bluuebunny/crossref_metadata_2025 huggingface dataset:
Acupuncture Versus Sham Acupuncture
Authors: Lenoir Dorine , De Pauw Robby , Van Oosterwijck Sophie , Cagnie Barbara , Meeus Mira
Published: February 2020

Editorial Note:

The original Letter to the Editor prepared by Jones et al was based on the initial electronic version then contained several important procedural errors that resulted in erroneous conclusions as noted by Jones et al in their original Letter. Subsequently, the authors of the Letter to the Editor were notified of the corrections and they then prepared the revised Letter to the Editor published here. Jones et al did note a remaining error in Table 5 of their corrected manuscript. Based on Jones et al’s observation, Lenoir et al were notified of an error on Table 5 and have addressed this in the current version of their paper published in this issue. We appreciate the input of the authors of the letter and the positive response of the author(s) of this article. Dennis C. Turk, PhD Editor-in-Chief

Objective:

Acupuncture is a common modality in the therapy of musculoskeletal disorders. The evidence for acupuncture has been examined frequently, but a clear synthesis of previous research is currently lacking. This meta-analysis aimed to summarize the evidence for nonimmediate effects of acupuncture on pain, functionality, and quality of life in patients with musculoskeletal disorders, when compared with sham acupuncture.

Methods:

Search results from PubMed and Web of Science were brought together. All screening procedures were executed twice by 2 independent researchers. The pooled standardized mean difference (SMD) with its confidence interval (CI) was estimated at follow-up at <1 month, 1 to 3 months, 3 to 6 months, and >6 months.

Results:

For pain, the SMD equalled respectively −0.47 (CI −0.76 to −0.19), −0.27 (CI −0.44 to −0.11), −0.32 (CI −0.51 to −0.13) and −0.12 (CI −0.36 to 0.11) for <1 month, 1 to 3 months, 3 to 6 months, and >6 months follow-up. For functionality, the pooled SMD equalled −0.43 (CI −0.76 to −0.10), −0.41 (CI −0.76 to −0.05), 0.07 (CI −0.22 to 0.36), and −0.13 (−0.46 to 0.19). In the area of QOL, pooled SMD of respectively 0.20 (CI 0.04 to 0.35), 0.19 (CI −0.01 to 0.39), 0.02 (CI −0.09 to 0.14) and −0.04 (CI −0.25 to 0.16) were obtained.

Discussion:

A significant difference in therapy effect, favoring acupuncture, was found for pain at <1 month, 1 to 3 months, and 3 to 6 months, as well as on quality of life at <1 month, and on functionality at <1 month and 1 to 3 months.
Attitudes Towards and Management of Opioid-induced Hyperalgesia
Authors: Kum Elena , Buckley Norman , de Leon-Casasola Oscar , Lema Mark , Busse Jason W.
Published: February 2020

Objectives:

Opioid-induced hyperalgesia (OIH) is a phenomenon whereby opioids increase patients’ pain sensitivity, complicating their use in analgesia. We explored practitioners’ attitudes towards, and knowledge concerning diagnosis, risk factors, and treatment of OIH.

Materials and Methods:

We administered an 18-item cross-sectional survey to 850 clinicians that managed chronic pain with opioid therapy.

Results:

The survey response rate was 37% (318/850). Most respondents (240/318, 76%) reported they had observed patients with OIH in their practice, of which 38% (84/222) reported OIH affected >5% of their chronic pain patients. The majority (133/222, 60%) indicated that OIH could result from any dose of opioid therapy. The most commonly endorsed chronic pain conditions associated with the development of OIH were fibromyalgia (109/216, 51%) and low back pain (91/216, 42%), while 42% (91/216) indicated that no individual chronic pain condition was associated with greater risk of OIH. The most commonly endorsed opioids associated with the development of OIH were oxycodone (94/216, 44%), fentanyl (86/216, 40%), and morphine (84/216, 39%); 27% (59/216) endorsed that no specific opioid was more likely to result in OIH. Respondents commonly managed OIH by opioid dose reduction (147/216, 68%), administering a nonopioid adjuvant (133/216, 62%), or discontinuing opioids (95/216, 44%).

Discussion:

Most clinicians agreed that OIH is a complication of opioid therapy, but were divided regarding the prevalence of OIH, etiological factors, and optimal management.
Artifact Processing Methods Influence on Intraoperative Hypotension Quantification and Outcome Effect Estimates
Authors: Pasma Wietze , Peelen Linda M. , van Buuren Stef , van Klei Wilton A. , de Graaff Jurgen C.
Published: February 2020

Background

Physiologic data that is automatically collected during anesthesia is widely used for medical record keeping and clinical research. These data contain artifacts, which are not relevant in clinical care, but may influence research results. The aim of this study was to explore the effect of different methods of filtering and processing artifacts in anesthesiology data on study findings in order to demonstrate the importance of proper artifact filtering.

Methods

The authors performed a systematic literature search to identify artifact filtering methods. Subsequently, these methods were applied to the data of anesthesia procedures with invasive blood pressure monitoring. Different hypotension measures were calculated (i.e., presence, duration, maximum deviation below threshold, and area under threshold) across different definitions (i.e., thresholds for mean arterial pressure of 50, 60, 65, 70 mmHg). These were then used to estimate the association with postoperative myocardial injury.

