Biologic Disease-Modifying Antirheumatic Drugs Do Not Increase Risk for Prosthetic Joint Infection in Setting of Total Knee Arthroplasty.

Over 25% of patients with rheumatoid arthritis (RA) are expected to undergo a joint replacement during their lifetime. Current practice guidelines recommend withholding biologic therapy 1 week prior to total hip arthroplasty, given its immunosuppressive effects. Most patients are on a regimen including biologic and nonbiologic therapy; however, the individual influences of these therapies are not well understood in the setting of total knee arthroplasty (TKA). Therefore, we sought to compare biologic, nonbiologic, and recipients of both types of therapy in patients with RA undergoing TKA. We specifically assessed (1) medical complications at 90 days; (2) surgical complications up to 1 year; and (3) independent risk factors for prosthetic joint infections (PJIs).A retrospective review was conducted using a national, all-payer database for patients undergoing primary TKA from January 2010 to April 2020 (n = 1.97 million). Patients diagnosed with RA were then separated into at least 1-year users of biologic (n = 3,092), nonbiologic (28,299), or dual (n = 10,949) therapy. Bivariate analyses were utilized to assess for 90-day medical and up to 1-year surgical outcomes. Additionally, multivariate regression models were utilized to assess for independent risk factors.The incidence and odds ratio for medical/surgical outcomes were equivocal among the biologic, nonbiologic, and recipients receiving both types of therapy (p > 0.061). No differences were observed between the type of therapy as additional risk factors for infection (p > 0.505). However, glucocorticoids at 90 days and alcohol abuse, diabetes mellitus, obesity, as well as tobacco use were identified as additional risk factors for PJI(p < 0.036).No appreciable differences in medical or surgical outcomes were associated with the independent use of biologic, nonbiologic, or recipients of both types of therapy in patients with RA. Additionally, alcohol abuse, diabetes mellitus, glucocorticoids, obesity, and tobacco use conferred an increased risk of PJI. These results can serve as an adjunct to current practice guidelines.

Antibiotic Prophylaxis is Often Unnecessary for Screening Colonoscopies Following Total Knee Arthroplasty.

BACKGROUND: Incidence of bacteremia following screening colonoscopy is low, but risk of hematogenous spread causing prosthetic joint infection (PJI) may exist in total knee arthroplasty (TKA) patients. In multivariate analyses, we examined PJI risk among 3 TKA cohorts: (1) colonoscopy recipients given antibiotic prophylaxis; (2) colonoscopy recipients not given antibiotic prophylaxis; and (3) no colonoscopy. We assessed 90-day to 1-year (A) PJI risk and (B) risk factors for postcolonoscopy PJI. METHODS: We queried a national, all-payer database for primary TKA recipients from 2010 to 2020. Patients who had colonoscopies and who did (n = 2,558) or did not have antibiotic prophylaxis (n = 20,000) were identified. These were compared those who did not undergo colonoscopy (n = 20,000). The 20,000 patients were randomly selected to mitigate type-1 errors. Multivariate regressions compared PJI risk factors, such as alcohol abuse (AA), rheumatoid arthritis (RA), and diabetes. RESULTS: Both colonoscopy cohorts had no increased PJI risk compared to noncolonoscopy (odds ratio (OR) ≤ 2.20, P ≥ .064). Alcohol abuse, diabetes, and RA were found to be risk factors further enhancing likelihood of PJI for TKA patients not receiving antibiotics undergoing colonoscopies (OR ≥ 1.35, P ≤ .044). CONCLUSION: Overall, antibiotic prophylaxis does not decrease PJI risk following colonoscopy TKA recipients. After adjusting for known risk factors, both colonoscopy cohorts demonstrated similar PJI risks compared to the noncolonoscopy cohort. However, AA, diabetes, and RA were associated with further increased PJI risk for TKA patients undergoing colonoscopies compared to those who did not. Therefore, if undergoing colonoscopy after TKA, our findings suggest that most patients do not need to have antibiotics except for these high-risk patients.

Disparities in Elective and Nonelective Total Hip Arthroplasty.

BACKGROUND: Prior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication. METHODS: Data were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as "elective" or "nonelective" if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively. RESULTS: After multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation. CONCLUSION: Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.

