bluuebunny/crossref_metadata_2025 huggingface dataset:
Neonatal Morbidity and Maternal Complication Rates in Women With a Delivery Body Mass Index of 60 or Higher
Authors: Kim Tana , Burn Sabrina C. , Bangdiwala Ananta , Pace Samantha , Rauk Phillip
Published: October 2017

OBJECTIVE:

To investigate neonatal morbidity and maternal complication rates with delivery body mass index (BMI) 60 or greater.

METHODS:

This retrospective, multicenter cohort study included singleton pregnancies between 23 and 42 weeks of gestation from January 2005 to April 2016. Women with BMI 60 or greater were compared with a random sample of women with BMI 30–59. The primary outcome, composite neonatal morbidity, was defined as 5-minute Apgar score less than 7, hypoglycemia, respiratory distress syndrome, sepsis, hospital stay greater than 5 days, neonatal intensive care unit admission, or neonatal death. Secondary outcomes included maternal labor and delivery characteristics and complication rates. Kruskal-Wallis tests and χ2 or Fisher exact tests were used to compare BMI categories. Multivariable logistic regression was used for adjusted analysis.

RESULTS:

The study included 338 women, with 39 in the BMI 60 or greater group. An association between obesity and neonatal morbidity was found. Increasing BMI correlated with increasing neonatal morbidity, with the highest rates among those with BMI 60 or greater (BMI 30–39 [17%], 40–49 [19%], 50–59 [22%], 60 or greater [56%]; P<.001). After adjustment for confounders, obese women with BMI less than 60 had at least a 75% reduction in odds of neonatal morbidity compared with women with BMI 60 or greater (BMI 30–39 adjusted odds ratio [OR] 0.22 [0.1–0.5], 40–49 adjusted OR 0.23 [0.1–0.6], 50–59 adjusted OR 0.25 [0.1–0.6]). Maternal complication rates including labor induction, cesarean delivery, wound complication, postpartum hemorrhage, and hospital stay greater than 5 days were also significantly increased with BMI 60 or greater.

CONCLUSION:

A BMI 60 or greater at the time of delivery is significantly associated with increased neonatal morbidity and increased maternal complication rates. In addition, neonatal morbidity and maternal complication rates with BMI 60 or greater were significantly higher when compared with women in any lesser obese BMI cohort between 30 and 59.
Maternal and Neonatal Outcomes in Indicated Preterm Births Based on the Intended Mode of Delivery
Authors: Kuper Spencer G. , Sievert Rachel A. , Steele Robin , Biggio Joseph R. , Tita Alan T. , Harper Lorie M.
Published: October 2017

OBJECTIVE:

To compare maternal and neonatal outcomes in women who underwent induction of labor or planned cesarean delivery in indicated preterm births before 34 weeks of gestation.

METHODS:

We conducted a retrospective cohort study of all indicated singleton preterm births (23–34 weeks of gestation) in a tertiary center from 2011 to 2014. The primary maternal outcome was a composite of early postpartum hemorrhage, blood transfusion, operative complications, postpartum complications, and clinical chorioamnionitis. The primary neonatal outcome was a composite of neonatal death, cardiopulmonary resuscitation in the delivery room, grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, culture-proven sepsis, birth trauma, arterial cord gas pH less than 7 or base excess less than −12, and 5-minute Apgar score 3 or less. Outcomes were compared by intended mode of delivery (induction of labor compared with cesarean) and adjusted for confounders. In secondary analyses, maternal and neonatal outcomes based on the intended mode of delivery were stratified by gestational age (23–27 6/7, 28–31 6/7, and 32–33 6/7 weeks of gestation).

RESULTS:

Of 629 patients with indicated early preterm births during the study period, 331 (53%) underwent induction of labor, of whom 208 (63%) delivered vaginally. Induction of labor was not associated with an increased risk of the primary maternal (16.3% compared with 19.5%, adjusted odds ratio [OR] 0.8, 95% CI 0.5–1.3) or neonatal composite outcome (14.5% compared with 35.9%, adjusted OR 0.7, 95% CI 0.4–1.1). Analyses stratified by gestational age were consistent with the overall analysis.

CONCLUSION:

Maternal and neonatal outcomes do not differ based on the intended mode of delivery. Induction of labor should be considered when early preterm birth is indicated.
Characterizing the Functional Decline of Older Women With Incident Urinary Incontinence
Authors: Parker-Autry Candace , Houston Denise K. , Rushing Julia , Richter Holly E. , Subak Leslee , Kanaya Alka M. , Kritchevsky Stephen B.
Published: October 2017

OBJECTIVE:

To characterize change in physical performance and differential prevalence of low skeletal muscle mass and strength (sarcopenia) and lower 25-hydroxyvitamin D concentrations among older women who developed urinary incontinence (UI) symptoms.

METHODS:

This is a secondary analysis of the Health, Aging, and Body Composition Study. Urinary incontinence symptoms were assessed using validated questions. The Short Physical Performance Battery measured physical performance. Sarcopenia, defined by low muscle mass and strength, was determined using validated cutoffs for gait speed, grip strength, and appendicular skeletal muscle mass. All parameters were evaluated at baseline and year 4. Serum 25-hydroxyvitamin D concentrations were assessed at year 2. The primary outcome was change in Short Physical Performance Battery total scores. Sarcopenia and lower serum 25-hydroxyvitamin D concentrations have been independently associated with poor physical performance and UI and were therefore included as secondary outcomes. Univariate and multivariate analyses were used to characterize the associations of change in physical performance from baseline to year 4, incidence of sarcopenia, and lower serum 25-hydroxyvitamin D on the development of UI symptoms.

