Controllable multi-halogenation of a non-native substrate by SyrB2 iron halogenase.

Geminal, multi-halogenated functional groups are widespread in natural products and pharmaceuticals, yet no synthetic methodologies exist that enable selective multi-halogenation of unactivated C-H bonds. Biocatalysts are powerful tools for late-stage C-H functionalization, as they operate with high degrees of regio-, chemo-, and stereoselectivity. 2-oxoglutarate (2OG)-dependent non-heme iron halogenases chlorinate and brominate aliphatic C-H bonds offering a solution for achieving these challenging transformations. Here, we describe the ability of a non-heme iron halogenase, SyrB2, to controllably halogenate non-native substrate alpha-aminobutyric acid (Aba) to yield mono-chlorinated, di-chlorinated, and tri-chlorinated products. These chemoselective outcomes are achieved by controlling the loading of 2OG cofactor and SyrB2 biocatalyst. By using a ferredoxin-based biological reductant for electron transfer to the catalytic center of SyrB2, we demonstrate order-of-magnitude enhancement in the yield of tri-chlorinated product that were previously inaccessible using any single halogenase enzyme. We also apply these strategies to broaden SyrB2's reactivity scope to include multi-bromination and demonstrate chemoenzymatic conversion of the ethyl side chain in Aba to an ethylyne functional group. We show how steric hindrance induced by the successive addition of halogen atoms on Aba's C4 carbon dictates the degree of multi-halogenation by hampering C3-C4 bond rotation within SyrB2's catalytic pocket. Overall, our work showcases the synthetic potential of iron halogenases to facilitate multi-C-H functionalization chemistry.

International Classification of Diseases Coding for Inflammatory Arthritides.

This quality improvement study investigates usage patterns of codes for inflammatory arthritides under International Statistical Classification of Diseases and Related Health Problems, Tenth Revision vs International Classification of Diseases, Ninth Revision.

Extramedullary plasmacytoma of the larynx - Case report.

Extramedullary plasmacytoma of the larynx is an extremely rare entity accounting for 0.04-0.45% of malignant tumours of the larynx. The objective of this clinical case report is to highlight the diagnosis and management of a unique case such as this. A 77-year-old gentleman presented with complaints of hoarseness for 1 year. Computed tomography image revealed a soft tissue mass lesion involving the right true vocal cord. Direct laryngoscopic biopsy was performed and subjected to histopathological examination, which showed collection of plasma cells. Immunohistochemistry confirmed the presence of Kappa and Lambda cells. Multiple myeloma (MM) was ruled out. The patient received radical intent radiation therapy using 3DCRT technique with a dose of 50Gy in 25# over 5 weeks. He experienced improvement in hoarseness on subsequent follow-up visits. At 1-year follow up, positron emission tomography computed tomography showed near total resolution of disease with no progression to MM. Radiation therapy alone is known to achieve good local control, recurrence free survival, and organ preservation in such cases.

Comparative negation of amphiphile production using nutrition factors: Amyloids versus biosurfactants.

Microbial amphiphiles play an important role in environmental activities such as microbial signaling, bioremediation, and biofilm formation. Microorganisms rely on their unique characteristics of interfaces to carry out critical biological functions, which are helped by amphipathic biomolecules known as amphiphiles. Bacillus amyloids aid in cell adhesion and biofilm formation. Pseudomonas sp. are essential in biofilm development and are a vital survival strategy for many bacteria. Furthermore, Pseudomonas and Bacillus are well-known for their ability to produce biosurfactants with a range of applications, including bioremediation and removing biological pollutants from different environments. The study employed 31 different media types and a range of analytical techniques to assess the presence of amyloid proteins and the absence of biosurfactants in Bacillus licheniformis K125 (GQ850525.1) and Pseudomonas fluorescens CHA0. The presence of amyloid proteins was confirmed through Congo red and thioflavin T staining. The carefully constructed medium also efficiently inhibited the synthesis of biosurfactants by these bacteria. Additionally, surface tension measurements, emulsification index, thin-layer chromatography, and high-performance thin-layer chromatography analyses indicated the absence of biosurfactants in the tested media.