A Prospective Cohort of Alcohol Use and Alcohol-related Problems Before and After Metabolic and Bariatric Surgery in Adolescents.

OBJECTIVE: To describe alcohol use, alcohol-related harm, and alcohol-related problems preoperatively and up to 8 years following metabolic and bariatric surgery (MBS) in adolescents. BACKGROUND: Risk for alcohol use and alcohol use disorders (AUD) increases post-Roux-en-Y gastric bypass and vertical sleeve gastrectomy in adults. However, data are lacking in adolescents who undergo MBS. METHODS: This study includes 217 adolescents (aged 13-19 y) enrolled in a 5-center prospective cohort study who underwent Roux-en-Y gastric bypass or vertical sleeve gastrectomy (2007-2011) and reported alcohol use preoperatively and annually postoperatively for up to 8 years. Time to elevated Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) score, alcohol-related harm, and alcohol-related problems were analyzed with Kaplan-Meier estimates of cumulative incidence. RESULTS: Preoperatively, the median age was 17 years; the median body mass index was 51 kg/m 2 . Alcohol use frequency and average quantity of drinks per drinking day increased postoperatively (2% consumed alcohol 2-4 times/month 6 months versus 24% 8 years postoperatively, P <0.001; 2% consumed≥3 drinks per drinking day 6 months versus 35% 8 years postoperatively, P <0.001). Cumulative incidence of postoperative onset elevated AUDIT-C score, alcohol-related harm, and alcohol-related problems at year 8 were 45% (95% CI:37-53), 43% (95% CI:36-51), and 47% (95% CI:40-55), respectively. CONCLUSIONS: Nearly half of those who underwent MBS as adolescents screened positively for AUD, symptoms of alcohol-related harm, or alcohol-related problems 8 years post-MBS, highlighting the risk for alcohol use and AUD after MBS in adolescents. AUD evaluation and treatment should be integrated into routine long-term care for adolescents undergoing MBS.

Association Between Bariatric Surgery and Alcohol Use-Related Hospitalization and All-Cause Mortality in a Veterans Affairs Cohort.

Importance: Bariatric surgery procedures, in particular Roux-en-Y gastric bypass (RYGB), have been associated with subsequent alcohol-related complications. However, previous studies lack data to account for changes in body mass index (BMI) or alcohol use over time, which are key potential confounders. Objective: To evaluate the association between RYGB, sleeve gastrectomy, or gastric banding on subsequent alcohol use disorder (AUD)-related hospitalization and all-cause mortality as compared with referral to a weight management program alone. Design, Setting, and Participants: This cohort study included 127 Veterans Health Administration health centers in the US. Patients who underwent RYGB, sleeve gastrectomy, or gastric banding or who were referred to MOVE!, a weight management program, and had a BMI (calculated as weight in kilograms divided by height in meters squared) of 30 or greater between January 1, 2008, and December 31, 2021, were included in the study. Exposures: RYGB, sleeve gastrectomy, or gastric banding or referral to the MOVE! program. Main Outcomes and Measures: The primary outcome was time to AUD-related hospitalization from the time of bariatric surgery or MOVE! referral. The secondary outcome was time to all-cause mortality. Separate propensity scores were created for each pairwise comparison (RYGB vs MOVE! program, RYGB vs sleeve gastrectomy, sleeve gastrectomy vs MOVE!). Sequential Cox regression approaches were used for each pairwise comparison to estimate the relative hazard of the primary outcome in unadjusted, inverse probability treatment weighting (IPTW)-adjusted (generated from the pairwise logistic regression models), and IPTW-adjusted approaches with additional adjustment for time-updating BMI and categorical Alcohol Use Disorders Identification Test-Concise scores. Results: A total of 1854 patients received RYGB (median [IQR] age, 53 [45-60] years; 1294 men [69.8%]), 4211 received sleeve gastrectomy (median [IQR] age, 52 [44-59] years; 2817 men [66.9%]), 265 received gastric banding (median [IQR] age, 55 [46-61] years; 199 men [75.1%]), and 1364 were referred to MOVE! (median [IQR] age, 59 [49-66] years; 1175 men [86.1%]). In IPTW Cox regression analyses accounting for time-updating alcohol use and BMI, RYGB was associated with an increased hazard of AUD-related hospitalization vs MOVE! (hazard ratio [HR], 1.70; 95% CI, 1.20-2.41; P = .003) and vs sleeve gastrectomy (HR, 1.98; 95% CI, 1.55-2.53; P < .001). There was no significant difference between sleeve gastrectomy and MOVE! (HR, 0.76; 95% CI, 0.56-1.03; P = .08). While RYGB was associated with a reduced mortality risk vs MOVE! (HR, 0.63; 95% CI, 0.49-0.81; P < .001), this association was mitigated by increasing alcohol use over time. Conclusions and Relevance: This cohort study found that RYGB was associated with an increased risk of AUD-related hospitalizations vs both sleeve gastrectomy and the MOVE! program. The mortality benefit associated with RYGB was diminished by increased alcohol use, highlighting the importance of careful patient selection and alcohol-related counseling for patients undergoing this procedure.