Results

After screening 3,585 papers, the authors included 38 papers that reported artifact filtering methods. The authors applied eight of these methods to the data of 2,988 anesthesia procedures. The occurrence of hypotension (defined with a threshold of 50 mmHg) varied from 24% with a median filter of seven measurements to 55% without an artifact filtering method, and between 76 and 90% with a threshold of 65 mmHg. Standardized odds ratios for presence of hypotension ranged from 1.16 (95% CI, 1.07 to 1.26) to 1.24 (1.14 to 1.34) when hypotension was defined with a threshold of 50 mmHg. Similar variations in standardized odds ratios were found when applying methods to other hypotension measures and definitions.

Conclusions

The method of artifact filtering can have substantial effects on estimates of hypotension prevalence. The effect on the association between intraoperative hypotension and postoperative myocardial injury was relatively small. Nevertheless, the authors recommend that researchers carefully consider artifacts handling and report the methodology used.

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Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery
Authors: Mazzinari Guido , Diaz-Cambronero Oscar , Alonso-Iñigo Jose Miguel , Garcia-Gregorio Nuria , Ayas-Montero Begoña , Ibañez Jose Luis , Serpa Neto Ary , Ball Lorenzo , Gama de Abreu Marcelo , Pelosi Paolo , Maupoey Javier , Argente Navarro Maria Pilar , Schultz Marcus J.
Published: February 2020

Background

Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure.

Methods

Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. “Targeted PEEP” (2 cm H2O above intraabdominal pressure) was compared with “standard PEEP” (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure.

Results

Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels.

Conclusions

Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.

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Classification of Current Procedural Terminology Codes from Electronic Health Record Data Using Machine Learning
Authors: Burns Michael L. , Mathis Michael R. , Vandervest John , Tan Xinyu , Lu Bo , Colquhoun Douglas A. , Shah Nirav , Kheterpal Sachin , Saager Leif
Published: February 2020

Background

Accurate anesthesiology procedure code data are essential to quality improvement, research, and reimbursement tasks within anesthesiology practices. Advanced data science techniques, including machine learning and natural language processing, offer opportunities to develop classification tools for Current Procedural Terminology codes across anesthesia procedures.

Methods

Models were created using a Train/Test dataset including 1,164,343 procedures from 16 academic and private hospitals. Five supervised machine learning models were created to classify anesthesiology Current Procedural Terminology codes, with accuracy defined as first choice classification matching the institutional-assigned code existing in the perioperative database. The two best performing models were further refined and tested on a Holdout dataset from a single institution distinct from Train/Test. A tunable confidence parameter was created to identify cases for which models were highly accurate, with the goal of at least 95% accuracy, above the reported 2018 Centers for Medicare and Medicaid Services (Baltimore, Maryland) fee-for-service accuracy. Actual submitted claim data from billing specialists were used as a reference standard.

Results

Support vector machine and neural network label-embedding attentive models were the best performing models, respectively, demonstrating overall accuracies of 87.9% and 84.2% (single best code), and 96.8% and 94.0% (within top three). Classification accuracy was 96.4% in 47.0% of cases using support vector machine and 94.4% in 62.2% of cases using label-embedding attentive model within the Train/Test dataset. In the Holdout dataset, respective classification accuracies were 93.1% in 58.0% of cases and 95.0% among 62.0%. The most important feature in model training was procedure text.

Conclusions

Through application of machine learning and natural language processing techniques, highly accurate real-time models were created for anesthesiology Current Procedural Terminology code classification. The increased processing speed and a priori targeted accuracy of this classification approach may provide performance optimization and cost reduction for quality improvement, research, and reimbursement tasks reliant on anesthesiology procedure codes.

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One-year Results of a Factorial Randomized Trial of Aspirin versus Placebo and Clonidine versus Placebo in Patients Having Noncardiac Surgery
Authors: Sessler Daniel I. , Conen David , Leslie Kate , Yusuf Salim , Popova Ekaterina , Graham Michelle , Kurz Andrea , Villar Juan Carlos , Mrkobrada Marko , Sigamani Alben , Biccard Bruce M. , Meyhoff Christian S. , Parlow Joel L. , Guyatt Gordon , Xavier Denis , Chan Matthew T. V. , Kumar Priya A. , Forget Patrice , Malaga German , Fleischmann Edith , Amir Mohammed , Torres David , Wang C. Y. , Paniagua Pilar , Berwanger Otavio , Srinathan Sadeesh , Landoni Giovanni , Manach Yannick Le , Whitlock Richard , Lamy André , Balasubramanian Kumar , Gilron Ian , Turan Alparslan , Pettit Shirley , Devereaux P. J.
Published: February 2020

Background

The authors previously reported that perioperative aspirin and/or clonidine does not prevent a composite of death or myocardial infarction 30 days after noncardiac surgery. Moreover, aspirin increased the risk of major bleeding and clonidine caused hypotension and bradycardia. Whether these complications produce harm at 1 yr remains unknown.