Ocular surface changes in patients who have undergone head and neck radiation therapy.

PURPOSE: Dry eye syndrome (DES) is a familiar sequelae of radiation therapy (RT) for head and neck cancers (HNC). Ocular surface changes such as DES occur due to injury to the conjunctival epithelium, goblet cells, corneal surface, lacrimal glands, and meibomian glands. This study aimed at the evaluation and early detection of changes in ocular surface parameters in patients receiving RT for extraocular HNC. METHODS: Forty-two eyes of 21 patients undergoing HNC RT were evaluated. Radiation technique and dose of radiation to the lens and eye were recorded. Subjects were evaluated for meibomian gland changes by meiboscore grading, ocular surface disease index (OSDI) questionnaire, Schirmer's test, tear film break-up time (TBUT), and slit-lamp examination before RT, immediately post RT, and 6 weeks post RT. A comparison of the ipsilateral eye on the irradiated side to the contralateral eye was done. RESULTS: A significant reduction in TBUT was seen immediately post RT and 6 weeks post RT ( P < 0.001 and 0.008, respectively), with an increase in meiboscore at both visits ( P < 0.001). An OSDI score of >13 was seen in 23.80% of patients post RT, with a significant difference from baseline ( P < 0.001). On comparing ipsilateral and contralateral eye groups, a significant difference from baseline was seen in TBUT ( P < 0.001 and 0.033, respectively) and meiboscore ( P < 0.001 for both eyes). A significant change of >1 second in TBUT and >1.7 in meiboscore was seen with a mean dose of around 8 Gy to the lens. CONCLUSION: All patients undergoing HNC RT should be followed up for ocular surface and meibomian gland changes. The contralateral eye should also be evaluated. Patients receiving lower doses to the ocular structures should also be kept under follow-up.

Physical Therapy Utilization Following Single Level Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Characterize physical therapy (PT) utilization following single-level posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA: PLF is a common procedure that is increasing in frequency. Following such surgeries, PT may be considered to facilitate mobilization and return to activities. However, the usage of such therapy has not been well-characterized in the literature. METHODS: Patients undergoing single-level PLF were identified from the 2010-2021 PearlDiver administrative database. These patients were stratified based on usage of therapy, home versus outpatient therapy, and timing of therapy within the year following surgery. To determine predictors of therapy, patient characteristics were determined and multivariable regressions were performed. RESULTS: A total of 213,240 patients undergoing single-level PLF were identified, of which therapy was done in the year following surgery for 63,231 (29.0%, of which home therapy accounted for 16.5% of therapy visits). Of those who utilized PT, the average number of visits was 10.6±10.6. Home therapy peaked within the first month following surgery and outpatient therapy peaked at month two. Factors associated with any PT following PLF in decreasing odds ratio (OR) were: having commercial insurance (OR: 1.68), being from the Northeast (OR:1.41), age (OR: 1.13 for 70+ of age) female sex (OR: 1.09), and ECI (OR: 1.04 per point) (P<0.001 for all). Of those who received therapy, factors associated with home PT utilization were: being from the Northeast (OR: 2.55), age (OR: 1.91 for 70+ of age), Medicaid insurance (OR: 1.48), female sex (OR: 1.39), and interbody fusion (OR:1.07) (P<0.001 for all). CONCLUSIONS: Following single-level PLF, the minority of patients received home or outpatient PT. Of those that did, there was significant variation in the number of visits, with nonmedical factors such as insurance plan and geographic region being strongly associated suggesting room for more consistent practice patterns. LEVEL OF EVIDENCE: III.

Severe Acute Respiratory Syndrome Coronavirus 2 Did Not Substantially Impact Injury Patterns or Performance of Players in the National Basketball Association From 2016 to 2021.

