Does Epidural Corticosteroid Application During Spinal Surgery Reduce Postoperative Pain?: An Adjunct to Multimodal Analgesia.

STUDY DESIGN: A prospective, randomized, placebo-controlled, double-blinded study. OBJECTIVE: To examine the effect of intraoperative epidural administration of Depo-Medrol on postoperative back pain and radiculitis symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). SUMMARY OF BACKGROUND DATA: Postoperative pain is commonly experienced by patients undergoing spinal fusion surgery. Adequate management of intense pain is necessary to encourage early ambulation, increase patient satisfaction, and limit opioid consumption. Intraoperative steroid application has been shown to improve postoperative pain in patients undergoing lumbar decompression surgeries. There have been no studies examining the effect of epidural steroids on both back pain and radicular pain in patients undergoing TLIF. METHOD: In all, 151 patients underwent TLIF surgery using rh-BMP2 with 3 surgeons at a single institution. Of those, 116 remained in the study and were included in the final analysis. Based on a 1:1 randomization, a collagen sponge saturated with either Saline (1 cc) or Depo-Medrol (40 mg/1 cc) was placed at the annulotomy site on the TLIF level. Follow-up occurred on postoperative days 1, 2, 3, 7, and postoperative months 1, 2, and 3. Lumbar radiculopathy was measured by a modified symptom- and laterality-specific Visual Analog Scale (VAS) regarding the severity of back pain and common radiculopathy symptoms. RESULTS: The patients who received Depo-Medrol, compared with those who received saline, experienced significantly less back pain on postoperative days 1, 2, 3, and 7 (P<0.05). There was no significant difference in back pain beyond day 7. Radiculopathy-related symptoms such as leg pain, numbness, tingling, stiffness, and weakness tended to be reduced in the steroid group at most time points. CONCLUSION: This study provides Level 1 evidence that intraoperative application of Depo-Medrol during a TLIF surgery with rh-BMP2 significantly reduces back pain for the first week after TLIF surgery. The use of epidural Depo-Medrol may be a useful adjunct to multimodal analgesia for pain relief in the postoperative period.

Case report: Recurrent cervical spinal stenosis masquerading as myalgic encephalomyelitis/chronic fatigue syndrome with orthostatic intolerance.

Introduction: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, chronic, multi-system disorder that is characterized by a substantial impairment in the activities that were well tolerated before the illness. In an earlier report, we had described three adult women who met criteria for ME/CFS and orthostatic intolerance, and had congenital or acquired cervical spinal stenosis. All three experienced substantial global improvements in their ME/CFS and orthostatic intolerance symptoms after recognition and surgical treatment of the cervical stenosis. After a several year period of improvement, one of the individuals in that series experienced a return of ME/CFS and orthostatic intolerance symptoms. Main symptoms and clinical findings: Radiologic investigation confirmed a recurrence of the ventral compression of the spinal cord due to a shift of the disc replacement implant at the involved cervical spinal level. Therapeutic intervention: Decompression of the spinal cord with removal of the implant and fusion at the original C5-C6 level was once again followed by a similar degree of improvement in function as had been observed after the first operation. Conclusion: This recapitulation of the outcomes after surgical management of cervical stenosis provides further evidence in support of the hypothesis that cervical spinal stenosis can exacerbate pre-existing or cause new orthostatic intolerance and ME/CFS. Especially for those with refractory symptoms and neurological signs, surgical interventions may offer relief for selected patients with this complex condition.

Fate of carbon in synthetic media fermentations containing Metschnikowia pulcherrima or Meyerozyma guilliermondii in the presence and absence of Saccharomyces cerevisiae.