Methods

The authors randomized 10,010 patients with or at risk of atherosclerosis and scheduled for noncardiac surgery in a 1:1:1:1 ratio to clonidine/aspirin, clonidine/aspirin placebo, clonidine placebo/aspirin, or clonidine placebo/aspirin placebo. Patients started taking aspirin or placebo just before surgery; those not previously taking aspirin continued daily for 30 days, and those taking aspirin previously continued for 7 days. Patients were also randomly assigned to receive clonidine or placebo just before surgery, with the study drug continued for 72 h.

Results

Neither aspirin nor clonidine had a significant effect on the primary 1-yr outcome, a composite of death or nonfatal myocardial infarction, with a 1-yr hazard ratio for aspirin of 1.00 (95% CI, 0.89 to 1.12; P = 0.948; 586 patients [11.8%] vs. 589 patients [11.8%]) and a hazard ratio for clonidine of 1.07 (95% CI, 0.96 to 1.20; P = 0.218; 608 patients [12.1%] vs. 567 patients [11.3%]), with effect on death or nonfatal infarction. Reduction in death and nonfatal myocardial infarction from aspirin in patients who previously had percutaneous coronary intervention at 30 days persisted at 1 yr. Specifically, the hazard ratio was 0.58 (95% CI, 0.35 to 0.95) in those with previous percutaneous coronary intervention and 1.03 (95% CI, 0.91to 1.16) in those without (interaction P = 0.033). There was no significant effect of either drug on death, cardiovascular complications, cancer, or chronic incisional pain at 1 yr (all P > 0.1).

Conclusions

Neither perioperative aspirin nor clonidine have significant long-term effects after noncardiac surgery. Perioperative aspirin in patients with previous percutaneous coronary intervention showed persistent benefit at 1 yr, a plausible sub-group effect.

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Does Iso-mechanical Power Lead to Iso-lung Damage?
Authors: Vassalli Francesco , Pasticci Iacopo , Romitti Federica , Duscio Eleonora , Aßmann David Jerome , Grünhagen Hannah , Vasques Francesco , Bonifazi Matteo , Busana Mattia , Macrì Matteo Maria , Giosa Lorenzo , Reupke Verena , Herrmann Peter , Hahn Günter , Leopardi Orazio , Moerer Onnen , Quintel Michael , Marini John J. , Gattinoni Luciano
Published: February 2020

Background

Excessive tidal volume, respiratory rate, and positive end-expiratory pressure (PEEP) are all potential causes of ventilator-induced lung injury, and all contribute to a single variable: the mechanical power. The authors aimed to determine whether high tidal volume or high respiratory rate or high PEEP at iso-mechanical power produce similar or different ventilator-induced lung injury.

Methods

Three ventilatory strategies—high tidal volume (twice baseline functional residual capacity), high respiratory rate (40 bpm), and high PEEP (25 cm H2O)—were each applied at two levels of mechanical power (15 and 30 J/min) for 48 h in six groups of seven healthy female piglets (weight: 24.2 ± 2.0 kg, mean ± SD).

Results

At iso-mechanical power, the high tidal volume groups immediately and sharply increased plateau, driving pressure, stress, and strain, which all further deteriorated with time. In high respiratory rate groups, they changed minimally at the beginning, but steadily increased during the 48 h. In contrast, after a sudden huge increase, they decreased with time in the high PEEP groups. End-experiment specific lung elastance was 6.5 ± 1.7 cm H2O in high tidal volume groups, 10.1 ± 3.9 cm H2O in high respiratory rate groups, and 4.5 ± 0.9 cm H2O in high PEEP groups. Functional residual capacity decreased and extravascular lung water increased similarly in these three categories. Lung weight, wet-to-dry ratio, and histologic scores were similar, regardless of ventilatory strategies and power levels. However, the alveolar edema score was higher in the low power groups. High PEEP had the greatest impact on hemodynamics, leading to increased need for fluids. Adverse events (early mortality and pneumothorax) also occurred more frequently in the high PEEP groups.

Conclusions

Different ventilatory strategies, delivered at iso-power, led to similar anatomical lung injury. The different systemic consequences of high PEEP underline that ventilator-induced lung injury must be evaluated in the context of the whole body.

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Neonatal Nurses' Self-reported Practices, Knowledge, and Attitudes Toward Use of Maternal Voice for Preterm Infants
Authors: Williamson Selena , McGrath Jacqueline M.
Published: February 2020

Background/Significance:

Infants born extremely premature (<1500 g) often experience lengthy stays in the challenging environment of the neonatal intensive care unit (NICU) separated from their parents.

Purpose:

The purpose of this study was to explore nurses' knowledge, attitude, and use of maternal voice as a therapeutic intervention for preterm infants in the NICU.

Methods:

Neonatal nurses (n = 117) completed an online survey about the use of maternal voice in their individual units. Questions included: (1) previous knowledge surrounding use of maternal voice in the NICU; (2) their attitudes about using maternal voice recordings and/or live maternal speech as an intervention; (3) whether their unit had the necessary equipment and environment conducive to using the therapy; (4) average amount of time parents were in the NICU with their neonate; and (5) in what situations they would personally encourage the use of maternal recordings (during procedures, rounds, etc).

