Association Between Age-stratified Cohorts and Perioperative Complications and 30-day and 90-day Readmission in Patients Undergoing Single-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To assess perioperative complication rates and readmission rates after ACDF in a patient population of advanced age. SUMMARY OF BACKGROUND DATA: Readmission rates after ACDF are important markers of surgical quality and, with recent shifts in reimbursement schedules, they are rapidly gaining weight in the determination of surgeon and hospital reimbursement. METHODS: Patients 18 years of age and older who underwent elective single-level ACDF were identified in the National Readmissions Database (NRD) and stratified into 4 cohorts: 18-39 ("young"), 40-64 ("middle"), 65-74 ("senior"), and 75+ ("elderly") years of age. For each cohort, the perioperative complications, frequency of those complications, and number of patients with at least 1 readmission within 30 and 90 days of discharge were analyzed. χ 2 tests were used to calculate likelihood of complications and readmissions. RESULTS: There were 1174 "elderly" patients in 2016, 1072 in 2017, and 1010 in 2018 who underwent ACDF. Their rate of any complication was 8.95%, 11.00%, and 13.47%, respectively ( P <0.0001), with dysphagia and acute posthemorrhagic anemia being the most common across all 3 years. They experienced complications at a greater frequency than their younger counterparts (15.80%, P <0.0001; 16.98%, P <0.0001; 21.68%, P <0.0001). They also required 30-day and 90-day readmission more frequently ( P <0.0001). CONCLUSION: It has been well-established that advanced patient age brings greater risk of perioperative complications in ACDF surgery. What remains unsettled is the characterization of this age-complication relationship within specific age cohorts and how these complications inform patient hospital course. Our study provides an updated analysis of age-specific complications and readmission rates in ACDF patients. Orthopedic surgeons may account for the rise in complication and readmission rates in this population with the corresponding reduction in length and stay and consider this relationship before discharging elderly ACDF patients.

Weekend Admission Increases Risk of Readmissions Following Elective Cervical Spinal Fusion.

OBJECTIVE: The "weekend effect" occurs when patients cared for during weekends versus weekdays experience worse outcomes. But reasons for this effect are unclear, especially amongst patients undergoing elective cervical spinal fusion (ECSF). Our aim was to analyze whether index weekend admission affects 30- and 90-day readmission rates post-ECSF. METHODS: All ECSF patients > 18 years were retrospectively identified from the 2016-2018 Healthcare Cost and Utilization Project Nationwide Readmissions Database (NRD), using unique patient linkage codes and International Classification of Diseases, Tenth Revision codes. Patient demographics, comorbidities, and outcomes were analyzed. Univariate logistic regression analyzed primary outcomes of 30- and 90-day readmission rates in weekday or weekend groups. Multivariate regression determined the impact of complications on readmission rates. RESULTS: Compared to the weekday group (n = 125,590), the weekend group (n = 1,026) held a higher percentage of Medicare/Medicaid insurance, incurred higher costs, had longer length of stay, and fewer routine home discharge (all p < 0.001). There was no difference in comorbidity burden between weekend versus weekday admissions, as measured by the Elixhauser Comorbidity Index (p = 0.527). Weekend admissions had higher 30-day (4.30% vs. 7.60%, p < 0.001) and 90-day (7.80% vs. 16.10%, p < 0.001) readmission rates, even after adjusting for sex, age, insurance status, and comorbidities. All-cause complication rates were higher for weekend admissions (8.62% vs. 12.7%, p < 0.001), specifically deep vein thrombosis, infection, neurological conditions, and pulmonary embolism. CONCLUSION: Index weekend admission increases 30- and 90-day readmission rates after ECSF. In patients undergoing ECSF on weekends, postoperative care for patients at risk for specific complications will allow for improved outcomes and health care utilization.

Weekend Admission Increases Risk of Readmissions Following Elective Thoracolumbar Spinal Fusion.