Modes of failure of hip hemiarthroplasty for femoral neck fracture.

BACKGROUND: Hemiarthroplasty is a common treatment for displaced femoral neck fractures, but limited Canadian data are available about hemiarthroplasty failure. We evaluated the frequency and predictors of hemiarthroplasty failure in Manitoba. METHODS: In this retrospective multicentre province-wide study, billing and joint registry databases showed 4693 patients who had hemiarthroplasty for treatment of femoral neck fracture in Manitoba over an 11-year period (2005-2015), including 155 hips with subsequent reoperations (open or closed) for treatment of hemiarthroplasty failure. Hospital records were reviewed to identify modes of hemiarthroplasty failure, comorbidities and reoperations. Data were analyzed using χ2 test and Poisson and γ regression models. RESULTS: During our study period, 155 hips (154 patients [3%]) underwent 230 reoperations. Of these, 131 hips (85%) initially had an uncemented unipolar modular implant. Indications for first-time reoperation included periprosthetic femur fracture (49 hips [32%]), dislocation (45 hips [29%]), acetabular wear (28 hips [18%]) and infection (26 hips [17%]). There were 46 hips (30%) that had 2 or more reoperations. Reoperation for dislocation was associated with presence of dementia; acetabular wear was associated with absence of dementia. Time from hemiarthroplasty to reoperation was associated inversely with age at hemiarthroplasty, dislocation and dementia and was directly associated with acetabular wear. The risk of having 2 or more reoperations was associated independently with dislocation, infection, and alcohol abuse. CONCLUSION: Hemiarthroplasty for femoral neck fracture in Manitoba had a low frequency of failure. Risk factors for multiple reoperations included dislocation, infection and alcohol abuse.

Predictive Factors for Aortic Graft Infection: A Case-Control Study.

BACKGROUND: Graft infections are one of the most serious complications in vascular surgery, with high mortality rates. Few studies addressed risk factors associated with a higher susceptibility to infection. The aim of this study is to identify perioperative factors associated with aortic graft infections (AGI). METHODS: We designed a retrospective, case-control study from patients subjected to open aortic repair between 2013 and 2019. Cases of AGI were defined according to the management of aortic graft infection collaboration (MAGIC) criteria and matched to controls without proven infection. Demographics, hospital complications, and laboratory workups were assessed. Predictors of AGI were identified through univariate and multivariate analysis. RESULTS: Most graft infections occurred in a late period (n = 17; 85%), after a median interval of 13.5 months interquartile range (IQR 1.5-36). Gram-negative bacteria were most frequently isolated in infected grafts, namely Enterobacteriaceae (n = 12). Cases had significantly lower postoperative serum albumin levels (1.9 g/dL vs. 2.4 g/dL; P = 0.002). Alcohol abuse, malignancy, prolonged lengths of stay, wound infection and dehiscence, in-hospital infection, postoperative heart failure or bowel ischemia were significantly correlated to the onset of AGI. In the multivariate analysis, prolonged hospital stays odds ratio (OR 1.05; P = 0.03), malignancy (OR 5.82; P = 0.03) and alcohol abuse (OR 42.41; P = 0.002) maintained a significant association. CONCLUSIONS: The risk of AGI seems to be higher in patients with concurrent malignancy, alcohol abuse or prolonged hospital stays. Strategies to mitigate this complication in these patients are of utmost importance.

