bluuebunny/crossref_metadata_2025_split huggingface dataset:
Glucocorticoid and opioid use in rheumatoid arthritis management
Authors: Moore Meriah N. , Wallace Beth I. 
Published: February 2021

Purpose of review
Glucocorticoids and opioids are longstanding, common treatments for rheumatoid arthritis (RA) symptoms. High-quality clinical trials have established that glucocorticoids improve outcomes in RA, but debate continues as to whether their benefits outweigh their risks. We reviewed recent studies on patterns of glucocorticoid and opioid prescribing in RA, and associated harms.

Recent findings
At present, a large proportion of RA patients remain on glucocorticoids and/or opioids long-term. Likelihood and risk of both glucocorticoid and opioid exposure vary across the population, and are influenced by provider factors. Opioids are also associated with delays in disease-modifying treatment initiation. Recent evidence increasingly demonstrates toxicity associated with even low-dose glucocorticoids (≤7.5 mg/day). Up to two-thirds of RA patients may be able to discontinue chronic low-dose glucocorticoids without flare or adrenal insufficiency. These new data have led to changes in clinical practice guidelines for glucocorticoid use in RA.

Summary
Although low-dose and short-term glucocorticoid use is extremely common and effective in RA management, increasing evidence of toxicity has led experts to begin recommending that such exposure be minimized. Despite a lack of data to suggest opioids improve RA disease activity, they are used commonly, continued long-term, and associated with delayed effective therapy.
Postoperative Myocardial Reinfarction Following Lumbar Spine Surgery
Authors: Harwin Brett , Roberts Sidney , Formanek Blake , Wang Jeffrey C. , Buser Zorica 
Published: February 2021

Study Design:
This study was a retrospective cohort database study which looked at the relationship between myocardial reinfarction following lumbar spine surgery.

Objective:
Current study aimed to determine the risk of reinfarction associated with the time between initial myocardial infarction (MI) and lumbar spine surgery, type of lumbar surgical procedure, and other risk factors.

Summary of Background Info:
Several studies have demonstrated a strong temporal pattern between postoperative reinfarction rate and the period between previous MI and surgery. To the best of our knowledge, no study has looked specifically at the temporal relationship between previous MI, lumbar spine surgery and incidence of postoperative myocardial reinfarction.

Materials and Methods:
The Humana database was analyzed from Q1 2007 through Q3 2016 and the Medicare database was analyzed from Q1 2005 through Q4 2014. Patients were placed into 1 of 5 groups based on time between MI and surgery: 0–3, 4–6, 7–12, 13–24, and 25+ months. Reinfarction rates were determined in these groups. Age, sex, and type of surgery were analyzed to determine association with postoperative reinfarction rates.

Results:
There was a strong correlation between postoperative myocardial reinfarction and lumbar spine surgery occurring 0–3 months after the patient’s initial MI (P<0.01). Those patients had a risk ratio >3 (P<0.01) compared with patients who underwent lumbar spine surgery after an interval >3 months between initial MI and lumbar spine surgery. In addition, spinal fusion procedures were associated with a greater risk of postoperative myocardial reinfarction than nonfusion procedures.

Conclusion:
In both databases, there was a clinically relevant and statistically significant increase in myocardial reinfarction in patients who experienced an MI 0–3 months before lumbar spine surgery. We believe that the current study helps in treatment planning for patients with a history of MI who are considering spine surgery.

Level of Evidence:
Level III.
One-Year Outcomes of Chiari Type 1 Malformation and Syringomyelia Treated With Posterior Fossa Decompression
Authors: Han Shiyuan , Gao Jun , Li Zhimin , Wang Xin , Li Yongning 
Published: February 2021

Study Design:
This was a retrospective cohort study.

Objective:
The objective of this study was to evaluate posterior fossa structural differences between Chiari type 1 malformation with and without syringomyelia, and assess data of the improvement of syringomyelia after different surgical options.

