Publications by authors named "Danny Lee"

83 Publications

Hip hemiarthroplasty for the treatment of femoral neck fractures in dialysis patients.

Hip Int 2021 Jul 26:11207000211028151. Epub 2021 Jul 26.

Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA.

Objectives: This study sought to delineate the postoperative outcomes in dialysis patients undergoing hip hemiarthroplasty (HHA) for the treatment of femoral neck fractures (FNF) in order to better optimise pre- and postoperative management and minimise short-term morbidity and mortality rates.

Methods: 16,955 patients who had undergone HHA for femoral neck fractures from 2005 to 2018 were isolated from a multi-institutional surgical registry, of which 343 (2.0%) were on dialysis and 16,612 (98.0%) were not. The cohorts were identified/analysed for differences in their comorbidities, demographic factors, and 30-day postoperative complications using Fischer's exact tests and Mann-Whitney U-tests. Coarsened exact matching (CEM) was implemented in order to control for baseline difference in demographics and comorbidities. Multivariate logistic regression analyses were used to assess the impact of dialysis as an independent risk factor for various complications, including reoperations, readmissions, and mortality.

Results: Upon CEM-matching (L1-statistic <0.001), weighted multivariate logistic regression analyses demonstrated dialysis to be an independent risk factor for minor complications (OR 3.051,   0.001), pneumonia (OR 3.943,   0.001), urinary tract infections (UTIs) (OR 2.684,   0.001), major complications (OR 1.892,   0.001), unplanned intubation (OR 2.555,   0.047), cardiac arrest (OR 11.897,   0.001), deep vein thrombosis (DVT), (OR 2.610,   0.049), and mortality (OR 2.960,   0.001).

Conclusions: Dialysis independently increased the risk for unplanned intubation, cardiac arrest, blood transfusions, pneumonia, DVT, and mortality. In communicating postoperative expectations, surgeons should aim to clarify the patients' preferences and potential resuscitation designations prior to surgical intervention due to the increased risk of serious complications. A lower threshold of suspicion for DVT in this population is reasonable. Identifying high-risk patient populations that may experience increased rates of complications, with the ensuing financial expenditures, due to medical complexity rather than subpar management may help providers avoid penalties in caring for these patients.
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http://dx.doi.org/10.1177/11207000211028151DOI Listing
July 2021

The ecology of COVID-19 and related environmental and sustainability issues.

Ambio 2021 Jul 19. Epub 2021 Jul 19.

USDA Forest Service, Southern Research Station, 200 WT Weaver Blvd, Asheville, NC, 28804, USA.

Around the globe, human behavior and ecosystem health have been extensively and sometimes severely affected by the unprecedented COVID-19 pandemic. Most efforts to study these complex and heterogenous effects to date have focused on public health and economics. Some studies have evaluated the pandemic's influences on the environment, but often on a single aspect such as air or water pollution. The related research opportunities are relatively rare, and the approaches are unique in multiple aspects and mostly retrospective. Here, we focus on the diverse research opportunities in disease ecology and ecosystem sustainability related to the (intermittent) lockdowns that drastically reduced human activities. We discuss several key knowledge gaps and questions to address amid the ongoing pandemic. In principle, the common knowledge accumulated from invasion biology could also be effectively applied to COVID-19, and the findings could offer much-needed information for future pandemic prevention and management.
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http://dx.doi.org/10.1007/s13280-021-01603-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8287844PMC
July 2021

Human Papillomavirus Vaccination Trends and Disparities in the United States: Who Is Getting Left Behind?

Sex Transm Dis 2021 Oct;48(10):714-719

Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA.

Background: United States guidelines recommend human papillomavirus (HPV) vaccination for males and females up to 26, with more recent extended coverage for those 27 to 45 years based on discussion with patients' clinician. This study seeks to assess trends and disparities of vaccination in the United States based on demographic characteristics.

Methods: Data were obtained from the National Health and Nutrition Examination Survey between 2007 and 2016. χ2 Analyses were used for statistical methods.

Results: Of 12,844 participants (median age, 22 years; range, 9-36 years), 2711 (21.3%) initiated HPV vaccination, of which 1358 (56.3%) completed the 3-dose vaccination series. Vaccination rates were higher in females compared with males (24.6% vs 13.0%; P < 0.001) and in Whites compared to Mexican Americans (22.6% vs 19.4%; P = 0.02). The uninsured had lower vaccination rates than private insurance and Medicaid (12.5% vs 22.4% vs 28.5%; P < 0.001). We divided the 10 year study into five separate periods (2007-2008, 2009-2010, 2011-2012, 2013-2014, and 2015-2016) to analyze trends. Vaccine initiation increased from 19.6% to 49.6% for 14-19-year olds (P < 0.001), 10.4% to 35.5% for females (P < 0.001), and 8.5% to 32.9% for Blacks (P < 0.001). Although on trend analyses, the vaccination rates with the highest proportional increase were found in those: older than 25 to 29 years (4.56-fold), Mexican Americans (4.56 fold), below high school education (2.32 fold), and low income group (2.90 fold) over time.

Conclusions: The HPV vaccination rates in Mexican Americans increased nearly 5-fold over the last 10 years. However, their vaccination rates continue to lag behind Whites and Blacks.
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http://dx.doi.org/10.1097/OLQ.0000000000001410DOI Listing
October 2021

Complications following regional anesthesia versus general anesthesia for the treatment of distal radius fractures.

Eur J Trauma Emerg Surg 2021 May 29. Epub 2021 May 29.

Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC, USA.

Purpose: Open reduction and internal fixation (ORIF) are commonly utilized for the repair of distal radius fractures (DRF). While general anesthesia (GA) is typically administered for ORIF, recent studies have also demonstrated promising results with the usage of regional anesthesia (RA) in the surgical treatment of distal radius fractures. This study will compare complication rates between the use of RA versus GA for ORIF of DRFs.