Neurosurgery in the Treatment of Alcohol Use Disorder: A Systematic Literature Review

Alcohol abuse has impacts on public health worldwide. Conservative treatment to achieve abstinence consists of detoxification combined with psychotherapy and the use of drugs, but it is estimated that only half of the individuals achieve long-term abstinence with the available treatments. In this sense, neurosurgery appears as a therapeutic proposal. The present study aimed to gather information about the circuitry related to alcohol use disorder (AUD), to describe possible surgical targets, and to establish whether a surgical approach could be a safe and effective treatment option. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The 14 selected articles analyze ablative operations, deep brain stimulation (DBS), and a new procedure in which the patient is first submitted to repetitive transcranial magnetic stimulation to evaluate their response, and later an implant is surgically positioned on the evaluated target to obtain more lasting results. The most relevant outcomes were found when the anterior cingulate cortex (ACC) and the nucleus accumbens (NAcc) were used as targets, demonstrating a large reduction in alcohol intake and even its cessation. However, important side effects were observed, such as psychotic symptoms, right frontal venous infarction, seizures after implantation in the ACC and a hypomanic period after DBS in the NAcc, which could be reversed. Due to the lack of studies involving the surgical treatment of AUD, more clinical trials are needed to compare targets, to assess surgical techniques, and to estimate the safety of these techniques.

Cirugía bariátrica y trastorno por abuso de alcohol y otras sustancias: una revisión sistemática / Bariatric surgery and alcohol and substance abuse disorder: A systematic review

Antecedentes: La cirugía bariátrica es un procedimiento quirúrgico relativamente seguro y con alta tasa de éxito. Sin embargo, reportes recientes indican una mayor prevalencia de abuso de alcohol u otras sustancias en este grupo de pacientes. El propósito del presente estudio fue revisar la evidencia que existe al respecto para que sea tomada en cuenta por el equipo multidisciplinario que atiende a este grupo de pacientes. Métodos: Se realizaron búsquedas en las bases de datos de PubMed y CENTRAL, y se extrajeron las razones de momio de los distintos artículos, comparando la prevalencia por abuso de alcohol o de otras sustancias en el periodo posquirúrgico vs. los niveles prequirúrgicos. También se comparó la prevalencia de abuso de alcohol tras distintos tipos de cirugía bariátrica. Resultados: Un total de 49.121 pacientes bariátricos (80,8% mujeres) fueron evaluados para abuso de alcohol. De manera general, se encontró que la cirugía bariátrica estaba asociada con un aumento en la prevalencia por abuso de alcohol (4,58±5,3 vs. 1,58±10,7% en el periodo prequirúrgico). También encontramos que la población de pacientes que se sometieron a cirugía de tipo RYGB tenía mayor prevalencia de abuso de alcohol que aquellos que se sometieron a otro tipo de cirugía (OR: 1,83; IC 95%: 1,51-2,21). La prevalencia de abuso de sustancias distintas al alcohol tras este procedimiento está menos estudiada, aunque parece existir un aumento en el riesgo por abuso a ciertas sustancias. Conclusiones: La cirugía bariátrica es el mejor tratamiento para la obesidad y sus complicaciones. La evidencia revisada sugiere que se relaciona con un aumento modesto, pero consistente en la prevalencia por abuso de alcohol y otras sustancias. El equipo médico a cargo del paciente bariátrico deberá estar informado acerca de esta eventualidad para su oportuna prevención, diagnóstico y tratamiento. (AU)

