Adjunctive Use of Bone Growth Stimulation Increases Cervical Spine Fusion Rates in Patients at Risk for Pseudarthrosis.

STUDY DESIGN: A prospective multicenter clinical trial (NCT03177473) was conducted with a retrospective cohort used as a control arm. OBJECTIVE: The purpose of this study was to evaluate cervical spine fusion rates in subjects with risk factors for pseudarthrosis who received pulsed electromagnetic field (PEMF) treatment. SUMMARY OF BACKGROUND DATA: Certain risk factors predispose patients to pseudarthrosis, which is associated with prolonged pain, reduced function, and decreased quality of life. METHODS: Subjects in the PEMF group were treated with PEMF for 6 months postoperatively. The primary outcome measure was fusion status at the 12-month follow-up period. Fusion status was determined using anterior/posterior, lateral, and flexion/extension radiographs and computed tomography (without contrast). RESULTS: A total of 213 patients were evaluated (PEMF, n=160; Control, n=53). At baseline, the PEMF group had a higher percentage of subjects who used nicotine ( P =0.01), had osteoporosis ( P <0.05), multi-level disease ( P <0.0001), and were >65 years of age ( P =0.01). The PEMF group showed over two-fold higher percentage of subjects that had ≥3 risk factors (n=92/160, 57.5%) compared with the control group (n=14/53, 26.4%). At the 12-month follow-up, the PEMF group demonstrated significantly higher fusion rates compared with the control (90.0% vs. 60.4%, P <0.05). A statistically significant improvement in fusion rate was observed in PEMF subjects with multi-level surgery ( P <0.0001) and high BMI (>30 kg/m 2 ; P =0.0021) when compared with the control group. No significant safety concerns were observed. CONCLUSIONS: Adjunctive use of PEMF stimulation provides significant improvements in cervical spine fusion rates in subjects having risk factors for pseudarthrosis. When compared with control subjects that did not use PEMF stimulation, treated subjects showed improved fusion outcomes despite being older, having more risk factors for pseudarthrosis, and undergoing more complex surgeries.

Transforaminal lumbar interbody fusion with an expandable interbody device: Two-year clinical and radiographic outcomes.

Background: The use of interbody cages as an adjunct to lumbar spinal fusion remains an important technique to enhance segmental stability, promote solid arthrodesis, maintain neuroforaminal decompression, and preserve/improve segmental lordosis. Appropriate segmental lumbar lordosis and sagittal balance is well-known to be critical for long-term patient outcomes. This study sought to evaluate the radiographic and clinical results of TLIF in patients using an articulating, expandable cage. Primary endpoint was clinical and radiographic outcomes, including complications, at 12 and 24 months. Methods: A total of 37 patients underwent open single-level or 2-level TLIF by a single surgeon using an expandable cage with concomitant bilateral pedicle screws and posterolateral arthrodesis. Clinical outcomes included ODI and VAS for back and legs. Radiographic outcomes included pelvic incidence and tilt, lumbar and segmental lordoses, and disc height at the operative level(s). All outcomes were collected at baseline, 2-weeks, 6-weeks, 3-months, 6-months, 12-months, and 24-months postop. Results: A total of 28 patients were available for analysis. Nine patients failed to follow-up at 24 months. Mean ODI scores showed significant improvement, from pre-to-postoperative at 24 months (55%; p<.0001). VAS for back and legs was significantly lower at 24 months on average by 72 and 79%, respectively (p<.0001 for both). Both segmental and lumbar lordoses significantly improved by 5.3° and 4.2° (p<.0001 and p=.049), respectively. Average disc height improved by 49% or 6.1 mm (p<.001). No device-related complications nor instances of measured subsidence. One patient had a superficial infection, and another had an intraoperatively repaired incidental durotomy. Conclusions: The use of an expandable cage contributed to improvement in both segmental and lumbar lordosis with no reported complications at 24-month follow-up. All clinical measures significantly improved as well. The expandable cage design represents an effective and safe option to increase cage size and allow significant segmental lordosis correction.

Pulsed Electromagnetic Field Stimulation in Lumbar Spine Fusion for Patients With Risk Factors for Pseudarthrosis.

