Maternal-Fetal Results of COVID-19-Infected Pregnant Women Treated with Extracorporeal Membrane Oxygenation: A Descriptive Report.

OBJECTIVE: COVID-19 infection may produce severe pneumonia, mainly in the adult population. Pregnant women with severe pneumonia are at high risk of developing complications, and conventional therapy sometimes fails to reverse hypoxemia. Therefore, extracorporeal membrane oxygenation (ECMO) is an option in cases with refractory hypoxemic respiratory failure. This study aims to evaluate the maternal-fetal risk factors, clinical characteristics, complications, and outcomes of 11 pregnant or peripartum patients with COVID-19 treated with ECMO. STUDY DESIGN: This is a retrospective descriptive study of 11 pregnant women undergoing ECMO therapy during the COVID-19 pandemic. RESULTS: In our cohort, four patients underwent ECMO during pregnancy (36.3%) and 7 during the postpartum period. Initially, they started on venovenous ECMO, and three patients were required to change modality due to clinical conditions. In total, 4/11 pregnant women (36.3%) died. We established two periods that differed in the implementation of a standardized care model for reducing associated morbidities and mortality. Neurological complications were responsible for most deaths. Regarding fetal outcomes at early-stage pregnancies on ECMO (4), we report three stillbirths (75%), and one newborn (twin pregnancy) survived and had a favorable evolution. CONCLUSION: At later-stage pregnancies, all newborns survived, and we did not identify any vertical infection. ECMO therapy is an alternative for pregnant women with severe hypoxemic respiratory failure due to COVID-19, and may improve maternal and neonatal results. Regarding fetal outcomes, the gestational age played a definitive role. However, the main complications reported in our series and others are neurological. It is essential to develop novel, future interventions to prevent these complications.

Improving Extracorporeal Membrane Oxygenation Survival in COVID-19. Effect of a Bundle of Care.

Veno-venous extracorporeal membrane oxygenation (ECMO) support surged during the COVID-19 pandemic. Our program changed the model of care pursuing to protect the multidisciplinary team from the risk of infection and to serve as many patients as possible. Patient-healthcare interactions were restricted, and the ECMO bed capacity was increased by reducing the ECMO specialist-patient ratio to 1:4 with non-ECMO trained nurses support. The outcomes worsened and we paused while we evaluated and modified our model of care. The ECMO bed capacity was reduced to allow a nurse ECMO-specialist nurse ratio 2:1 with an ECMO trained nurse assistant's support. Intensivists, general practitioners, nurse assistants, and physical and respiratory therapists were trained on ECMO. Tracheostomy, bronchoscopy, and microbiological molecular diagnosis were done earlier, and family visits and rehabilitation were allowed in the first 48 hours of ECMO cannulation. There were 35 patients in the preintervention cohort and 66 in the postintervention cohort. Ninety days mortality was significantly lower after the intervention (62.9% vs. 31.8%, p = 0.003). Factors associated with increased risk of death were the need for cannulation or conversion to veno arterial or veno arterio venous ECMO, hemorrhagic stroke, and renal replacement therapy during ECMO. The interventions associated with a decrease in the risk of death were the following: early fiberoptic bronchoscopy and microbiological molecular diagnostic tests. Increasing the ECMO multidisciplinary team in relation to the number of patients and the earlier performance of diagnostic and therapeutic interventions, such as tracheostomy, fiberoptic bronchoscopy, molecular microbiological diagnosis of pneumonia, rehabilitation, and family support significantly decreased mortality of patients on ECMO due to COVID-19.

Surgical Management of Multi-Level Cervical Spine Synovial Chondromatosis.