While sequentially inoculating non-Saccharomyces yeasts with Saccharomyces cerevisiae can lower the alcohol contents of wine, the abilities of these yeasts to utilize/produce ethanol or generate other byproducts remained unclear. Metschnikowia pulcherrima or Meyerozyma guilliermondii were inoculated into media with or without S. cerevisiae to assess byproduct formation. Both species metabolized ethanol in a yeast-nitrogen-base medium but produced the alcohol in a synthetic grape juice medium. In fact, Mt. pulcherrima and My. guilliermondii generated less ethanol per gram of metabolized sugar (0.372 and 0.301 g/g, respectively) compared to S. cerevisiae (0.422 g/g). Sequentially inoculating each non-Saccharomyces species with S. cerevisiae into grape juice media achieved up to 3.0% v/v alcohol reduction compared to S. cerevisiae alone while producing variable glycerol, succinic acid, and acetic acid concentrations. However, neither non-Saccharomyces yeasts released appreciable CO2 under fermentative conditions regardless of incubation temperature. Despite equivalent peak populations, S. cerevisiae produced more biomass (2.98 g/L) than the non-Saccharomyces yeasts while sequential inoculations yielded higher biomass with Mt. pulcherrima (3.97 g/L) but not My. guilliermondii (3.03 g/L). To reduce ethanol concentrations, these non-Saccharomyces species may metabolize ethanol and/or produce less from metabolized sugars compared to S. cerevisiae but also divert carbon towards glycerol, succinic acid, and/or biomass.

Sensory properties of 6- and 18-month-stored wines made with pectinase-producing non-Saccharomyces yeasts.

Recently, the use and commercial availability of non-Saccharomyces yeasts (NSY) in winemaking to reduce alcohol content have increased. However, research exploring the influence on sensory quality of the wine, particularly during storage, is limited. Therefore, the objective of this study was to characterize the sensory profiles of Merlot and Chardonnay wines made with pectinase-producing NSY, with added substrate, that is, pectin. Apple pectin (0 or 0.5 g/L) was added to Merlot and Chardonnay grape musts after inoculation with (a) only Saccharomyces cerevisiae or (b) a three species mixture of NSY; after 3 days, S. cerevisiae was added. Addition of NSY with added pectin resulted in higher concentrations of d-galacturonic acid and glycerol concentration in the wines after 6 months of aging. However, mouthfeel (viscosity or weight) of wines with or without added pectin as determined by a sensory evaluation panel was not altered by the presence of these yeasts. Significant interactions among the yeast utilized, pectin addition, and 6-month aging affected some flavors (solvent) of Merlot, while addition of NSY increased other attributes (cherry) during aging. No sensory differences were perceived among Chardonnay samples due to NSY; however, aging from 6 to 18 months increased the intensity of 40 sensory attributes. Though mouthfeel was not specifically affected, the utilization of NSY may be a useful tool to alter wine quality in Merlot by increasing specific aromas during storage. PRACTICAL APPLICATION: We found that must fermented with pectinase-producing non-Saccharomyces yeasts (NSY) modified the chemical composition of the final young wine. After one additional year of aging, an increase in cherry flavor was observed in Merlot wines made with NSY, which may increase perceived quality. Thus, the use of these pectinase-producing NSY may be a useful tool for winemakers.

Staged Cement Injections for Massive Sacral Hemangioma.

Vertebral hemangiomas are typically asymptomatic; however, they can also be a source of severe axial back pain. In this report, the authors describe the case of an unusually large sacral hemangioma that was effectively treated with staged cement augmentation. A 57-year-old man presented with chronic mid-sacral pain that was episodically severe. Magnetic resonance imaging revealed a massive lytic defect involving a majority of the body of S1 with features consistent with a hemangioma. It was theorized that the patient's pain could be attributed to the compromised structural integrity of the proximal sacrum with associated microfractures. Extensive conservative treatment failed to ameliorate the pain. A cement augmentation procedure was therefore recommended to stabilize the proximal sacrum. Due to concern about the potential for cement embolic complications, a staged bilateral approach was chosen. In the first procedure, 12 mL of bone cement was injected into the right proximal sacrum. The pain was partially improved by this injection. A 2-month interval was observed before the second cement injection in order to give time for pulmonary recovery from any potential microscopic emboli. In the second stage, 8 mL of bone cement was injected into the left proximal sacrum with excellent pain relief. There were no complications from either injection. At the 5-year follow-up, the patient reported no recurrence of mid-sacral pain. To the authors' knowledge, this is the first case reporting the effective treatment of a sacral hemangioma with staged cement injections. [Orthopedics. 2023;46(4):e253-e256.].

Improving the chemical and sensory characteristics of red and white wines with pectinase-producing non-Saccharomyces yeasts.