Purpose: To perform a descriptive epidemiologic analysis of National Basketball Association (NBA) injuries from 2016 to 2021, to evaluate the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019, or COVID-19) on injury patterns and performance statistics, and to determine the effect of infection with SARS-CoV-2 on individual performance statistics. Methods: Injury epidemiology in the NBA from the 2016 to 2021 seasons was collected using a comprehensive online search. Injuries and time missed were categorized by injury location and type. Player positions and timing of injury were recorded. Performance statistics were collected including traditional game statistics and Second Spectrum (speed, distance) statistics. Comparisons were made over seasons and comparing the pre-COVID-19 pandemic seasons to the pandemic era seasons. Players diagnosed with COVID-19 were analyzed for changes in performance in the short or long term. Results: Of the 3,040 injuries captured, 1,880 (61.84%) were in the lower extremity. Guards (77.44%) and forwards (75.88%) had a greater proportion of soft-tissue injuries (P < .001) than centers. Guards had the highest proportion of groin (3.27%, P = .001) and hamstring (6.21%, P < .001) injuries. Despite minor differences on a per-season basis, there were no differences in injury patterns identified between pre-COVID-19 and COVID-19 eras. Of players diagnosed with COVID-19 during the NBA Bubble, there were no detriments in short- or long-term performance identified, including traditional game statistics and speed and distance traveled. Conclusions: In the NBA seasons from 2016 to 2021, most injuries were to the lower extremity. The SARS-CoV-2 pandemic did not substantially impact injury patterns in the NBA, including locations of injury and type of injury (bony or soft tissue). Furthermore, infection with SARS-CoV-2 does not appear to have a significant impact on performance in basketball-specific or speed and distance measures. Level of Evidence: Level IV, prognostic case series.

Importance of microbial amphiphiles: interaction potential of biosurfactants, amyloids, and other exo-polymeric-substances.

Microorganisms produce a diverse group of biomolecules having amphipathic nature (amphiphiles). Microbial amphiphiles, including amyloids, bio-surfactants, and other exo-polymeric substances, play a crucial role in various biological processes and have gained significant attention recently. Although diverse in biochemical composition, these amphiphiles have been reported for common microbial traits like biofilm formation and pathogenicity due to their ability to act as surface active agents with active interfacial properties essential for microbes to grow in various niches. This enables microbes to reduce surface tension, emulsification, dispersion, and attachment at the interface. In this report, the ecological importance and biotechnological usage of important amphiphiles have been discussed. The low molecular weight amphiphiles like biosurfactants, siderophores, and peptides showing helical and antimicrobial activities have been extensively reported for their ability to work as quorum-sensing mediators. While high molecular weight amphiphiles make up amyloid fibers, exopolysaccharides, liposomes, or magnetosomes have been shown to have a significant influence in deciding microbial physiology and survival. In this report, we have discussed the functional similarities and biochemical variations of several amphipathic biomolecules produced by microbes, and the present report shows these amphiphiles showing polyphyletic and ecophysiological groups of microorganisms and hence can `be replaced in biotechnological applications depending on the compatibility of the processes.

Bucket-Handle Meniscus Tear Management With Meniscectomy Versus Repair Correlates With Patient, Socioeconomic, and Hospital Factors.

INTRODUCTION: Bucket-handle meniscus tears are common knee injuries that are often treated surgically with meniscectomy or meniscal repair. Although clinical factors may influence the choice of one treatment approach over the other, the influence of patient, socioeconomic, and hospital factors remains poorly characterized. This study aimed to estimate the relative nationwide utilization of these two procedures and delineate a variety of factors that are associated with the selection of one treatment approach over the other. METHODS: Meniscal repair and meniscectomy procedures conducted for isolated bucket-handle meniscus tears in 2016 and 2017 were identified in the Nationwide Ambulatory Surgery Sample database. Cases were weighted using nationally representative discharge weights. Univariate analyses and a multivariable logistic regression model were used to compare patient, socioeconomic, and hospital factors associated with meniscal repair versus meniscectomy. RESULTS: In total, 12,239 cases were identified, which represented 17,236 cases after weighting. Of these, meniscal repair was conducted for 4,138 (24.0%). Based on the logistic regression model, meniscal repair was less likely for older and sicker patients. By contrast, several factors were associated with markedly higher odds of undergoing meniscal repair compared with meniscectomy. These included urban teaching hospitals; geographic location in the midwest, south, and west; and higher median household income. DISCUSSION: Using a large nationally representative cohort, the current data revealed that only 24.0% of surgically treated bucket-handle meniscus tears were treated using repair. Identification of patient, socioeconomic, and hospital factors differentially associated with meniscal repair suggest that other factors may systematically influence surgical decision-making for this patient population. Surgeons should be conscious of these potential healthcare disparities when determining the optimal treatment for their patients. LEVEL OF EVIDENCE: Level III.

Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations: A Single Institution's Perspective.

STUDY DESIGN: A retrospective cohort study of a patient undergoing treatment at a single institution's Spine Center. OBJECTIVE: The current study assessed the rates and eventual disposition of pre-authorizations required before spine MRIs are ordered from an academic spine center. SUMMARY OF BACKGROUND DATA: Spine magnetic resonance imaging (MRI) often requires preauthorization by insurance carriers. While there are potential advantages to ensuring consistent indicators for imaging modalities, previous studies have found that such processes can add administrative burdens and barriers to care. METHODS: Patients from a single academic institution's spine center who were covered by commercial insurance and had a spine MRI ordered between January 2013 and December 2019 were identified. The requirement for preauthorization and eventual disposition of each of these studies was tracked. Multivariate logistic regression was used to determine if commercial insurance carriers or anatomic region MRIs were associated with requiring a preauthorization. The eventual disposition of studies associated with this process was tracked. RESULTS: In total, 2480 MRI requests were identified, of which preauthorization was needed for 2122 (85.56%). Relative to cervical spine scans, preauthorization had greater odds of being required for thoracic (OR=2.71, P =0.003) and lumbar (OR=2.46, P <0.001) scans. Relative to a reference insurer, 4 of the 5 commercial carriers had statistically significant increased odds of requiring preauthorization (OR=1.54-10.17 P <0.050 for each).Of the imaging studies requiring preauthorization, peer to peer review was required for 204 (9.61%), and 1,747 (82.33% of all requiring preauthorization) were approved. Of 375 (17.67%) initially cancelled or denied by the preauthorization process, 290 (77.33% of those initially cancelled or denied) were completed within 3 months. In total, only 85 were not eventually approved and completed. CONCLUSION: Of 2480 distinct MRI orders, commercial insurers required preauthorization for 85.56%. Nonetheless, 96.57% of all scans went on to be completed within 3 months, raising questions about the costs, benefits, and overall value of this administrative process.

Postoperative spine surgical site infections: high rate of failure of one-stage irrigation and debridement.

BACKGROUND CONTEXT: Following spine surgery, postoperative surgical site infection (SSI) is a rare but potentially devastating complication. Previous studies have assessed risk factors for spine SSI and one aimed to develop risk stratification tool to assess management options, but this tool has not been externally validated or regularly used. PURPOSE: The current study aimed to investigate the rate of SSI following elective spine surgery, surgical management pursued, and success of traditionally utilized one-stage of irrigation and debridement (I&D) with closure over drains. STUDY DESIGN: Retrospective case-control study. PATIENT SAMPLE: Adult, elective spine surgeries performed at a single academic institution between 2013 and 2021 were evaluated. Patients who developed SSI requiring surgical intervention were identified. OUTCOME MEASURES: Those who underwent initial management with I&D and closure over drains were assessed for need of subsequent I&D (considered failure of initial infection management). METHODS: Of spine surgeries meeting inclusion criteria, those with SSI were identified and management was characterized. For those who did and did not fail attempted one stage I&D with closure over drains, pre-operative and surgical variables from the index procedure as well as infection characteristics were assessed and compared with univariable and multivariable analyses. RESULTS: Of 11,023 elective spine surgeries, SSI was identified for 76 (0.7%). For initial management, I&D with closure over drains was used for 66 (86.8%) while I&D and wound vacuum management was used 10 (13.2%). Failure of attempted one stage I&D (requiring subsequent I&D procedure) was identified for 18 (27% of those undergoing I&D and closure over drains). Of multiple patient, surgical, and infection characteristics, the only factor identified as independently predictive of one stage I&D failure was presence of bacteremia (odds ratio [OR] 38.3, p=0.0007). Within the sub-cohort of patients with bacteremia, failure of attempted one stage I&D was noted for 80%. CONCLUSION: Less than one percent of a large cohort of patients undergoing spine surgery were found to develop SSIs. Of those undergoing attempted one stage I&D, most patient, surgical, and infection variables did not influence outcome of the intervention. However, those with bacteremia were at 38.3 times greater odds of failing attempted one-stage I&D. These results suggest considering delayed closure approaches in these cases.