Introduction: Bariatric surgery is a relatively safe surgical procedure with a high success rate. However, recent reports indicate a higher prevalence of alcohol or substance abuse disorder in this patient group. The purpose of this study was to review the related evidence to serve as a reference for multidisciplinary teams who treat these patients. Methods: We searched the PubMed and CENTRAL databases. The odds ratios were extracted from the different articles, comparing the prevalence of the abuse of alcohol or other substances in the postoperative period versus preoperative levels. We also compared the prevalence of alcohol use disorder after different types of bariatric surgery. Results: A total of 49 121 bariatric patients (80.8% female) were evaluated for alcohol use disorder. In general, bariatric surgery was found to be associated with an increase in the prevalence of alcohol abuse (4.58±5.3 vs. 1.58±10.7% in the preoperative period). We also found that the population of patients who underwent RYGB procedures had a higher prevalence of alcohol use disorder than patients who underwent another type of surgery (OR: 1.83; 95% CI: 1.51-2.21). The prevalence of substance abuse disorder (other than alcohol) after this procedure is less studied, although there appears to be an increased risk of abuse of certain substances. Conclusions: Bariatric surgery is the best treatment for obesity and its complications. The evidence reviewed suggests that it correlates with a modest but consistent increase in the prevalence of abuse of alcohol and other substances. Medical teams who treat bariatric patients must be informed about this eventuality for its timely prevention, diagnosis and treatment. (AU)

Interoception and alcohol addiction: Vagotomy induces long-lasting suppression of relapse-type behavior.

Drug addictions are chronic mental disorders characterized by compulsive drug seeking and drug use, despite their negative consequences. It is a priority to find therapeutic alternatives to prevent relapse, as there are still no treatments that can ensure abstinence. One of the neural systems implicated in the appearance of the states of discomfort that motivate relapse is the interoceptive system, which oversees our internal body states. However, less attention has been given to the peripheral components of the interoceptive system and their role in addictions. Within these pathways, the vagus nerve represents one of the main visceral afferents of the interoceptive system. We hypothesized that the interruption of visceral afferent pathways would decrease the motivational effects of the drug, thereby either decreasing or preventing drug cravings. To test this idea, we used rats of a high-alcohol-drinking line and measured the effect that vagus nerve resection had on the relapse-like alcohol drinking, expressed as the alcohol deprivation effect, a phenomenon that has been linked to addiction-related events such as alcohol cravings. We found that even though vagotomy completely eliminates the effect of alcohol deprivation, it has no impact on water consumption or animal weight. These results give us valuable information about the relationship between the autonomic nervous system and alcohol use disorders and allow us to propose new clinical research that might have translational options.

Alcohol Use Relapse Following Liver Transplantation for Alcoholic Liver Disease.

BACKGROUND Alcohol use disorders affect 10% of the European population. Alcohol-related liver disease (ALD) is the most common indication for liver transplantation in Slovakia. The aim of this study was to determine the proportion of patients with ALD who received a liver transplant who had alcohol relapsed, and the risk factors for alcohol relapse, as well as to compare clinical outcomes according to relapse. MATERIAL AND METHODS A retrospective study of consecutive patients with ALD, who underwent liver transplantation in a single transplant center between May 2008 and December 2017. We included adult patients who received a liver transplant due to ALD and excluded those who died <1 month after liver transplantation. We recorded demographic and clinical characteristics, graft injury, and overall mortality and compared them between relapsers and abstainers. RESULTS During the study period, we reviewed 196 cases of liver transplantation in 191 patients. We excluded 87 patients for non-ALD etiology and 15 patients by predefined criteria. The final analysis was carried out in 89 patients, mean aged 55 years; 24.7% were female. We diagnosed relapse in 23 patients (26%) with harmful drinking in 52% and occasional drinking in 48% of relapsers. The independent risk factors associated with relapse were: smoking (OR=5.92, P=0.006), loss of social status (OR=7.61, P=0.002), and time after liver transplantation (OR=1.0008, P=0.015). Graft injury was more frequent in relapsers with 2 independent risk factors: occasional drinking (OR=12.7, P=0.0005), and harmful drinking (OR=36.6, P<0.0001); overall survival was unaffected. CONCLUSIONS We found relapse to alcohol drinking in 26% of patients who received a liver transplant for ALD. Risk factors associated with alcohol drinking relapse were time, cigarette smoking, and loss of social status. Graft injury was more frequent in relapsers, but mortality was similar between relapsers and non-relapsers.

Leptin Expression and Gene Methylation Patterns in Alcohol-Dependent Patients with Ethyltoxic Cirrhosis-Normalization After Liver Transplantation and Implications for Future Research.