This study examined the influence of pectinase-producing non-Saccharomyces yeasts on the chemical and sensory attributes of red and white wines with added pectin. Merlot and Chardonnay wines were produced with or without a mixture of pectinase-producing non-Saccharomyces yeasts (Cryptococcus adeliensis, Issatchenkia orientalis, and Pichia kluyveri) added to the must prior to alcoholic fermentation conducted by a commercial strain of Saccharomyces cerevisiae. To ensure sufficient substrate was present, varying concentrations of apple pectin (up to 1.25 g/L for red wines and 1.00 g/L for white wine) were added at the start of fermentation. After bottling, trained panelists (n = 10) analyzed these wines for aroma, flavor, taste, and mouthfeel attributes. For both wines, significant interactions were noted between the presence of non-Saccharomyces yeasts and pectin addition which affected pH, titratable acidity, and concentrations of D-galacturonic acid. While no significant sensory differences were observed among the red wines, limited changes were noted for white wines. However, a strong positive correlation was found between the D-galacturonic acid and buttery aroma for Chardonnay and with flavor for Merlot. Increasing D-galacturonic acid concentrations, through utilization of non-Saccharomyces yeasts, may improve the wine quality as a buttery aroma is often associated with high-quality Chardonnay. For both red and white wines, the utilization of these particular non-Saccharomyces yeasts significantly influenced chemical properties but yielded minor sensory changes without any faults. PRACTICAL APPLICATION: With the recent trend to reduce alcohol content in commercial wines, the interest in non-Saccharomyces yeasts has grown. This study showed that the addition of non-Saccharomyces yeasts, perhaps due to their pectinase activity, influenced the chemical characteristics of red and white wines with limited sensory differences, making these yeasts a useful tool for winemakers to modify wine properties.

Is C7-T1 cervical disc replacement a viable technique: A case series.

INTRODUCTION: Cervical disc replacement (CDR) surgery is well established for the treatment of disc degeneration from C3-C7, but there is little data regarding the safety and efficacy of CDR at the cervicothoracic junction, C7-T1. CDR is an appealing option, in terms of range of motion preservation, symptom relief, and absence of risk for nonunion. Currently, C7-T1 CDR is not approved by the Food and Drug Administration, and the existing literature is limited to two case reports that describe the results of a combined two patients. This series explores whether C7-T1 CDR is a reasonable treatment and alternative to fusion. METHODS: We present a case series of seven consecutive patients who underwent CDR at C7-T1 by a single surgeon from January to December of 2019. There were five females and two males with an average age of 61.3 ± 6.4 years. RESULTS: Average follow up was 18.9 ± 2.5 months. The average postoperative NDI score was 22.6 % ± 14.0. We also recorded qualitative data regarding patient satisfaction and revision surgery status. There was one complication of disc subsidence following three months of complete pain resolution. The six other patients reported being very satisfied with their surgical outcome. CONCLUSION: These seven cases dramatically increase the volume of data in the literature on clinical outcomes and patient satisfaction following CDR at the cervicothoracic junction. Additionally, the heterogeneity of cases shows the effectiveness of this treatment in many real-world cases. A greater volume of cases with longer follow up will be necessary to better establish long-term clinical success.

Synthesis and Optical Characterization of a Rhodamine B Spirolactam Dimer.

Amide derivatives of xanthene dyes such as rhodamine B are useful in a variety of sensing applications due to their colorimetric responses to stimuli such as acidity changes and UV light. The optical properties of these molecules can be influenced by intermolecular associations into dimeric structures, but the exact impact can be hard to predict. We have designed a covalently linked intramolecular dimer of the dye rhodamine B utilizing p-phenylenediamine to link the two dyes via amide bonds. The doubly closed spirolactam version of this dimer, RSL2, is isolated as a colorless solid. Under acidic conditions or UV exposure, RSL2 solutions develop a pink color that is expected for the ring-opened form of the molecule. However, nuclear magnetic resonance (NMR) and single-crystal diffraction data show that the equilibrium still prefers the closed dimer state. Interestingly, the emission profile of RSL2 shows solvatochromic blue fluorescence. Control studies of model compounds with similar structural motifs do not display similar blue fluorescence, indicating that this optical behavior is unique to the dimeric form. This behavior may lend itself to applications of such xanthene dimers to more sophisticated sensors beyond those with traditional binary on/off fluorescence profiles.