BACKGROUND: Lumbar spinal fusion surgeries are increasing steadily due to an aging and ever-growing population. Patients undergoing lumbar spinal fusion surgery may present with risk factors that contribute to complications, pseudarthrosis, prolonged pain, and reduced quality of life. Pulsed electromagnetic field (PEMF) stimulation represents an adjunct noninvasive treatment intervention that has been shown to improve successful fusion and patient outcomes following spinal surgery. METHODS: A prospective, multicenter study investigated PEMF as an adjunct therapy to lumbar spinal fusion procedures in patients at risk for pseudarthrosis. Patients with at least 1 of the following risk factors were enrolled: prior failed fusion, multilevel fusion, nicotine use, osteoporosis, or diabetes. Fusion status was determined by radiographic imaging, and patient-reported outcomes were also evaluated. RESULTS: A total of 142 patients were included in the analysis. Fusion status was assessed at 12 months follow-up where 88.0% (n = 125/142) of patients demonstrated successful fusion. Fusion success for patients with 1, 2+, or 3+ risk factors was 88.5%, 87.5%, and 82.3%, respectively. Significant improvements in patient-reported outcomes using the Short Form 36, EuroQol 5 Dimension (EQ-5D) survey, Oswestry Disability Index, and visual analog scale for back and leg pain were also observed compared with baseline scores (P < 0.001). A favorable safety profile was observed. PEMF treatment showed a positive benefit-risk profile throughout the 6-month required use period. CONCLUSIONS: The addition of PEMF as an adjunct treatment in patients undergoing lumbar spinal surgery provided a high rate of successful fusion with significant improvements in pain, function, and quality of life, despite having risk factors for pseudarthrosis. CLINICAL RELEVANCE: PEMF represents a useful tool for adjunct treatment in patients who have undergone lumbar spinal surgery. Treatment with PEMF may result in improved fusion and patient-reported outcomes, regardless of risk factors. TRIAL REGISTRATION: NCT03176303.

Strategic Choice and Implementation of Workplace Wellness Programs in the United States.

Despite widespread discussion and public policy support for workplace wellness programs in the United States, their diffusion has been slow. Using data from the 2017 Workplace Health Administration Survey, this paper explored the importance of establishment characteristics, unionization, and strategic choice in the adoption of workplace health initiatives and employee participation in these programs. An ordinary least squares analysis revealed that unionization (ß = 1.59, 95% CI = 1.20−1.97, p < 0.001) and management support (ß = 1.67, 95% CI = 1.25−2.10, p < 0.001) were the strongest predictors of the number of programs adopted by an establishment. In logistic regression analyses of nine workplace wellness programs, it was also found that unionization and management were the strongest predictors of the adoption of these programs. Management support was also correlated with employee participation of in nutrition (OR = 2.66, 95% CI = 1.23−5.71, p < 0.05) and obesity programs (OR = 3.66, 95% CI = 1.03−12.97, p < 0.05).

Adoption and Implementation Barriers for Worksite Health Programs in the United States.

Worksite health promotion programs have been identified as having the potential to mitigate chronic health risks. In the most recent 2017 U.S. CDC survey of workplace health promotion, respondents identified several perceived barriers related to program adoption and implementation. The analysis indicates that challenges negatively associated with having worksite program were lack of senior management support (OR = 0.50, 95% CI: 0.32-0.78), lack of qualified vendors (OR = 0.56, 95% CI: 0.4-0.79), lack of qualified personnel (OR = 0.56, 95% CI: 0.35-0.73), and cost (OR = 0.58, 95% CI: 0.39-0.88). Challenges associated with having a program were lack of employee interest (OR = 2.09, 95% CI = 1.44-3.03), lack of space (OR = 1.76, 95% CI: 1.26-2.48), and demonstrating program results (OR = 2.09, 95% CI = 1.44-3.03). These findings can provide insights to policy makers, insurers, and employers seeking to implement workplace-based health promotion initiatives.

Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers.

BACKGROUND: The study examines the effectiveness of a workplace violence and harassment prevention and response program with female homecare workers in a consumer driven model of care. METHODS: Homecare workers were randomized to either; computer based training (CBT only) or computer-based training with homecare worker peer facilitation (CBT + peer). Participants completed measures on confidence, incidents of violence, and harassment, health and work outcomes at baseline, 3, 6 months post-baseline. RESULTS: Homecare workers reported improved confidence to prevent and respond to workplace violence and harassment and a reduction in incidents of workplace violence and harassment in both groups at 6-month follow-up. A decrease in negative health and work outcomes associated with violence and harassment were not reported in the groups. CONCLUSION: CBT alone or with trained peer facilitation with homecare workers can increase confidence and reduce incidents of workplace violence and harassment in a consumer-driven model of care.

The power of local action in occupational health: the adoption of local exhaust ventilation in the Chicago tuckpointing trade.