Primary Neuroendocrine Carcinoma of the Larynx: A Case Report.

Neuroendocrine tumours can originate from any part of the body. The most common site in the head and neck is the larynx, accounts for less than 0.6%. The neuroendocrine carcinomas (NECs) of the larynx are rare tumours with high incidence of widespread metastases and poor prognosis. Here we report a 50-year-old male with localised primary moderately differentiated NEC of the larynx. He was treated with surgery followed by adjuvant chemotherapy and concurrent chemoradiation. He is free of his disease and is doing well.

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease.

Background: Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology. Methods: The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD. Results: After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality. Conclusions: After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

Comparison of postoperative outcomes in patients with and without osteoporosis undergoing single-level anterior cervical discectomy and fusion.

Background: Osteoporosis is ubiquitous in elderly populations, such as those undergoing ACDF. Short- and longer-term outcomes might be affected in the setting of osteoporosis related to graft subsidence, bony union, and stresses on adjacent segments. Better understanding the potential correlation of osteoporosis and outcomes after ACDF might affect patient counseling and surgical planning. The current study compares 90-day adverse events and 5-year reoperations following single-level anterior cervical discectomy and fusion (ACDF) between patients with and without osteoporosis. Methods: Single-level ACDF procedures were identified in a national administrative database. Exclusion criteria included age under 18 years, less than 90 days of follow-up in the database, multi-level procedures, posterior concomitant procedures, and surgeries performed for trauma, neoplasm, or infection. After matching based on patient characteristics, 90-day perioperative adverse events were compared with multivariate analyses and five-year reoperations were compared with log-rank analysis. Reasons for reoperations were also evaluated. Results: Relative to age, sex, and comorbidity-matched patients without osteoporosis, those with osteoporosis had a small but statistically greater incidence of experiencing any 90-day adverse event (10.9% vs 9.4%, p < 0.001) and 5-year reoperations (19.1% vs 17.0%, p < 0.001). Of those requiring reoperation, those in the osteoporosis group had a greater proportion for nonunion (7.5% vs 5.6% p = 0.003). Conclusions: Following single-level ACDF, patients with osteoporosis experience slightly greater 90-day adverse events and 5-year reoperations. These results suggest the importance of recognizing osteoporosis in the ACDF population and accounting for this with surgical planning and patient counselling.

Correlation of Patient Reported Satisfaction With Adverse Events Following Elective Posterior Lumbar Fusion Surgery: A Single Institution Analysis.