AIMS: Liver transplantation is the only curative treatment available for patients with end-stage alcoholic liver disease. As different studies showed a significant association between leptin plasma levels, gene methylation patterns and the extent of craving in alcohol-dependent patients, we investigated the effect of liver transplantation on leptin expression and promoter methylation. SHORT SUMMARY: The present study shows that in alcohol-dependent patients with liver cirrhosis leptin is significantly higher before liver transplantation and decreases significantly after transplantation. Alcohol-dependent patients on the waiting list had significantly higher leptin promoter methylation values than patients who underwent liver transplantation for other reasons than alcoholic liver disease. METHODS: Only plasma of 118 and peripheral blood mononuclear cells of 121 patients were used: healthy controls (C, n = 24/22), alcohol-dependent patients without ethyltoxic liver cirrhosis (AD, n = 24/22), patients after liver transplantation for other reasons than ethyltoxic liver cirrhosis (C-Tx, n = 18/21), alcohol-dependent patients suffering from ethyltoxic liver cirrhosis on the transplantation waiting list (Pre-Tx, n = 30/28) and patients with prior ethyltoxic liver cirrhosis after liver transplantation (Post-Tx, n = 22/28). RESULTS: Leptin protein was significantly elevated in the pre-transplantation cohort when compared to post-transplantation and alcohol-dependent cohorts. Furthermore, leptin promoter methylation was higher in ethyltoxic patients before transplantation compared to non-ethyltoxic patients after transplantation, but not when compared to ethyltoxic patients after transplantation. C-Tx had lower methylation values than all other groups except for Post-Tx. CONCLUSIONS: Our study outlines the role of leptin protein levels as a marker for AD-related liver damage, contrasting it from AD without severe liver damage. With regard to the results of the methylation analysis, inflammation of the liver appears to cause mechanisms of leptin regulation to deviate from transcriptional regulation. Our data also suggest that leptin regulation is altered in ethyltoxic liver disease when compared to liver cirrhosis caused by other pathologies.

Risk Factors for Readmissions Following Anterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective study of prospectively collected data. OBJECTIVE: To analyze the incidence and risk factors for readmissions following anterior lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: No study has yet reported readmission rates for a specific lumbar surgical approach. There is evidence to indicate differences in perioperative complication rates between anterior versus posterior lumbar interbody fusion techniques, which may translate into differences in readmission rates. METHODS: The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent anterior lumbar interbody fusion. Patients were separated into groups of those with and without 30-day readmissions. Univariate analysis and multivariate logistic regression were used to analyze the effect of different risk factors on 30-day readmissions. RESULTS: Multivariate analysis showed that morbid obesity (odds ratio 15.6, P = 0.002) and alcohol use (odds ratio 16.9, P = 0.004) independently predicted unplanned 30-day readmission. Sex, pulmonary comorbidity, cardiac comorbidity, and steroid use were not found to be significant independent predictors of unplanned 30-day readmission in anterior lumbar interbody fusion. CONCLUSION: Adult patients undergoing anterior lumbar interbody fusion who were morbidly obese and had history of alcohol use are at increased risk for 30-day readmissions. Future studies should look to directly compare readmission rates and risk factors between alternative lumbar interbody surgical approaches with longer follow-up and more clinical and radiological parameters investigated. LEVEL OF EVIDENCE: 3.

Delirio postoperatorio en pacientes con historial de abuso de alcohol / Postoperative delirium in patients with history of alcohol abuse