BACKGROUND: Silica is a pervasive and potentially deadly occupational hazard in construction. The occupational risk posed by silica has long been known, but efforts to use engineering controls to minimize dust generation in tuckpointing operations, a masonry restoration specialty, have been slow. OBJECTIVES: The objective of this study is to explore how local innovation in occupational safety and health may emerge, absent the establishment of national standards. METHOD: This study uses a case study to explore the adoption of local exhaust ventilation in tuckpointing operations in the Chicago area. Sources of data for this research include interviews with a diverse range of key informants and the review of archival material. RESULTS: This case study found local unions, municipal regulators, contractors, and major public users of construction services played a central role in the events and milestones that led to the early adoption of local exhaust ventilation in Chicago. The adoption of local exhaust ventilation technology in Chicago demonstrates the potential for local actors to fill an important void when rulemaking in vital areas of occupational of health impedes effective national regulation.

Exploring workplace violence among home care workers in a consumer-driven home health care program.

Nominal research has examined sexual harassment and workplace violence against home care workers within consumer-driven home care models such as those offered in Oregon. This study examined home care workers' experiences of violence while providing care to consumer employers, the patients who hire and manage home care workers. Focus groups and interviews were conducted in Oregon with 83 home care workers, 99 Oregon Department of Human Services (DHS) employees, and 11 consumer employers. Home care workers reported incidents of workplace physical violence (44%), psychological abuse (65%), sexual harassment (41%), and sexual violence (14%). Further, three themes were identified that may increase the risk of workplace violence: (1) real and perceived barriers to reporting violence; (2) tolerance of violence; and (3) limited training to prevent violence. To ensure worker safety while maintaining quality care, safety policies and training for consumer employers, state DHS employees, and home care workers must be developed.

Employers' Perceptions of Intimate Partner Violence among a Diverse Workforce.

OBJECTIVES: Intimate partner violence (IPV) is a significant global public health concern, affecting 5.3 million US individuals annually. An estimated 1 in 3 women globally are abused by an intimate partner in their lifetime, and the effects carry over into the workplace. This article examines employers' perceptions of IPV in the workplace, targeting supervisors of Latina employees. METHODS: Fourteen employers and supervisors of small service-sector companies in Oregon were interviewed using semi-structured interviews. Interpretive description was used to identify themes. These qualitative interviews preceded and helped to formulate a larger workplace intervention study. RESULTS: THE FOLLOWING THEMES WERE FOUND AND ARE DETAILED: (1) factors associated with recognizing IPV in the workplace, (2) effects of IPV on the work environment and (3) supervisors' responses to IPV-active vs. passive involvement. Also, supervisors' suggestions for addressing IPV in the workplace are summarized. CONCLUSION: These findings demonstrate the need for more IPV-related resources in the workplace to be available to supervisors as well as survivors and their coworkers. The needs of supervisors and workplaces vary by site, demonstrating the need for tailored interventions, and culturally appropriate workplace interventions are needed for Latinas and other racially and ethnically diverse populations.

Ergonomic best practices in masonry: regional differences, benefits, barriers, and recommendations for dissemination.

Within construction the masonry trade has particularly high rates of musculoskeletal disorders (MSDs). A NIOSH-sponsored meeting of masonry stakeholders explored current and potential "Best Practices" for reducing MSDs in masonry and identified potential regional differences in use of practices. To verify and better understand the regional effects and other factors associated with differences in practice use, a national telephone survey of masonry contractors was conducted. The United States was divided into four regions for evaluation: Northeast, Southeast, Midwest, and West Coast. Nine practices with the potential to reduce MSDs in masonry workers were evaluated. Masonry contractors, owners, and foremen completed 183 surveys. The results verify regional differences in use of best practices in masonry. Half-weight cement bags and autoclave aerated concrete were rarely used anywhere, while lightweight block and mortar silos appear to be diffusing across the country. The Northeast uses significantly fewer best practices than other regions. This article examines reasons for regional differences in masonry best practice, and findings provide insight into use and barriers to adoption that can be used by safety managers, researchers, and other safety advocates to more effectively disseminate ergonomic solutions across the masonry industry.

Nonsurgical treatment of lumbosacral blastomycosis involving L2-S1: a case report.