STUDY DESIGN: Retrospective database study. OBJECTIVES: The goal of this study was to assess the influence of weekend admission on patients undergoing elective thoracolumbar spinal fusion by investigating hospital readmission outcomes and analyzing differences in demographics, comorbidities, and postoperative factors. METHODS: The 2016-2018 Nationwide Readmission Database was used to identify adult patients who underwent elective thoracolumbar spinal fusion. The sample was divided into weekday and weekend admission patients. Demographics, comorbidities, complications, and discharge status data were compiled. The primary outcomes were 30-day and 90-day readmission. Univariate logistic regression analyzed the relationship between weekday or weekend admission and 30- or 90-day readmission, and multivariate regression determined the impact of covariates. RESULTS: 177,847 patients were identified in total, with 176,842 in the weekday cohort and 1005 in the weekend cohort. Multivariate regression analysis found that 30-day readmissions were significantly greater for the weekend cohort after adjusting for sex, age, Medicare or Medicaid status, and comorbidity status (OR 2.00, 95% CI: 1.60-2.48; P < .001), and 90-day readmissions were also greater for the weekend cohort after adjustment (OR 2.01, 95% CI: 1.68-2.40, P < .001). CONCLUSIONS: Patients undergoing elective thoracolumbar spinal fusion surgery who are initially admitted on weekends are more likely to experience hospital readmission. These patients have increased incidence of deep vein thrombosis, postoperative infection, and non-routine discharge status. These factors are potential areas of focus for reducing the impact of the "weekend effect" and improving outcomes for elective thoracolumbar spinal fusion.

The Impact of Computer-Assisted Navigation on Charges and Readmission in Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective National Database Study. OBJECTIVES: The purpose of this study is to evaluate the cost and patient outcomes associated with the utilization of computer-assisted navigation (CAN) utilization on patients undergoing lumbar spinal fusion. BACKGROUND: CAN systems have demonstrated comparable outcomes with instrumentation and procedural speed when compared with traditional techniques. In recent years, CAN systems have seen increased adoption in spinal surgery as they allow for better contextualization of anatomical structures with the goal of improving surgical accuracy and reproducibility. METHODS: The 2016 National Readmission Database was queried for patients with lumbar spinal fusion ICD-10 codes, with 2 subgroups created based on computer-aided navigation ICD-10 codes. Nonelective cases and patients below 18 years of age were excluded. Univariate analysis on demographics, surgical data, and total charges was performed. Postoperative complication rates were calculated based on diagnosis. Lastly, multivariate analysis was performed to assess navigation's impact on cost and postoperative outcomes. RESULTS: A total of 88,445 lumbar fusion surgery patients were identified. Of the total, 2478 (2.8%) patients underwent lumbar fusion with navigation utilization, while 85,967 (97.2%) patients underwent surgery without navigation. The average total charges were $150,947 ($150,058, $151,836) and $161,018 ($155,747, $166,289) for the non-CAN and CAN groups, respectively ( P <0.001). The 30-day readmission rates were 5.3% for the non-CAN cohort and 3.1% for the CAN cohort ( P <0.05). The 90-day readmission rates were 8.8% for the non-CAN cohort and 5.2% for the CAN cohort ( P <0.001). CONCLUSIONS: CAN use was found to be significantly associated with increased cost and decreased 30-day and 90-day readmissions. Although patients operated on with CAN had increased routine discharge and decreased readmission risk, future studies must continue to evaluate the cost-benefit of CAN. Limitations include ICD-10 codes for CAN utilization being specific to region of surgery, not to exact type. LEVEL OF EVIDENCE: Level III.

The Impact of Computer-Assisted Navigation on Charges and Readmission in Patients Undergoing Posterior Cervical Fusion Surgery.