RESULTS:

Of the 1,583 women enrolled, 910 were excluded (730 had baseline UI; 180 with missing data). Six hundred seventy-three women were continent at baseline; 223 (33%) developed UI symptoms at year 4. SPPB total scores significantly declined in women with UI versus continent women (mean difference continent−incident UI 0.32, 95% CI 0.04–0.60, P=.02). Of subscale measures, standing balance showed the greatest decline at 0.20 (0.05–0.36; continent−incident UI, respectively; P=.009). Sarcopenia developed at a higher rate with incident UI (adjusted odds ratio [OR] 1.7, 95% CI 1.0–2.9). Low 25-hydroxyvitamin D was not associated with incident UI (adjusted OR 1.1, 95% CI 0.7–1.6 and 1.1, 95% CI 0.7–1.6 for deficient or insufficient versus sufficient status, respectively).

CONCLUSION:

We observed a significant decline in standing balance among older women who developed UI symptoms. This decline may be associated with coinciding development of sarcopenia.
Contraception and Conception After Bariatric Surgery
Authors: Menke Marie N. , King Wendy C. , White Gretchen E. , Gosman Gabriella G. , Courcoulas Anita P. , Dakin Gregory F. , Flum David R. , Orcutt Molly J. , Pomp Alfons , Pories Walter J. , Purnell Jonathan Q. , Steffen Kristine J. , Wolfe Bruce M. , Yanovski Susan Z.
Published: October 2017

OBJECTIVE:

To examine contraceptive practices and conception rates after bariatric surgery.

METHODS:

The Longitudinal Assessment of Bariatric Surgery-2 is a multicenter, prospective cohort study of adults undergoing first-time bariatric surgery as part of routine clinical care at 10 U.S. hospitals. Recruitment occurred between 2005 and 2009. Participants completed preoperative and annual postsurgical assessments for up to 7 years until January 2015. This report was restricted to women 18–44 years old with no history of menopause, hysterectomy, or estrogen and progesterone therapy. Primary outcomes were self-reported contraceptive practices, overall conception rate, and early (less than 18 months) postsurgical conception. Contraceptive practice (no intercourse, protected intercourse, unprotected intercourse, or tried to conceive) was classified based on the preceding year. Conception rates were determined from self-reported pregnancies.

RESULTS:

Of 740 eligible women, 710 (95.9%) completed follow-up assessment(s). Median (interquartile range) preoperative age was 34 (30–39) years. In the first postsurgical year, 12.7% (95% CI 9.4–16.0) of women had no intercourse, 40.5% (95% CI 35.6–45.4) had protected intercourse only, 41.5% (95% CI 36.4–46.6) had unprotected intercourse while not trying to conceive, and 4.3% (95% CI 2.4–6.3) tried to conceive. The prevalence of the first three groups did not significantly differ across the 7 years of follow-up (P for all >.05); however, more women tried to conceive in the second year (13.1%, 95% CI 9.3–17.0; P<.001). The conception rate was 53.8 (95% CI 40.0–71.1) per 1,000 woman-years across follow-up (median [interquartile range] 6.5 [5.9–7.0] years); 42.3 (95% CI 30.2–57.6) per 1,000 woman-years in the 18 months after surgery. Age (adjusted relative risk 0.41 [95% CI 0.19–0.89] per 10 years, P=.03), being married or living as married (adjusted relative risk 4.76 [95% CI 2.02–11.21], P<.001), and rating future pregnancy as important preoperatively (adjusted relative risk 8.50 [95% CI 2.92–24.75], P<.001) were associated with early conception.

CONCLUSIONS:

Postsurgical contraceptive use and conception rates do not reflect recommendations for an 18-month delay in conception after bariatric surgery.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT00465829.
Cadaveric Nerve and Artery Proximity to Sacrospinous Ligament Fixation Sutures Placed by a Suture-Capturing Device
Authors: Katrikh Aaron Z. , Ettarh Rajuno , Kahn Margie A.
Published: October 2017

OBJECTIVE:

To simulate sacrospinous ligament fixation on cadaveric specimens, describe the surrounding retroperitoneal anatomy, and estimate the risk to nerves and arteries for the purposes of optimizing safe suture placement.

METHODS:

Sacrospinous ligament fixation was performed on eight fresh-tissue female cadavers using a Capio ligature capture device. Distances from placed sutures to the following structures were measured: ischial spine; fourth sacral root; pudendal nerve; the nerve to coccygeus muscle; the nerve to levator ani muscle; inferior gluteal artery; and internal pudendal artery. Periligamentous anatomy was examined in an additional 17 embalmed cadaver dissections.

RESULTS:

Sacrospinous ligament length was not seen to differ significantly between sides. The fourth sacral spinal nerve was seen most commonly associated with the medial third of the ligament, whereas the pudendal nerve and the nerves to coccygeus and levator ani muscles were associated with the lateral third. The inferior gluteal artery was seen leaving the greater sciatic foramen a median 15.8 mm (range 1.8–48.0, CI 14.9–22.3) above the ligament, whereas the internal pudendal artery exited just above the ischial spine. The two sets of sutures were placed 20.5 mm (range 9.2–34.4, CI 19.7–24.7) and 24.8 mm (range 12.4–46.2, CI 24.0–30.0) medial to the ischial spine, respectively. No structures were directly damaged by placed sutures. The nerves to coccygeus and levator ani were closest and arteries farthest from the placed sutures.

