Exacerbation of Renal, Cardiovascular, and Respiratory Outcomes Associated with Changes in Climate.

Exposure to environmental variables including declining air quality and increasing temperatures can exert detrimental effects on human health including acute exacerbations of chronic diseases. We aim to investigate the association between these exposures and acute health outcomes in a rural community in Colorado. Meteorological and adult emergency department visit data were retrospectively collected (2013-2017); for asthma outcomes, additional data were available (2003-2017). Daily environmental exposure data included PM10, maximum daily temperature (MDT), and mean humidity and precipitation. Total daily counts of emergency department (ED) diagnoses for myocardial infarction, congestive heart failure, urolithiasis, and exacerbation of chronic obstructive pulmonary disease (COPD) and asthma, were calculated during the study period. Time series models using generalized estimating equations were fit for each disease and included all four environmental factors. Between 2013 and 2017, asthma and COPD exacerbation accounted for 30.8% and 25.4% of all ED visits (n=5,113), respectively. We found that for every 5˚C increase in MDT, the rate of urolithiasis visits increased by 13% (95% CI: 2%, 26%) and for every 10µg/m3 increase in 3-day moving average PM10, the rate of urolithiasis visits increased by 7% (95% CI: 1%, 13%). The magnitude of association between 3-day moving average PM10 and rate of urolithiasis visits increased with increasing MDT. The rate of asthma exacerbation significantly increased as 3-day, 7-day, and 21-day moving average PM10 increased. This retrospective study on ED visits is one of the first to investigate the impact of several environmental exposures on adverse health outcomes in a rural community. Research into mitigating the negative impacts of these environmental exposures on health outcomes is needed.

Delay to Surgery Greater Than 6 Months Leads to Substantial Deformity Progression and Increased Intervention in Immature Adolescent Idiopathic Scoliosis (AIS) Patients: A Retrospective Cohort Study.

DESIGN: A retrospective, multi-institution series of adolescent idiopathic scoliosis (AIS) patients whose date of surgery exceeded six months from date of surgical recommendation were identified. A case-matched comparison of surgical outcomes of skeletally immature patients who delayed surgery versus a cohort of nondelayed patients. OBJECTIVES: We sought to identify 1) whether patients at risk for significant curve progression when delaying surgery could be identified with available clinical and radiographic data and 2) whether patients who delay surgery have longer fusions/more complex procedures. BACKGROUND: Multiple factors can lead to a delay in treatment of AIS once surgical treatment is recommended, and larger Cobb magnitudes have been associated with a more complex surgery. METHODS: 143 AIS patients who delayed surgery had deformity progression (major Cobb angle change over time) analyzed by Risser grade, triradiate cartilage (TRC) status, and menarche status. Comparison of at-risk patients with regard to surgical outcomes to a cohort of matched patients who had not delayed surgery. RESULTS: Risser 0 patients (n = 34) had a greater major Cobb progression than Risser 1-5 patients (n = 109): mean 1.6°/mo versus 0.4°/mo, p < .001. Twenty-eight premenarchal patients had significantly greater increases in Cobb angle measures than their postmenarchal counterparts (n = 86) (13.2° vs. 4.3°, p < .001). An open TRC also conferred increasing rate of progression. Radiographic variables of stable vertebra and last vertebra touched by central sacral vertical line were more likely to change in immature patients, but we did not demonstrate longer fusions or higher estimated blood loss as a result when compared to nondelayed, age-matched peers. CONCLUSION: AIS patients who are premenarchal, TRC open, or Risser 0 who delay surgery greater than 6 months risk clinically significant Cobb angle progression, which is statistically greater than their more mature peers. Clinical ramifications of this remain unclear. Skeletally mature patients do not progress rapidly, allowing elective timing of surgical intervention. LEVEL OF EVIDENCE: Level III.

Compliance With a Comprehensive Antibiotic Protocol Improves Infection Incidence in Pediatric Spine Surgery.