Background: With increasing emphasis on patient satisfaction metrics, such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, hospital reputations and reimbursements are being affected by their results. The purpose of the current study is to determine if post-operative self-reported patient satisfaction differed among patients who experienced any adverse event (AAE) following elective posterior lumbar fusion (PLF) surgery compared to those who did not. Methods: Patients who underwent elective PLF surgery performed at a single institution between February 2013 and May 2020 and returned an HCAHPS survey following discharge were included in the retrospective cohort analysis. Demographic, comorbidity, and HCAHPS survey data were compared between patients who did and did not experience any adverse event (AAE) in the 30-days postoperatively. Results: Of 5,117 PLF patients, the HCAHPS survey was returned by 1,071 patients, of which 30-day AAE was experienced by 40 (3.73%). Of those that experienced AAE, the survey response rate was significantly lower (13.94% versus 21.35%, p=0.003). Those responding reported lower scores pertaining to if medication side-effects were adequately explained (22.22% versus 52.56%, p=0.002) and if post-discharge care was adequately explained (79.17% versus 93.76%, p=0.005), as well as overall top-box responses (67.62% versus 75.93% survey average, p<0.001). Conclusions: Patients experiencing AAE after elective PLF surgery are less likely to respond to surveys about their hospital experience. For those who did respond, they report less satisfaction with multiple aspects of their hospital care measured by the HCAHPS survey. Understanding how postoperative adverse events impact patients' perception of healthcare quality provides insight into what patients value and has implications for optimizing their care.

In-hospital complications after cervical fusion in cases with versus without cerebral palsy.

Background: Patients with cerebral palsy (CP) are at increased risk for cervical spine pathology. Cervical fusion surgery may be considered in this population, but perioperative outcomes relative to patients without CP remains poorly understood. The purpose of this study was to compare in-hospital complications after cervical fusion in patients with versus without cerebral palsy (CP) using a retrospective cohort design. Methods: Cervical fusion cases with and without CP were identified in the National Inpatient Sample (NIS) database. In-hospital adverse events were tabulated and grouped into any (AAE), serious (SAE), and minor adverse events (MAE). Length of hospital stay (LOS) and mortality were assessed. Multiple logistic regression models with and without 1:1 propensity matching were used to compare outcomes between cases with and without CP, controlling for demographic and preoperative variables. Results: After weighting, 1,518,012 cases were included in the study population, of which 4,554 (0.30%) had CP. Those with CP were younger, more often male, suffered more comorbidities, more frequently operated on from a posterior or combined approach, and were more frequently addressed at more than one level. By multiple logistic regression after matching, CP cases had higher odds of AAE (OR 1.72; 95% CI 1.05-2.81; p=0.030) and MAE (OR 2.07; 95% CI 1.20-3.57; p=0.009), but no differences in odds of SAE or in-hospital mortality. Conclusions: As there is increasing awareness of potentially cervical pathology in the CP population, the current study suggests that surgical intervention for this population can be appropriately considered without severe in-hospital morbidity or mortality.

Patient Demographic and Socioeconomic Factors Associated With Physical Therapy Utilization After Uncomplicated Meniscectomy.

INTRODUCTION: The extent to which physical therapy (PT) is used after meniscectomy is unknown. The objective of this study was to estimate the extent to which PT is implemented after meniscectomy and to identify factors associated with its utilization. METHODS: The Mariner PearlDiver database was queried to identify patients who underwent uncomplicated meniscectomy. The number of PT visits for each patient was tabulated. Logistic regressions were used to compare demographic factors associated with no use of PT and use of nine or more PT visits. RESULTS: In total, 92,291 patients met inclusion criteria. Of these patients, 72.21% did not use PT and 27.8% used 1 or more PT visits. Of the patients who used PT, 19.76% had 1 to 8 PT visits and 8.03% had 9 or more PT visits. Older age and noncommercial insurance types were associated with no PT use. Male sex, Medicaid, and Medicare were associated with markedly lower odds of increased PT utilization. CONCLUSION: PT is used in the minority of the time after meniscectomy. Among patients who do use PT, however, notable variation exists in the amount of PT visits used. Patient age, sex, insurance status, and geographic variables were independently associated with PT utilization.

Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion.

Background: Postoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use. Methods: Single-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients' age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression. Results: Out of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001). Conclusions: More than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.

Underweight patients are the highest risk body mass index group for perioperative adverse events following stand-alone anterior lumbar interbody fusion.