The Relationship between Workplace Incivility and Well-Being in Administrative Court Judges.

Judicial stress is an important area of study, as judges' decisions have life-altering consequences for the immediate parties and, sometimes, society in general. Although there are numerous studies of judicial stress, few have specifically investigated the relationship between judicial stress and workplace incivility (i.e., rude or condescending behavior with ambiguous intent). This survey investigated relationships between workplace incivility and judicial stress, health, and job outcomes in a group of administrative judges. Overall, judges reported moderate levels of stress and low exposure to incivility. They indicated that incivility is a moderate problem, with attorneys as the most common source of incivility. Supporting the Model of Judicial Stress, workplace incivility was positively associated with levels of stress and compassion fatigue and negatively associated with job satisfaction. The relationships between incivility and measures of mental health, physical health, and compassion fatigue were all mediated by stress. Implications for judicial stress interventions include the need for judicial training and interventions to curb incivility.

Treatment of cervical non-union with cervical disc replacement: A case series.

INTRODUCTION: Cervical disc replacement (CDR) has become prevalent in the treatment of cervical pathology. CDR is an appealing option for several reasons, including improvement of symptoms, preservation of range of motion, and the absence of risk for nonunion - a complication of an anterior cervical decompression and fusion (ACDF) surgery. In this case series, we explore the use of CDR to treat cervical nonunion. METHODS: Four patients, ages 50 to 64, presented to one surgeon with symptomatic cervical nonunion. Three of the four patients possessed risk factors for further nonunion and were therefore considered especially well-suited to a CDR rather than a revision ACDF. X-ray, MRI, and CT were used to confirm the presence of nonunion and to determine the architectural feasibility of replacing the level with a cervical disc arthroplasty. Six total nonunion levels were present in four patients (two levels in two patients and one level in two patients). Each of the nonunion levels was successfully treated with a revision decompression and CDR. RESULTS: Postoperatively, all four patients experienced improvement of nonunion symptoms. Neck Disability Index improved on average by 75% (preoperative score 51% to postoperative score 13%). Flexion-extension X-rays were available in three patients, which showed an increase in an average range of motion from 2 degrees to 7 degrees at the revised levels. CONCLUSION: The series describing four successful cases expands the current literature and provides support for future investigation into CDR as a treatment for cervical nonunion. We propose CDR as a viable option to treat symptomatic cervical nonunion and restore range of motion in patients without significant arthrosis and with preserved endplate architecture.

Spinal Anesthesia with Targeted Sedation based on Bispectral Index Values Compared with General Anesthesia with Masked Bispectral Index Values to Reduce Delirium: The SHARP Randomized Controlled Trial.

BACKGROUND: Reducing depth of anesthesia and anesthetic exposure may help prevent delirium, but trials have been conflicting. Most studies were conducted under general anesthesia or in cognitively impaired patients. It is unclear whether reducing depth of anesthesia beyond levels consistent with general anesthesia reduces delirium in cognitively intact patients. The authors' objective was to determine whether a bundled approach to reduce anesthetic agent exposure as determined by Bispectral Index (BIS) values (spinal anesthesia with targeted sedation based on BIS values) compared with general anesthesia (masked BIS) reduces delirium. METHODS: Important eligibility criteria for this parallel-arm randomized trial were patients 65 yr or greater undergoing lumbar spine fusion. The intervention group received spinal anesthesia with targeted sedation to BIS greater than 60 to 70. The control group received general anesthesia (masked BIS). The primary outcome was delirium using the Confusion Assessment Method daily through postoperative day 3, with blinded assessment. RESULTS: The median age of 217 patients in the analysis was 72 (interquartile range, 69 to 77). The median BIS value in the spinal anesthesia with targeted sedation based on BIS values group was 62 (interquartile range, 53 to 70) and in the general anesthesia with masked BIS values group was 45 (interquartile range, 41 to 50; P < 0.001). Incident delirium was not different in the spinal anesthesia with targeted sedation based on BIS values group (25.2% [28 of 111] vs. the general anesthesia with masked BIS values group (18.9% [20 of 106]; P = 0.259; relative risk, 1.22 [95% CI, 0.85 to 1.76]). In prespecified subgroup analyses, the effect of anesthetic strategy differed according to the Mini-Mental State Examination, but not the Charlson Comorbidity Index or age. Two strokes occurred among patients receiving spinal anesthesia and one death among patients receiving general anesthesia. CONCLUSIONS: Spinal anesthesia with targeted sedation based on BIS values compared with general anesthesia with masked BIS values did not reduce delirium after lumbar fusion.