Summary of Background Data:
Syringomyelia is among the most common concomitant complications of Chiari malformation (CM). However, posterior fossa decompression cannot definitely make the syringomyelia disappear even in the long term. Also, there are no universal criteria defining improvement in syrinx.

Materials and Methods:
All admitted CM patients at our institution from 2013 to 2018 with a 1-year follow-up were analyzed. Patients without syringomyelia were compared with those who had syringomyelia. Patients were divided into 3 groups according to the procedures performed: posterior fossa decompression versus posterior fossa decompression with duralplasty (PFDD) versus PFDD plus obex unblocking. Divergent prognosis of syringomyelia was defined as a 3-category ordinal variable. A multivariable ordinal regression model was used to estimate the relationship between patient variables and increased odds for better resolution of syringomyelia.

Results:
No significant linear difference in bony structure was found between syringomyelia and nonsyringomyelia patients. Among syringomyelia patients, the regression analysis demonstrated that patients with shorter posterior fossa height (P=0.032), lower Pavlov ratio (P=0.029), and obex unblocking (vs. PFDD, P<0.001; vs. posterior fossa decompression, P=0.037) were more likely to gain a better resolution of syringomyelia.

Conclusions:
Syringomyelia of CM patients may not simply originate from single linear anatomic variation. Patients with shorter posterior fossa height and lower Pavlov ratio received better syringomyelia resolution. Also, unblocking the obex received better syringomyelia resolution compared with duraplasty alone and bony decompression alone with the avoidance of increased postoperative complications and worse clinical outcomes.
Incidence and Risk Factors for Postoperative Venous Thromboembolic Events in Patients Undergoing Cervical Spine Surgery
Authors: Bui Annelise , Lashkari Nassim , Formanek Blake , Wang Jeffrey C. , Buser Zorica , Liu John C. 
Published: February 2021

Study Design:
This was a retrospective database study.

Objective:
The objective of this study was to investigate preoperative risk factors and incidence of venous thromboembolic events (VTEs) after cervical spine surgery.

Summary of Background Data:
VTEs are preventable complications that may occur after spinal procedures. Globally, VTEs account for a major cause of morbidity and mortality. Preoperative risks factors associated with increased VTE incidence after cervical spine surgery have not been well-characterized.

Materials and Methods:
Patients undergoing anterior cervical discectomy and fusion (ACDF); posterior cervical fusion (PCF); discectomy; and decompression from 2007 to 2017 were identified using the PearlDiver Database. International Classification of Diseases (ICD) Ninth and 10th Revision codes were used to identify VTEs at 1 week, 1 month, and 3 months postoperative as well as preoperative risk factors.

Results:
Risk factors with the highest incidence of VTE at 3 months were primary coagulation disorder [ACDF=7.82%, odds ratio (OR)=3.96; decompression=11.24%, OR=3.03], central venous line (ACDF=5.68%, OR=2.11; PCF=12.58%, OR=2.27; decompression=10.17%, OR=2.80) and extremity paralysis (ACDF=6.59%, OR=2.73; PCF=18.80%, OR=2.99; decompression=11.86, OR=3.74). VTE incidence at 3 months for populations with these risks was significant for all surgery types (P<0.001) with the exception of patients with primary coagulation disorder who underwent PCF. Tobacco use had the lowest VTE incidence for all surgery types.

Conclusions:
The total cumulative incidence of VTEs at 3-month follow-up was 3.10%, with the highest incidence of VTEs occurring within the first postoperative week (0.65% at 1 wk, 0.61% at 1 mo, 0.53% at 3 mo for ACDF; 2.56% at 1 wk, 1.93% at 1 mo, 1.45% at 3 mo for PCF; 1.37% at 1 wk, 0.93% at 1 mo, 0.91% at 3 mo for decompression). Several preoperative risk factors were found to be significant predictors for postoperative VTEs and can be used to suggest those at increased risk as well as decrease the incidence of preventable VTEs after cervical spine surgery.