Cervical synovial chondromatosis is a benign condition which most commonly affects the knee joint. The involvement of the spinal column is rare, with only a few reports in the literature describing surgical treatment for compressive spinal lesions. Given the rarity of this condition, the best treatment methodology is yet to be established. We describe the case of a 38-year-old female who presented with progressively worsening myeloradicular symptoms localizing to the cervical spinal cord. Imaging revealed a multilevel osseous and epidural lesion involving the subaxial cervical spine. A computed tomography-guided biopsy was performed to obtain a diagnosis to aid further treatment planning. Subsequently, surgical decompression and stabilization were performed after which the patient made an excellent recovery. She continues to do well at 2 years follow-up. Cervical synovial chondromatosis is a rare condition which can present with pain, radiculopathy, and/or myelopathy. Surgical treatment should focus on complete resection, decompression, and stabilization with arthrodesis and fusion to prevent recurrence. We propose that the lack of motion provided by stabilization and fusion after gross total resection prevents disease recurrence.

Quantile modeling through multivariate log-normal/independent linear regression models with application to newborn data.

In this article, we propose and study the class of multivariate log-normal/independent distributions and linear regression models based on this class. The class of multivariate log-normal/independent distributions is very attractive for robust statistical modeling because it includes several heavy-tailed distributions suitable for modeling correlated multivariate positive data that are skewed and possibly heavy-tailed. Besides, expectation-maximization (EM)-type algorithms can be easily implemented for maximum likelihood estimation. We model the relationship between quantiles of the response variables and a set of explanatory variables, compute the maximum likelihood estimates of parameters through EM-type algorithms, and evaluate the model fitting based on Mahalanobis-type distances. The satisfactory performance of the quantile estimation is verified by simulation studies. An application to newborn data is presented and discussed.

Immediate Postoperative Pain Scores Predict Neck Pain Profile up to 1 Year Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort review. OBJECTIVE: To assess whether immediate postoperative neck pain scores accurately predict 12-month visual analog scale-neck pain (VAS-NP) outcomes following Anterior Cervical Discectomy and Fusion surgery (ACDF). METHODS: This was a retrospective study of 82 patients undergoing elective ACDF surgery at a major academic medical center. Patient reported outcomes measures VAS-NP scores were recorded on the first postoperative day, then at 6-weeks, 3, 6, and 12-months after surgery. Multivariate correlation and logistic regression methods were utilized to determine whether immediate postoperative VAS-NP score accurately predicted 1-year patient reported VAS-NP Scores. RESULTS: Overall, 46.3% male, 25.6% were smokers, and the mean age and body mass index (BMI) were 53.7 years and 28.28 kg/m2, respectively. There were significant correlations between immediate postoperative pain scores and neck pain scores at 6 weeks VAS-NP (P = .0015), 6 months VAS-NP (P = .0333), and 12 months VAS-NP (P = .0247) after surgery. Furthermore, immediate postoperative pain score is an independent predictor of 6 weeks, 6 months, and 1 year VAS-NP scores. CONCLUSION: Our study suggests that immediate postoperative patient reported neck pain scores accurately predicts and correlates with 12-month VAS-NP scores after an ACDF procedure. Patients with high neck pain scores after surgery are more likely to report persistent neck pain 12 months after index surgery.

Pediatric Supratentorial Ganglioneuroblastoma: Case Report and Review of Literature.

BACKGROUND: Pediatric cerebral ganglioneuroblastoma is an exceedingly rare tumor. CASE DESCRIPTION: We describe the case of a 4-year-old boy with sudden mental status decline who was found to have a large intracranial lesion with intraventricular extension. CONCLUSION: Management of the case and pathologic findings are discussed, along with a review of the literature on this rare entity.

Utility of Intraoperative Monitoring in the Resection of Spinal Cord Tumors: An Analysis by Tumor Location and Anatomical Region.