The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: A quasi-experimental study.

BACKGROUND: Healthcare systems have widely adopted consecutive 12 h day and night shifts for nurses, but the effects of these shifts on cognition, sleepiness, and nursing performance remains understudied. OBJECTIVE: To determine the extent of changes in cognition and sleepiness in nurses working three consecutive 12 h shifts, quantify the respective impacts of these changes on different aspects of nursing performance, and investigate individual differences in all measures. DESIGN: A quasi-experimental, between-within design collected data from nurses between November 2018 and March 2020. The between-groups component was comprised of day shift nurses vs. night shift nurses, while the within-groups component was comprised of two separate test sessions for each nurse: one immediately following a third consecutive shift (fatigued) and one after three consecutive days off work (rested). SETTING: Participants were tested in a northwestern US university's nursing simulation laboratory. PARTICIPANTS: A volunteer sample of 94 registered nurses involved in direct patient care working 12 h shifts were recruited from two local hospitals. METHODS: Simulated nursing performance was measured in seven separate domains and an aggregate score from the Creighton Competence and Evaluation Inventory, covering both lower- and higher-level constructs like procedural skills, assessment, decision-making, etc. Cognition and sleepiness were assessed through measures of sustained attention, predicted cognitive effectiveness, and subjective sleepiness. RESULTS: In our 94 nurses, individual differences in all our measures varied from trivial to extensive. For six domains of performance and the aggregate score there were no significant differences in means across groups or conditions. For the seventh, Communication skills were lower for night nurses than day nurses, but this effect was small. After three consecutive shifts, sustained attention and predicted cognitive effectiveness decreased, and subjective sleepiness increased. Predicted cognitive effectiveness was particularly low for fatigued night nurses relative to other conditions and was positively correlated with Communication while controlling for other predictors. CONCLUSIONS AND RELEVANCE: Nurses maintained their levels of performance for all domains after three consecutive shifts. Individual differences in predicted cognitive effectiveness could account for variation in performance by shift type for Communication skills but for no other domain of performance. Communication skills and predicted cognitive effectiveness may interest researchers in the development of fatigue-mitigation strategies for night nurses, but our findings also suggest that more sensitive measures of performance may be necessary to capture other meaningful effects of long, consecutive shifts-if any-on patient care. Tweetable abstract: The effects of three consecutive 12 h shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: A quasi-experimental study.

Toward a rational and ethical sociotechnical system of autonomous vehicles: A novel application of multi-criteria decision analysis.

The impacts of autonomous vehicles (AV) are widely anticipated to be socially, economically, and ethically significant. A reliable assessment of the harms and benefits of their large-scale deployment requires a multi-disciplinary approach. To that end, we employed Multi-Criteria Decision Analysis to make such an assessment. We obtained opinions from 19 disciplinary experts to assess the significance of 13 potential harms and eight potential benefits that might arise under four deployments schemes. Specifically, we considered: (1) the status quo, i.e., no AVs are deployed; (2) unfettered assimilation, i.e., no regulatory control would be exercised and commercial entities would "push" the development and deployment; (3) regulated introduction, i.e., regulatory control would be applied and either private individuals or commercial fleet operators could own the AVs; and (4) fleets only, i.e., regulatory control would be applied and only commercial fleet operators could own the AVs. Our results suggest that two of these scenarios, (3) and (4), namely regulated privately-owned introduction or fleet ownership or autonomous vehicles would be less likely to cause harm than either the status quo or the unfettered options.

Incidence and Risk Factors for Postoperative Urinary Retention Following Lumbar Spine Fusion.