STUDY DESIGN: A case report and clinical discussion. OBJECTIVE: To discuss the diagnosis and treatment of Blastomyces dermatitidis in the spine. SUMMARY OF BACKGROUND DATA: Blastomycosis, like other fungal organisms, has a nonspecific appearance on radiographs, and is often mistaken for TB or a neoplasm. Nonsurgical treatment of this infection is possible, however, as seen in this case. The difficulty in diagnosing fungal infections often leads to a delay in treatment. METHODS: We report on a 37-year-old Arabian woman who presented initially with progressive low back and anterior thigh pain without precipitating trauma. She was found to have 2 draining fistulas. Computed tomography-guided percutaneous drainage of the paravertebral phlegmon yielded purulent material that was pan cultured. The KOH preparation was consistent with a fungal pathogen, which was later identified as Blastomyces dermatitidis by polymerase chain reaction. RESULTS: Radiologic studies of the lumbar spine and sacrum performed revealed extensive involvements with osseous destruction of L2-S1. The destruction was most severe at L3 with mild boney retropulsion at that level. Throughout the patient's treatment course, she complained of mild-to-moderate lower back pain and had no neurologic symptoms. Therefore, surgery was deferred. CONCLUSION: There are no pathognomonic findings of blastomycosis on magnetic resonance imaging. Fungal osteomyelitis is rarely identified in this country, and blastomycosis is even less often diagnosed. This case illustrates that fungal osteomyelitis should be considered in the radiographic differential diagnosis until a definitive diagnosis is made through biopsy.

A roadmap to diffuse ergonomic innovations in the construction industry: there is nothing so practical as a good theory.

Despite the availability of resources and practices that would reduce work-related morbidity and mortality in the construction industry, their diffusion to workers has been slow, partly because the ties between management and trade workers are weak. In promoting an innovation, it is necessary to target the stakeholders who will be making the decisions related to it. The authors' focus is on ergonomics, but their observations may be applied more broadly to other areas of intervention-effectiveness research.

Infections of the spine in patients with human immunodeficiency virus.

BACKGROUND: Musculoskeletal infections in patients with the human immunodeficiency virus (HIV) have been described. However, the prevalence, specific characteristics, and outcomes of spinal infections in these patients have not been studied in a large group of patients to our knowledge. METHODS: The computerized records of all patients discharged with the diagnosis of spinal osteomyelitis, discitis, epidural abscess, or tuberculosis from our institution from October 1994 through September 2000 were reviewed. Patients with the diagnosis of HIV were identified, and the charts were examined in detail. RESULTS: During the six-year period, 7338 unique patients who were HIV positive were admitted. Seventeen (0.23%) of them were treated for a spinal infection. The prevalence of spinal infection was 23.2 per 10,000 admissions of HIV-positive patients and 7.1 per 10,000 admissions of HIV-negative patients (p < 0.0001). Eight patients who had discitis and/or osteomyelitis had a mean CD4 T-cell count of 339.6 cells/mm(3), and all eight had clinical resolution of the infection after six to twelve weeks of appropriate antibiotic therapy. In contrast, six patients who had spinal tuberculosis had a mean CD4 count of 75.7 cells/mm(3) (p = 0.005), and one of them died during the hospitalization. The remaining three patients, who had epidural abscesses, had a mean CD4 count of 20.67 cells/mm(3) (p = 0.001), and two of them died. CONCLUSIONS: Discitis and/or osteomyelitis occurs in HIV-positive patients with a mild-to-moderate decrease (>/=200 cells/mm(3)) in the CD4 T-cell count, and the infection responds to appropriate antibiotics. Patients with a more severely decreased CD4 count (50 to 200 cells/mm(3)) may have spinal tuberculosis develop, and patients with the lowest CD4 counts are more likely to have epidural abscesses develop. The three fatalities in this study occurred in these two groups of patients. As a group, HIV-positive patients are significantly more likely to have a spinal infection develop than are HIV-negative patients (p < 0.0001). Although the CD4 count can be used as a predictor of the clinical course, identification of the organism remains paramount in the treatment of this complex patient population.

Health and employment practices: ethical, legal, and social implications of advances in toxicogenomics.

Advances in toxicogenomics research may allow the identification of individuals who may be hyper-susceptible to occupational exposures and could create a shift from population to individual-based risk assessment in occupational health. Although many states have passed legislation to prevent the misuse of genetic information in employment, there is no general federal protection from the use of genetic information after a conditional offer of employment. Occupational health professionals have a crucial role in shaping future guidelines governing the use of genetic information in employment.

The 2002 Marshall Urist Young Investigator Award Paper. Lumbar arthrodesis gene expression: a comparison of autograft with osteogenic protein-1.