STUDY DESIGN: Retrospective cohort study of 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database (NRD). OBJECTIVE: The aim was to evaluate cost and outcomes associated with navigation use on posterior cervical fusion (PCF) surgery patients. SUMMARY OF BACKGROUND DATA: Computer-assisted navigation systems demonstrate comparable outcomes with hardware placement and procedural speed compared with traditional techniques. Innovations in technology continue to improve surgeons' performance in complicated procedures, causing need to analyze the impact on patient care. METHODS: The 2016 NRD was queried for patients with PCF surgery ICD-10 codes. Cost and readmission rates were compared with and without navigation. Nonelective cases and patients below 18 years of age were excluded. Univariate analysis on demographics, surgical data, and total charges was performed. Lastly, multivariate analysis was performed to assess navigation's impact on cost and postoperative outcomes. RESULTS: A total of 11,834 patients were identified, with 137 (1.2%) patients undergoing surgery with navigation and 11,697 (98.8%) patients without. Average total charge was $131,939.47 and $141,270.1 for the non-navigation and navigation cohorts, respectively ( P =0.349). Thirty-day and 90-day readmission rates were not significantly lower in patients who received navigation versus those that did not ( P =0.087). This remained insignificant after adjusting for several variables, age above 65, sex, medicare status, mental health history, and comorbidities. The model adjusting for demographic and comorbidities maintained insignificant results of navigation being associated with decreased 30-day and 90-day readmissions ( P =0.079). CONCLUSIONS: Navigation use in PCF surgery was not associated with increased cost, and patients operated on with navigation did not significantly have increased routine discharge or decreased 90-day readmission. As a result, future studies must continue to evaluate the cost-benefit of navigation use for cervical fusion surgery. LEVEL OF EVIDENCE: Level III.

Scoliosis surgery in social media: a natural language processing approach to analyzing the online patient perspective.

PURPOSE: The purpose of this study is to analyze posts shared on Instagram, Twitter, and Reddit referencing scoliosis surgery to evaluate content, tone, and perspective. METHODS: Public posts from Instagram, Twitter, and Reddit were parsed in 2020-2021 and selected based on inclusion of the words 'scoliosis surgery' or '#scoliosissurgery. 100 Reddit posts, 5022 Instagram posts, and 1414 tweets were included in analysis. The Natural Language Toolkit (NLTK) python library was utilized to perform computational text analysis to determine content and sentiment analysis to estimate the tone of posts across each platform. RESULTS: 46.4% of Tweets were positive in tone, 39.4% were negative, and 13.8% were neutral. Positive content focused on patients, friends, or hospitals sharing good outcomes after a patient's surgery. Negative content focused on long wait times to receive scoliosis surgery. 64.7% of Instagram posts were positive in tone, 16.3% were negative, and 19.0% were neutral. Positive content centered around post-operative progress reports and educational resources, while negative content focused on long-term back pain. 37% of Reddit posts were positive in tone, 38% were negative, and 25% were neutral. Positive posts were about personal post-operative progress reports, while negative posts were about fears prior to scoliosis surgery and questions about risks of the procedure. CONCLUSION: This study highlights scoliosis surgery content in social media formats and stratifies how this content is portrayed based on the platform it is on. Surgeons can use this knowledge to better educate and connect with their own patients, thus harnessing the power and reach of social media. LEVEL OF EVIDENCE: IV.

Significance of Hospital Size in Outcomes of Single-Level Elective Anterior Cervical Discectomy and Fusion: A Nationwide Readmissions Database Analysis.

OBJECTIVE: To elucidate risk factors for 90-day readmission in anterior cervical discectomy and fusion (ACDF) for small, medium, and large hospitals. To assess differences in length of stay, charges, and complication rates across hospitals of different size. METHODS: A retrospective analysis was performed using elective, single-level ACDF data from 2016 to 2018 in the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Elective single-level ACDF cases were stratified into 3 groups by hospital bed size (small, medium, and large). All-cause complication rates, mean charges, length of stay, and 90-day readmission rates were compared across hospital size. Frequencies of specific comorbidities were compared between readmitted and nonreadmitted patients for each hospital size. Comorbidities significant on univariate analysis were evaluated as independent risk factors for 90-day readmission for each hospital size using multivariate regression. RESULTS: The overall 90-day readmission rate was 6.43% in 36,794 patients, and the rates for small, medium, and large hospitals were 6.25%, 6.28%, and 6.56%, respectively (P = 0.537). Length of stay increased significantly with hospital size (P < 0.001), and small hospitals had the lowest charges (P < 0.001). Although different independent predictors of 90-day readmission were identified for each hospital size, cardiac arrhythmia, chronic pulmonary disease, neurologic disorders, and rheumatic disease were identified as risk factors for hospitals of all sizes. CONCLUSIONS: Hospital size is a determining factor for charges and length of stay associated with elective single-level ACDF. Variation in risk factors for readmission exists across hospital size in context of similar 90-day readmission rates.