CONCLUSION:

The middle segment of the sacrospinous ligament has the lowest incidence of nerves and arteries associated with it. This study confirms that the nerves supplying the pelvic floor muscles are at a higher risk from entrapment than the pudendal nerve.
What Is New in Cesarean Delivery?
Authors: Rouse Dwight J.
Published: October 2017

This month we focus on current research in cesarean delivery. Dr. Rouse discusses six recent publications, which are concluded with a “bottom line” that is a take-home message. A complete reference for each can be found on Box 1 on this page along with direct links to abstracts.
Incidence of Congenital Spinal Abnormalities Among Pediatric Patients and Their Association With Scoliosis and Systemic Anomalies
Authors: Passias Peter G. , Poorman Gregory W. , Jalai Cyrus M. , Diebo Bassel G. , Vira Shaleen , Horn Samantha R. , Baker Joseph F. , Shenoy Kartik , Hasan Saqib , Buza John , Bronson Wesley , Paul Justin C. , Kaye Ian , Foster Norah A. , Cassilly Ryan T. , Oren Jonathan H. , Moskovich Ronald , Line Breton , Oh Cheongeun , Bess Shay , LaFage Virginie , Errico Thomas J.
Published: October 2017

Background:

Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies.

Methods:

A retrospective cohort analysis on Health care Cost and Utilization Project’s Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. Outcome Measures: Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies. Frequencies of congenital spine anomalies were estimated using KID hospital-and-year-adjusted weights. Poisson distribution in contingency tables tabulated concurrence of other congenital anomalies, grouped by body system.

Results:

Of 12,039,432 patients, rates per 100,000 cases were: 9.1 hemivertebra, 4.3 Klippel-Fiel, 56.3 Chiari malformation, 52.6 tethered cord, 83.4 spina bifida, 1.2 absence of vertebra, and 6.2 diastematomyelia. Diastematomyelia had the highest concurrence of other anomalies: 70.1% of diastematomyelia patients had at least one other congenital anomaly. Next, 63.2% of hemivertebra, and 35.2% of Klippel-Fiel patients had concurrent anomalies. Of the other systems deformities cooccuring, cardiac system had the highest concurrent incidence (6.5% overall). In light of VACTERL’s definition of a patient being diagnosed with at least 3 VACTERL anomalies, hemivertebra patients had the highest cooccurrence of ≥3 anomalies (31.3%). With detailed analysis of hemivertebra patients, secundum ASD (14.49%), atresia of large intestine (10.2%), renal agenesis (7.43%) frequently cooccured.

Conclusions:

Congenital abnormalities of the spine are associated with serious systemic anomalies that may have delayed presentations. These patients continue to be at a very high, and maybe higher than previously thought, risk for comorbidities that can cause devastating perioperative complications if not detected preoperatively, and full MRI workups should be considered in all patients with spinal abnormalities.

Level of Evidence:

Level III.
Is Routine Spine MRI Necessary in Skeletally Immature Patients With MHE? Identifying Patients at Risk for Spinal Osteochondromas
Authors: Jackson Taylor J. , Shah Apurva S. , Arkader Alexandre
Published: October 2017

Background:

Multiple hereditary exostoses (MHE) is an autosomal dominant condition leading to development of osteochondromas throughout the body. Although long bones are most often affected, spine involvement may occur and usually requires advanced imaging for diagnosis. However, the high cost of detection, infrequent occurrence, and very low likelihood of spinal cord compression and neurological injury, create a management conundrum. The purpose of our investigation is to identify patients at greatest risk for spinal lesions and refine indications for advanced imaging.

Methods:

All MHE patients in a 24-year period were retrospectively reviewed. Skeletally immature patients with advanced imaging of the spine were further evaluated. The demographic characteristics, family history, clinical presentation, past surgical history, tumor burden, and distribution of patients with spinal lesions were compared with those without.

Results:

In total, 227 MHE patients were identified and 21 underwent advanced spinal imaging. Spinal lesions were found in 8 of the 21 screened patients (38.1%, 3.5% overall), of which 4 were intracanal and 1 was symptomatic (4.8%, 0.4% overall). Only the symptomatic patient underwent excision of the spinal lesion. Patients with spinal lesions had higher tumor burden than those without (median, 28.5 vs. 19 locations; P=0.010). There was a significant association with rib (P=0.018) and pelvic (P=0.007) lesions, which may serve as “harbinger” lesions. The presence of both a rib and a pelvic lesion used as a screening tool for spinal lesions produces a sensitivity of 100% and specificity of 69%.

Conclusions:

Symptomatic spinal involvement in children with MHE is rare and tends to occur in patients with higher tumor burden. We recommend limiting advanced spine imaging to children with neurological symptoms or with rib and pelvic “harbinger” lesions. Patients without these findings are unlikely to have spine involvement needing intervention. This approach offers an opportunity to avoid unnecessary testing and substantially reduce costs of diagnostic imaging.