STUDY DESIGN: Retrospective review of institutional data. OBJECTIVE: The aim of this study was to assess the utility of somatosensory-evoked potentials (SSEP) and transcranial electric motor-evoked potentials (MEP) in the resection of spine tumors and evaluate the ability of both single and multi-modal monitoring to predict postoperative neurological deficits. SUMMARY OF BACKGROUND DATA: Although the utility of intraoperative monitoring (IOM) is well established in scoliosis and degenerative surgery, studies in spine tumor patients have been limited. METHODS: A series of consecutive patients who underwent resection with the use of IOM at a single institution between August 2009 and March 2013 was identified. Demographic, clinical, and neuromonitoring data were collected preoperatively, during surgery, at the moment of discharge, and at a 6-month follow-up visit. Three cohorts were established based on the anatomical location of the tumor: intramedullary, intradural extramedullary, and extradural. Additional groupings were formed based on spinal region. Patients with significant changes in SSEPs or MEPs during surgery were identified and the rate of neurological deficits was assessed. RESULTS: A total of 52 patients were analyzed. A change in SSEPs or MEPs was detected in 11 (21.2%) cases whereas 14 patients (26.9%) developed permanent postoperative deficits. SSEPs predicted deficits in the resection of intramedullary tumors (P = 0.015) (area under cover, AUC = 0.83), and intradural extramedullary tumors (P = 0.048; AUC = 0.70). MEP monitoring did not predict postoperative deficits in the resection of intramedullary (P = 0.21; AUC = 0.69) or intradural extramedullary tumors (P = 0.31; AUC = 0.63). Neither SSEPs nor MEPs predicted deficits for extradural tumors. CONCLUSION: The efficacy of IOM in spine tumor resection is dependent on tumor location relative to the spinal cord and dura. The accuracy of SSEPs and their ability to predict postoperative deficits was greatest for intramedullary lesions. For this series, MEP and multi-modal monitoring did not confer a benefit in predicting permanent neurological deficits. LEVEL OF EVIDENCE: 4.

Effect of Social Support and Marital Status on Perceived Surgical Effectiveness and 30-Day Hospital Readmission.

STUDY DESIGN: Retrospective cohort review. OBJECTIVE: To determine whether higher levels of social support are associated with improved surgical outcomes after elective spine surgery. METHODS: The medical records of 430 patients (married, n = 313; divorced/separated/widowed, n = 71; single, n = 46) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized by their marital status at the time of surgery. Patient demographics, comorbidities, and postoperative complication rates were collected. All patients had prospectively collected outcomes measures and a minimum of 1-year follow-up. Patient reported outcomes instruments (Oswestry Disability Index, Short Form-36, and visual analog scale-back pain/leg pain) were completed before surgery, then at 1 year after surgery. RESULTS: Baseline characteristics were similar in all cohorts. There was no statistically significant difference in the length of hospital stay across all 3 cohorts, although "single patients" had longer duration of in-hospital stays that trended toward significance (single 6.24 days vs married 4.53 days vs divorced/separated/widowed 4.55 days, P = .05). Thirty-day readmission rates were similar across all cohorts (married 7.03% vs divorced/separated/widowed 7.04% vs single 6.52%, P = .99). Additionally, there were no significant differences in baseline and 1-year patient reported outcomes measures between all groups. CONCLUSIONS: Increased social support did not appear to be associated with superior short and long-term clinical outcomes after spine surgery; however, it was associated with a shorter duration of in-hospital stay with no increase in 30-day readmission rates.

Assessing the effectiveness of routine use of post-operative in-patient physical therapy services.

BACKGROUND: The association between functional decline occurring with prolonged bed rest after surgery is well-known. Immediate in-patient post-operative ambulation with the physical therapy (PT) service has been reported to improve pain and disability, while decreasing the incidence of perioperative complications. Whether formal PT evaluation prior to hospital discharge leads to improved ambulation (number of steps ambulated), shorter duration of hospital stay and lower peri-operative complications compared to nurse-assisted ambulation protocols remain unknown. METHODS: The medical records of 274 patients (No PT: n=87, PT: n=187) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized based on whether PT services were delivered during the post-operative in-patient stay. Patient demographics, comorbidities, and post-operative complication rates were collected and compared. Ambulation status and the number of steps ambulated were recorded. RESULTS: Baseline characteristics were similar in both cohorts. Operative variables were similar between both cohorts, with no significant difference in operative time, estimated blood loss (EBL), and number of fusion levels. Peri-operative complication rates were similar between the cohorts. Compared to patients in the nurse-assisted ambulation cohort (No PT), patients in the PT cohort had a longer duration of hospital stay (4.17 vs. 3.39 days, P=0.15). 30-day readmission rates, although higher in the PT cohort, was not statistically significantly different (PT 6.57% vs. No PT: 2.30%, P=0.13). CONCLUSIONS: Our study suggests that the routine use of the PT services compared to nurse-assisted ambulation programs is associated with a modest increase in the duration of hospital stay without any significant reduction in peri-operative complications profile. In a health conscious healthcare climate, appropriate screening mechanisms and risk stratification should be performed to optimize utilization of post-operative in-patient PT services.