Methods: A multi-institutional surgical registry was utilized to identify patients who had undergone ORIF for DRFs from 2005 to 2018-these patients were stratified into GA and RA cohorts. Patients were matched utilizing coarsened-exact-matching (CEM) to compare postoperative outcomes and rates of 30-day complications were compared between the two cohorts.

Results: Upon CEM-matching, 1191 patients receiving RA were matched to 9250 patients who had received GA, with a multivariate imbalance measure (L1) statistic of < 0.001. In the matched-cohort analysis, no significant differences were observed in rates of any complication (all p ≥ 0.083). On multivariate regression analyses, RA was not associated with increased risk for any complication (p = 0.445), minor complications (p = 0.093), major complications (p = 0.758), unplanned reoperations (p = 0.355), unplanned readmissions (p = 0.799), or mortality (p = 0.579).

Conclusion: With similar safety profiles, RA is a safe and reasonable alternative to GA when managing DRFs surgically. RA may be the preferred anesthetic technique for ORIF of DRFs in patients at high risk with GA, such as those with reactions to GA in the past or with significant cardiopulmonary risk factors.
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http://dx.doi.org/10.1007/s00068-021-01704-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164052PMC
May 2021

Applying Artificial Intelligence to Gynecologic Oncology: A Review.

Obstet Gynecol Surv 2021 May;76(5):292-301

Director of Gynecologic Oncology, Palo Alto Medical Foundation Research Institute, Palo Alto, CA.

Importance: Artificial intelligence (AI) will play an increasing role in health care. In gynecologic oncology, it can advance tailored screening, precision surgery, and personalized targeted therapies.

Objective: The aim of this study was to review the role of AI in gynecologic oncology.

Evidence Acquisition: Artificial intelligence publications in gynecologic oncology were identified by searching "gynecologic oncology AND artificial intelligence" in the PubMed database. A review of the literature was performed on the history of AI, its fundamentals, and current applications as related to diagnosis and treatment of cervical, uterine, and ovarian cancers.

Results: A PubMed literature search since the year 2000 showed a significant increase in oncology publications related to AI and oncology. Early studies focused on using AI to interrogate electronic health records in order to improve clinical outcome and facilitate clinical research. In cervical cancer, AI algorithms can enhance image analysis of cytology and visual inspection with acetic acid or colposcopy. In uterine cancers, AI can improve the diagnostic accuracies of radiologic imaging and predictive/prognostic capabilities of clinicopathologic characteristics. Artificial intelligence has also been used to better detect early-stage ovarian cancer and predict surgical outcomes and treatment response.

Conclusions And Relevance: Artificial intelligence has been shown to enhance diagnosis, refine clinical decision making, and advance personalized therapies in gynecologic cancers. The rapid adoption of AI in gynecologic oncology will depend on overcoming the challenges related to data transparency, quality, and interpretation. Artificial intelligence is rapidly transforming health care. However, many physicians are unaware that this technology is being used in their practices and could benefit from a better understanding of the statistics and computer science behind these algorithms. This review provides a summary of AI, its applicability, and its limitations in gynecologic oncology.
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http://dx.doi.org/10.1097/OGX.0000000000000902DOI Listing
May 2021

Experimental evaluation of four-dimensional Magnetic Resonance Imaging for radiotherapy planning of lung cancer.

Phys Imaging Radiat Oncol 2021 Jan 7;17:32-35. Epub 2021 Jan 7.

Radiation Oncology, Calvary Mater Newcastle, Australia.

Radiotherapy planning for lung cancer typically requires both 3D and 4D Computed Tomography (CT) to account for respiratory related movement. 4D Magnetic Resonance Imaging (MRI) with self-navigation offers a potential alternative with greater reliability in patients with irregular breathing patterns and improved soft tissue contrast. In this study 4D-CT and a 4D-MRI Radial Volumetric Interpolated Breath-hold Examination (VIBE) sequence was evaluated with a 4D phantom and 13 patient respiratory patterns, simulating tumour motion. Quantification of motion related tumour displacement in 4D-MRI and 4D-CT found no statistically significant difference in mean motion range. The results demonstrated the potential viability of 4D-MRI for lung cancer treatment planning.
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http://dx.doi.org/10.1016/j.phro.2020.12.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058028PMC
January 2021

Telehealth practice in surgery: Ethical and medico-legal considerations.

Surg Pract 2021 Feb 10;25(1):42-46. Epub 2021 Feb 10.

Department of Surgery The Chinese University of Hong Kong Hong Kong China.

There was rapid growth of telehealth practice during the COVID-19 outbreak in 2020. In surgery, there were beneficial effects in terms of saving time and avoiding physical contact between healthcare professionals and patients when using telehealth in the delivery of perioperative care. As telehealth is gaining momentum, the evolving ethical and medico-legal challenges arising from this alternative mode of doctor-patient interaction cannot be underestimated. With reference to the "Ethical Guidelines on Practice of Telemedicine" issued by the Medical Council of Hong Kong and some published court and disciplinary cases from other common law jurisdictions, this article discusses relevant ethical and medico-legal issues in telehealth practice with emphasis on the following areas: duty of care; communication and contingency; patient-centred care and informed consent; limitations and standard of care; keeping medical records, privacy, and confidentiality; and cross-territory practice. Whilst existing ethical and legal obligations of practicing medicine are not changed when telehealth is used as opposed to in-person care, telehealth practitioners are advised to familiarize themselves with the ethical guidelines, to keep abreast of the medico-legal developments in this area, and to observe the licensure requirements and regulatory regimes of both the jurisdiction where they practice and where their patients are located.
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http://dx.doi.org/10.1111/1744-1633.12479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013586PMC
February 2021

Racial disparities in high-risk uterine cancer histologic subtypes: A United States Cancer Statistics study.

