Preoperative embolization in surgical treatment of spinal metastases originating from non-hypervascular primary tumors: a propensity score matched study using 495 patients.

BACKGROUND CONTEXT: Preoperative embolization (PE) reduces intraoperative blood loss during surgery for spinal metastases of hypervascular primary tumors such as thyroid and renal cell tumors. However, most spinal metastases originate from primary breast, prostate, and lung tumors and it remains unclear whether these and other spinal metastases benefit from PE. PURPOSE: To assess the (1) efficacy of PE on the amount of intraoperative blood loss and safety in patients with spinal metastases originating from non-hypervascular primary tumors, and (2) secondary outcomes including perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality. STUDY DESIGN: Retrospective propensity-score matched, case-control study at 2 academic tertiary medical centers. PATIENT SAMPLE: Patients 18 years of age or older undergoing surgery for spinal metastases originating from primary non-thyroid, non-renal cell, and non-hepatocellular tumors between January 1, 2002 and December 31, 2016 were included. OUTCOME MEASURES: The primary outcomes were estimated amount of intraoperative blood loss and complications attributable to PE, such as neurologic injury, wound infection, thrombosis, or dissection. The secondary outcomes included perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality. METHODS: In total, 495 patients were identified, of which 54 (11%) underwent PE. After propensity score matching on 21 variables, including primary tumor, number of spinal levels, and surgical treatment, 53 non-PE patients were matched to 53 PE patients. Matching was adequate measured by comparing the matched variables, testing the standardized mean differences (<0.25), and inspecting Kernel density plots. The degree of embolization was noted to be complete, until stasis, or successful in 43 (80%) patients. RESULTS: Intraoperative blood loss did not differ between both groups with a median blood loss in liters of 0.6 (IQR, 0.4-1.2) for non-PE patients and 0.9 (IQR, 0.6-1.2) for PE patients (p=.32). No complications occurred during embolization or the time between embolization and surgery. No differences were found in terms of the secondary outcomes. CONCLUSIONS: Our data suggest that, although no complications occurred and the embolization procedure can be considered safe, patients with non-hypervascular spinal metastases might not benefit from PE. A larger, prospective study could confirm or refute these study findings and aid in elucidating a subset of spinal metastases that might benefit from PE.

Practice Variation Within a Single Institution in Management of Degenerative Spondylolisthesis.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to assess variation in care for degenerative spondylolisthesis (DS) among surgeons at the same institution, to establish diagnostic and therapeutic variables contributing to this variation, and to determine whether variation in care changed over time. SUMMARY OF BACKGROUND DATA: Like other degenerative spinal disorders, DS is prone to practice variation due to the wide array of treatment options. Focusing on a single institution can identify more individualized drivers of practice variation by omitting geographic variability of demographics and socioeconomic factors. MATERIALS AND METHODS: We collected number of office visits, imaging procedures, injections, electromyography (EMG), and surgical procedures within 1 year after diagnosis. Multivariable logistic regression was used to determine predictors of surgery. The coefficient of variation (CV) was calculated to compare the variation in practice over time. RESULTS: Patients had a mean 2.5 (±0.6) visits, 1.8 (±0.7) imaging procedures, and 0.16 (±0.09) injections in the first year after diagnosis. Thirty-six percent (1937/5091) of patients had physical therapy in the 3 months after diagnosis. CV was highest for EMG (95%) and lowest for office visits (22%). An additional spinal diagnosis [odds ratio (OR)=3.99, P <0.001], visiting a neurosurgery clinic (OR=1.81, P =0.016), and diagnosis post-2007 (OR=1.21, P =0.010) were independently associated with increased surgery rates. The CVs for all variables decreased after 2007, with the largest decrease seen for EMG (132% vs. 56%). CONCLUSIONS: While there is variation in the management of patients diagnosed with DS between surgeons of a single institution, this variation seems to have gone down in recent years. All practice variables showed diminished variation. The largest variation and subsequent decrease of variation was seen in the use of EMG. Despite the smaller amount of variation, the rate of surgery has gone up since 2007.

Accuracy and clinical relevance of the single-lead Apple Watch electrocardiogram to identify atrial fibrillation.

Background: The Apple Watch (AW) is the first commercially available wearable device with built-in electrocardiogram (ECG) electrodes to perform a single-lead ECG to detect atrial fibrillation (AF). Methods: Patients with AF who were scheduled for electrical cardioversion (ECV) were included in this study. The AW ECGs were obtained pre-ECV and post-ECV. In case of an unclassified recording, the AW ECG was obtained up to 3 times. The 12-lead ECG was used as the reference standard. Sensitivity, specificity, and kappa coefficient were calculated. Results: In total, 74 patients were included. Mean age was 67.1 ± 12.3 years and 20.3% were female. In total 65 AF and 64 sinus rhythm measurements were obtained. The first measurement with the AW showed a sensitivity of 93.5% and specificity of 100% (κ = 0.94). A second measurement resulted in a sensitivity of 94.6% and specificity of 100% (κ = 0.95). A third measurement resulted in a sensitivity of 93% and a specificity of 96.5% (κ = 0.90). Adjudication of unclassified recordings by a physician reduced the total unclassified recordings from 27.9% to 1.6%, but also reduced the accuracy. The kappa coefficient for unclassified single-lead ECGs was 0.58. Conclusion: The single-lead ECG of the AW shows a high accuracy for identifying AF in a clinical setting. Repeating the recording once decreases the total of unclassified recordings; however, a third recording resulted in a lower accuracy and the occurrence of false-positive measurements. Unclassified results of the AW can be reduced by physicians' interpretation of the single-lead ECG; however, the interrater agreement is only moderate.