Level of Evidence:
Level III.
Accuracy of Subaxial Cervical Pedicle Screw Placement Using Direct Visualization Versus Computed Tomography–Based Navigation
Authors: Farber S. Harrison , Godzik Jakub , Hlubek Randall J. , Zhou James J. , Walker Corey T. , Kakarla U. Kumar , Uribe Juan S. , Turner Jay D. 
Published: February 2021

Study Design:
Retrospective analysis of operative data from cadaveric cervical spines.

Objective:
To evaluate the accuracy of neuronavigation compared with laminotomy with direct visualization (DV) of the pedicle for placement of subaxial pedicle screws.

Summary of Background Data:
Subaxial pedicle screws provide superior fixation compared with other posterior cervical fixation strategies. However, high accuracy is required for safe placement, given the proximity of critical neurovascular structures. Computed tomography (CT)–based neuronavigation has increased in popularity for placement of spinal implants, including subaxial pedicle screws. However, the accuracy of the technique for this application has not been extensively evaluated.

Methods:
Six fresh-frozen cadaveric spines (occiput to T2) were prepared. Pedicle screws were placed from C3 to C7 on either side using either the DV or neuronavigation technique (alternating sides between specimens). Pedicles with diameters <4 mm were excluded. For the DV technique, a hemilaminotomy was performed for DV of pedicle borders and to determine appropriate screw medialization and trajectory. Neuronavigation screws were placed using CT-based navigation with a reference frame mounted on the C2 spinous process. Screw position was evaluated using postoperative CT, and breaches were classified using the Neo classification.

Results:
Fifty pedicle screws were placed at 25 levels in 6 cadaveric spines; 25 screws each were placed using neuronavigation or DV. No significant difference in accuracy was found between the 2 techniques. Three (12%) breaches occurred in the DV group, and 9 (36%) breaches occurred in the neuronavigation group (P=0.10). The breaches were evenly distributed across all levels. There were no high-grade breaches with DV and only 1 (4.0%) with neuronavigation (P>0.99). Average pedicle cortical and medullary bone widths were higher for levels with no breach (P=0.009 and P=0.02, respectively).

Conclusions:
High accuracy can be achieved with both neuronavigation and DV for placement of subaxial cervical pedicle screws in cadavers.
A Retrospective Analysis of Superior Facet Joint Violation Between Open and Minimally Invasive Transforaminal Lumbar Interbody Fusion and its Relation to Adjacent Segment Disease
Authors: Maharjan Sujan , Zeng Zhili , Yu Yan , Cheng Liming 
Published: February 2021

Study Design:
A retrospective study.

Objective:
The aim was to analyze the superior facet joint violation (SFV) between open transforaminal lumbar interbody fusion (open-TLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and its effect on the superior and inferior adjacent segment disc height, segmental lordosis, lumbar lordosis, and facet joint degeneration.

Summary of Background Data:
We compared SFV between open-TLIF and MIS-TLIF and its correlation with different factors as well as its effect on adjacent segment disease.

Materials and Methods:
We retrospectively studied data of patients undergoing single level TLIF surgery from January 2013 to February 2016 in single institutional hospital. Axial and coronal postoperative computed tomography scan images were used to analyze SFV. In secondary analysis patients were divided into nonfacet violation group (NSFVG) and facet violation group (SFVG) and compared the changes on the superior and inferior adjacent level disc height, segmental lordosis, lumbar lordosis, and facet joint degeneration.

Results:
Mean SFV grade was significantly greater in MIS-TLIF compared with open-TLIF (odds ratio: 0.638, confidence interval: 0.431-0.944; P=0.025). There was more grade 2 (10.71% vs. 5.60%) and grade 3 (4.46% vs. 1.29%) SFV in MIS-TLIF. Patient with age below 60 and body mass index (BMI) >30 kg/m2 in MIS-TLIF were more prone to high-grade SFV compared with open-TLIF. Further, logistic regression showed patients with BMI ≥30 kg/m2 has 7.137 increased odds of high-grade SFV (95% confidence interval: 3.261-15.618; P=0.000) compared with patients with BMI <30 kg/m2. Compared with NSFVG, SFVG has more SFV (0.096±0.244 vs. 0.177±0.317; P=0.012) and less improvement in lumbar visual analog scale scores −0.65±0.073 versus −0.67±0.074 (P=0.006).