Level of Evidence:

Level III.
Is Systemic Inflammatory Response Syndrome Relevant to Pulmonary Complications and Mortality in Multiply Injured Children?
Authors: Al-Mahdi Waleed , Ibrahim Mazen M. , Spiegel David A. , Arkader Alexandre , Nance Michael , Baldwin Keith
Published: October 2017

Background:

Systemic inflammatory response syndrome (SIRS) is a well-recognized phenomenon in adult trauma populations. The “initial hit” of the traumatic event is often coupled with a systemic immune response characterized by changes in vital signs and laboratory indicators. A “second hit” from surgery during this time frame often results in acute lung injury, along with deterioration of the patient’s clinical condition. We hypothesized that children and adolescents would experience SIRS physiology, but would not experience adult respiratory distress syndrome (ARDS) or “second hit” related death to the extent seen in the adult populations.

Methods:

We queried the trauma database of our level 1 pediatric trauma center from January 2005 to December 2015 for patients with injury severity scores of >16. We used the electronic medical record to track SIRS criteria in patients days 1 to 4 posttrauma. Trends were examined in patients with an orthopaedic injury (OI) and with no orthopaedic injury. Patients were further subcategorized and analyzed by age group based on the convention for definition of pediatric SIRS. Patients in the orthopaedic cohort were further examined for pulmonary complications and death. Logistic regression was used to identify risk factors for SIRS physiology in the first 4 days of hospitalization.

Results:

81.4% (OI) and 69.1% no orthopaedic injury reached the threshold for SIRS within their first 4 days of hospitalization. Nine patients died in the hospital. Only 3 OI patients developed the criteria for ARDS, and only 3 patients with orthopaedic injuries died, 2 died within 24 hours of presentation and 1 within 48 hours, all had severe brain trauma. Increasing age groups showed increasing proportion of patients with SIRS. Increasing injury severity score and increasing age were independent predictors of SIRS during days 1 to 4.

Discussion:

SIRS seems to be as common in children as the reported rates for adults, and the proportion of SIRS in children increases with increasing age and injury severity. The high mortality rate and rate of ARDS observed in adults was not observed in our cohort. The presence or absence of major orthopaedic injuries was not a significant predictor. The SIRS response in polytraumatized children is poorly understood. The clinical phenomenon of acute lung injury/ARDS is observed less often in children, but the exact mechanism by which this occurs is unknown.

Level of Evidence:

Level III—case control.
The Epidemiology of Brachial Plexus Birth Palsy in the United States: Declining Incidence and Evolving Risk Factors
Authors: DeFrancesco Christopher J. , Shah Divya K. , Rogers Benjamin H. , Shah Apurva S.
Published: October 2017

Background:

The epidemiology of brachial plexus birth palsy (BPBP) in the United States may be changing over time due to population-level changes in obstetric care.

Methods:

The Kids’ Inpatient Database from 1997 to 2012 was analyzed. Annual estimates of BPBP incidence and disease determinant distribution were calculated for the general population and the study population with BPBP. Long-term trends were analyzed. A multivariate logistic regression model was used to quantify the risk associated with each determinant.

Results:

The database yielded a combined total of 5,564,628 sample births extrapolated to 23,385,597 population births. The population incidence of BPBP dropped 47.1% over the 16-year study period, from 1.7 to 0.9 cases per 1000 live births (P<0.001). Female, black, and Hispanic subgroups had moderately increased risks of BPBP. Among children with BPBP, 55.0% had no identifiable risk factor. Shoulder dystocia was the strongest risk factor for BPBP in the regression model [odds ratio (OR), 113.2; P<0.001], although the risk of sustaining a BPBP in the setting of shoulder dystocia decreased from 10.7% in 1997 to 8.3% in 2012 (P=0.006). Birth hypoxia was independently associated with BPBP (OR, 3.1; P<0.001). Cesarean delivery (OR, 0.16; P<0.001) and multiple gestation birth (OR, 0.45; P<0.001) were associated with lower incidence of BPBP. Notably, the rate of cesarean delivery increased by 62.8% during the study period, from 20.9% in 1997 to 34.0% in 2012 (P<0.001).

Conclusions:

Over a 16-year period, the incidence of BPBP fell dramatically, paralleled by a significant increase in the rate of cesarean delivery. Systemic changes in obstetric practice may have contributed to these trends. As more than half of BPBP cases have no identifiable risk factor, prospective investigation of established risk factors and characterization of new disease determinants are needed to more reliably identify infants at greatest risk. Racial and geographic inequalities in disease burden should be investigated to identify interventional targets.

Level of Evidence:

Level III—case series.
Incidence and Risk Factors of Acute Pancreatitis After Scoliosis Surgery
Authors: Feng Fan , Tan Haining , Li Xingye , Qiao Yi , Chen Chong , Lin Youxi , Li Zheng , Shen Jianxiong
Published: October 2017

Study Design.

A prospective study.

Objective.

To investigate the incidence and risk factors of acute pancreatitis after scoliosis surgery.

Summary of Background Data.

Pancreatitis has been recognized as a possible complication of extra-abdominal surgeries. However, there were few reports on the incidence and risk factors of acute pancreatitis after scoliosis surgery.

Methods.

