Lowest instrumented vertebrae in early onset scoliosis: is there a role for a more selective approach?

PURPOSE: This purpose of this study was to assess the impact of patient and implant characteristics on LIV selection in ambulatory children with EOS and to assess the relationship between the touched vertebrae (TV), the last substantially touched vertebrae (LSTV), the stable vertebrae (SV), the sagittal stable vertebrae (SSV), and the LIV. METHODS: A multicenter pediatric spine database was queried for patients ages 2-10 years treated by growth friendly instrumentation with at least 2-year follow up. The relationship between the LIV and preoperative spinal height, curve magnitude, and implant type were assessed. The relationships between the TV, LSTV, SV, SSV, and the LIV were also evaluated. RESULTS: Overall, 281 patients met inclusion criteria. The LIV was at L3 or below in most patients with a lumbar LIV: L1 (9.2%), L2 (20.2%), L3 (40.9%), L4 (29.5%). Smaller T1 - T12 length was associated with more caudal LIV selection (p = 0.001). Larger curve magnitudes were similarly associated with more caudal LIV selection (p = < 0.0001). Implant type was not associated with LIV selection (p = 0.32) including MCGR actuator length (p = 0.829). The LIV was caudal to the TV in 78% of patients with a TV at L2 or above compared to only 17% of patients with a TV at L3 or below (p < 0.0001). CONCLUSIONS: Most EOS patients have an LIV of L3 or below and display TV-LIV and LSTV-LIV incongruence. These findings suggest that at the end of treatment, EOS patients rarely have the potential for selective thoracic fusion. Further work is necessary to assess the potential for a more selective approach to LIV selection in EOS. LEVEL OF EVIDENCE: III.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis.

BACKGROUND: The effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient's ability to mobilize after the fusion is not well understood. AIM: To see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability. METHODS: A retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room. RESULTS: The ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967). CONCLUSION: Spinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.

Barriers to Increasing Diversity in Orthopaedics: The Residency Program Perspective.

BACKGROUND: There are little data to explain why the surgical subspecialty of orthopaedic surgery struggles with improving the racial/ethnic composition of its workforce. The current work sought to determine what orthopaedic residency program directors and coordinators believe are the barriers to improving diversity at their own programs. METHODS: Between November 17, 2018, and April 1, 2019, a 17-question survey was electronically distributed to the program directors and coordinators of 155 allopathic orthopaedic surgery residency programs. Seventy-five of 155 programs (48.4%) responded to the survey. A p-value of < 0.05 was used to determine statistical significance. RESULTS: The most commonly stated barriers to increasing diversity within the orthopaedic surgery programs were the following: "We do not have enough minority faculty, which may deter the applicants" (69.3%), "We consistently rank minority applicants high but can never seem to match them" (56%), and "Not enough minorities are applying to our program" (54.7%). Programs with higher percentages of underrepresented minority (URM) faculty had higher percentages of URM residents (p = 0.001). Programs participating in the Nth Dimensions and/or Perry Initiative programs had a higher percentage of URM faculty as compared to the residency programs that did not participate in these programs (p = 0.004). URM residents represented 17.5% of all residents who resigned and/or were dismissed in the 10 years preceding the survey while also only representing 6% of all orthopaedic residents during the same time period. CONCLUSIONS: From the orthopaedic residency program perspective, the greatest perceived barrier to increasing the racial/ethnic diversity of residents in their program is their lack of URM faculty. Surveyed programs with more URM faculty had more URM residents, and programs participating in Nth Dimensions and/or Perry Initiative programs had a higher percentage of URM faculty.

Autophagy is involved in endoplasmic reticulum stress-induced cell death of rat hepatocytes.