Data from animals have revealed that osteogenic protein-1 induces solid intertransverse process fusion more reliably than autograft, and has motivated the question: What is the difference in the fusion bed environment engendered by the addition of osteogenic protein-1? To address this question, an established New Zealand White rabbit model of spinal arthrodesis was used to evaluate the effect of iliac crest autograft, and alternatively osteogenic protein-1, on cytokine gene expression in the developing spinal fusion mass. The autograft group and the osteogenic protein-1 group had a similar pattern of gene expression for most of the cytokines investigated, highlighting the finding that the application of one bone morphogenetic protein to the fusion bed results in nearly the same gene expression as that resulting from application of autologous bone. Some differences in cytokine expression were observed at the fusion bed with the addition of osteogenic protein-1. The increased level of expression of particular osteogenic, chondrogenic, and angiogenic growth factors at the later stages of fusion may be responsible for the improved rate of solid fusion with osteogenic protein-1 as compared with autograft alone. Sequences for bone morphogenetic protein-5 and bone morphogenetic protein-7 were determined, and their respective expression in the developing spinal fusion mass was observed for the first time.

A participatory ergonomics intervention to reduce risk factors for low-back disorders in concrete laborers.

Construction laborers rank high among occupational groups with work-related musculoskeletal injuries involving time way from work. The goals of this project were to: (1) introduce an ergonomic innovation to decrease the risk of low-back disorder (LBD) group membership, (2) quantitatively assess exposure, and (3) apply a participatory intervention approach in construction. Laborers manually moving a hose delivering concrete to a placement site were evaluated. The hypothesis tested was that skid plates would prevent hose joints from catching on rebar matting, and the hose would slide more easily. This would decrease the need for repetitive bending and use of excessive force. Four laborers were evaluated wearing the Lumbar Motion Monitor (LMM), a tri-axial electrogoniometer that records position, velocity and acceleration. Workers were measured during three comparable concrete pours. Worker perceptions of the innovation utility and exertion were surveyed. During initial use of skid plates, flexion increased significantly (p < 0.001) while velocity, acceleration and moments did not change. After implementing a worker modification, low back velocity, acceleration and moments were significantly reduced (p < 0.05). Reductions in these factors have been associated with decreased risk of belonging to an occupational group with LBDs. Use of secured skid plates during horizontal concrete hose movement may in part decrease the risk of LBD group membership among concrete laborers. Crew participation resulted in skid plates being a more effective intervention. The LMM is a promising tool for quantitative assessment in construction.

HDAC7, a thymus-specific class II histone deacetylase, regulates Nur77 transcription and TCR-mediated apoptosis.

We report that HDAC7, a class II histone deacetylase, is highly expressed in CD4(+)CD8(+) double-positive thymocytes. HDAC7 inhibits the expression of Nur77, an orphan receptor involved in apoptosis and negative selection, via the transcription factor MEF2D. HDAC7 is exported from the nucleus during T cell receptor activation, leading to Nur77 expression. A triple HDAC7 mutant (S155A, S318A, S448A) is not exported from the nucleus in response to TCR activation and suppresses TCR-mediated apoptosis. Conversely, a fusion of HDAC7 to the transcriptional activator VP16 activates Nur77 expression. Inhibition of HDAC7 expression by RNA interference causes increased apoptosis in response to TCR activation. These observations define HDAC7 as a regulator of Nur77 and apoptosis in developing thymocytes.

Magnetic resonance imaging of the multiple-ligament injured knee.

OBJECTIVE: To evaluate magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in detecting soft tissue, neurovascular, and bony injury after multiple ligament knee injury, including knee dislocation. MATERIALS AND METHODS: A retrospective search was performed for patients presenting with reported knee dislocation from May 1993 through May 2000 who underwent both MRI and surgical reconstruction. Twenty-one patients met these criteria (15 men and six women; age range 14 to 75 years; mean 32.6 years). Magnetic resonance diagnoses of soft tissue and bony injury were compared with the patients' operative findings. MRA of the popliteal vessels was performed in seventeen of our twenty-one patients, and the results of these studies are described. RESULTS: Multiple ligamentous, tendinous, meniscal, chondral, osseous, and neural injuries were seen. There was excellent correlation (kappa > 0.8) between the magnetic resonance and operative findings with regard to the size and location of tears. Regarding meniscal tears, the type (e.g., bucket, radial split, meniscocapsular separation) and location correlated well with surgery. All ten nerve injuries noted on magnetic resonance were confirmed at surgery. Six of our patients had both conventional angiograms and MRAs with 100 percent agreement between the studies. In one patient an intimal flap in the popliteal artery was seen on MRA and confirmed on conventional angiographic images. CONCLUSION: MRI is an accurate method of assessing soft tissue, osseous, and neural damage after knee dislocation. Our early experience with popliteal fossa MRA is encouraging with complete agreement between the MRA and conventional angiography in patients who had both studies.