A prospective clinical study was performed at our center from September 2014 to October 2015. One hundred seventy-six patients undergoing posterior spinal correction surgery were enrolled. The diagnosis of acute pancreatitis was based on their clinical manifestations combined with laboratory examination. Demographic, intraoperative, and radiological parameters were evaluated to identify the risk factors of acute pancreatitis after scoliosis surgery.

Results.

Thirteen patients (7.4%) were diagnosed with acute pancreatitis. Compared with patients without pancreatitis, pancreatitis patients had lower body mass index (BMI) (15.5 vs. 19.5, P = 0.001), larger preoperative Cobb angle of major curve (87.5° vs. 59.2°, P < 0.001), lower correction rate (57.4% vs. 69.0%, P = 0.045), lower intraoperative mean arterial pressure (57.9 mmHg vs. 66.1 mmHg, P < 0.001), and longer fusion levels (13.3 vs. 10.1, P < 0.001). No significant differences were noted with respect to operation time, intraoperative blood loss, or the amount of sagittal profile correction. Furthermore, multivariate logistic analysis revealed that BMI (odds ratio [OR] = 1.542, P = 0.009), lowest intraoperative mean arterial pressure (OR = 1.126, P = 0.039), and segments of fusion (OR = 0.551, P = 0.025) were independent risk factors for postoperative acute pancreatitis. All cases were treated with bowel rest, intravenous fluids, and fasting and completely recovered with 3.3 (2–5) days.

Conclusion.

The incidence of postoperative acute pancreatitis after scoliosis surgery was 7.4%. The low BMI, lowest intraoperative mean arterial pressure, and long segments of fusion were independent risk factors for acute pancreatitis after scoliosis surgery.

Level of Evidence: 3
A Mouse Intervertebral Disc Degeneration Model by Surgically Induced Instability
Authors: Oichi Takeshi , Taniguchi Yuki , Soma Kazuhito , Chang Song Ho , Yano Fumiko , Tanaka Sakae , Saito Taku
Published: October 2017

Study Design.

An experimental study to develop a mouse model of lumbar intervertebral disc degeneration (IDD).

Objective.

The aim of this study was to develop a mouse lumbar IDD model using surgically induced instability and to compare the findings of this model to those in human IDD.

Summary of Background Data.

Previously, various kinds of inducers have been used to reproduce IDD in experimental animals; however, there is yet no standard mouse lumbar IDD model without direct injury to intervertebral disc.

Methods.

A total number of 59 C57BL/6J male mice at 8 weeks old were used. Instability of lumbar spine was induced by surgical resection of posterior elements, including facet joints, supra- and interspinous ligaments. We then analyzed time course changes in radiographical (n = 17) and histological analyses (n = 42), and compared these findings with those in human IDD.

Results.

Radiographical analyses showed that the disc height began to decrease in the first 2 weeks after the surgery, and the decrease continued throughout 12 weeks. Bone spurs at the vertebral rims were observed in the late stage of 8 and 12 weeks after the surgery. Histological analyses showed that the disorder of the anterior anulus fibrosus (AF) was initially obvious, followed by posterior shift and degeneration of the nucleus pulposus (NP). Proteoglycan detected in inner layer of AF and periphery of NP was decreased after 8 weeks. Immunohistochemistry displayed the increase of type I and X collagen, and matrix metalloproteinase 13 in the anterior AF.

Conclusion.

Surgical resection of posterior elements of mouse lumbar spine resulted in reproducible IDD. Because the present procedure does not employ direct injury to intervertebral disc and the radiological and histological findings are compatible with those in human IDD, it may contribute to further understanding of the native pathophysiology of IDD in future.

Level of Evidence: N/A
Comparison of Outcomes for Anterior Cervical Discectomy and Fusion With and Without Anterior Plate Fixation
Authors: Oliver Jeremie D. , Goncalves Sandy , Kerezoudis Panagiotis , Alvi Mohammed Ali , Freedman Brett A. , Nassr Ahmad , Bydon Mohamad
Published: October 2017

Study Design.

Systematic review and meta-analysis.

Objective.

To compare postoperative surgical, radiographic, and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with and without plate fixation.

Summary of Background Data.

ACDF has evolved significantly over the years, including the placement of an anterior plate construct. Although promoting bony osseo-integration at the fusion site, there are a number of plate-related complications that can arise. The non-plating approach is less invasive, however, greater rates of cage subsidence have been associated with this model.

Methods.

We performed an electronic literature search for human studies that directly compared ACDF with and without anterior plate fixation. Outcomes of interest comprised of postoperative dysphagia, fusion success, and cage subsidence as well as patient reported outcomes, including the Neck Disability Index (NDI) scores and Visual Analog Scale (VAS) for both neck and arm pain.

Results.

A total of 15 studies (12 observational and 3 randomized controlled trials) and 893 patients (57% males) were included. Overall, ACDF with plate fixation was associated with significantly higher vertebral fusion rates (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.16–3.37), lower subsidence rates (odds ratio [OR] 0.31, 95% CI 0.18–0.52), and more favorable VAS-neck pain scores at last follow-up (mean difference [MD] 0.59, 95% CI −0.78 to −0.41). Conversely, ACDF procedures without plate fixation had marginally better long-term VAS-arm pain scores (mean difference [MD] 0.2, 95% CI 0.04–0.36). No difference was found with regards to dysphagia (OR 1.21, 95% CI, 0.57–2.56) and NDI (MD 0.06, 95% C.I −0.54 to 0.42).