BACKGROUND: A multidisciplinary task force, designated Target Zero, has developed protocols for prevention of surgical site infection (SSI) for spine surgery at our institution. The purpose of this study was to evaluate how compliance with an antibiotic bundle impacts infection incidences in pediatric spine surgery. METHODS: After institutional review board approval, a consecutive series of 511 patients (517 procedures) who underwent primary spine procedures from 2008 to 2012 were retrospectively reviewed to identify patients who developed SSI. Patients were followed for a minimum of 90 days postoperatively. Compliance data were collected prospectively in 511 consecutive patients and a total of 517 procedures. Three criteria were required for antibiotic bundle compliance: appropriate antibiotics completely administered within 1 hour before incision, antibiotics appropriately redosed intraoperatively for blood loss and time, and antibiotics discontinued within 24 hours postoperatively. A multivariable logistic regression analysis was used to test the association between compliance and the development of an infection. RESULTS: Overall antibiotic bundle compliance rate was 85%. After adjusting for risk category, estimated blood loss, and study year, the likelihood of an infection was increased in the noncompliant group compared with the compliant group (adjusted odds ratio: 3.0, 95% CI, 0.96-9.47, P=0.0587). When expressed as the number needed to treat, strict adherence to antibiotic bundle compliance prevented 1 SSI within 90 days of surgery for every 26 patients treated with the antibiotic bundle. Reasons for noncompliance included failure to infuse preoperative antibiotics 1 hour before incision (10.3%), failure to redose antibiotics intraoperatively based on time or blood loss (5.5%), and failure to discontinue antibiotics within 24 hours postoperatively (1.9%). CONCLUSIONS: Compliance with a comprehensive antibiotic protocol can lead to meaningful reductions in SSI incidences in pediatric spine surgery. Institutions should focus on improving compliance with prophylactic antibiotic protocols to decrease SSI in pediatric spine surgery. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Cross-Links Do Not Improve Clinical or Radiographic Outcomes of Posterior Spinal Fusion With Pedicle Screws in Adolescent Idiopathic Scoliosis: A Multicenter Cohort Study.

STUDY DESIGN: Retrospective, comparative analysis. OBJECTIVES: Comparative analysis was performed to determine the differences, if any, between adolescent idiopathic scoliosis (AIS) patients who underwent posterior spinal fusion (PSF) with and without cross-links. SUMMARY OF BACKGROUND DATA: Cross-links are frequently used during PSF for AIS. It is unclear whether they provide any advantage for patients with all-pedicle screw constructs. METHODS: A prospectively collected multicenter database of patients with AIS undergoing spinal fusion was retrospectively queried. Study inclusion criteria were primary PSF with all-pedicle screw fixation (greater than 90% fixation points) and minimum 2 years' follow-up. Collected data included demographics, radiographic measures, complications, Scoliosis Research Society-22r and Spinal Appearance Questionnaire (SAQ) scores. RESULTS: A total of 500 patients were included (377 cross-link and 123 non-cross-link). Age, body mass index, gender, and preoperative major Cobb angle were not different between groups. Except for a slightly decreased lumbar Cobb angle (2.7°) in the cross-link group, no other radiographic measures were different at follow-up. Complications were not significantly different between groups: 21 of 377 (6%) crosslink and 9 of 123 (7%) non-cross-link. Infection occurred in 1 patient in the cross-link group and none in the non-cross link group. Reoperation occurred in 4 patients, all with cross-links (3 for implant removal and 1 for distal adding-on). Scoliosis Research Society-22r scores, total and individual domains, improved by a similar amount in both groups. At follow-up, parent and patient SAQ appearance scores were not significantly different. The SAQ expectations domain scores were similar for all visits and improved for both patients and parents. CONCLUSIONS: There do not appear to be significant clinical or radiographic outcome differences in patients with AIS undergoing PSF based on the use of cross-links at 2-year follow-up. Surgeons should consider eliminating cross-links in patients with AIS who have PSF with all-pedicle screw constructs. This may have substantial cost savings without affecting patient outcome.