Results:

Of those responding, 73.3% of nurse (n = 117) respondents agreed they were willing to incorporate maternal recordings into caregiving, with 80.8% indicating they were open to learning and employing different therapies to improve parental involvement in infant care.

Implications for Practice:

When the appropriate equipment is available, neonatal nurses are interested and willing to use alternative therapies that incorporate parental participation into direct caregiving as well as utilizing maternal voice recordings.

Implications for Research:

Further research with larger, more diverse samples is needed to determine the current knowledge, attitudes, and practices of maternal voice recordings by NICU nurses. Future research can also focus on barriers to utilization of the therapy during daily care.
Perioperative Safety of Surgery for Pelvic Organ Prolapse in Elderly and Frail Patients
Authors: Chapman Graham C. , Sheyn David , Slopnick Emily A. , Hijaz Adonis K. , Mahajan Sangeeta T. , Mangel Jeffrey , El-Nashar Sherif A.
Published: February 2020

OBJECTIVE:

To evaluate the effects of old age and frailty on complication rates after surgery for pelvic organ prolapse.

METHODS:

The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for prolapse from 2010 to 2017. We compared our control group (45–64 years, index population) to those aged 65–79 years (elderly) and 80 years and older (very elderly). Frailty was assessed using the National Surgical Quality Improvement Program Modified Frailty Index-5. The primary outcome was the composite rate of serious complications and mortality.

RESULTS:

We analyzed 27,403 patients in the index population, 20,567 in the elderly group, and 3,088 in the very elderly group. The composite rate of serious complications in the index population was 4.5%, compared with 4.7% in the elderly group (odds ratio [OR] 1.0, 95% CI 0.9–1.1) and 9.0% in the very elderly group (OR 2.1, 95% CI 1.8–2.4). Compared with the index group, the very elderly group had notably elevated risks of cardiac complications (OR 11.9, 95% CI 6.2–23.0), stroke (OR 26.6, 95% CI 5.4–131.8), and mortality (OR 39.9, 95% CI 8.6–184.7). On multivariate logistic regression, the only age group independently associated with serious complications was the very elderly group (adjusted odds ratio [aOR] 2.01, 95% CI 1.8–2.3). The Modified Frailty Index-5 score was independently predictive of complications (aOR 1.4, 95% CI 1.1–2.0). Stratified analysis using interaction terms revealed the Modified Frailty Index-5 score to be predictive of complications in the elderly age group (aOR 2.5, 95% CI 1.3–4.6), but not in the very elderly group.

CONCLUSION:

Serious complications surrounding prolapse surgery increase substantially in the cohort of patients older than 80 years of age, independent of frailty and medical or surgical risk factors.
Long-term Device Outcomes of Mesh Implants in Pelvic Organ Prolapse Repairs
Authors: Chughtai Bilal , Mao Jialin , Asfaw Tirsit S. , Heneghan Carl , Rardin Charles R. , Sedrakyan Art
Published: February 2020

OBJECTIVE:

To evaluate the longer-term safety and reintervention outcomes of mesh implants in pelvic organ prolapse (POP) repairs.

METHODS:

We conducted a population-based cohort study of women undergoing POP repairs in inpatient and outpatient surgical settings between 2008 and 2016 in New York State. Multivariable logistic regression was used based on patient and procedural characteristics and hospital volume between mesh and nonmesh groups to obtain propensity scores for each individual. Long-term safety events and reinterventions were assessed using time-to-event analysis.

RESULTS:

We identified 54,194 women undergoing POP repairs (12,989 with mesh, and 41,205 without mesh). Mean age was 59.8 (±13.1) years, and median follow-up was 4.7 years (interquartile range, 2.4–6.8 years). In the propensity score-matched 12,284 pairs of women, POP repair with mesh was associated with a higher risk of reintervention when compared with POP repair without transvaginal mesh (hazard ratio 1.40, 95% CI 1.27–1.54, P<.001). The estimated risk of undergoing a reintervention at 5 years was 8.8% (95% CI 8.2–9.3%) in the mesh group and 6.3% (5.9–6.8%) in the nonmesh group. Among patients who had reinterventions, 18.5% of those operated with mesh had a reintervention related to mesh-related complications.

CONCLUSION:

Even though transvaginal mesh has been removed from the market, the risk of mesh complications did not diminish over time and these women warrant close follow-up. Continued surveillance of mesh in POP repairs is essential to ensure safety for the women who have already been implanted.
Risk Calculator to Predict Cesarean Delivery Among Women Undergoing Induction of Labor
Authors: Rossi Robert M. , Requarth Erin , Warshak Carri R. , Dufendach Kevin R. , Hall Eric S. , DeFranco Emily A.
Published: February 2020

OBJECTIVE:

To develop and validate a predictive risk calculator for cesarean delivery among women undergoing induction of labor.

METHODS:

We performed a population-based cohort study of all women who had singleton live births after undergoing induction of labor from 32 0/7 to 42 6/7 weeks of gestation in the United States from 2012 to 2016. The primary objective was to build a predictive model estimating the probability of cesarean delivery after induction of labor using antenatal factors obtained from de-identified U.S. live-birth records. Multivariable logistic regression estimated the association of these factors on risk of cesarean delivery. K-fold cross validation was performed for internal validation of the model, followed by external validation using a separate live-birth cohort from 2017. A publicly available online calculator was developed after validation and calibration were performed for individual risk assessment. The seven variables selected for inclusion in the model by magnitude of influence were prior vaginal delivery, maternal weight at delivery, maternal height, maternal age, prior cesarean delivery, gestational age at induction, and maternal race.