BACKGROUND: Both endoplasmic reticulum (ER) stress and autophagy have been shown to display dual roles in cell survival in multiple cell lines. There is a reported but poorly understood link between ER stress, autophagy, and cell death. We hypothesized that autophagy plays a role in ER stress-dependent cell death in rat hepatocytes. MATERIALS AND METHODS: Primary hepatocytes isolated from both lean and obese male Zucker rats were cultured and treated with tunicamycin (TM), tauroursodeoxycholic acid, 3-methyladenine, and wortmannin for 12 h. The ER stress-associated genes glucose-regulated protein 78 and C/EBP homologous protein were examined via quantitative real time polymerase chain reaction. Immunostaining with microtubule-associated protein 1 light chain 3 as well as electron microscopy were used to evaluate autophagy activity. Trypan blue exclusion was used to determine hepatocyte cell viability. RESULTS: In both lean and steatotic hepatocytes, we found that TM induced both C/EBP homologous protein and glucose-regulated protein 78 messenger RNA expression. Cells with increased ER stress were undergoing increased autophagy and had a significant decrease in cell viability. Both tauroursodeoxycholic acid and 3-methyladenine treatments attenuated TM induced ER stress, autophagy, and cell death, whereas wortmannin treatment reduced autophagy and cell death but without changing ER stress. CONCLUSIONS: These data suggest that autophagy is a likely downstream mediator of ER stress-induced cell death in rat hepatocytes. Further exploration of the link between autophagy and ER stress in hepatocyte injury will yield important information that may be leveraged for treatment of liver injuries such as ischemia/reperfusion.

Nutritional assessment.

Hospital-based malnutrition continues to be an important comorbidity affecting clinical outcomes. Knowledge of performing an appropriate nutrition assessment and implementing a rational nutrition therapy should be part of any patient's hospital plan of care. Familiarity with nutrition assessment scoring systems and nutrition assessment tools should be part of any gastroenterologist's expertise. Assessment of a patient's caloric and protein needs should be part of any hospital patient's clinical evaluation.

Efficacy of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy: a randomized controlled trial.

BACKGROUND AND AIMS: Bispectral (BIS) monitoring provides an objective, non-invasive measure of the level of consciousness in sedated patients. BIS has been shown to lag behind the level of sedation during induction and emergence of sedation with propofol. In this study, we sought to determine whether BIS is a useful adjunctive maneuver to registered nurse-administered propofol sedation (NAPS) as measured by reductions in recovery time and doses of propofol administered. METHODS: A randomized controlled trial of 102 outpatients presenting for colonoscopy was performed. BIS values were recorded continuously in all subjects. Patients were randomized to receive NAPS with BIS visible to nurse and endoscopist versus BIS invisible to nurse and endoscopist. In phase 1 (47 patients), the nurse and endoscopist team were instructed to consider BIS (when visible) as only adjunctive information with regard to titrating sedation. In phase 2 (55 patients), the nurse endoscopist team was instructed to use BIS as the primary endpoint for titration of sedation, and to target BIS to greater than 60 (60-70 is deep sedation). RESULTS: In phase 1, the mean (SD) BIS value from scope-in (SI) to scope-out (SO) for BIS was 59.3 (9.9) and was not different from controls at 59.9 (10.1; p= 0.82). The mean (SD) propofol dose (mg/min) was 15.8 (5.6) and 17.2 (6.2) for BIS and controls, respectively (p= 0.45). The mean (SD) recovery time with BIS visible in phase 1 was 20.6 min (5.5) versus 19.2 min (4.5) in controls (p= 0.34). In phase 2, the mean (SD) BIS from SI to SO in those randomized to have BIS visible was 64.1 (5.4) versus 63.1 (8.5) in controls (p= 0.58). The mean (SD) dose of propofol (mg/min) was 16.1 (11.2) and 16.4 (12.3) for BIS and control groups, respectively (p= 0.92). The mean (SD) recovery time in phase 2 with BIS visible was 18.7 (3.5) versus 20.1 (5.6) in controls (p= 0.27). CONCLUSIONS: BIS did not lead to reductions in mean propofol dose or recovery time when used as an adjunct to NAPS for colonoscopy, or when used as the primary target for sedation. No clinically important role for BIS monitoring as an adjunct to NAPS has yet been established.