Rates and Characteristics of Patients Leaving against Medical Advice after Spine Surgery.

Introduction: Leaving against medical advice (AMA) has been associated with higher rates of readmission and worse postoperative outcomes in various surgical fields. Patients who have undergone spine surgery often require careful postoperative follow-up to ensure an uncomplicated recovery. In this study, we aim to investigate the demographic and hospital variables that may have contributed to patients leaving the hospital AMA following spine surgery. Methods: We performed a retrospective analysis of patients receiving spine surgery; we used the data from the Healthcare Cost and Utilization Project (HCUP) database for the years 2011-2020. Demographics, household income status, insurance status, time from admission to operation, length of stay, length of recovery, and discharge disposition were collected and analyzed. Multivariate linear regression was used to determine the odds ratios of each factor and their association to patient decision of leaving AMA. Results: As per our findings, patients aged 30-49 had 1.666 times greater odds of leaving AMA following spine surgery (P<0.001), patients aged 50-64 had 1.222 times greater odds of leaving AMA (P=0.001), and patients older than 65 had 0.490 times lesser odds of leaving AMA (P<0.001). Additionally, black patients were 1.612 times more likely to leave AMA (P<0.001), whereas white patients were 0.675 times less likely to do so (<0.001). Women were 0.555 times less likely to leave AMA than the rest of the population (P<0.001). Moreover, patients with private insurance were 0.268 times less likely to leave AMA (P<0.001), while patients on Medicare and Medicaid were 1.692 times (P<0.001) and 3.958 times more likely to leave AMA (P<0.001) following spine surgery, respectively. Finally, patients in the lowest quartile of income were 1.691 times more likely to leave AMA (P<0.001), while patients in the higher quartile of income were 0.521 times less likely to do so (P<0.001). Conclusions: It is critical that spine surgeons are aware of the factors that predispose patients to leave AMA in order to mitigate postoperative complications.

Novel Approaches Guiding the Future of Spinal Biologics for Bone Regeneration.

PURPOSE OF REVIEW: Despite the continued growth of spine fusion procedures, the ideal material for bone regeneration remains unclear. Current bone graft substitutes and extenders in use such as exogenous BMP-2 or demineralized bone matrix and hydroxyapatite either have serious complications associated with use or lead to clinically significant rates of non-union. The introduction of nanotechnology and 3D printing to regenerative medicine facilitates the development of safer and more efficacious bone regenerative scaffolds that present solutions to these problems. Many researchers in orthopedics recognize the importance of lowering the dose of recombinant growth factors like BMP-2 to avoid the complications associated with its normal required supraphysiologic dosing to achieve high rates of fusion in spine surgery. RECENT FINDINGS: Recent iterations of bioactive scaffolds have moved towards peptide amphiphiles that bind endogenous osteoinductive growth factor sources at the site of implantation. These molecules have been shown to provide a highly fluid, natural mimetic of natural extracellular matrix to achieve 100% fusion rates at 10-100 times lower doses of BMP-2 relative to controls in pre-clinical animal posterolateral fusion models. Alternative approaches to bone regeneration include the combination of existing natural growth factor sources like human bone combined with bioactive, biocompatible components like hydroxyapatite using 3D-printing technologies. Their elastomeric, 3D-printed scaffolds demonstrate an optimal safety profile and high rates of fusion (~92%) in the rat posterolateral fusion model. Bioactive peptide amphiphiles and developments in 3D printing offer the promising future of a recombinant growth factor- free bone graft substitute with similar efficacy but improved safety profiles compared to existing bone graft substitutes.

Opportunistic muscle measurements on staging chest CT for extremity and truncal soft tissue sarcoma are associated with survival.

BACKGROUND AND OBJECTIVES: Computed tomography (CT) measurements of sarcopenia have been proposed as biomarkers associated with outcomes in various cancers and have typically been evaluated at the L3 vertebral level. However, staging imaging for patients with extremity and truncal soft tissue sarcoma (STS) often only includes chest CT imaging which precludes evaluation at L3. Therefore, we sought to evaluate muscle metrics at T12 on standard staging chest CT scans and evaluate for correlation with overall and event-free survival in patients with STS. METHODS: CT chest imaging for 89 patients with intermediate and high-grade STS (53 male, 36 female; 58.5 ± 19.0 years old, follow-up 37.4 ± 27.1 months) was reviewed on PACS at T12 for skeletal muscle density (SMD) and skeletal muscle index (SMI). RESULTS: Overall survival increased with increased SMD on univariate (hazard ratio [HR] = 0.61 [0.43, 0.86]) and age-adjusted analysis (HR = 0.65 [0.42, 0.89]. Event-free survival also increased with increased SMD in univariate analyses (HR = 0.68 [0.49, 0.95]) but did not maintain significance after adjusting for age (HR = 0.68 [0.43, 1.07]). SMI was not a predictor of overall or event-free survival. CONCLUSIONS: Higher SMD measured on routinely obtained staging chest CTs in STS patients is associated with improved survival.

Update on ciliary body laser procedures.

PURPOSE OF REVIEW: There are currently various options available for glaucoma treatment procedures ranging from laser to penetrating to nonpenetrating surgeries. Innovations in glaucoma surgical therapeutics include features such as external application, focused tissue effects, and minimal manipulation as these factors all help lower the risk of side-effects in addition to increasing the success rate of the treatment. Traditional diode laser transscleral cyclophotocoagulation (TSCPC) is invasive and destructive. This review aims to provide an overview of the latest ciliary body laser modalities, including micropulse diode laser transscleral cyclophotocoagulation (MP-TSCPC), as well as endoscopic cyclophotocoagulation. RECENT FINDINGS: MP-TSCPC and endoscopic cyclophotocoagulation, less invasive interventional procedures than filtering surgeries, have shown promise in having reduced postoperative complications while demonstrating reasonably good success rates. These modalities allow direct effects to the inflow system of the eye. The precision of these interventions has led to comparable or greater control of intraocular pressure (IOP) and lower inflammatory-fibrotic response in comparison to conventional TSCPC. Recent studies of these procedures have focused on their repeatability, long-term survival rate, and ability to be combined with cataract surgery. SUMMARY: The development of new minimally invasive surgical modalities such as MP-TSCPC and endoscopic cyclophotocoagulation has provided new options for treating glaucoma with a relatively safe side-effects profile as compared with filtration surgeries. These new treatments can lead to a significant decline in the number of postsurgical medications needed for IOP control.