STUDY DESIGN: This was a prospective cohort study (observational-retrospective chart review). OBJECTIVE: The objective of this study was to determine clinical rates and correlations of postoperative urinary retention (POUR) in elective spine decompression and fusion procedures. SUMMARY OF BACKGROUND DATA: POUR is a common postoperative complication that often has a major adverse impact on a patient's recovery from elective lumbar spine surgery. The etiology of POUR in most cases is unknown. Patients undergoing lumbar spine surgery are considered to be at increased risk for POUR due to prone positioning during surgery and intraoperative cauda equina nerve root manipulation. Current studies reporting on POUR after elective spine surgery provide limited insight regarding risk factors and effective prevention strategies for this at-risk population. The purpose of this study is to identify risk factors for POUR after elective lumbar spine surgery and strategies for reducing its incidence. MATERIALS AND METHODS: Two hundred consecutive patients aged 50 years or older undergoing combined lumbar decompression and fusion procedures over a 5-month period at a single institution were prospectively observed. Demographic and clinical data were prospectively recorded, including: medical history, surgical data, medications administered, complications, and postoperative hospital course. Factors correlating with POUR through a univariate analysis with P≤0.20 were considered for multivariate analysis. RESULTS: POUR occurred in 19 of 200 patients. Those with POUR were more likely to be male (20% vs. 4%, odds ratio=6.2). Administration of scopolamine (P=0.02), neostigmine (P=0.01), and the total number of levels operated on (P=0.02) were found to be independent risk factors for the development of POUR. Length of surgery, surgical level, the performance of an interbody fusion did not have a bearing on the development of POUR (P>0.05). DISCUSSION: We describe a single institution's experience of POUR incidence in 200 consecutive patients aged 50 years or older undergoing single or multilevel lumbar spine fusion procedures by 1 of 4 surgeons. Specific demographic and clinical risk factors were identified and a codified classification for POUR in a surgical population is presented.The results of this study will help clinicians appropriately counsel patients undergoing elective lumbar fusion about the potential development of POUR. The perioperative administration of scopolamine and neostigmine should be cautiously considered in men over 50 years of age due to the increased POUR risk. CONCLUSIONS: Perioperative scopolamine and neostigmine administration in men over 50 should be avoided when possible to minimize the risk of POUR. LEVEL OF EVIDENCE: Level III.

Native yeast and non-yeast fungal communities of Cabernet Sauvignon berries from two Washington State vineyards, and persistence in spontaneous fermentation.

To address a knowledge gap about the grape berry mycobiome from Washington State vineyards, next-generation sequencing of the internal transcribed spacer region (ITS1) was used to identify native yeast and fungal species on berries of cultivar 'Cabernet Sauvignon' from two vineyards at veraison and harvest in 2015 and 2016. Four hundred fifty-six different yeast amplicon sequence variants (ASV), representing 184 distinct taxa, and 2467 non-yeast fungal ASV (791 distinct taxa) were identified in this study. A set of 50 recurrent yeast taxa, including Phaeococcomyces, Vishniacozyma and Metschnikowia, were found at both locations and sampling years. These yeast species were monitored from the vineyard into laboratory-scale spontaneous fermentations. Taxa assignable to Metschnikowia and Saccharomyces persisted during fermentation, whereas Curvibasidium, which also has possible impact on biocontrol and wine quality, did not. Sulfite generally reduced yeast diversity and richness, but its effect on the abundance of specific yeasts during fermentation was negligible. Among the 106 recurring non-yeast fungal taxa, Alternaria, Cladosporium and Ulocladium were especially abundant in the vineyard. Vineyard location was the primary factor that accounted for the variation among both communities, followed by year and berry developmental stage. The Washington mycobiomes were compared to those from other parts of the world. Sixteen recurrent yeast species appeared to be unique to Washington State vineyards. This subset also contained a higher proportion of species associated with cold and extreme environments, relative to other localities. Certain yeast and non-yeast fungal species known to suppress diseases or modify wine sensory properties were present in Washington vineyards, and likely have consequences to vineyard health and wine quality.

Does Local Steroid Reduce Dysphagia After Cervical Disc Replacement? A Prospective, Randomized, Placebo-controlled, Double-blinded Study.

