consisting of PTAs had significantly more visits, despite no significant change in outcomes. Randomized controlled trials are needed as the reasons for these findings can be many and require further research.

Factors Associated With the Rate of Recovery After Cervical Decompression Surgery for Degenerative Cervical Myelopathy: A Retrospective Analysis.

Introduction Degenerative cervical myelopathy (DCM) is a debilitating spinal condition with a wide variety of symptoms that can differ greatly among individuals. Common symptoms include numbness, extremity weakness, loss of balance, and gait instability. Decompression surgeries are commonly indicated for the treatment of DCM with varying outcomes reported in the literature. However, there is little evidence on the rate of recovery defined as the time until improvement in symptoms such as numbness, balance, and strength after surgery for DCM. The purpose of this study was to determine the rate of neurological recovery after surgery for DCM and its subsequent association with various risk factors to guide clinicians while providing care and improve patient education. Methods This study was a retrospective case series (n=180 patients) examining patients who underwent cervical decompression surgery for DCM. All patients had a clinical presentation of DCM, were diagnosed with DCM, had radiographic degenerative changes and cervical stenosis, and received surgical management from 2010 to 2020 in a tertiary hospital system. Data recorded included age, smoking status, duration of pre-operative symptoms, preoperative and postoperative pain, and postoperative rate of recovery (days until improvement) in numbness, upper extremity strength, and balance. Results Patients (n=180) had an average age of 65.7 years (SD ±9.2 years, range 43-93 years). The mean ± standard deviation for the rate of recovery (days until improvement) in numbness, upper extremity strength, and balance was 84.5 ± 94.4 days, 50.6 ± 42.8 days, and 60.4 ± 69.9 days, respectively. There was only a marginally significant association between the rate of recovery for numbness after surgery and patient age (p=0.053). The average rate of recovery in numbness for patients older than 60 years was significantly longer than those younger than 60 years (99.3 versus 60.2 days). Preoperative smoking status was significantly associated with persistent moderate to severe pain (p=0.032) within the six-month postoperative period. No significant correlations were seen between the rate of recovery for balance or strength and patient age or preoperative duration of symptoms. Conclusion There was great variability in the rate of recovery for postoperative symptoms after surgery for DCM. A longer time for improvement in postoperative numbness was only marginally correlated with the increased patient age after surgery for DCM. There was no correlation found between strength or balance recovery times and patient age. Smoking status was associated with moderate to severe postoperative pain after surgery for DCM. Furthermore, the duration of preoperative symptoms was not associated with improvement in postoperative symptoms after surgery for DCM. More research is needed to determine factors impacting the rate of recovery after surgery for DCM.

Utilization of Clinical Practice Guideline Interventions in the Conservative Management of Mechanical Neck Pain: A Retrospective Analysis.

INTRODUCTION: Neck pain is a common musculoskeletal condition frequently treated by physical therapists. The American Physical Therapy Association (APTA) published a clinical practice guideline (CPG) in 2008 with a revision in 2017 to improve the diagnosis and treatment of neck pain. One subset of neck pain in the CPG is "Neck Pain with Mobility Deficits," also called mechanical neck pain. Little data exists on the adherence of physical therapists to the CPG-recommended treatments for neck pain as well as the outcomes associated with the utilization of the CPG. The purpose of this study is to examine both CPG treatment adherence and associated outcomes in patients treated for mechanical neck pain by physical therapists in the outpatient setting. METHODS: Retrospective chart review of patients (n=224) who received physical therapy for neck pain between 2018 and 2022. Data ranges were chosen due to the publication of the CPG revision in 2017. Six interventions for mechanical neck pain from the CPG were examined: thoracic manipulation, cervical mobilization, transcutaneous electrical stimulation (TENS), dry needling, advice to stay active, and scapular resistance exercises. The exclusion criteria were a history of cervical spine surgery. Other data collected included age, sex, characteristics of the evaluating physical therapist, and the number of visits. RESULTS: For CPG treatment adherence, 4.5% of patients received thoracic manipulation, 47.8% of patients received cervical mobilization, 12.5% of patients received TENS, 22.8% of patients received dry needling, 99.1% of patients received advice to stay active, and 89.3% of patients received scapular resistance exercises. There was no significant improvement in pain, range of motion (ROM), and function based on a number of CPG interventions used during the bout of physical therapy (p=0.17 to p=0.74). Patients who were evaluated by a physical therapist who was an Orthopedic Certified Specialist (OCS) were more likely to receive more interventions recommended by the CPG (p<0.01). CONCLUSION: CPG-recommended treatments are used with varying frequency by physical therapists when treating mechanical neck pain. Thoracic manipulation is rarely used while scapular resistance exercises are frequently used. There was no significant improvement in pain, ROM, or function based on the number of CPG-recommended treatments used during the bout of physical therapy.

High-frequency vibration effects on material removal mechanisms in ultrasonic transverse scratching of carbon fiber reinforced plastics.

This paper represented some fundamental investigations on the potential effects of the high-frequency vibration on material removal mechanisms in ultrasonic transverse scratching of carbon fiber reinforced plastics (CFRPs). It was found that the ultrasonic superimposition brought about the evident reduction of the ductile-brittle transition depth of the unidirectional CFRPs. For the scratched groove generated without ultrasonic, the tensile stress and compressive stress caused by the indenter penetration were respectively responsible for the formations of the radial cracks at the leading edges and the central region. Under the combination of the inertia effects induced by the ultrasonic superposition and the skin-core structure of the carbon fibers, the micro-defects situated at the interior of the fibers were nucleated simultaneously, and their propagations caused the formations of the oblique cracks. Incorporated with the strain rate effects of the materials, a fresh theoretical model was proposed to describe the evolution of the mechanical stress during the scratching process. The fiber fragments induced by the oblique cracks were just concentrated on the top surface of the scratched groove, due to the coupling effects of the small penetration depth of the indenter and the express reduction of strain rate.