Quality metrics in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: Quality improvement and patient safety are relevant to the advancement of clinical care, particularly in the field of minimally invasive gynecologic surgery (MIGS). Although safety and feasibility of MIGS have been established, identification of quality metrics in this field is also necessary. RECENT FINDINGS: Surgical quality improvement has focused on national overarching measures to reduce mortality, surgical site infections (SSIs), and complications. Quality improvement in minimally invasive surgery has additionally led to advancements in postoperative patient recovery and long-term outcomes. Process measures in minimally invasive surgery include use of bundles and enhanced recovery after surgery (ERAS) programs. However, procedure-specific quality metrics for MIGS outcomes are poorly defined at this time. SUMMARY: Quality metrics in minimally invasive gynecology are well defined for structural measures and select process measures. Creation of relevant benchmarks for outcome measures in minimally invasive gynecologic surgery are needed.

Wilderness Medicine Education in the Time of Social Distancing and COVID-19.

Wilderness medicine (WM) education has traditionally been conducted as in-person training. The current COVID-19 pandemic has forced medical schools to cancel clerkships and clinical electives and pivot to remote education. With online media modalities, it is possible to conduct a WM student elective remotely. The use of recorded audio lectures, instructional videos, choice-based simulations, and video conferencing allows students access to nearly all necessary content under the guidance of instructors. Although hands-on practicums are still essential to WM education, the process outlined here enables a temporary alternative during the time of necessary social distancing.

Safety and Efficacy of Locoregional Treatment during Immunotherapy with Nivolumab for Hepatocellular Carcinoma: A Retrospective Study of 41 Interventions in 29 Patients.

PURPOSE: To assess the safety of locoregional treatment (LRT) combined with nivolumab for intermediate and advanced hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A single-center retrospective review included 29 patients undergoing 41 LRTs-transarterial chemoembolization or yttrium-90 transarterial radioembolization-60 days before or concurrently with nivolumab. Demographic, clinical, and laboratory values and adverse events were reviewed before and after nivolumab initiation and after each LRT. Treatment response and time to progression were assessed using Modified Response Evaluation Criteria in Solid Tumors. Clinical events, including nivolumab termination, death, and time of last follow-up, were assessed. RESULTS: Over a median nivolumab course of 8.1 months (range, 1.0-30) with a median of 14.2 2-week cycles (range, 1-53), predominantly Child-Pugh A (22/29) patients-12 Barcelona Clinic Liver Cancer (BCLC) B and 17 BCLC C-underwent 20 transarterial chemoembolization and 21 transarterial radioembolization LRTs at a median of 67 days (range, 48-609) after nivolumab initiation. Ten patients underwent multiple LRTs. During a median follow-up of 11.5 months (range, 1.8-35.1), no grade III/IV adverse events attributable to nivolumab were observed. There were five instances of grade III/IV hypoalbuminemia or hyperbilirubinemia within 3 months after LRT. There were no nivolumab-related deaths, and 30-day mortality after LRT was 0%. CONCLUSIONS: LRTs performed concurrently with nivolumab immunotherapy demonstrate an acceptable safety profile in patients with intermediate and advanced HCC.

A Near-Peer Educational Model for Online, Interactive Learning in Emergency Medicine.

INTRODUCTION: The COVID-19 pandemic led to a large disruption in the clinical education of medical students, particularly in-person clinical activities. To address the resulting challenges faced by students interested in emergency medicine (EM), we proposed and held a peer-led, online learning course for rising fourth-year medical students. METHODS: A total of 61 medical students participated in an eight-lecture EM course. Students were evaluated through pre- and post-course assessments designed to ascertain perceived comfort with learning objectives and overall course feedback. Pre- and post-lecture assignments were also used to increase student learning. RESULTS: Mean confidence improved in every learning objective after the course. Favored participation methods were three-person call-outs, polling, and using the "chat" function. Resident participation was valued for "real-life" examples and clinical pearls. CONCLUSION: This interactive model for online EM education can be an effective format for dissemination when in-person education may not be available.