Gynecol Oncol 2021 05 13;161(2):470-476. Epub 2021 Mar 13.

Division of Gynecologic Oncology, Palo Alto Medical Foundation, California Pacific Medical Center, Sutter Health, San Francisco, CA, USA. Electronic address:

Objective: Black women with uterine cancer on average have worse survival outcomes compared to White women, in part due to higher rates of aggressive, non-endometrioid subtypes. However, analyses of incidence trends by specific high-risk subtypes are lacking, including those with hysterectomy and active pregnancy correction. The objective of our study was to evaluate racial disparities in age-adjusted incidence of non-endometrioid uterine cancer in 720,984 patients.

Methods: Data were obtained from United States Cancer Statistics using SEER*Stat. We used the Behavioral Risk Factor Surveillance System to correct for hysterectomy and active pregnancy. Age-adjusted, corrected incidence of uterine cancer from 2001 to 2016 and annual percent change (APC) were calculated using Joinpoint regression.

Results: Of 720,984 patients, 560,131 (77.7%) were White, 72,328 (10.0%) were Black, 56,239 (7.8%) were Hispanic, and 22,963 (3.2%) were Asian/Pacific Islander. Age-adjusted incidence of uterine cancer increased from 40.8 (per 100,000) in 2001 to 42.9 in 2016 (APC = 0.5, p < 0.001). Black women had the highest overall incidence at 49.5 (APC = 2.3, p < 0.001). The incidence of non-endometrioid subtypes was higher in Black compared to White women, with the most pronounced differences seen in serous carcinoma (9.1 vs. 3.0), carcinosarcoma (6.1 vs. 1.8), and leiomyosarcoma (1.3 vs. 0.6). In particular, Black women aged 70-74 with serous carcinoma had the highest incidence (61.3) and the highest APC (7.3, p < 0.001).

Conclusions: Black women have a two to four-fold higher incidence of high-risk uterine cancer subtypes, particularly serous carcinoma, carcinosarcoma, and leiomyosarcoma, compared to White women after correcting for hysterectomy and active pregnancy.
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http://dx.doi.org/10.1016/j.ygyno.2021.02.037DOI Listing
May 2021

Outcomes following outpatient anterior cervical discectomy and fusion for the treatment of myelopathy.

J Clin Orthop Trauma 2021 Apr 9;15:161-167. Epub 2020 Aug 9.

Washington Spine and Scoliosis Clinic, OrthoBethesda in Bethesda, MD, USA.

Introduction: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of degenerative cervical disease. With continued increase in U.S. healthcare expenditure, surgeons have begun to more closely examine the benefits of performing ACDF in an outpatient setting to increase efficiency, reduce the overall financial burden on patients/providers, and provide streamlined care for these patients. The purpose of this study was to analyze outcomes following outpatient ACDF for the treatment of myelopathy.

Methods: 14,490 patients who had undergone ACDF for myelopathy from 2010 to 2018 were included in this retrospective study, of which 2956 (20.40%) patients were considered to have undergone outpatient surgery. Pearson chi-squared tests and Fischer's Exact Tests were used to analyze differences in categorical variables of demographics, preoperative comorbidities, and postoperative complications, while Mann-Whitney-U-Tests were used to compare mean values of continuous variables. Coarsened-exact-matching (CEM) was implemented to control for baseline differences in demographics and comorbidities, and post-matching diagnostics included multivariate and univariate imbalance measure assessment. Outcomes were compared between the CEM-matched inpatient and outpatients ACDF cohorts.

Results: Upon CEM-matching (L1-statistic <0.001), the outpatient cohort (n = 2610, 25.13%) demonstrated significantly lower rates of any complication (p < 0.001), minor complications (p = 0.001), urinary tract infections (p = 0.029), blood transfusions (p < 0.001), major complications (p < 0.001), deep incisional surgical site infections (p = 0.017), ventilator dependence (p = 0.027), cardiac arrest (p = 0.028), unplanned reoperations (p = 0.001), and mortality (p = 0.006) in the 30-day postoperative period when compared to inpatient controls (n = 7774, 74.87%).

Conclusion: ACDF has been a target amongst spinal procedures as a prime candidate for outpatient surgery. However, no previous reports have described complication rates and perioperative parameters in the sub-population of outpatient ACDF patients with myelopathy. In addition to shorter times from admission to operating room, operative time, and LOS, our study also demonstrated lower rates of major and overall complications in outpatient ACDF's for myelopathy in comparison to their inpatient counterparts. Performing ACDF's for myelopathy in an outpatient setting may help to curb costs, improve outcomes, and serve as a valuable learning resource for graduate medical education with rapid turnovers and shorter operative times.
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http://dx.doi.org/10.1016/j.jcot.2020.07.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920123PMC
April 2021

Association between operational positive depression symptom screen scores on hospital admission and 30-day readmissions.

Gen Hosp Psychiatry 2021 May-Jun;70:38-43. Epub 2021 Feb 8.

Cedars-Sinai Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA; Enterprise Information Services, Cedars-Sinai Medical Center, 6500 Wilshire Blvd, Los Angeles, CA 90048, USA; Cedars-Sinai Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA.

Background: Positive scores on inpatient depression symptom screens have been found to be associated with readmissions, yet most studies have used depression screens collected as part of research studies.

Objective: We evaluated whether the relationship between depression severity and readmission persisted when depression screening data was obtained for operational purposes.

Design: Retrospective analysis studying prospective use of PHQ data.

Setting: Large academic medical center.