Introducción. El delirio postoperatorio (DPO) es un estado confusional agudo caracterizado por cambios fluctuantes en el nivel de consciencia y la función cognitiva, que se desarrolla en un corto período de tiempo. El objetivo de este estudio fue evaluar la relación entre el abuso de alcohol y el desarrollo de DPO. Métodos. Estudio prospectivo incluyendo pacientes programados para cirugía electiva, admitidos en la unidad de cuidados post-anestésicos. Previamente a la cirugía, se preguntó a los pacientes sobre el consumo de alcohol, el cual se evaluó mediante el cuestionario Cutting Down, Annoyance, Guilt and Eye-opener (CAGE); la puntuación ≥2 se definió como abuso de alcohol. Las comparaciones se realizaron utilizando las pruebas exacta de Fischer o de χ2. Los factores de riesgo se analizaron mediante una regresión logística multivariante con razón de momios (RM) e intervalos de confianza del 95% (IC95%). Resultados. Doscientos veintiún pacientes fueron estudiados. El delirio se observó en el 11% de los pacientes. La incidencia del abuso de alcohol fue del 10%. Los pacientes con abuso de alcohol eran más frecuentemente varones (p<0,001) y tenían un mayor grado de riesgo perioperatorio de la ASA (ASAIII/IV) (p=0,021). La edad (RM: 5,9; IC95%: 2,2-15,9; p<0,001 para pacientes mayores de 65años), el estado físico ASAIII/IV (RM: 4,2; IC95%: 1,7-10,7; p=0,002) y el abuso de alcohol (RM: 4,2; IC 95%: 1,4-12,9; p=0,013) resultaron ser factores predictivos independientes del DPO. Conclusiones. Las características más frecuentes en los pacientes con DPO fueron la edad avanzada, una mayor puntuación para el estado físico según la clasificación ASA y el abuso de alcohol. El abuso de alcohol se considera un factor de riesgo independiente para el DPO (AU)

Introduction. Postoperative delirium (POD) is an acute confusional state characterized by changes in consciousness and cognition, which may be fluctuating, developing in a small period of time. The aim of this study was to evaluate the relationship between alcohol abuse and the development of POD. Methods. We prospectively evaluated consecutively all postoperative patients admitted in the Post-anesthesia Care Unit over a 1-month period for delirium, using the Portuguese versions of the the Nursing Delirium Screening Scale. Before surgery, alcohol consumption was inquired and alcohol abuse was assessed by the CAGE (Cutting Down, Annoyance, Guilt and Eye-opener) questionnaire; a score ≥2 defined alcohol abuse. Fischer exact test or chi-square was applied for comparisons. Risk factors were analyzed in a multivariate analysis using a logistic regression with odds ratios (OR) and 95% confidence intervals (95%CI). Results. Two hundred twenty-one patients were enrolled. Delirium was seen in 11% patients. The incidence of alcohol abuse was 10%. Patients with alcohol abuse were more frequently men (P<.001) and had a higher ASA physical status III/IV (P=.021). POD was more frequent in patients with alcohol abuse (30% vs. 9%; P=.002). Age (OR: 5.9; 95%CI: 2.2-15.9; P<.001 for patients ≥65years), ASA physical statusIII/IV (OR: 4.2; 95%CI: 1.7-10.7; P=.002) and alcohol abuse (OR: 4.2; 95%CI: 1.4-12.9; P=.013) were found to be independent predictors for POD. Conclusions. Older patients, higher ASA physical status and alcohol abuse were more frequent in patients with POD. Alcohol abuse was considered an independent risk factor for POD (AU)

Outcomes and predictors of harmful relapse following liver transplantation for alcoholic liver disease in an Australian population.

BACKGROUND: Limited studies of patient survival and alcoholic relapse following transplantation for alcoholic liver disease have been described in Australian populations. AIM: To describe these outcomes in an Australian population, to determine the association between harmful alcoholic relapse and patient survival, and to examine pre-transplant variables associated with harmful relapse. METHODS: Single centre, retrospective review of consecutive patients transplanted at the South Australian Liver Transplant Unit. Relapse was identified by an independent investigator using case note review and confidential patient questionnaire. RESULTS: A total of 87 patients (median age 52 years, 84% male, median Model for End-Stage Liver Disease (MELD) score 18) was included in the study with a median follow-up time of 50 months. The 1-, 3- and 5-year survival of patients was 93.1, 87.4 and 82.0% respectively. Two deaths were directly attributable to graft failure due to alcohol. Fourteen (16%) patients fulfilled criteria for harmful relapse and 18 (21%) patients experienced any form of relapse to alcohol. Harmful relapse was associated with increased mortality (hazard ratio (HR) 3.2, 95% confidence interval (CI) 1.1-9.7, P = 0.041). Only two factors were independently associated with harmful relapse on multivariate analysis; prior alcohol rehabilitation (HR 8.4, 95% CI 2.5-28.4, P = 0.001) and single versus married status (HR 0.09, 95% CI 0.02-1.2, P = 0.019). CONCLUSION: Good patient survival outcomes were seen for this South Australian population. Harmful alcohol relapse occurs in a minority of patients and rarely results in direct graft loss. Modifiable pre-transplant factors that predict harmful relapse were not identified.