RESULTS:

From 2012 to 2016, there were 19,844,580 live births in the United States, of which 4,177,644 women with singleton gestations underwent induction of labor. Among these women, 800,423 (19.2%) delivered by cesarean. The receiver operating characteristic curve for the seven-variable model achieved an area under the curve (AUC) of 0.787 (95% CI 0.786–0.788). External validation demonstrated a consistent measure of discrimination with an AUC of 0.783 (95% CI 0.764–0.802).

CONCLUSION:

This validated predictive model uses seven variables that were obtainable from the patient's medical record and discriminates between women at increased or decreased risk of cesarean delivery after induction of labor. This risk calculator, found at https://ob.tools/iol-calc, can be used in addition to the Bishop score by health care providers in counseling women who are undergoing an induction of labor and allocating appropriate resources for women at high risk for cesarean delivery.
Peripartum Blood Transfusion Among Rural Women in the United States
Authors: Hartenbach Ellen M. , Kuo Hsiang-Hui Daphne , Greene Madelyne Z. , Shrider Emily A. , Antony Kathleen M. , Ehrenthal Deborah B.
Published: February 2020

OBJECTIVE:

To evaluate the peripartum transfusion rates for rural women compared with urban women in the United States.

METHODS:

In this population-based retrospective cohort study, geocoded birth records from 2014 to 2016 from the National Center for Health Statistics were used to examine the rural–urban differences in blood transfusion among nulliparous women delivering singleton, vertex pregnancies at term. We compared transfusion rates across the counties on a continuum from urban to rural. We generated a multivariable logistic regression model controlling for age, race, nativity, education, insurance, prenatal care, maternal health, gestational age, intrapartum care, mode of delivery, peripartum factors, and county of delivery.

RESULTS:

Among 3,346,816 births, the transfusion rates based on maternal county of residence increased as the counties became more rural: large metropolitan-center (1.9/1,000 live births); large metropolitan-fringe (2.4); medium metropolitan (2.6); small metropolitan (2.6); micropolitan (4.5); and noncore rural (5.3). Rural women living and delivering in a rural county had more transfusions (8.5/1,000 live births) than women in more urban counties (2.5/1,000). After adjusting for key covariates, the odds of transfusion were higher among women living in micropolitan (adjusted odds ratio [aOR] 2.25, 95% CI 2.09–2.43) and noncore rural (aOR 2.59, 95% CI 2.38–2.81) counties when compared with women living in large metropolitan counties. County of delivery had a higher association with transfusion than resident county. After adding delivery county to the regression model, the association of transfusion and living in a micropolitan (aOR 1.39, 95% CI 1.19–1.63) or noncore rural (aOR 1.32, 95% CI 1.12–1.55) county diminished.

CONCLUSION:

The odds of blood transfusion were higher for women in rural areas. The results indicate that the rurality of the county where the birth occurred was associated with more transfusion. This may reflect differences in maternity and blood banking services in rural hospitals and warrants further study to identify opportunities for intervention.
The Effect of Spinopelvic Parameters on the Development of Proximal Junctional Kyphosis in Early Onset: Mean 4.5-Year Follow-up
Authors: Gomez Jaime A. , Kubat Ozren , Tovar Castro Mayra A. , Hanstein Regina , Flynn Tara , Lafage Virginie , Hurry Jennifer K. , Soroceanu Alexandra , Schwab Frank , Skaggs David L. , El-Hawary Ron
Published: February 2020

Background:

Proximal junctional kyphosis (PJK) is a major complication after posterior spinal surgery. It is diagnosed radiographically based on a proximal junctional angle (PJA) and clinically when proximal extension is required. We hypothesized that abnormal spinopelvic alignment will increase the risk of PJK in children with early-onset scoliosis (EOS).

Methods:

A retrospective study of 135 children with EOS from 2 registries, who were treated with distraction-based implants. Etiologies included 54 congenital, 10 neuromuscular, 37 syndromic, 32 idiopathic, and 2 unknown. A total of 89 rib-based and 46 spine-based surgeries were performed at a mean age of 5.3±2.83 years. On sagittal radiographs, spinopelvic parameters were measured preoperatively and at last follow-up: scoliosis angle (Cobb method, CA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope and PJA. Radiographic PJK was defined as PJA≥10 degrees and PJA≥10 degrees greater than preoperative measurement. The requirement for the proximal extension of the upper instrumented vertebrae was considered a proximal junctional failure (PJF). Analysis of risk factors for the development of PJK and PJF was performed.