Conclusion.

Available evidence, although limited, suggests superior surgical outcomes in ACDF procedures with anterior plate fixation (increased fusion, decreased subsidence) and slightly better VAS-neck pain scores at last follow-up. Future longitudinal, multicenter randomized controlled trials should be completed to validate any associations found in this study.

Level of Evidence: 3
Examining the Ability of Artificial Neural Networks Machine Learning Models to Accurately Predict Complications Following Posterior Lumbar Spine Fusion
Authors: Kim Jun S. , Merrill Robert K. , Arvind Varun , Kaji Deepak , Pasik Sara D. , Nwachukwu Chuma C. , Vargas Luilly , Osman Nebiyu S. , Oermann Eric K. , Caridi John M. , Cho Samuel K.
Published: October 2017

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
The Feature of Clinical and Radiographic Outcomes in Elderly Patients With Cervical Spondylotic Myelopathy
Authors: Machino Masaaki , Ando Kei , Kobayashi Kazuyoshi , Ito Kenyu , Tsushima Mikito , Matsumoto Akiyuki , Morozumi Masayoshi , Tanaka Satoshi , Ito Keigo , Kato Fumihiko , Nishida Yoshihiro , Ishiguro Naoki , Imagama Shiro
Published: October 2017

Study Design.

A prospective cohort study.

Objective.

The purpose of this study was to compare the surgical outcomes between nonelderly and elderly patients with cervical spondylotic myelopathy (CSM) and to characterize the preoperative symptoms and postoperative residual symptoms in elderly patients.

Summary of Background Data.

Age at the time of surgery influences the surgical outcome. However, no report has elucidated residual symptoms after surgery in elderly patients with CSM. We designed a large-scale cohort study examining the surgical outcomes of CSM in elderly patients from a single surgery.

Methods.

A total of 1025 consecutive patients with CSM (642 men and 383 women; mean age, 64.4 yr; range, 23–93 yr) who underwent laminoplasty were included. Patients were divided into three groups based on age: nonelderly (<65 yr), young-old (65–74 yr), and old-old (≥75 yr), and the number of patients in each group was 488, 329, and 208, respectively. The pre- and postoperative neurological statuses were evaluated using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy. The recovery rate (RR) of each function was compared among the three groups. Radiographic data including alignment and range of motion were also assessed.

Results.

The mean preoperative JOA scores of motor function of the lower extremity in nonelderly, young-old, and old-old groups were 2.8, 2.2, and 1.6, respectively (P < 0.0001). Elderly patients showed significantly lower JOA scores for bladder function than nonelderly patients (2.7, 2.5, and 2.2, P < 0.0001). Cervical lordosis in the neutral position increased gradually with age. Total range of motion decreased with increasing age. After surgery, the mean RRs of motor function of the lower extremity were 57.7%, 38.6%, and 24.0%, respectively. Gait disturbance significantly increased with age (P < 0.0001).

Conclusion.

Postoperative gait disturbance persisted more than other symptoms in elderly patients than in nonelderly patients.

Level of Evidence: 2
Finer Needles Reduce Pain Associated With Injection of Local Anesthetic Using a Minimal Insertion Injection Technique
Authors: Zelickson Blake R. , Goldberg Leonard H. , Rubenzik Marc K. , Wu Wesley J.
Published: October 2017

BACKGROUND

The injection of local anesthetic into the skin is often the only memorable event described by the patient after dermatologic procedures.

OBJECTIVE

The authors compared the pain felt during injection of local anesthetic using a minimal needle insertion technique with a 30- or 33-gauge needle.

MATERIALS AND METHODS

Three hundred eighteen patients with tumors on the head and neck were injected with lidocaine using a previously described technique with either a 30- or 33-gauge needle. After injection, patients were surveyed using the visual assessment scale for pain.

RESULTS

Seventy-seven percent of patients felt no pain with injection on the face using a 33-gauge needle compared with 64% with a 30 gauge, whereas 94% of patients felt no pain on the scalp with a 33-gauge needle compared with 54% with a 30 gauge. Visual analog scale scores were also significantly decreased on the face and scalp using the smaller needle. There was no difference in pain between the 2 needles with injection on the neck.

CONCLUSION

This study further validates the use of this technique for the injection of lidocaine and the preference of a 33 gauge over a 30-gauge needle for the initial injection on the face and scalp.
Long-Pulsed Nd:YAG Laser Treatment for Nail Psoriasis
Authors: Kartal Selda Pelin , Canpolat Filiz , Gonul Muzeyyen , Ergin Can , Gencturk Zeynep
Published: October 2017

BACKGROUND

Psoriasis is a chronic inflammatory skin disease in which lesions display angiogenesis and increased vascularity.

OBJECTIVE

The long-pulsed 1,064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser treats vascular lesions which suggests that it might also be used to treat nail psoriasis.

METHODS

Sixteen patients (10 males and 6 females) with isolated nail psoriasis or nail with only mild cutaneous involvement were enrolled in the study. Nails were treated for 3 sessions with long-pulsed 1,064-nm Nd:YAG laser once monthly. During the course of the treatment, nail bed and matrix Nail Psoriasis Severity Index (NAPSI) scores were recorded.