Effects of immediate post-operative pain medication on length of hospital stay: does it make a difference?

BACKGROUND: Patient reported outcomes and length of hospital stay (LOS) are being used as a proxy for hospital care. An extra day of hospitalization costs thousands of health care dollars. The choice of intraoperative pain medications has been associated with decreased pain scores in other surgical subspecialties. However, the effects of immediate post-operative patient-controlled analgesics (PCA)/intravenous (IV) pain medication on patient care are not well understood in spine surgery. The aim of this study is to determine the effects of different immediate post-operative pain medications on post-operative complications profile, LOS, and patient reported outcomes (PROs) after elective spine surgery. METHODS: The medical records of 230 patients (morphine: n=98, fentanyl: n=61, hydromorphone: n=71) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized by the immediate post-operative pain medication they were on, with the most common medications being PCA/IV morphine, fentanyl, and hydromorphone. Patient demographics, comorbidities, and post-operative complication rates were collected. All patients had retrospectively collected outcomes measures and a minimum of 6-month follow up. Patient reported outcomes instruments [Oswestry Disability Index (ODI), SF-36 and Neck/Back/Leg-Pain Visual Analog Scale (VAS-NP/BP/LP)] were completed before surgery, then at 3- and 6-month after surgery. RESULTS: Baseline characteristics were similar in all cohorts. Operative variables were also similar in all cohorts, with no difference in operative time, estimated blood loss (EBL), or fusion levels. Complication rates were similar between cohorts, with the fentanyl-cohort having an increased percentage of urinary tract infection (UTI) than the morphine and hydromorphone cohorts (16.39% vs. 5.15% vs. 5.63%, P=0.0277). The morphine-cohort had a decreased LOS than the fentanyl and hydromorphone cohorts (4.18 vs. 5.56 vs. 5.69 days, P=0.0376). There was a significant difference in the number of feet first ambulated by the patient post-operatively for the morphine and hydromorphone cohorts than the fentanyl-cohort (morphine: 118.44±18.15 vs. fentanyl: 59.26±20.78 vs. hydromorphone: 125.91±19.85, P=0.0420). There was no significant differences in 30-day hospital readmission rates between the cohorts, morphine-cohort did trend lower than the other cohorts (morphine: 5.10 vs. fentanyl: 11.48 vs. hydromorphone: 11.27, P=0.2492). There were no significant differences in PROs between the two cohorts in ODI, SF-36, and VAS-NP/BP/LP at baseline, 3- and 6-month. CONCLUSIONS: Our study demonstrates that the choice of immediate post-operative pain medication can make a difference in the hospital course for patients. Identifying these types of factors might help increase patient care and reduce health care costs.

Prophylactic use of intraoperative vancomycin powder and postoperative infection: an analysis of microbiological patterns in 1200 consecutive surgical cases.