Feasibility of Yttrium-90 Radioembolization Dose Calculation Utilizing Intra-procedural Open Trajectory Cone Beam CT.

PURPOSE: Dose calculation for transarterial radioembolization (TARE) with glass yttrium-90 (Y90) labeled microspheres is based on liver lobe and tumor volumes, currently measured from preprocedural MRI or CT. The variable time between MRI and radioembolization may not account for relevant tumor progression. Advances in cone beam computed tomography (CBCT) allow for intra-procedural assessment of these volumes that avoids this factor. Liver lobe and hepatocellular carcinoma tumor volume measurements and dose calculations using intra-procedural CBCT were compared to those using preprocedural MRI in order to determine feasibility. METHODS: Retrospective analysis was performed in 20 patients with proven hepatocellular carcinoma (HCC) who underwent planning angiography with open trajectory CBCT acquisitions prior to radioembolization, and an MRI performed within 6 weeks prior to treatment planning. Liver lobe and tumor burden volumes were measured based on CBCT using embolization planning and guidance software and measured on preprocedural MRI using standard volume analysis software. Y90 doses were subsequently calculated using each measured volume. Comparisons of volume measurements and calculated Y90 doses between the two modalities were evaluated for significance using paired t tests. RESULTS: All target liver lobes and all tumors were completely depicted on CBCT. Mean liver lobe and tumor burden volumes measured on intra-procedural CBCT and preprocedural MRI showed no significant difference (p = 0.71). Mean calculated Y90 dose based on each modality showed no significant difference (p = 0.18). CONCLUSIONS: Lobar and tumor volume measurement with CBCT is a reliable alternative to measurement with preprocedural MRI. Utilization of CBCT 3D segmentation software during planning angiography may be useful to provide up-to-date volume measurements and dose calculations prior to radioembolization.

Assess Before Rx: Reducing the Overtreatment of Asymptomatic Blood Pressure Elevation in the Inpatient Setting.

BACKGROUND: Asymptomatic blood pressure elevation is common in the inpatient setting. National guidelines recommend treating with oral agents to slowly decrease blood pressure; however, many clinicians use intravenous antihypertensive medications, which can lead to unpredictable changes in blood pressure. OBJECTIVE: To decrease the number of inappropriate orders (without symptoms of hypertensive emergency or order for NPO) of intravenous antihypertensives and adverse events associated with intravenous orders. DESIGN: Quasi-experimental study with multidisciplinary intervention. PARTICIPANTS: Inpatients with a one-time order for an intravenous antihypertensive agent from January 2016 to February 2018. MAIN MEASURES: The main outcomes were the total numbers of orders and inappropriate orders, adverse events, and alternate etiologies per 1,000 patient-days. As a balancing measure, patients were monitored for adverse events when blood pressure was elevated and not treated. KEY RESULTS: There were a total of 260 one-time orders of intravenous antihypertensives on two medical units. Inappropriate orders decreased from 8.3 to 3.3 per 1,000 patient days (P = .0099). Adverse events associated with intravenous antihypertensives decreased from 3.7 to 0.8 per 1,000 patient days (P = .0072). CONCLUSION: This initiative demonstrated a significant reduction in inappropriate use of IV antihypertensives and an associated reduction in adverse events.

Quantitative comparison of pre-therapy 99mTc-macroaggregated albumin SPECT/CT and post-therapy PET/MR studies of patients who have received intra-arterial radioembolization therapy with 90Y microspheres.