Intervention: Ward nurses obtained depression screens from patients soon after admission. Patients who answered 'yes' to at least one Patient Health Questionnaire (PHQ)-2 question were screened using the PHQ-9.

Main Outcomes And Measures: We examined the association between depression severity and 30-day readmissions using logistic regression, adjusting for known predictors of hospital readmission.

Results: From July 2014-June 2016, 18,792 discharged adult medicine inpatients received an initial depression screen (PHQ-2) and 1105 patients (5.90%) had at least one positive response. Of this group, 3163 patients (6.32%) were readmitted within 30 days. 1128 patients received the PHQ-9. Compared to patients with no depression, patients with moderately-severe depression had 3.03 higher odds (95%CI, 1.44-6.38) and patients with severe depression had 1.63 higher odds (95%CI, 0.70-3.78) of being readmitted, after adjusting for known predictors of hospital admission. Adding PHQ-9 results did not significantly improve the predictive power of a readmissions model.

Conclusions: Our mixed results call into question whether PHQ data obtained for operational purposes may differ compared to data obtained for research purposes. Differences in training of screening staff or patient discomfort with discussing depression in the hospital could explain our findings.
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http://dx.doi.org/10.1016/j.genhosppsych.2021.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136146PMC
February 2021

A novel quality assurance procedure for trajectory log validation using phantom-less real-time latency corrected EPID images.

J Appl Clin Med Phys 2021 Mar 26;22(3):176-185. Epub 2021 Feb 26.

Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

The use of trajectory log files for routine patient quality assurance is gaining acceptance. Such use requires the validation of the trajectory log itself. However, the accurate localization of a multileaf collimator (MLC) leaf while it is in motion remains a challenging task. We propose an efficient phantom-less technique using the EPID to verify the dynamic MLC positions with high accuracy. Measurements were made on four Varian TrueBeams equipped with M120 MLCs. Two machines were equipped with the S1000 EPID; two were equipped with the S1200 EPID. All EPIDs were geometrically corrected prior to measurements. Dosimetry mode EPID measurements were captured by a frame grabber card directly linked to the linac. All leaf position measurements were corrected both temporally and geometrically. The readout latency of each panel, as a function of pixel row, was determined using a 40 × 1.0 cm sliding window (SW) field moving at 2.5 cm/s orthogonal to the row readout direction. The latency of each panel type was determined by averaging the results of two panels of the same type. Geometric correction was achieved by computing leaf positions with respect to the projected isocenter position as a function of gantry angle. This was determined by averaging the central axis position of fields at two collimator positions of 90° and 270°. The radiological to physical leaf end position was determined by comparison of the measured gap with that determined using a feeler gauge. The radiological to physical leaf position difference was found to be 0.1 mm. With geometric and latency correction, the proposed method was found to be improve the ability to detect dynamic MLC positions from 1.0 to 0.2 mm for all leaves. Latency and panel residual geometric error correction improve EPID-based MLC position measurement. These improvements provide for the first time a trajectory log QA procedure.
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http://dx.doi.org/10.1002/acm2.13202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984475PMC
March 2021

Coagulation Profile as a Significant Risk Factor for Short-Term Complications and Mortality after Anterior Cervical Discectomy and Fusion.

World Neurosurg 2021 04 9;148:e74-e86. Epub 2020 Dec 9.

Department of Neurological Surgery, West Virginia University, Berkeley Medical Center, Martinsburg, West Virginia, USA. Electronic address:

Background: Cervical degenerative disc disease is the most common indication for anterior cervical discectomy and fusion. Given the possible complications, patients are stratified before anterior cervical discectomy and fusion by preoperative risk factors to optimize treatment. One preoperative factor is a patient's coagulation profile.

Methods: The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patient preoperative coagulation profile and postoperative complications. By generating binary logistic regression models, each of the 4 abnormal coagulation categories (bleeding disorder, low platelet count, high partial thromboplastin time, and high international normalized ratio [INR]) were analyzed for their independent impact on increased risk for complications compared with the control cohort.

Results: A total of 61,977 patients were assessed. The most common abnormal coagulation was abnormal platelet count (n = 2149). The most common postoperative outcome was an extended length of hospital stay among patients with an abnormal coagulation profile relative to the control cohort. After multivariate analysis, patients with an abnormal INR (odds ratio, 2.2 [1.3-3.8]; P = 0.003) or abnormal platelet count (odds ratio, 1.5 [1.2-2.1]; P = 0.003) had a higher chance of having an extended length of hospital stay relative to patients having a normal coagulation profile. Having an abnormal INR was found to be associated with an increased risk for having "Any complication."

Conclusions: Our results show significant differences in the incidence rates of a multitude of complications among the 5 groups based on univariate analysis. Patients with any abnormal coagulation disorder had increased rates of developing any complication or having an extended length of hospital stay.
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http://dx.doi.org/10.1016/j.wneu.2020.12.007DOI Listing
April 2021

Differences in 30-day complications associated with total ankle arthroplasty and ankle arthrodesis: A matched cohort study.

Foot (Edinb) 2021 Mar 18;46:101750. Epub 2020 Nov 18.

Department of Orthopaedic Surgery, Johns Hopkins Sibley Memorial Hospital, Washington, DC, United States.

Background: The objective of this study was to identify whether total ankle arthroplasty (TAA) was associated with greater risk for 30-day complications and/or greater financial burden in comparison to ankle arthrodesis (AA).

Methods: The PearlDiver Patient Records Database was queried to identify all patients who underwent an arthroscopic/open AA or TAA from 2006 to 2013. The two cohorts were then matched in a 1:1 manner to control for comorbidities and demographics. Postoperative complications were compared between the two cohorts, in addition to the associated costs with respect to each procedure.