OBJECTIVE Wound infections following spinal surgery for deformity place a high toll on patients, providers, and the health care system. The prophylactic application of intraoperative vancomycin powder has been shown to lower the infection risk after thoracolumbar decompression and fusion for deformity correction. The purpose of this study was to assess the microbiological patterns of postoperative surgical site infections (SSIs) after prophylactic use of vancomycin powder in adult patients undergoing spinal deformity surgery. METHODS All cases involving adult patients who underwent spinal deformity reconstruction at Duke University Medical Center between 2011 and 2013 with a minimum of 3 months of clinical follow-up were retrospectively reviewed. In all cases included in the study, crystalline vancomycin powder was applied to the surgical bed for infection prophylaxis. Baseline characteristics, operative details, rates of wound infection, and microbiological data for each case were gathered by direct medical record review. RESULTS A total of 1200 consecutive spine operations were performed for deformity between 2011 and 2013. Review of the associated records demonstrated 34 cases of SSI, yielding an SSI rate of 2.83%. The patients' mean age (± SD) was 62.08 ± 14.76 years. The patients' mean body mass index was 30.86 ± 7.15 kg/m2, and 29.41% had a history of diabetes. The average dose of vancomycin powder was 1.41 ± 2.77 g (range 1-7 g). Subfascial drains were placed in 88% of patients. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50%. In 74% of the SSIs cultures were positive, with about half the organisms being gram negative, such as Citrobacter freundii, Proteus mirabilis, Morganella morgani, and Pseudomonas aeruginosa. There were no adverse clinical outcomes related to the local application of vancomycin. CONCLUSIONS Our study suggests that in the setting of prophylactic vancomycin powder use, the preponderance of SSIs are caused by gram-negative organisms or are polymicrobial. Further randomized control trials of prophylactic adjunctive measures are warranted to help guide the choice of empirical antibiotic therapy while awaiting culture data.

Impact of Discharge Disposition on 30-Day Readmissions Following Elective Spine Surgery.

BACKGROUND: Readmissions are a significant economic burden on the health care system and increasingly being utilized as a metric of quality. Patients discharged to home vs an inpatient facility have different characteristics, which might influence the readmissions following spine surgery. OBJECTIVE: To determine the effect of discharge disposition on readmission rates and causes of readmission after spine surgery. METHODS: Patients enrolled in a prospective registry and undergoing elective spine surgery were analyzed. Readmissions (30 d), demographic, clinical variables, and baseline patient-reported outcomes were recorded. Patients were dichotomized as discharged home vs inpatient facility. RESULTS: Of total 1631 patients, 1444 (89%) patients were discharged home and 187 (11%) discharged to an inpatient facility. Sixty-five (4%) patients were readmitted at 30 d. There was no significant difference in readmissions between patients discharged to a facility 10 (5%) vs home 55 (4%; P = .210). In a multivariable analysis, adjusting for all the comorbidities, the discharge destination was not associated with readmission within 30 d. The medical complications (80%) were the most common cause of readmission in those discharged to a facility. Patients discharged home had significantly higher readmissions related to surgical wound issues (67%; P = .034). CONCLUSION: Despite the older age and higher comorbidities in patients discharged to an inpatient facility, the proportion of readmissions was comparable to those discharged home. Patients discharged home had a higher proportion of readmissions related to surgical wound complications and those discharged to facility had higher readmissions associated with medical complications. Understanding causes of readmission based on discharge destination may allow targeted intervention to reduce the readmission rates following spine surgery.

Depression as an independent predictor of postoperative delirium in spine deformity patients undergoing elective spine surgery.

OBJECTIVE Depression is the most prevalent affective disorder in the US, and patients with spinal deformity are at increased risk. Postoperative delirium has been associated with inferior surgical outcomes, including morbidity and mortality. The relationship between depression and postoperative delirium in patients undergoing spine surgery is relatively unknown. The aim of this study was to determine if depression is an independent risk factor for the development of postoperative delirium in patients undergoing decompression and fusion for deformity. METHODS The medical records of 923 adult patients (age ≥ 18 years) undergoing elective spine surgery at a single major academic institution from 2005 through 2015 were reviewed. Of these patients, 255 (27.6%) patients had been diagnosed with depression by a board-certified psychiatrist and constituted the Depression group; the remaining 668 patients constituted the No-Depression group. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient and compared between groups. The primary outcome investigated in this study was rate of postoperative delirium, according to DSM-V criteria, during initial hospital stay after surgery. The association between depression and postoperative delirium rate was assessed via multivariate logistic regression analysis. RESULTS Patient demographics and comorbidities other than depression were similar in the 2 groups. In the Depression group, 85.1% of the patients were taking an antidepressant prior to surgery. There were no significant between-group differences in intraoperative variables and rates of complications other than delirium. Postoperative complication rates were also similar between the cohorts, including rates of urinary tract infection, fever, deep and superficial surgical site infection, pulmonary embolism, deep vein thrombosis, urinary retention, and proportion of patients transferred to the intensive care unit. In total, 66 patients (7.15%) had an episode of postoperative delirium, with depressed patients experiencing approximately a 2-fold higher rate of delirium (10.59% vs 5.84%). In a multivariate logistic regression analysis, depression was an independent predictor of postoperative delirium after spine surgery in spinal deformity patients (p = 0.01). CONCLUSIONS The results of this study suggest that depression is an independent risk factor for postoperative delirium after elective spine surgery. Further studies are necessary to understand the effects of affective disorders on postoperative delirium, in hopes to better identify patients at risk.