Conclusion:
MIS-TLIF has more high-grade SFV as well as overall mean SFV in comparison to open-TLIF with BMI >30 kg/m2 and location of pedicle screw as an independent risk factor for SFV and risk of adjacent segment disease increases with SFV.

Level of Study:
Level III.
High-Sensitivity Estimate of the Incidence of New-Onset Atrial Fibrillation in Critically Ill Patients
Authors: McIntyre William F. , Belley-Côté Emilie P. , Vadakken Maria E. , Rai Anand S. , Lengyel Alexandra P. , Rochwerg Bram , Bhatnagar Akash K. , Deif Bishoy , Um Kevin J. , Spence Jessica , Connolly Stuart J. , Bangdiwala Shrikant I. , Rao-Melacini Purnima , Healey Jeff S. , Whitlock Richard P. 
Published: February 2021

Objective:
To estimate the incidence of new-onset atrial fibrillation in critically ill patients.

Design:
Prospective cohort.

Setting:
Medical-surgical ICU.

Subjects:
Consecutive patients without a history of atrial fibrillation but with atrial fibrillation risk factors.

Interventions:
Electrocardiogram patch monitor until discharge from hospital or up to 14 days.

Measurements and Main Results:
A total of 249 participants (median age of 71 yr [interquartile range] 64–78 yr; 35% female) completed the study protocol of which 158 (64%) were admitted to ICU for medical illness, 78 (31%) following noncardiac surgery, and 13 (5%) with trauma. Median Acute Physiology and Chronic Health Evaluation II score was 16 (interquartile range, 12–22). Median duration of patch electrocardiogram monitoring, ICU, and hospital lengths of stay were 6 (interquartile range, 3–12), 4 (interquartile range, 2–8), and 11 days (interquartile range, 5–23 d), respectively.
Atrial fibrillation ≥ 30 seconds was detected by the patch in 44 participants (17.7%), and three participants (1.2%) had atrial fibrillation detected clinically after patch removal, resulting in an overall atrial fibrillation incidence of 18.9% (95% CI, 14.2–24.3%).
Total duration of atrial fibrillation ranged from 53 seconds to the entire monitoring time. The proportion of participants with ≥1 episode(s) of ≥6 minute, ≥1 hour, ≥12 hour and ≥24 hour duration was 14.8%, 13.2%, 7.0%, and 5.3%, respectively. The clinical team recognized only 70% of atrial fibrillation cases that were detected by the electrocardiogram patch.

Conclusions:
Among patients admitted to an ICU, the incidence of new-onset atrial fibrillation is approximately one in five, although approximately one-third of cases are not recognized by the clinical team.
Lung-Protective Ventilation Over 6 Years at a Large Academic Medical Center: An Evaluation of Trends, Adherence, and Perceptions of Benefit
Authors: Gao Catherine A. , Howard Frederick M. , Siner Jonathan M. , Candido Thomas D. , Ferrante Lauren E. 
Published: February 2021

Objectives:
The main objective of this study was to evaluate trends in set tidal volumes across all adult ICUs at a large academic medical center over 6 years, with a focus on adherence to lung-protective ventilation (≤ 8-cc/kg ideal body weight). A secondary objective was to survey providers on their perceptions of lung-protective ventilation and barriers to its implementation.

Design:
Retrospective observational analysis (primary objective) and cross-sectional survey study (secondary objective), both at a single center.

Participants:
Mechanically ventilated adult patients with a set tidal volume (primary objective) and providers rotating through the Medical and Neurosciences ICUs (secondary objective).

Interventions:
None.