Anterior Cingulate Implant for Alcohol Dependence: Case Report.

BACKGROUND AND IMPORTANCE: Alcohol dependence is related to dysfunctional brain processes, in which a genetic background and environmental factors shape brain mechanisms involved with alcohol consumption. Craving, a major component determining relapses in alcohol abuse, has been linked to abnormal brain activity. CLINICAL PRESENTATION: We report the results of a treatment-intractable, alcohol-addicted patient with associated agoraphobia and anxiety. Functional imaging studies consisting of functional magnetic resonance imaging and resting-state electroencephalogram were performed as a means to localize craving-related brain activation and for identification of a target for repetitive transcranial magnetic stimulation and implant insertion. Repetitive transcranial magnetic stimulation of the dorsal anterior cingulate cortex with a double-cone coil transiently suppressed his very severe alcohol craving for up to 6 weeks. For ongoing stimulation, 2 "back-to-back" paddle electrodes were implanted with functional magnetic resonance imaging neuronavigation guidance for bilateral dorsal anterior cingulate cortex stimulation. Using a recently developed novel stimulation design, burst stimulation, a quick improvement was obtained on craving, agoraphobia, and associated anxiety without the expected withdrawal symptoms. The patient has remained free of alcohol intake and relieved of agoraphobia and anxiety for over 18 months, associated with normalization of his alpha and beta activity on electroencephalogram in the stimulated area. He perceives a mental freedom by not being constantly focused on alcohol. CONCLUSION: This case report proposes a new pathophysiology-based target for the surgical treatment of alcohol dependence and suggests that larger studies are warranted to explore this potentially promising avenue for the treatment of intractable alcohol dependence with or without anxiety and agoraphobia. ABBREVIATIONS: ACC, anterior cingulate cortexBOLD, blood oxygen level dependentdACC, dorsal anterior cingulate cortexDBS, deep brain stimulationEEG, electroencephalogramfMRI, functional magnetic resonance imagingrTMS, repetitive transcranial magnetic stimulationSMA, supplementary motor areaTMS, transcranial magnetic stimulation.

Safety and drinking outcomes among patients with comorbid alcohol dependence and borderline personality disorder treated with high-dose baclofen: a comparative cohort study.

In France, the off-label use of high-dose baclofen (HDB) for alcohol dependence is spreading. HDB induces frequent neuropsychiatric adverse events (AEs). Borderline personality disorder (BPD) is a major axis-two psychiatric disorder that exposes to frequent comorbid alcohol dependence and increased risky behaviors. We investigated the drinking and safety outcomes of patients with BPD treated with HDB for comorbid alcohol dependence. In a prospective cohort of 204 patients with alcohol dependence treated by HDB, 23 patients fulfilled the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. criteria for BPD. We paired two control participants without a psychiatric history with each BPD patient according to age and sex. We compared the average lengths of follow-up, average doses of baclofen received, rates of heavy drinking days, rates of serious AEs, and rates of AEs resulting in baclofen withdrawal. Between BPD patients (n=23) and controls (n=46), there were no significant differences in mean age (45.3±11.2 vs. 45.2±11.2 years), sex ratio (43.5% women), mean duration of follow-up (8.0±4.0 vs. 7.7±4.2 months; P=0.77), and average daily dose of baclofen (102.2±42.7 vs. 94.6±9.7 mg/day; P=0.44). However, the mean rate of heavy drinking days (74.3±25.3 vs. 41.7±33.3%; P<10E-4), the rate of serious AEs (65.2 vs. 6.5%; P<10E-4), and the rate of treatment discontinuation after AEs (52.2 vs. 8.6%; P<10E-4) were significantly higher in BPD. The benefit/risk balance of HDB appears to be unfavorable in comorbid BPD patients compared with nonpsychiatric patients.