RESULTS

The mean baseline NAPSI score was 26 ± 7.2. The means of total NAPSI scores after the first, second, and third treatment sessions were as follows: 22 ± 6.6, 13 ± 6, and 5.7 ± 4.3, respectively. The decline in NAPSI score was statistically significant. At the end of the 3 treatment sessions, both nail bed and matrix lesions significantly responded to Nd:YAG laser treatment.

CONCLUSION

The Nd:YAG laser is a promising treatment option for nail psoriasis.
A Novel Treatment of Acne Keloidalis Nuchae by Long-Pulsed Alexandrite Laser
Authors: Tawfik Abeer , Osman Mai Abdelraouf , Rashwan Iman
Published: October 2017

BACKGROUND

Acne keloidalis nuchae (AKN) is a dermatological condition characterized by follicular-based papules and pustules that later form hypertrophic or keloid-like scars. Laser-assisted hair reduction such as 810-nm diode laser and 1,064-nm Nd:YAG laser have been used for treating AKN with promising results.

OBJECTIVE

To evaluate the therapeutic effect and safety of alexandrite laser in the treatment of different lesions of AKN.

METHODS

Seventeen male patients with AKN received 6 sessions of 755-nm alexandrite laser. Papule and pustule count, keloidal plaque size, pliability, tenderness, and itching were assessed at the fourth session and 4 weeks after the sixth session. Patient satisfaction and Dermatology Life Quality Index (DLQI) questionnaire were performed at the end of treatment. Patients were followed up for 3 months after the final treatment.

RESULTS

There was a significant decrease in the mean papule, pustule count, keloidal plaque size, and pliability at the fourth and sixth laser sessions when compared with baseline. Reduction of the hair density in the treated area is the only complication observed, which was accepted by the patients because of its reversible course. There was a statistically significantly higher percentage of improvement in the early lesions (papulopustular) compared with late (keloidal plaque) lesions. By the end of laser sessions, DLQI scores were significantly reduced. Temporary hair loss was noted in 4 patients in the treated sites. No lesional recurrence was detected in the follow-up period.

CONCLUSION

Using 755-nm alexandrite laser for treatment of AKN is a safe and effective procedure with low recurrence rates. Alexandrite laser can significantly improve the quality of life of those patients suffering from this disfiguring chronic disorder.
Improving Sun-Protective Behaviors and Self-Skin Examinations Among African Americans: A Randomized Controlled Trial
Authors: Tsai Sheena , Frank Scott H. , Bordeaux Jeremy S.
Published: October 2017

BACKGROUND

Few studies describing sun-protective behaviors, knowledge, and self-efficacy in African Americans exist. Although educational programs targeting Caucasians and Hispanics have been successful in increasing melanoma awareness and knowledge, no such investigation has been applied to African Americans.

OBJECTIVE

To evaluate the effectiveness of a brochure or video educational intervention on the sun-protective behaviors, knowledge, and self-efficacy regarding melanoma in African Americans.

MATERIALS AND METHODS

A randomized controlled trial of a presurvey and postsurvey, in an academic outpatient dermatology clinic. Participants were self-identified African Americans, at least 18 years old, fluent, and literate in English. Patients randomized to the brochure-intervention group (n = 72) received a melanoma brochure from the National Cancer Institute. Patients randomized to the video-intervention group (n = 71) received the brochure and watched an online melanoma tutorial.

RESULTS

Sun-protective behaviors, knowledge, and self-efficacy regarding melanoma all improved equally from pre-to posteducation, in both the brochure- and video-intervention groups.

CONCLUSION

Melanoma educational interventions similar to those previously demonstrated to be successful in Caucasian and Hispanic populations are also effective among African Americans.
Tracheocutaneous Fistula Closure with Turnover Flap and Polydioxanone Plate
Authors: Bryant Justin R. , Boonipat Thanapoom , Chaiyasate Kongkrit
Published: October 2017

An alternative surgical treatment is proposed for closure of tracheocutaneous fistulas. The authors present a new technique for reconstruction of persistent tracheocutaneous fistula resultant from temporary tracheostomy. The single-stage closure under local anesthesia involves a fistulous tract turnover flap with a perforated 0.15 mm polydioxanone plate between the flap and the subcutaneous closure. This article presents 3 cases of persistent tracheocutaneous fistula treated by this method. At follow-up examination after follow-up, no recurrent fistula formation had occurred, and no respiratory deformity was present.
INTRAOCULAR LENS POSITION IN COMBINED PHACOEMULSIFICATION AND VITREORETINAL SURGERY
Authors: Ozates Serdar , Kiziltoprak Hasan , Koc Mustafa , Uzel Mehmet Murat , Teke Mehmet Yasin
Published: October 2017

Purpose:

To assess the decentration and angle of tilt of the intraocular lens (IOL) according to the intravitreal tamponade types used in combined phacoemulsification and vitreoretinal surgery.

Methods:

This prospective and randomized clinical study involved 73 eyes of 69 patients who underwent combined vitreoretinal surgery. Eyes with intravitreal tamponades formed the study group and eyes without intravitreal tamponades formed the control group. The study group was further divided into silicone oil and gas tamponade subgroups. Cross-sectional IOL images were captured using a Pentacam HR (Oculus, Germany) and tilt and decentration were calculated with Adobe Photoshop software (Adobe, San Jose, CA).