Results:

At final follow-up (mean: 4.5±2.6 y), CA decreased (P<0.005), LL (P=0.029), and PI (P<0.005) increased, whereas PI−LL (pelvic incidence minus lumbar lordosis) did not change (P=0.706). Overall, 38% of children developed radiographic PJK and 18% developed PJF. Preoperative TK>50 degrees was a risk factor for the development of radiographic PJK (relative risk: 1.67, P=0.04). Children with high postoperative CA [hazard ratio (HR): 1.03, P=0.015], postoperative PT≥30 degrees (HR: 2.77, P=0.043), PI−LL>20 degrees (HR: 2.92, P=0.034), as well as greater preoperative to postoperative changes in PT (HR: 1.05, P=0.004), PI (HR: 1.06, P=0.0004) and PI−LL (HR: 1.03, P=0.013) were more likely to develop PJF. Children with rib-based constructs were less likely to develop radiographic PJK compared with children with spine-based distraction constructs (31% vs. 54%, respectively, P=0.038).

Conclusions:

In EOS patients undergoing growth-friendly surgery for EOS, preoperative TK>50 degrees was associated with increased risk for radiographic PJK. Postoperative PI−LL>20 degrees, PT≥30 degrees, and overcorrection of PT and PI−LL increased risk for PJF. Rib-based distraction construct decreased the risk for radiographic PJK in contrast with the spine-based constructs.

Level of Evidence:

Level III.
The Reliability of the AOSpine Thoracolumbar Classification System in Children: Results of a Multicenter Study
Authors: Mo Andrew Z. , Miller Patricia E. , Glotzbecker Michael P. , Li Ying , Fletcher Nicholas D. , Upasani Vidyadhar V. , Riccio Anthony I. , Hresko Michael T. , Krengel Walter F. , Spence David , Garg Sumeet , Hedequist Daniel J.
Published: February 2020

Background:

The purpose of this study was to determine whether the new AOSpine thoracolumbar spine injury classification system is reliable and reproducible when applied to the pediatric population.

Methods:

Nine POSNA (Pediatric Orthopaedic Society of North America) member surgeons were sent educational videos and schematic papers describing the AOSpine thoracolumbar spine injury classification system. The material also contained magnetic resonance imaging and computed tomography imaging of 25 pediatric patients with thoracolumbar spine injuries organized into cases to review and classify. The evaluators classified injuries into 3 primary categories: A, B, and C. Interobserver reliability was assessed for the initial reading by Fleiss kappa coefficient (k

F
) along with 95% confidence interval (CI). For A and B type injuries, subclassification was conducted including A0 to A4 and B1 to B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff alpha (α
k
) along with bootstrapped 95% CI. Imaging was reviewed a second time by all evaluators ~1 month later. All imaging was blinded and randomized. Intraobserver reproducibility was assessed for the primary classifications using Fleiss kappa and subclassification reproducibility was assessed by Krippendorff alpha (α
k
) along with 95% CI. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement.

Results:

Twenty-five cases were read for a total of 225 initial and 225 repeated evaluations. Adjusted interobserver reliability was almost perfect (k

F
=0.82; CI, 0.77-0.87) across all raters. Subclassification reliability was substantial (α

K
=0.79; CI, 0.62-0.90). Adjusted intraobserver reproducibility was almost perfect (k

F
=0.81; CI, 0.71-0.90) for both primary classifications and for subclassifications (α
k
=0.81; CI, 0.73-0.86).

Conclusions:

The reliability for the AOSpine thoracolumbar spine injury slassification System was high amongst POSNA surgeons when applied to pediatric patients. Given a lack of a uniform classification in the pediatric population, the AOSpine thoracolumbar spine injury classification system has the potential to be used as the first universal spine fracture classification in children.

Level of Evidence:

Level III.
Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial for Intervertebral Disc Herniation
Authors: Oster Brittany A. , Kikanloo Sina Rashidi , Levine Nicole L. , Lian Jayson , Cho Woojin
Published: February 2020

Mini

We summarized the 10-year outcomes of Spine Patient Outcomes Research Trial for intervertebral disc herniation through a systematic review. The observational cohort 2-year analysis and the as-treated analysis of the randomized control trial at 4 and 8 years showed statistically greater improvements in those patients who were treated surgically.

Study Design.

We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Objective.

We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for intervertebral disc herniation.

Summary of Background Data.

The Spine Patient Outcomes Research Trial (SPORT) was a landmark study. SPORT compared surgical and nonoperative management of the three most common spinal pathologies.

Methods.

Keywords utilized included: SPORT, spine patient outcomes research trial, disc herniation, and surgical outcomes.

Results.

The observational cohort analysis revealed statically greater improvement in primary outcomes at 3 months and 2 years in patients who had surgery, while analysis of the randomized control trial cohort failed to show a significant difference based on the intent-to-treat principle due to significant patient crossover. However, 4 year and 8 year as-treated analysis showed statistically greater improvements in those patients who were treated surgically. SPORT's subgroup analysis evaluated important factors when considering the treatment of IDH, including patient characteristics, level of herniation, duration of symptoms, recurrence of pain, presence of retrolistheiss, patient functional status, effects of previous treatment with epidural steroid injections and opioid medication, outcomes after incidental durotomy, MRI reader reliability, reoperation rates, and risk factors for reoperation. The clinical impact of SPORT was also investigated and included comparison of SPORT patients to NSQIP patients to determine generalizability, outcome differences in SPORT's surgical center sites, patient preferences, patient expectations, level of education, and effects of watching an evidence-based video.

Conclusion.

Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of IDH. Results showed significantly greater improvements in patients treated surgically.

Level of Evidence: 3
Risk Factors for Cement Leakage and Adjacent Vertebral Fractures in Kyphoplasty for Osteoporotic Vertebral Fractures
Authors: Chen Changhong , Fan Pan , Xie Xinhui , Wang Yuntao
Published: February 2020

Purpose:

Cement leakage and adjacent vertebral fractures are not uncommon after percutaneous augmentation. However, conclusive identification of risk factors for postprocedural complications remains elusive. The anticipation of leakage and successive fractures through the identification of risk factors will help physicians better inform patients of potential complications and establish procedural refinements key to risk reduction. The aim of this retrospective study was to summarize available reports of the risk factors for cement leak and adjacent vertebral fracture in or after kyphoplasty for osteoporotic vertebral compression fractures.

Methods:

A total of 102 cases of bilateral percutaneous kyphoplasty (PKP), performed between January 2014 and December 2016, were retrospectively reviewed. Each case surveyed in this review included a minimum 1-year follow-up and data on age, sex, bone mineral density, Visual Analog Scale score, preoperative compression rate, kyphotic angle, treatment time, the volume of cement, and the intactness of the vertebral posterior wall (computed tomography scan) were collected. Pearson χ2 test and independent samples test were used to determine the relative risk factors of cement leak and adjacent vertebral fracture in patient subsets.

Results:

Diabetic status and alteration in the Cobb angle after PKP exhibited a statistically significant correlation with the incidence of new adjacent vertebral fracture (group B) (P<0.05). In addition, the integrity of vertebral walls (P=0.001) and the volume of injected cement (P=0.026) significantly boosted the potential risk of cement leakage (P<0.05), although these variables did not associate with the adjacent fracture. Additional examined variables, including age, sex, Visual Analog Scale scores, number of fractures were not significantly associated with leakage or adjacent vertebral fracture risk.

Conclusions:

Diabetes and the alteration of the Cobb angle following PKP are factors positively related to the occurrence of postoperative adjacent vertebral fractures. It is also demonstrated that the integrity of vertebral walls and average volumes of injected cement are the possible risk factors of cement leakage while performing the PKP.
Physician Decision-making in Return to Play After Cervical Spine Injury
Authors: Ukogu Chierika , Bienstock Dennis , Ferrer Christopher , Zubizarreta Nicole , McAnany Steven , Chaudhary Saad B. , Iatridis James C. , Hecht Andrew C.
Published: February 2020

Summary of Background Data:

Cervical spine injuries commonly occur during athletic play, and such injuries carry significant risk for adverse sequelae if not properly managed. Although guidelines for managing return to play exist, adherence among spine surgeons has not been thoroughly examined.

Study Design:

Prospective analysis of survey data collected from surgeon members of the Cervical Spine Research Society (CSRS) and the International Society for the Advancement of Spine Surgery (ISASS).

Objective:

The objective of this study was to characterize consensus among spine surgeons regarding decision-making on return to competitive sports and level of impact following significant cervical spine injuries from real-life scenarios.

Materials and Methods:

Return to play decisions for 15 clinical cervical spine injury scenarios were compared with current guidelines. Surgeon demographic information such as orthopedic board certification status and years in practice were also analyzed. Weighted kappa analysis was utilized to determine interrater reliability in survey responses.

Results:

Survey respondents had a poor agreement with both Watkins and Torg guidelines (average weighted κ of 0.027 and 0.066, respectively). Additional kappa analysis of surgeon agreement regarding the “Types of Play” and “Level of Play” for return was still remained poor (Kendall W of 0.312 and 0.200, respectively). Responses were also significantly influenced by surgeon demographics.

Conclusions:

There is poor consensus among spine surgeons for return to play following cervical spine injury. These results support the concept that given the gravity of cervical spine injuries, a more standardized approach to decision-making regarding return to play after cervical spine injury is necessary.
Nurses' Compliance With Bar-code Medication Administration Technology
Authors: Othman Elham H. , Darawad Muhammad W.
Published: February 2020

Medication administration using bar-code medication administration technology enhances the verification of medication administration rights. Nurses' compliance with bar-code medication administration procedure is essential to maximize the benefits. This study evaluated the current rate of nurses' compliance with bar-code medication administration use through direct observation. A descriptive design was used and 134 RNs were recruited from two public hospitals located in the middle region of Jordan. Compliance with bar-code medication administration was evaluated using an evidence-based checklist of 17 items. Participants' compliance with the bar-code medication administration was 55%, which had a significant positive correlation with their level of comfort using bar-code medication administration, usefulness, and ease of use, perceived job productivity, and overall rating of bar-code medication administration. Stakeholders can benefit from assessing end-user acceptance and perceptions regarding the bar-code medication administration technology to promote acceptance and compliance.
Bilateral Vocal Cord Paralysis Due to an Immune-related Adverse Event of Nivolumab: A Case Report
Authors: Willegers Tim , Janssen Jorien B.E. , Boers-Sonderen Marye J. , Bekkers Stijn
Published: February 2020