Impact of surgical approach on complication rates after elective spinal fusion (≥3 levels) for adult spine deformity.

BACKGROUND: While there are variations in techniques and surgical approaches to spinal fusion, there is not a defined consensus on a recommended surgical approach. The aim of this study is to determine if there was a difference in intra- and post-operative complication rates between different surgical approaches after elective spinal fusion (≥3 levels) for adult spine deformity. METHODS: The medical records of 443 adult spine deformity patients undergoing elective spinal fusion (≥3) at a major academic institution from 2005 to 2015 were reviewed. We identified 96 (21.7%) anterior only, 225 (50.8%) posterior only, and 122 (27.5%) combined anterior/posterior approaches taken for spinal fusion (anterior: n=96; posterior: n=225). Patient demographics, comorbidities, anatomical location, and complication rates were collected for each patient. The primary outcome investigated in this study was the rate of intra- and post-operative complications. RESULTS: Patient demographics and comorbidities were similar between all groups. The posterior approach had significantly higher EBL (P<0.0001) and number of PRBC blood transfusions (P<0.002), while the combined approach had a higher operative time (P<0.0001). The posterior approach had a significantly higher rate of intraoperative durotomies than anterior and combined (anterior: 0% vs. posterior: 11.1% vs. combined: 4.1%, P<0.0001). There was no significant difference in the rate 30-day readmissions between the cohorts (anterior: 10.4% vs. posterior: 12.8% vs. combined: 13.1%, P=0.80). CONCLUSIONS: Our study suggests that posterior approaches to spinal fusion may lead to a higher incidence of complications compared to anterior or combined anterior/posterior approaches.

Effect of employment status on length of hospital stay, 30-day readmission and patient reported outcomes after spine surgery.

BACKGROUND: Growing scrutiny has placed hospitals at the center of readmission prevention. The relationship between pre-operative employment status, length of hospital stays (LOS) and 30-day readmission rates after elective spine surgery remains unclear. METHODS: The medical records of 360 patients (employed: n=174, unemployed: n=70, retired: n=40, disabled: n=76) undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and post-operative complication rates were recorded. All patients had comprehensive 1-year patient reported outcomes (PROs) measures. We hypothesized that employment status is associated with decreased LOS and decreased risk of 30-day readmission after elective spine surgery. All-cause readmissions within 30 days of discharge was the primary outcome variable. RESULTS: Baseline characteristics were similar in all cohorts. There was no difference in operative time, estimated blood loss (EBL), or number of fusion levels between all patient cohorts. There were no significant differences in peri-operative complication rates between patient cohorts. On average, the LOS was shorter for the employed compared to non-employed patients (4.89 vs. 5.26 days). The rate of 30-day readmission was 2-fold greater unemployed compared to employed patients (5.17% vs. 10%). At 1-year after surgery, employed patients were more likely to express functional improvement (change in ODI score) compared to unemployed patients (ODI: employed: 33.80 vs. unemployed: 41.93). CONCLUSIONS: Our study suggests that employment status may be associated with shorter duration of hospital stay, lower 30-day readmission rates and greater functional improvement. Future interventions to reduce unplanned hospital readmissions should consider pre-operative employment status.