Results: No significant differences in risk for postoperative complications were noted between the two procedures with the numbers available. Significant differences were demonstrated in total length of hospital stay (LOS), with a mean of 2.13 days for the TAA cohort and 2.42 days for the AA cohort (p < 0.001). Higher mean total hospital costs were noted for TAA (x¯ = $62,416.62) compared to AA (x¯ = $37,737.43, p < 0.001); however, TAA was associated with a higher mean total reimbursement (x¯ = $12,254.43) than AA (x¯ = $7915.72, p < 0.001).

Conclusion: With no notable differences in 30-day complication rates, TAA remains a viable alternative to AA in the appropriately selected patient and provides the ability to preserve tibiotalar motion resulting in superior functional scores. Additionally, TAA demonstrated higher total costs to implant, but also greater reimbursement, in line with the recent literature suggesting TAA to be a cost-effective alternative to AA.

Level Of Evidence: III Retrospective study.
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http://dx.doi.org/10.1016/j.foot.2020.101750DOI Listing
March 2021

The Prevalence of Intimate Partner Violence and Association With Depression in University Students: Results of a Cross-Sectional Study.

J Nerv Ment Dis 2021 01;209(1):71-75

Department of Psychiatry and Human Behavior, University of California Irvine, Orange, California.

The purpose of this cross-sectional study was to determine the prevalence of intimate partner violence (IPV) among university students, investigate the potential predictors of IPV in this population, and study the link between IPV and depression. The survey included sociodemographic, relationship quality, and depression-related questions. From 498 respondents, the prevalence of IPV was 4.8%, depression was 30.9%, and suicidal ideation was 20.3%. After adjusting for covariates and confounders, relationship satisfaction (odds ratio [OR], 0.201; 95% confidence interval [CI], 0.101-0.401; p < 0.001) and jealousy (OR, 0.270; 95% CI, 0.094-0.776; p = 0.015) were significant predictors of IPV. Relationship satisfaction predicted depressive disorders (OR, 0.504; 95% CI, 0.365-0.698; p < 0.001). IPV trended toward predicting the presence of a depressive disorder (OR, 0.436; 95% CI, 0.170-1.113; p = 0.083). Relationship satisfaction and jealousy predicted IPV. Although IPV did not predict depression, poor relationship satisfaction increased the odds of depression, implicating the influence of relationship satisfaction on both IPV and depression.
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http://dx.doi.org/10.1097/NMD.0000000000001255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092032PMC
January 2021

The Prevalence of Intimate Partner Violence and Association With Depression in University Students: Results of a Cross-Sectional Study.

J Nerv Ment Dis 2021 01;209(1):71-75

Department of Psychiatry and Human Behavior, University of California Irvine, Orange, California.

The purpose of this cross-sectional study was to determine the prevalence of intimate partner violence (IPV) among university students, investigate the potential predictors of IPV in this population, and study the link between IPV and depression. The survey included sociodemographic, relationship quality, and depression-related questions. From 498 respondents, the prevalence of IPV was 4.8%, depression was 30.9%, and suicidal ideation was 20.3%. After adjusting for covariates and confounders, relationship satisfaction (odds ratio [OR], 0.201; 95% confidence interval [CI], 0.101-0.401; p < 0.001) and jealousy (OR, 0.270; 95% CI, 0.094-0.776; p = 0.015) were significant predictors of IPV. Relationship satisfaction predicted depressive disorders (OR, 0.504; 95% CI, 0.365-0.698; p < 0.001). IPV trended toward predicting the presence of a depressive disorder (OR, 0.436; 95% CI, 0.170-1.113; p = 0.083). Relationship satisfaction and jealousy predicted IPV. Although IPV did not predict depression, poor relationship satisfaction increased the odds of depression, implicating the influence of relationship satisfaction on both IPV and depression.
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http://dx.doi.org/10.1097/NMD.0000000000001255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092032PMC
January 2021

Increased Rates of Septic Shock, Cardiac Arrest, and Mortality Associated With Chronic Steroid Use Following Anterior Cervical Discectomy and Fusion for Cervical Stenosis.

Int J Spine Surg 2020 Oct 12;14(5):649-656. Epub 2020 Oct 12.

Washington Spine and Scoliosis Clinic, OrthoBethesda, Bethesda, Maryland.

Objective: Anterior cervical discectomy and fusion (ACDF) is an established treatment modality for cervical spondylosis. Many patients are on immunosuppressant therapy in the management of various inflammatory spinal pathologies and other comorbid conditions. The impact of chronic steroid use on postoperative complications has not been examined in cervical fusion procedures. The objective of this study was to identify specific postoperative complications associated with steroid/immunosuppressant use following ACDF for cervical stenosis.

Methods: A multi-institutional surgical registry was queried to identify 5377 patients with ACDF diagnosed with cervical stenosis. Patients were stratified into cohorts with a history of steroid/immunosuppressant use for chronic conditions (n = 198, 3.3%) versus those who did not (n = 5179, 96.7%). Propensity-score matching without replacement was implemented to control for preoperative demographics and comorbidities. Pearson χ and Fischer exact tests were used in comparing the prevalence of demographics, comorbidities, and complication rates.

Results: Upon propensity matching, increased rates of pulmonary embolisms (0.51% vs 0.00%, = .025), cardiac arrest requiring resuscitation (1.01% vs 0.10%, = .020), septic shock (0.51% vs 0.00%, = .025), and mortality (1.52% vs 0.20%, = .009) in the postoperative 30-day period in patients on chronic steroid/immunosuppressant use were observed.

Conclusions: The results indicate that steroid use/immunosuppression in patients with ACDF has a higher associated rate of pulmonary embolisms, cardiac arrest, septic shock, and mortality. The risk of mortality and these other complications should be carefully considered prior to operative intervention. Future research may investigate steroid-tapering protocols that reduce the rate of infection and other postoperative complications in the subset of immunosuppressed ACDF patients.