STUDY DESIGN: A prospective, randomized, placebo-controlled, double-blinded study. OBJECTIVE: To examine the effect of intraoperatively administered local Depo-Medrol on the incidence and severity of postoperative dysphagia in patients undergoing cervical disk replacement (CDR) surgery. SUMMARY OF BACKGROUND DATA: Dysphagia is often reported as an adverse event after anterior cervical surgeries. One method for reducing the incidence of postoperative dysphagia in patients undergoing anterior cervical discectomy and fusion surgeries is the intraoperative application of topical corticosteroids to the retroesophageal space. There have been no studies examining the effect of local steroids on dysphagia after CDR surgery. MATERIALS AND METHODS: Seventy-three patients underwent CDR surgery by a single surgeon at a single institution. A 1 cm ×3 cm ×3 mm gel foam collagen sponge was saturated by the nurse with either saline (1 cc) or Depo-Medrol (40 mg/1 cc) based on randomization protocol. The sponge was placed ventral to the cervical disk implant in the retroesophageal space. Study follow-up occurred on postoperative day 1, 4, 7, 14 and postoperative month 1, 2, and 3. Dysphagia outcomes were classified using the Bazaz Dysphagia Score and Eating Assessment Tool 10. RESULTS: The steroid group, compared with the control group, had significantly reduced incidence of dysphagia (50% vs. 75%; P=0.0427) and severe dysphagia (12% vs. 36% Bazaz score, P=0.0253; 18% vs. 42% Eating Assessment Tool 10, P=0.0378) at POD4. There was no significant long-term difference in rates of dysphagia between the control and the steroid group. CONCLUSIONS: This study provides level 1 evidence that the use of intraoperative locally administered Depo-Medrol significantly reduces the incidence and severity of dysphagia within the first week after CDR surgery. The use of local steroid may provide patients undergoing CDR surgery with a more pleasant early recovery experience with respect to dysphagia.

Operative versus nonoperative treatment for adult symptomatic lumbar scoliosis at 5-year follow-up: durability of outcomes and impact of treatment-related serious adverse events.

OBJECTIVE: Although short-term adult symptomatic lumbar scoliosis (ASLS) studies favor operative over nonoperative treatment, longer outcomes are critical for assessment of treatment durability, especially for operative treatment, because the majority of implant failures and nonunions present between 2 and 5 years after surgery. The objectives of this study were to assess the durability of treatment outcomes for operative versus nonoperative treatment of ASLS, to report the rates and types of associated serious adverse events (SAEs), and to determine the potential impact of treatment-related SAEs on outcomes. METHODS: The ASLS-1 (Adult Symptomatic Lumbar Scoliosis-1) trial is an NIH-sponsored multicenter prospective study to assess operative versus nonoperative ASLS treatment. Patients were 40-80 years of age and had ASLS (Cobb angle ≥ 30° and Oswestry Disability Index [ODI] ≥ 20 or Scoliosis Research Society [SRS]-22 subscore ≤ 4.0 in the Pain, Function, and/or Self-Image domains). Patients receiving operative and nonoperative treatment were compared using as-treated analysis, and the impact of related SAEs was assessed. Primary outcome measures were ODI and SRS-22. RESULTS: The 286 patients with ASLS (107 with nonoperative treatment, 179 with operative treatment) had 2-year and 5-year follow-up rates of 90% (n = 256) and 74% (n = 211), respectively. At 5 years, compared with patients treated nonoperatively, those who underwent surgery had greater improvement in ODI (mean difference -15.2 [95% CI -18.7 to -11.7]) and SRS-22 subscore (mean difference 0.63 [95% CI 0.48-0.78]) (p < 0.001), with treatment effects (TEs) exceeding the minimum detectable measurement difference (MDMD) for ODI (7) and SRS-22 subscore (0.4). TEs at 5 years remained as favorable as 2-year TEs (ODI -13.9, SRS-22 0.52). For patients in the operative group, the incidence rates of treatment-related SAEs during the first 2 years and 2-5 years after surgery were 22.38 and 8.17 per 100 person-years, respectively. At 5 years, patients in the operative group who had 1 treatment-related SAE still had significantly greater improvement, with TEs (ODI -12.2, SRS-22 0.53; p < 0.001) exceeding the MDMD. Twelve patients who received surgery and who had 2 or more treatment-related SAEs had greater improvement than nonsurgically treated patients based on ODI (TE -8.34, p = 0.017) and SRS-22 (TE 0.32, p = 0.029), but the SRS-22 TE did not exceed the MDMD. CONCLUSIONS: The significantly greater improvement of operative versus nonoperative treatment for ASLS at 2 years was durably maintained at the 5-year follow-up. Patients in the operative cohort with a treatment-related SAE still had greater improvement than patients in the nonoperative cohort. These findings have important implications for patient counseling and future cost-effectiveness assessments.