Increased 30-Day Complication Rates Associated with Laminectomy in 874 Adult Patients with Spinal Deformity Undergoing Elective Spinal Fusion: A Single Institutional Study.

OBJECTIVE: Recent studies have reported that decompression with fusion leads to superior outcomes in correction of spinal deformity. The aim of this study was to determine if there is a difference in intraoperative and 30-day postoperative complication rates in patients undergoing spinal fusion with and without decompression. METHODS: Medical records of 874 adult (≥18 years old) patients with spinal deformity undergoing elective spinal fusion at a major academic institution from 2005 to 2015 were reviewed; 374 (42.8%) patients underwent laminectomy in addition to spinal fusion. The primary outcome investigated was the rate of intraoperative and 30-day complications. RESULTS: Patient demographics and comorbidities were similar between groups. The laminectomy cohort had significantly higher estimated blood loss (P < 0.0001), incidence of allogeneic blood transfusions (P = 0.0001), and rate of intraoperative durotomies (laminectomy cohort 10.4% vs. no-laminectomy cohort 3.1%; P < 0.0001). The laminectomy cohort had a significantly higher proportion of patients in the intensive care unit (28.6% vs. 17.7%; P < 0.001). There was no significant difference in 30-day readmission rate between cohorts (laminectomy cohort 13.0% vs. no-laminectomy cohort 9.8%; P = 0.13). Within 30 days after initial discharge, the laminectomy cohort had significantly higher rates of altered mental status (3.2% vs. 1.2%; P = 0.05), urinary tract infection (4.3% vs. 1.4%; P = 0.009), wound drainage (7.2% vs. 3.1%; P = 0.007), and instrumentation failure (1.1% vs. 0.0%; P = 0.03). CONCLUSIONS: Patients undergoing spinal fusion with laminectomy may have higher complication rates than patients undergoing spinal fusion alone.

Association of Intraoperative Blood Transfusions on Postoperative Complications, 30-Day Readmission Rates, and 1-Year Patient-Reported Outcomes.

STUDY DESIGN: Ambispective cohort review. OBJECTIVE: The aim of this study was to determine the effect of allogeneic red blood cell (RBC) transfusion on postoperative patient complications profiles and 30-day readmission rates following elective spine surgery. SUMMARY OF BACKGROUND DATA: Thirty-day hospital readmission rates are being used as a proxy for quality of care. Intra- or perioperative allogeneic RBC transfusions are associated with deleterious effects. Whether allogeneic RBC transfusions are associated with higher perioperative complications and 30-day readmission rates after elective spine surgery remains unknown. METHODS: The medical records of 160 patients undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and postoperative complication rates were collected. All patients completed patient-reported outcomes instruments (Oswestry Disability Index, SF-36, and VAS-NP/BP/LP) before surgery, then at 3, 6, and 12 months after surgery. The association between intra- or perioperative allogeneic RBC transfusions and 30-day readmission rate was assessed via multivariate logistic regression analysis. RESULTS: Baseline characteristics were similar in both cohorts. The mean pre- and postoperative hemoglobin levels were lower for the transfusion than nontransfusion cohorts. Postoperative complication rates were 44.67% and 23.00% in the transfusion and nontransfusion cohorts, respectively. Overall, 9.38% of patients were re-admitted within 30 days of hospital discharge, with a three-fold higher increase in 30-day readmission rate in the transfusion cohort compared to the nontransfusion cohort (no transfusion: 5% vs. transfusion: 16.67%, P = 0.01). In a multivariate logistic regression model, intra- or perioperative allogeneic RBC transfusion was an independent predictor of 30-day readmission after elective spine surgery (P = 0.005). CONCLUSION: Our study suggests that allogeneic RBC transfusions may be associated with increased postoperative complications, length of hospital stay, and 30-day readmission rates. LEVEL OF EVIDENCE: 3.

Impact of Race on 30-Day Complication Rates After Elective Complex Spinal Fusion (≥5 Levels): A Single Institutional Study of 446 Patients.