BACKGROUND CONTEXT: Prior studies investigating the association between Body Mass Index (BMI) and patient outcomes following spine surgery have had inconsistent conclusions, likely owing to insufficient power, confounding variables, and varying definitions and cutoffs for BMI categories (eg, underweight, overweight, obese, etc.). Further, few studies have considered outcomes among low BMI cohorts. PURPOSE: The current study analyzes how anterior lumbar interbody fusion (ALIF) perioperative outcomes vary along the BMI spectrum, using World Health Organization (WHO) categories of BMI. STUDY DESIGN/SETTING: A retrospective cohort study. PATIENT SAMPLE: Patients undergoing stand-alone one or two-level anterior lumbar interbody fusion (ALIF) found in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) databases. OUTCOME MEASURES: Thirty-day adverse events, hospital readmissions, post-operative infections, and mortality. METHODS: Stand-alone one or two-level ALIF surgical cases were identified and extracted from the 2005-2018 National Surgical Quality Improvement Program (NSQIP) database. Posterior cases and those primary diagnoses of trauma, tumor, infection, or emergency presentation were excluded. Patients were then binned into WHO guidelines of BMI. The incidence of adverse outcomes within 30-day post-operation was defined. Odds ratios of adverse outcomes, normalized to the average risk of normal-weight subjects (BMI 18.5-24.9 kg/m3), were calculated. Multivariate analysis was then performed controlling for patient factors. RESULTS: In total, 13,710 ALIF patients were included in the study. Incidence of adverse events was elevated in both the underweight (BMI<18.5 kg/m3) and super morbidly obese (>50 kg/m3), however, multivariate risks for adverse events and postoperative infection were elevated for underweight patients beyond those found in any other BMI category. No effect was noted in these identical variables between normal, overweight, obese class 1, or even obese class 2 patients. Multivariate analysis also found overweight patients to show a slightly protective trend against mortality while the super morbidly obese had elevated odds. CONCLUSIONS: Underweight patients are at greater odds of experiencing postoperative adverse events than normal, overweight, obese class 1, or even obese class 2 patients. The present study identifies underweight patients as an at-risk population that should be given additional consideration by health systems and physicians, as is already done for those on the other side of the BMI spectrum.

Analysis of the Frequency, Characteristics, and Reasons for Termination of Spine-related Clinical Trials.

STUDY DESIGN: Cross-sectional analysis of completed and terminated spine-related clinical trials in the ClinicalTrials.gov registry. OBJECTIVE: The aim was to quantify completed and terminated spine-related clinical trials, assess reasons for termination, and determine predictors of termination by comparing characteristics of completed and terminated trials. SUMMARY OF BACKGROUND DATA: Clinical trials are key to the advancement of products and procedures related to the spine. Unfortunately, trials may be terminated before completion. ClinicalTrials.gov is a registry and results database maintained by the National Library of Medicine that catalogs trial characteristics and tracks overall recruitment status (eg, ongoing, completed, terminated) for each study as well as reasons for termination. Reasons for trial termination have not been specifically evaluated for spine-related clinical trials. METHODS: The ClinicalTrials.gov database was queried on July 20, 2021 for all completed and terminated interventional studies registered to date using all available spine-related search terms. Trial characteristics and reason for termination, were abstracted. Univariate and multivariate analyses were performed determine predictors of trial termination. RESULTS: A total of 969 clinical trials were identified and characterized (833 completed, 136 terminated). Insufficient rate of participant accrual was the most frequently reported reason for trial termination, accounting for 33.8% of terminated trials.Multivariate analysis demonstrated increased odds of trial termination for industry-sponsorship [odds ratio (OR)=1.59] relative to sponsorship from local groups, device studies (OR=2.18) relative to investigations of drug or biological product(s), and phase II (OR=3.07) relative to phase III studies ( P <0.05 for each). CONCLUSIONS: Spine-related clinical trials were found to be terminated 14% of the time, with insufficient accrual being the most common reason for termination. With significant resources put into clinical studies and the need to advance scientific objectives, predictors, and reasons for trial termination should be considered and optimized to increase the completion rate of trials that are initiated.