Nivolumab is an anti-programmed death-1 inhibitor used in the treatment of cancer. Nivolumab has recently been approved as an adjuvant treatment for patients with stage IIIB, IIIC, and completely resected stage IV melanoma in the Netherlands. Despite the promising results of nivolumab, there is a wide variation in toxic side effects. A nivolumab-induced bilateral vocal cord paralysis (BVCP) was not reported. In this case, we present a nivolumab-induced BVCP. A 75-year-old man received nivolumab as adjuvant therapy for stage III melanoma. After the first cycle of nivolumab, this patient developed immune-related hepatitis and colitis. During admission, the patient became respiratory insufficient as a result of a BVCP. This case report describes immune-related hepatitis, colitis, and BVCP after the first cycle of nivolumab in the treatment of stage IIIb melanoma. Follow-up has not yet shown improvement in the mobility of the vocal cords.
Concerned topics of epidural labor analgesia: labor elongation and maternal pyrexia: a systematic review
Authors: Li Cai-Juan , Xia Fan , Xu Shi-Qin , Shen Xiao-Feng
Published: February 2020

Objective:

Labor is a complex process and labor pain presents challenges for analgesia. Epidural analgesia (EA) has a well-known analgesic effect and is commonly used during labor. This review summarized frequently encountered and controversial problems surrounding EA during labor, including the labor process and maternal intrapartum fever, to build knowledge in this area.

Data sources:

We searched for relevant articles published up to 2019 in PubMed using a range of search terms (eg, “labor pain,” “epidural,” “analgesia,” “labor process,” “maternal pyrexia,” “intrapartum fever”).

Study selection:

The search returned 835 articles, including randomized control trials, retrospective cohort studies, observational studies, and reviews. The articles were screened by title, abstract, and then full-text, with a sample independently screened by two authors. Thirty-eight articles were included in our final analysis; 20 articles concerned the labor process and 18 reported on maternal pyrexia during EA.

Results:

Four classic prospective studies including 14,326 participants compared early and delayed initiation of EA by the incidence of cesarean delivery. Early initiation following an analgesia request was preferred. However, it was controversial whether continuous use of EA in the second stage of labor induced adverse maternal and neonatal outcomes due to changes in analgesic and epidural infusion regimens. There was a high incidence of maternal pyrexia in women receiving EA and women with placental inflammation or histologic chorioamnionitis compared with those receiving systemic opioids.

Conclusions:

Early EA (cervical dilation ≥1 cm) does not increase the risk for cesarean section. Continuous epidural application of low doses of analgesics and programmed intermittent epidural bolus do not prolong second-stage labor duration or impact maternal and neonatal outcomes. The association between EA and maternal pyrexia remains controversial, but pyrexia is more common with EA than without. A non-infectious inflammatory process is an accepted mechanism of epidural-related maternal fever.
Optimum interval time of programmed intermittent epidural bolus of ropivacaine 0.08% with sufentanyl 0.3 μg/mL for labor analgesia: a biased-coin up-and-down sequential allocation trial
Authors: Zhou Shuang-Qiong , Wang Jing , Du Wei-Jia , Song Yu-Jie , Xu Zhen-Dong , Liu Zhi-Qiang
Published: February 2020

Background:

The programmed intermittent epidural bolus (PIEB) technique is widely used in labor analgesia, but the parameter settings of PIEB have not yet been standardized. We designed a study to identify the optimal interval duration for PIEB using 10 mL of ropivacaine 0.08% and sufentanyl 0.3 μg/mL, a regimen commonly used to control labor pain in China, to provide effective analgesia in 90% of women during the first stage of labor without breakthrough pain.

Methods:

We conducted a double-blind sequential allocation trial to obtain the effective interval 90% (EI90%) during the first stage of labor between April 2019 and May 2019. This study included the American Society of Anesthesiologists physical status II–III nulliparous parturients at term, who requested epidural analgesia. The bolus volume was fixed at 10 mL of ropivacaine 0.08% with sufentanyl 0.3 μg/mL. Participants were divided into four groups (groups 60, 50, 40, and 30) according to the PIEB intervals (60, 50, 40, and 30 min, respectively). The interval duration of the first parturient was set at 60 min and that of subsequent parturients varied according to a biased-coin design. The truncated Dixon and Mood method and the isotonic regression analysis method were used to estimate the EI90% and its 95% confidence intervals (CIs).

Results:

Forty-four women were enrolled in this study. The estimated optimal interval was 44.1 min (95% CI 41.7–46.5 min) and 39.5 min (95% CI 32.5–50.0 min), using the truncated Dixon and Mood method and isotonic regression analysis, respectively. The maximum sensory block level above T6 was in nearly 20% of parturients in group 30; however, 5.3%, 0%, and 0% of the parturients presented with sensory block level above T6 in groups 40, 50, and 60, respectively. There were no cases of hypotension and only one parturient complained of motor block.

Conclusion:

With a fixed 10 mL dose of ropivacaine 0.08% with sufentanyl 0.3 μg/mL, the optimal PIEB interval is about 42 min. Further studies are warranted to define the efficacy of this regimen throughout all stages of labor.

Trial registration: Chinese Clinical Trial Registry, ChiCTR1900022199; http://www.chictr.org.cn/com/25/historyversionpuben.aspx?regno=ChiCTR1900022199.