OBJECTIVE: Racial disparities have been shown to affect surgical outcomes. However, the effect of race on complex spinal fusion outcomes remains understudied. The aim of this study is to determine if patient race affects 30-day complication rates after elective complex spinal fusion (≥5 levels). METHODS: The medical records of 490 adult patients with spinal deformity undergoing elective complex spinal fusion (≥5 levels) at a major academic institution from 2005 to 2015 were reviewed. We identified 52 black patients (11.7%) and 438 white patients (88.3%). Patient demographics, comorbidities, and intraoperative and 30-day postoperative complication and readmission rates were collected. The primary outcome investigated in this study was the rate of 30-day postoperative complications. RESULTS: Patient demographics and comorbidities were similar between both groups, including age, gender, and body mass index. Median (interquartile range) number of fusion levels and operative time were similar between the cohorts (black, 6.5 [5-9] vs. white, 7 [5-9]; P = 0.55; and black, 307.3 ± 120.2 minutes vs. white, 321.3 ± 135.3 minutes; P = 0.45, respectively). Both cohorts had similar postoperative complications and lengths of hospital stay (black, 7.2 ± 5.4 days vs. white: 6.5 ± 4.9; P = 0.37). There was no significant difference in 30-day readmission between the cohorts (black, 9.6% vs. white, 12.8%; P = 0.66). There were no observed differences in 30-day complication rates, including: pain (P = 0.74), urinary tract infection (P = 0.68), hardware failure (P = 0.36), wound dehiscence (P = 0.29), and drainage (P = 0.86). CONCLUSIONS: Our study suggests that there is no difference between races in 30-day complication and readmission rates after complex spinal surgery requiring ≥5 levels of fusion.

[Standardization of gastric emptying scintigraphy with egg white labeled with 99mTc-sulfur colloid]. / Estandarización de la gammagrafía de vaciamiento gástrico con albúmina de huevo marcada con 99mTc sulfuro coloidal.

BACKGROUND: Gastric emptying scintigraphy has become the gold standard, by excellence, in gastric emptying studies. This method must be standardized for the correct interpretation of results. The ideal protocol must be performed with an egg sandwich or egg white poder, both labeled with 99mTc sulphur colloid. The aim of this study was to standardize and determine the protocol with99m Tc sulphur colloid incorporated in egg white and compare it with a hamburger labeled with 99mTc sulphur colloid as well. METHODS: We studied 30 patients who underwent gastric emptying scintigraphy with the two aforementioned meals. RESULTS: Emptying percentages and retention with both meals were similar within an hour and two; however, statistical significance arose until the third hour with a p value of 0.26 by using Student's t for independent samples. CONCLUSIONS: Gastric emptying studies in both protocols where similar with normal ranges. The egg white ingested must be consistent for reproducible results in gastric motility disease, like organoleptic and volume characteristics.

Introducción: la gammagrafía de vaciamiento gástrico (VG) es el estándar de oro para determinar el porcentaje de VG. La estandarización del método permite la obtención de resultados reproducibles. La dieta estandarizada se compone de un sándwich de albúmina de huevo en polvo reconstituida y marcada con 99mTc sulfuro coloidal (SC). El objetivo fue estandarizar y determinar el porcentaje de vaciamiento gástrico tras la ingesta del sándwich de albúmina de huevo y compararlo con el porcentaje de ingesta de una hamburguesa, ambos marcados con 99mTc sulfuro coloidal. Método: se incluyeron 30 pacientes a los que se les realizó estudio de gammagrafía de vaciamiento gástrico con las dos dietas propuestas. Resultados: los porcentajes de vaciamiento y retención con ambos tipos de alimentos fueron similares a la hora y a las dos horas; sin embargo, hubo diferencias significativas a las tres horas con un valor de p = 0.26, calculado mediante t de Student para muestras independientes. Conclusiones: los tiempos de vaciamiento gástrico con ambas dietas estuvieron dentro de rangos normales. La dieta estandarizada con albúmina de huevo reconstituida aporta ventajas en cuanto al estudio de las posibles alteraciones de la motilidad gástrica, como sus características organolépticas y de volumen.