Variations in Protection Provisions Among State Medical Amnesty Laws.

BACKGROUND: Studies indicate that a leading reason young people do not seek medical assistance for alcohol-related emergencies is worry of "getting in trouble". To assuage these fears, over 30 states and numerous universities have passed medical amnesty laws. However, there are variations in protections between states. Objectives: This study aimed to (1) assess students' knowledge of Nevada's medical amnesty law; (2) knowledge of alcohol poisoning indicators; (3) whether variations in the law's coverage relates to differences in intention to seek medical attention; (4) whether knowledge of the law is associated with intent to seek medical attention; and (5) whether attitudes, perceived norms, and personal agency are associated with intent to seek medical attention for an alcohol-related emergency, specifically alcohol poisoning. Method: This study surveyed 564 graduate and undergraduate students aged 18 and older from the University of Nevada, Reno. Results: The results suggest that that students were severely undereducated about the state's medical amnesty law. Having a medical amnesty law at all is related to increased intent to call for medical attention in an alcohol poisoning situation. Further, components of the integrated behavior model (i.e. attitudes, perceived norms, and perceived personal agency) are associated with increased intent to call for medical attention. Conclusions: The presence of medical amnesty laws versus a law providing no protections for underage drinkers is positively related to an individual's intention to seek medical attention in an alcohol-related emergency. Educational implications and recommendations for policy implementation are discussed.

Impacts of non-Saccharomyces species and aeration on sequential inoculation with Saccharomyces cerevisiae to produce lower alcohol Merlot wines from Washington state.

BACKGROUND: Species of non-Saccharomyces yeasts isolated from Washington vineyards were evaluated for their abilities to reduce alcohol contents of wines. As many of these yeasts benefit from some oxygen, the effect of limited aeration was also studied. RESULTS: Although fermentations of a high sugar Merlot grape must (310 g L-1 ) did not reach dryness, inoculation of Metschnikowia chrysoperlae, Mt. pulcherrima, Meyerozyma guillermondii, Pichia kluyveri, or P. membranifaciens yielded in wines with lower amounts of ethanol without excessive levels of acetic acid. Aeration frequently resulted in wines with less ethanol but with more acetic acid compared to non-aerated fermentations. Inoculation of Mt. pulcherrima or My. guilliermondii into another Merlot grape must that contained a lower initial amount of fermentable sugar (266 g L-1 ) resulted in dry wines that contained less alcohol. CONCLUSIONS: Inoculation of My. guilliermondii or Mt. pulcherrima before primary alcoholic fermentation resulted in wines with reduced alcohol contents without excessive acetic acid production. © 2020 Society of Chemical Industry.

A Rare Case of Massive Ovarian Mucinous Cystadenoma With Postmenopausal Bleeding.

Mucinous cystadenomas are among the most common benign ovarian neoplasms. They are known for their massive size causing compressive effects ranging from pressure, pain, bloating, and urinary symptoms. Over time, these adnexal masses can lead to fatal complications, such as ovarian torsion or hemorrhage. Incidental findings of these tumors are common as many of these patients are asymptomatic. Pelvic examinations and imaging studies can be used to further diagnose symptomatic patients and aid physicians in developing an appropriate course of treatment. We report a rare case of a large mucinous cystadenoma, with a size of 25 × 25 cm and concurrent management of postmenopausal bleeding. We present the data from the admission of the patient to her discharge, including history and physical examination, diagnostic reports, transabdominal ultrasound, CT scan, surgical evaluation, and surgical-pathology reports. Abdominal pain can present in a variety of different scenarios, and ovarian masses only represent a small portion of the differentials. Mucinous cystadenomas constitute an even smaller percentage of these ovarian growths. As discussed in this case report, a large ovarian mucinous cystadenoma was compressing the surrounding structures resulting in a wide array of symptoms. The case describes the importance of extensive diagnostic evaluation and prompt surgical management of these ovarian tumors. It also brings attention to the significance of diagnosing a medical condition such as postmenopausal bleeding promptly to avoid potential negative outcomes.