OBJECTIVE: The aim of our study was to compare yttrium -90 (90Y) dosimetry obtained from pre-therapy 99mTc-macroaggregated albumin (MAA) SPECT/CT versus post-therapy PET/MRI imaging among patients with primary or metastatic hepatic tumors. MATERIALS AND METHODS: Prior to 90Y radioembolization (RE), 32 patients underwent a scan using MAA mimicking 90Y distribution. After RE with 90Y microspheres, the patients were imaged on a PET/MRI system. Reconstructed images were transferred to a common platform and used to calculate 90Y dosimetry. The Passing-Bablok regression scatter diagram and the Bland and Altman method were used to analyze the difference between dosimetry values. RESULTS: For MAA and PET/MRI modalities, the mean liver doses for all 32 subjects were 43.0 ±â€¯20.9 Gy and 46.5 ±â€¯22.7 Gy, respectively, with a mean difference of 3.4 ±â€¯6.2 Gy. The repeatibility coefficient was 12.1 (27.0% of the mean). The Spearman rank correlation coefficient was high (ρ = 0.92). Although, there was a substantial difference in the maximum doses to the liver between the modalities, the mean liver doses were relatively close, with a difference of 24.0% or less. CONCLUSIONS: The two main contributors to the difference between dosimetry calculations using MAA versus 90Y PET/MRI can be attributed to the changes in catheter positioning as well as the liver ROIs used for the calculations. In spite of these differences, our results demonstrate that the dosimetry values obtained from pre-therapy MAA SPECT/CT scans and PET/MRI post-therapy 90Y studies were not significantly different.

Examining the Ability of Artificial Neural Networks Machine Learning Models to Accurately Predict Complications Following Posterior Lumbar Spine Fusion.

STUDY DESIGN: A cross-sectional database study. OBJECTIVE: The aim of this study was to train and validate machine learning models to identify risk factors for complications following posterior lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Machine learning models such as artificial neural networks (ANNs) are valuable tools for analyzing and interpreting large and complex datasets. ANNs have yet to be used for risk factor analysis in orthopedic surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent posterior lumbar spine fusion. This query returned 22,629 patients, 70% of whom were used to train our models, and 30% were used to evaluate the models. The predictive variables used included sex, age, ethnicity, diabetes, smoking, steroid use, coagulopathy, functional status, American Society for Anesthesiology (ASA) class ≥3, body mass index (BMI), pulmonary comorbidities, and cardiac comorbidities. The models were used to predict cardiac complications, wound complications, venous thromboembolism (VTE), and mortality. Using ASA class as a benchmark for prediction, area under receiver operating curves (AUC) was used to determine the accuracy of our machine learning models. RESULTS: On the basis of AUC values, ANN and LR both outperformed ASA class for predicting all four types of complications. ANN was the most accurate for predicting cardiac complications, and LR was most accurate for predicting wound complications, VTE, and mortality, though ANN and LR had comparable AUC values for predicting all types of complications. ANN had greater sensitivity than LR for detecting wound complications and mortality. CONCLUSION: Machine learning in the form of logistic regression and ANNs were more accurate than benchmark ASA scores for identifying risk factors of developing complications following posterior lumbar spine fusion, suggesting they are potentially great tools for risk factor analysis in spine surgery. LEVEL OF EVIDENCE: 3.

5-HT2C receptors in the BNST are necessary for the enhancement of fear learning by selective serotonin reuptake inhibitors.

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed to treat anxiety and depression, yet they paradoxically increase anxiety during initial treatment. Acute administration of these drugs prior to learning can also enhance Pavlovian cued fear conditioning. This potentiation has been previously reported to depend upon the bed nucleus of the stria terminalis (BNST). Here, using temporary inactivation, we confirmed that the BNST is not necessary for the acquisition of cued or contextual fear memory. Systemic administration of the SSRI citalopram prior to fear conditioning led to an upregulation of the immediate early gene Arc (activity-regulated cytoskeleton-associated protein) in the oval nucleus of the BNST, and a majority of these neurons expressed the 5-HT2C receptor. Finally, local infusions of a 5-HT2C receptor antagonist directly into the oval nucleus of the BNST prevented the fear memory-enhancing effects of citalopram. These findings highlight the ability of the BNST circuitry to be recruited into gating fear and anxiety-like behaviors.