Results:

The mean angle of tilt and decentration at the vertical meridian were significantly higher in both tamponade groups than in the control group (P < 0.05 for all). No significant difference was observed among the groups regarding IOL position parameters at the horizontal meridian (P > 0.05). When comparing the silicone oil and gas tamponade subgroups, no significant differences were noted on the position of IOL at both meridians (P > 0.05 for all).

Conclusion:

Intravitreal tamponades have an important effect on the position of IOL in combined vitreoretinal surgery. Silicone oil and gas tamponades may induce postoperative tilt and decentration of one-piece acrylic IOLs.
CHOROIDAL STRUCTURAL CHANGES AND VASCULARITY INDEX IN STARGARDT DISEASE ON SWEPT SOURCE OPTICAL COHERENCE TOMOGRAPHY
Authors: Ratra Dhanashree , Tan Roy , Jaishankar Durgasri , Khandelwal Neha , Gupta Arushi , Chhablani Jay , Agrawal Rupesh
Published: October 2017

Purpose:

To evaluate structural changes in the choroid of patients with Stargardt disease using swept source optical coherence tomography scans.

Methods:

A retrospective comparison cohort study was conducted on 39 patients with Stargardt disease, and on 25 age and gender matched-healthy controls. Subfoveal choroidal thickness (SFCT) was computed from the swept source optical coherence tomography machine, and the scans were binarized into luminal area and stromal areas, which were then used to derive choroidal vascularity index (CVI). Choroidal vascularity index and SFCT were analyzed independently using linear mixed effects model.

Results:

There was no significant difference in SFCT between the 2 groups (347.20 ± 13.61 μm in Stargardt disease vs. 333.09 ± 18.96 μm in the control group, P = 0.548). There was a significant decrease in the CVI among eyes with Stargardt disease as compared with the normal eyes (62.51 ± 0.25% vs. 65.45 ± 0.29%, P < 0.001). There was a negative association between visual acuity and CVI (correlation coefficient = −0.75, P < 0.001) and a positive association between visual acuity and SFCT (correlation coefficient = 0.21, P = 0.035).

Conclusion:

Choroidal vascularity index appears to be a more robust tool compared with SFCT for choroidal changes in Stargardt disease. Choroidal vascularity index can possibly be used as a surrogate marker for disease monitoring. A decrease in CVI was associated with a decrease in visual function in eyes with Stargardt disease.
TREFOIL FACTOR FAMILY 1 EXPRESSION CORRELATES WITH CLINICAL OUTCOME IN PATIENTS WITH RETINOBLASTOMA
Authors: Busch Maike , Metz Klaus , Beier Manfred , Biewald Eva , Dünker Nicole
Published: October 2017

Purpose:

Correlation of trefoil factor family 1 (TFF1) expression in retinoblastoma tumors with different clinical parameters to evaluate a potential involvement of TFF1 in tumor development and progression.

Methods:

A representative cohort of 59 enucleated eyes from individual patients with retinoblastoma was analyzed for its TFF1 expression profile by immuno staining and real-time PCR. Trefoil factor family 1 expression was correlated with demographics, laterality, tumor-node-metastasis stage, International Classification of Retinoblastoma, tumor differentiation level, and treatment.

Results:

According to our analysis, increased TFF1 expression significantly correlates with unilateral tumors diagnosed in older children and with poorly differentiated tumors and higher tumor-node-metastasis stages.

Conclusion:

This retrospective study reveals that unilateral tumors at a higher clinical tumor-node-metastasis stage and poorly differentiated tumor cells express significantly higher levels of TFF1 than those of differentiated tumors at lower tumor-node-metastasis stages. Besides, TFF1 expression correlates with the age of the patients at the time of tumor diagnosis. Our data indicate that TFF1 expression levels are potentially useful additional markers in the classification of tumor staging and prognosis of patients with retinoblastoma.
INTRAOCULAR DEXAMETHASONE IMPLANT POSITION IN SITU AND OCULAR HYPERTENSION
Authors: Sudhalkar Aditya , Kodjikian Laurent , Chhablani Jay , Bhojwani Deepak , Vasavada Abhay
Published: October 2017

Purpose:

To determine the association between the dexamethasone implant position in the vitreous cavity and ocular hypertension (OHT).

Methods:

Retrospective review of patients with at least one intravitreal dexamethasone implant injection between 2012 and 2016. Patients who had a minimum follow-up for 6 months and documented evidence of the implant position were included in the study. Steroid responders, glaucoma patients, vitrectomized eyes, and eyes with liquefied vitreous were excluded. Relevant data were collected from patient charts. Three positions (P1, P2, and P3) were identified: P1 (in contact with the pars plana/ciliary body region), P2 (anterior to vortex veins), and P3 (posterior to vortex veins). Ocular hypertension was defined as absolute intraocular pressure > 25 mmHg and/or intraocular pressure rise > 10 mmHg. The relationship between implant position and intraocular pressure rise after factoring in other characteristics was the outcome measure. Appropriate statistical analysis was performed.

Results:

A total of 377 patients (432 eyes; 257 males; 677 injections) were eligible for analysis. The median age was 57.24 (±6.32) years. Eighty-eight eyes had OHT. Of these, 54 eyes had the implant in P1. P1 was associated with high intraocular pressure response (>15 mmHg; P = 0.004) and early (<15 days) onset OHT (r = 0.84, P < 0.001).

Conclusion:

Anterior position of dexamethasone implant in situ increases the risk of OHT.