Clinical Relevance: By elucidating the complication rates of ACDF patients on steroids for cervical stenosis, orthopedic surgeons can better stratify patients for risk of postoperative morbidity. Surgeons may have deeper risk-benefit discussions with these specific patients before they elect to have the operation.
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http://dx.doi.org/10.14444/7095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671449PMC
October 2020

Prevalence of idiopathically elevated ESR and CRP in patients undergoing primary total knee arthroplasty as a function of body mass index.

J Clin Orthop Trauma 2020 Oct 29;11(Suppl 5):S722-S728. Epub 2020 May 29.

Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.

Background: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly used inflammatory markers utilized to aid in the diagnosis of periprosthetic infection (PJI). Patients with obesity, however, are known to have elevated baseline levels of these inflammatory markers. Therefore, this retrospective study aimed to determine the relationship between elevated ESR and CRP and body mass index (BMI) in patients undergoing total knee arthroplasty (TKA). In doing so, physicians can better determine whether BMI should be taken into account when evaluating the prognostic value of elevated preoperative ESR and CRP levels for risk of PJI in primary TKA patients.

Methods: This is a retrospective case series of 181 patients who had undergone primary TKA at a single institution. Patients undergoing primary unilateral TKA were eligible unless they had undergone previous TKA, contralateral knee symptoms, or elevated white blood cell (WBC) count. A linear regression model was utilized to demonstrate the relationship between proportions of patients with elevated biomarker values and categories of BMI. Analysis of variance and independent two-sample t-tests were utilized to assess differences in mean ESR, CRP, and WBC levels between the "healthy patients" and "patients with comorbidities" subgroups within each BMI category.

Results: Eligible patients (n = 181) were stratified by BMI category. Elevated ESR was associated significantly with BMI (ESR: r = 0.89,  < 0.001) unlike elevated CRP (r = 0.82,  = 0.133) and WBC count (r = .01;  = .626). No statistically significant differences in ESR values and WBC count between the "healthy patients" versus "patients with comorbidities" were demonstrated within any BMI category. In patients of normal weight (BMI 20-25 kg/m), "healthy patients" had a statistically significantly higher mean CRP level than "patients with comorbidities" (1.73 mg/L vs. 0.70 mg/L,  < 0.001). There were no other statistically significant differences in mean CRP levels by health status.

Conclusion: Caution is advised when utilizing ESR and CRP to diagnose periprosthetic joint infection without considering BMI given that increasing preoperative levels of ESR and CRP are correlated with higher BMI.
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http://dx.doi.org/10.1016/j.jcot.2020.05.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7503783PMC
October 2020

Risk Factors for Postoperative Urinary Tract Infections Following Anterior Lumbar Interbody Fusion.

Int J Spine Surg 2020 Aug 31;14(4):493-501. Epub 2020 Jul 31.

Department of Orthopaedic Surgery, The George Washington University, Washington, D.C.

Background: Although risk factors contributing to UTI have been studied in posterior approaches to lumbar fusion, there is a lack of literature on factors contributing to UTI in anterior lumbar interbody fusion (ALIF). Our purpose was to identify preoperative independent risk factors for postoperative urinary tract infection (UTI) following anterior lumbar interbody fusion (ALIF) so that surgeons may be able to initiate preventative measures and minimize the risk of UTI-related morbidity following ALIF.

Methods: The American College of Surgeons-National Surgical Quality Improvement Program database was queried to identify 10 232 patients who had undergone ALIF from 2005 to 2016; 144 patients (1.41%) developed a postoperative UTI while 10 088 patients (98.59%) did not. Univariate analyses were conducted to compare the 2 cohorts' demographics and preoperative comorbidities. Multivariate logistic regression models were then utilized to identify significant predictors of postoperative UTI following ALIF while controlling for differences seen in univariate analyses.

Results: Age ≥ 60 years ( = .022), female sex ( < .001), alcohol use ( = .014), open wound or wound infections ( = .019), and steroid use ( = .046) were independent risk factors for postoperative UTI. Longer operative times were also independent predictors for developing UTI: 120 minutes ≤ x < 180 minutes ( = .050), 180 minutes ≤ x < 240 minutes ( = .025), and ≥ 240 minutes ( = .001). Postoperative UTI independently increased the risk for pneumonia, blood transfusions, sepsis, thromboembolic events, and extended length of stay as well.

Conclusions: Age ≥ 60 years, female sex, alcohol use, steroid use, and open wound or wound infections independently increased the risk for UTI following ALIF. Future work analyzing the efficacy of tapering alcohol and steroid use preoperatively and reducing procedural time with the aim of lowering UTI risk is warranted. Preoperative wound care is strongly encouraged to decrease UTI risk.

Level Of Evidence: III.
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http://dx.doi.org/10.14444/7065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478062PMC
August 2020

Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient.

Arthroplast Today 2020 Sep 1;6(3):296-304. Epub 2020 Jun 1.

Department of Orthopaedic Surgery, Georgetown University MedStar Health, Washington, DC, USA.

Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally. Bilateral THA was ultimately performed, and the patient had favorable outcomes at 1 year postoperatively. In determining the optimal management strategy for such patients, a multidisciplinary approach should be used, with input from the patient's family, pediatrician, pediatric endocrinologist, pediatric orthopaedic surgeon, and adult reconstruction surgeon. From a surgical standpoint, this report highlights the importance of selecting the appropriate bearing surfaces, broaching technique, mode of implant fixation, and implant features when performing THA in the active pediatric patient.
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http://dx.doi.org/10.1016/j.artd.2020.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264979PMC
September 2020

Total hip arthroplasty in an adult patient with pelvic dysmorphism, unilateral sacroiliac joint autofusion, and developmental hip dysplasia.