Measurements and Main results:
From 2013 to 2018, the average initial set tidal volume (cc/kg ideal body weight) decreased from 8.99 ± 2.19 to 7.45±1.34 (p < 0.001). The cardiothoracic ICU had the largest change in tidal volume from 11.09 ± 1.96 in 2013 to 7.97 ± 1.03 in 2018 (p < 0.001). Although the majority of tidal volumes across all ICUs were between 6.58 and 8.01 (interquartile range) in 2018, 27% of patients were still being ventilated at volumes greater than 8-cc/kg ideal body weight. Most surveyed respondents felt there was benefit to lung-protective ventilation, though many did not routinely calculate the set tidal volume in cc/kg ideal body weight, and most did not feel it was easily calculable with the current electronic medical record system.

Conclusions:
Despite a trend toward lower tidal volumes over the years, in 2018, over a quarter of mechanically ventilated adult patients were being ventilated with tidal volumes greater than 8 cc/kg. Survey data indicate that despite respondents acknowledging the benefits of lung-protective ventilation, there are barriers to its optimal implementation. Future modifications of the electronic medical record, including a calculator to set tidal volume in cc/kg and the use of default set tidal volumes, may help facilitate the delivery of and adherence to lung-protective ventilation.
Effect of Hospital Linens on Unit-Acquired Pressure Injuries for Adults in Medical ICUs: A Cluster Randomized Controlled Trial
Authors: Montague-McCown Mary , Bena James , Burchill Christian N. 
Published: February 2021

Objectives:
Researchers have shown in laboratory studies that different types of fabrics were associated with changes in skin moisture, friction, shear, and temperature that may predispose patients to pressure injury. There was an association between type of fiber used in hospital linens and pressure injury development in previous clinical studies. We examined if bed linens made from a newly developed synthetic fiber fabric affected occurrence rate, time to development, and severity of unit-acquired pressure injury in critically ill adult inpatients.

Design:
Cluster randomized controlled trial.

Setting:
Five adult medical ICUs within one quaternary care center in the Midwest United States.

Patients:
Patients were assigned to a unit based on bed availability. In total, there were 3,332 patients in the study.

INTERVENTIONS:
Participating medical ICUs were randomly assigned to cotton fiber or synthetic fiber linens for the first 6 months of the study period, and assignment reversed after a 14-day washout period for the final 6 months.

Measurements and Main Results:
Unit-acquired pressure injury occurrence rate, time to first unit-acquired pressure injury, and severity were evaluated using generalized mixed effect models with patient as a random effect, and a marginal Cox proportional hazards model with repeated admissions from the same patient accounted for by use of a sandwich estimator of the variance. There were 1,706 patients on cotton fiber linens and 1,626 patients on synthetic fiber linens. Groups were similar on demographics except race and admitting diagnosis groupings. Occurrence rate (p = 0.99), time to development (p = 0.99), and maximum severity of unit-acquired pressure (p = 0.86) were similar between groups before and after controlling for race and admitting diagnosis groupings.

Conclusions:
Linen type did not affect unit-acquired pressure injury occurrence rate, severity, or timing. Standard unit-acquired pressure injury prevention efforts may be more cost-effective than investment in synthetic fiber linens.
Life Support Limitations in Mechanically Ventilated Stroke Patients
Authors: de Montmollin Etienne , Schwebel Carole , Dupuis Claire , Garrouste-Orgeas Maité , da Silva Daniel , Azoulay Elie , Laurent Virginie , Thiéry Guillaume , Grinea Alexandra , Marcotte Guillaume , Oziel Johanna , Gainnier Marc , Siami Shidasp , Reignier Jean , Sztrymf Benjamin , Adrie Christophe , Ruckly Stephane , Sonneville Romain , Timsit Jean-François 
Published: February 2021

Objectives:
The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions.

Design:
Multicenter prospective French observational study.

Setting:
Fourteen ICUs of the French OutcomeRea network.

PATIENTS:
From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission.

INTERVENTION:
None.

MEASUREMENTS AND MAIN RESULTS:
We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78–4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97–5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3–9] vs 2 d [1–6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01–2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27–4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43–3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08–4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82–0.97]).

Conclusions:
In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.