Screening for Vertebrobasilar pathology and upper cervical instability by physical therapists treating neck pain: a retrospective chart review.

INTRODUCTION: Vertebrobasilar vascular pathology and upper cervical ligament instability may contraindicate the use of cervical manual therapy. We examined physical therapists' documentation of screening for these conditions and hypothesized screening would be more common with specific risk factors and when using manual therapy. METHODS: This chart review included adults with neck pain presenting for outpatient physical therapy from 2015-2021. Exclusions were age<18 and history of cervical spine surgery. Demographics, vertebrobasilar and upper cervical ligament instability screening questions and examination tests, risk factors (i.e. hypertension, whiplash), and use of manual therapy were extracted. RESULTS: 260 patients were included (mean age ± standard deviation 59.6 ± 16.2 years, 70.8% female). Physical therapists infrequently administered vertebrobasilar and upper cervical ligament instability tests (each<14%). Screening questions were generally more common (e.g. headache, visual disturbances; each>13%). There was no significant difference in any frequency of screening method given the presence of hypertension, whiplash, or use of manual therapy (p > .05 for each). CONCLUSION: In the present study, physical therapists infrequently documented performance of vertebrobasilar or upper cervical ligament instability screening for adults with neck pain, even in the presence of risk factors or preceding manual therapy. Further research should corroborate these findings and explore reasons for use/avoidance of screening.

Emergency Department Utilization Is Low After Outpatient Elective Rotator Cuff Repair.

INTRODUCTION: The purpose of this study was to establish emergency department (ED) utilization rate and reasons for presentation to the ED after outpatient rotator cuff repair (RCR) and determine preoperative predictors for these ED visits. METHODS: Patients who underwent outpatient RCR between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and stratified. Univariate and multivariate analyses were done to identify independent predictors of ED utilization. RESULTS: The 7- and 30-day ED visit rates were 3.2% and 5.0%, respectively. The most common cause for an ED visit after outpatient RCR at 7- and 30-days postoperatively were postoperative pain (29.0%) and GI complaints (16.3%), respectively. African American race (odds ratio [OD], 1.69; P < 0.001), Hispanic race (OD, 1.47; P = 0.005), and comorbid diagnoses of hypertension (OD, 1.51; P < 0.001), diabetes (OD, 1.58; P < 0.001), and/or schizophrenia (OD, 5.14; P < 0.001) were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare (OD, 2.01; P < 0.001) or Medicaid (OD, 2.61; P < 0.001) were more than twice as likely to present to the ED within 30 days than those with private health insurance. DISCUSSION: ED utilization after outpatient RCR is uncommon with postoperative pain as the most common chief concern for ED visits within the first 7 days and GI issues as the most common reason for ED encounters at up to 30 days postoperatively. Hypertension, diabetes, renal failure, liver disease, rheumatologic diseases, schizophrenia, depression, and Medicare and Medicaid insurance were independent predictors of ED encounters at up to 30 days postoperatively. Procedures done at freestanding surgery centers were protective against ED utilization. LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

High-frequency vibration effects on the hole integrity in rotary ultrasonic drilling of carbon fiber-reinforced plastic composites.

This investigation represented a fundamental research on the potential effects of the high-frequency vibration on the hole integrity involved in rotary ultrasonic drilling (RUD) of carbon fiber-reinforced plastic (CFRP) composites. It was found the increased thickness of the CFRP plate shrunk the flowing velocity of the coolant, which brought about the residual chippings gradually accumulated at the radial clearance between the tool and the material. Furthermore, the chipping accumulation at the clearance seriously increased the friction effects and the resultant thermal load, thus leading to the chipping adhesions on the tool surface and machined cylinder jamming at the central hole of the tool. The mutual constrain between two vertical bundles brought the delamination around the holes generated in conventional drilling (CD) process to a termination at the bundle interface. The ultrasonic superimposition reduced the thrust force of the diamond tool which provided inadequate energy for the delaminated fibers reaching the bundle interface. Moreover, hole position on the two-dimensional orthogonal fabrics significantly influenced the propagation of the delaminated fibers, which weakened the effects of the drilling parameters on the delamination dimensions. Additionally, superimposing an ultrasonic vibration prolonged the abrasive trajectories and increased their overlapping probability, and the induced smoothing effects resulted in the obvious reduction of the surface roughness. The tensile stress exerted on the margin of the machined surface was responsible for the initiation of the CD delamination. After the delaminated fibers reached the bundle interface, the further extrusion of tool brought about the margin suffered from the shear stress, thus leading to the collapse of the machined cylinder. Considering the thrust force of the diamond tool and the undrilled thickness of the machined surface, the critical conditions of the delamination initiation were developed, which revealing that the decreasing of the thrust force caused the reduction of the critical undrilled thickness.

Detecting an infiltrated intravenous catheter using indigo carmine: a novel method.

An extravasated IV catheter may have serious clinical consequences. These include the inability to circulate emergency medications, cause pain on injection, infection at the site, and tissue damage. Clinical signs such as swelling, redness, and pain with injection are valuable, but may not be helpful in the presence of obesity, edema, or in a tracheally intubated and sedated patient. Here we describe a case illustrating a novel approach in which we used an IV dye injection (indigo carmine) to detect a correctly placed and then an extravasated IV. The ability to see visible flow of IV dye intravascularly helped confirm the correct placement. The technique we describe is quick, safe, and inexpensive.