Arthroplast Today 2020 Mar 30;6(1):41-47. Epub 2019 Nov 30.

Department of Orthopaedic Surgery, MedStar Washington Hospital Center, Washington, DC, USA.

This case describes the challenges associated with total hip arthroplasty in a patient with unique anatomy, including developmental dysplasia of the hip, pelvic dysmorphism, and unilateral sacroiliac joint autofusion. A 30-year-old female, with a history of developmental dysplasia of the hip treated with presumed pelvic osteotomy complicated by postoperative infection, presented with hip pain refractory to conservative management. Radiographic studies demonstrated a 10-cm leg length discrepancy, 20° of acetabular retroversion, severe hemipelvic dysmorphism, ipsilateral sacroiliac joint autofusion, and significant femoral head dysplasia. Total hip arthroplasty was performed using a revision acetabular component and modular femoral component, resulting in improvement in the postoperative leg length discrepancy. There were no neurovascular or other perioperative complications, and the patient was ambulating without pain or assistive devices at 1-year follow-up.
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http://dx.doi.org/10.1016/j.artd.2019.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083716PMC
March 2020

Lateral Unicompartmental Knee Arthroplasty.

JBJS Rev 2020 03;8(3):e0044

Washington Orthopaedics and Sports Medicine.

Lateral unicompartmental knee arthroplasty affords excellent functional results and implant survivorship for properly selected patients. More high-quality studies are necessary to determine whether expanded indications for medial unicompartmental knee arthroplasty also apply to lateral unicompartmental knee arthroplasty. Operative adjuncts such as robotics, custom implants, and navigation technology hold promise in minimizing the technical burden and unfamiliarity of lateral unicompartmental knee arthroplasty. Improvements in lateral-specific implants may translate to operational efficiency and improved outcomes, but few lateral-specific implants currently exist. Mobile-bearing devices have increased rates of failure due to bearing dislocation, and further studies are warranted to evaluate this complication with newer designs. Future registry and cohort studies should show medial unicompartmental knee arthroplasty and lateral unicompartmental knee arthroplasty separately to allow for better understanding of the nuances and technical differences between these uniquely different procedures.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00044DOI Listing
March 2020

A systematic review of the effect of regional anesthesia on diagnosis and management of acute compartment syndrome in long bone fractures.

Eur J Trauma Emerg Surg 2020 Dec 18;46(6):1281-1290. Epub 2020 Feb 18.

Department of Orthopaedic Surgery, The George Washington University, 2300 M St NW, 5th floor, Washington, DC, 20037, USA.

Purpose: Peripheral nerve blockade (PNB) is a useful tool for pain control in the perioperative period. However, there are significant concerns about the use of PNBs following acute orthopaedic trauma due to the theoretical risk of masking acute compartment syndrome (ACS). This study aims to systematically review the effects of PNBs on diagnosis of ACS following long bone fractures.

Methods: A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: Six studies, all of which were single-patient case reports, met criteria for inclusion in this review. Two studies reported a delay in diagnosis of ACS in the setting of PNB use, while four studies did not.

Conclusions: Due to the low incidence of ACS, there is a paucity of literature available on ACS following PNB use in the setting of orthopedic trauma. There is no consensus in the literature about the safety of PNB use in the setting of acute long bone fractures, and this review could draw no conclusions from the literature, as the level of evidence is limited to case reports. PNBs should be administered to orthopedic trauma patients only in strictly controlled research environments, and surgeons should be highly cautious about using PNBs for orthopedic long bone fractures, particularly in cases at increased risk for developing ACS.
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http://dx.doi.org/10.1007/s00068-020-01320-5DOI Listing
December 2020

The impact of chronic kidney disease on postoperative complications in patients undergoing revision total knee arthroplasty: A propensity matched analysis.

J Clin Orthop Trauma 2020 Jan-Feb;11(1):147-153. Epub 2019 Jun 4.

Department of Orthopaedic Surgery, The George Washington University, 900 23rd Street NW, Washington, DC, 20037, USA.

Objectives: Though the role of chronic kidney disease (CKD) has been studied previously in primary arthroplasty procedures of the hips and knees, there is a paucity of literature analyzing CKD's impact on surgical outcomes in revision total knee arthroplasty (rTKA) patients. As the number of patients with CKD requiring revision surgery increases, more vigilant pre-operative and post-operative measures can be taken to ensure successful outcomes. This retrospective study sought to 1) determine differences in demographics and preoperative comorbidities of patients with normal or mild CKD and those with moderate/severe CKD and 2) establish moderate/severe CKD as an independent risk factor for complications in the 30-day postoperative period in patients undergoing rTKA.

Methods: The ACS-NSQIP database was queried for patients who had undergone rTKA from 2005 to 2016. Patient were assigned to one of five CKD severity classes after eGFR calculation and were further stratified into two cohorts: stages 1/2 vs. stages 3/4/5. After propensity matching to generate a matched normal/mild CKD cohort of rTKA patients, univariate and multivariate analyses were used to assess differences and the impact of severe CKD on the risk for complications.

Results: There were significant differences in several demographic features, comorbidities, and complications between the two cohorts upon univariate analyses. Upon multivariate analyses, CKD of moderate/severe/failure status was found to be a significant independent risk factor for acute renal failure (OR 18.097, 95% CI 4.970-65.902, p < 0.001), blood transfusions (OR 1.697, 95% CI 1.500-1.919, p < 0.001), return to the operating room (OR 1.257, 95% CI 1.009-1.566, p = 0.041), extended length of stay (OR 1.707, 95% CI 1.292-2.255, p < 0.001), and mortality (OR 2.165, 95% CI 1.116-4.200, p = 0.022) in the 30-day postoperative period.

Conclusion: This current study found moderate/severe CKD to be an independent risk factor for several complications and should guide healthcare professionals for better patient-optimization. Orthopaedic surgeons should factor in CKD severity in the management of patients undergoing rTKA to effectively mitigate the effects of adverse events.
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http://dx.doi.org/10.1016/j.jcot.2019.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6985015PMC
June 2019

Impact of diabetes mellitus on surgical complications in patients undergoing revision total knee arthroplasty: Insulin dependence makes a difference.

J Clin Orthop Trauma 2020 Jan-Feb;11(1):140-146. Epub 2019 Jul 17.

Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA.

Objectives: Assessing the effects of diabetes mellitus (DM), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) on revision TKA (rTKA) has become increasingly imperative due to the increased rates of revisions associated with DM. This study sought to identify complications in rTKA that were independently associated with NIDDM/IDDM compared to non-diabetic (Non-DM) patients and whether IDDM was associated with specific postoperative complications compared to NIDDM.

Methods And Materials: 16,428 rTKA patients were identified from the ACS-NSQIP database from 2005 to 2016 and stratified into three separate cohorts. 12,922 (78.66%) were Non-DM, 2335 (14.21%) had NIDDM, and 1171 (7.13%) had IDDM. Univariate analyses were utilized to assess for differences in demographics, preoperative comorbidities, and postoperative complication rates. Multivariate logistic regression analyses were then employed to control for significant differences in patients characteristics to assess NIDDM and IDDM as independent risk factors for complications in comparison to Non-DM. IDDM was further analyzed as a risk factor in comparison to NIDDM for the purpose of elucidating the impact of insulin dependence on risk for postoperative complications.

Results: NIDDM was an independent risk factor for deep incisional surgical site infections (Odds Ratio (OR): 2.477) and urinary tract infections (UTI) (OR 1.862) (p < 0.05). Compared to NIDDM, IDDM was independently associated with greater risk for pneumonia (OR 2.603), septic shock (OR 6.597), blood transfusions (OR 1.326), and an extended length of stay (OR: 1.331) (p < 0.05). IDDM additionally increased the risk for acute renal failure (OR 3.269) and cardiac arrest (OR 3.268) (p < 0.05) when compared to Non-DM. DM patients overall had increased rates of worse outcomes and infectious complications.

Conclusion: Although differences between diabetes and non-diabetes rTKA patients were seen, differences in complication rates between diabetes patients further divided based on insulin dependence status were also noted. Future work examining whether targeting perioperative glucose levels <200 mg/dL in DM rTKA patients decreases infectious complications is warranted. Future work analyzing the role of tranexamic acid administration and 24-h postoperative antibiotics in rTKA IDDM patients may be warranted given the elevated risk of pneumonia, septic shock, and blood transfusions.
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http://dx.doi.org/10.1016/j.jcot.2019.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6985014PMC
July 2019

Repeat irrigation & debridement for patients with acute septic knee arthritis: Incidence and risk factors.

J Clin Orthop Trauma 2020 Feb 13;11(Suppl 1):S177-S183. Epub 2019 Dec 13.

The George Washington University Hospital Department of Orthopaedic Surgery, 2300 M St NW, Washington, DC, 20037, USA.

Background: Septic knee arthritis is considered an orthopedic emergency due to its significant morbidity and potential to be life-threatening. One important outcome in treatment of septic knee arthritis is whether return to the operating room for repeat irrigation and debridement is required. This complication presents extra burden to the patient, as well as to the health care system. This study aims to first isolate the incidence of repeat irrigation and debridement at the authors' home institution and then define risk factors for repeat washout for septic arthritis of the knee.

Methods: Records from all patients at a single academic institution with acute septic knee arthritis who had arthroscopic or open I&D of the knee joint from January 2005-December 2015 were collected retrospectively. Patients were initially identified on the basis of diagnosis coding in the institution's medical information system. Following collection/screening based on strict inclusion/exclusion criteria, a cohort of 63 patients was ultimately included. 18 patients were assigned to a "repeat washout" (RW) cohort and 45 patients were assigned to a "no repeat washout" (NRW) cohort. Univariate analyses and multivariable regression models were performed between the two washout cohorts to identify variables associated with repeat washout.

Results: Patients requiring a repeat washout (RW) had a statistically significant association with African American/Hispanic race, higher BUN levels, higher serum white blood cell (WBC) count on admission, concurrent infection, and isolated bacteremia when compared to those patients who did not require a repeat washout (NRW) (all respective  < 0.05). Multivariable regression analysis demonstrated concurrent infection and higher synovium WBC count to increase the risk for another repeat washout. Patients who had a concurrent infection were shown to have nearly 12-fold higher odds of needing a repeat washout than those without a concurrent infection (95% CI:2.40-56.88;  = 0.0023). For every 1000 unit increase in synovium WBC count, the odds of needing a repeat washout increased by 1% in patients with concurrent infection (95% CI:1-2%;  = 0.0168).

Conclusion: This study retrospectively isolated risk factors associated with repeat surgical lavage. In the multivariable regression analysis, both concurrent infection and increased synovial WBC count were significantly associated with the need for repeat knee I&D. This finding is significant, as it may signify a potential for increased infectious resilience for acute septic arthritis of the knee secondary to seeding from systemic infection, thus requiring multiple I&Ds to meet resolution. This finding may carry clinical significance in the early stages of patient counseling regarding hospital course and prognosis.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.jcot.2019.12.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978190PMC
February 2020

Rapid Induction of Buprenorphine/Naloxone for Chronic Pain Using a Microdosing Regimen: A Case Report.

A A Pract 2020 Jan;14(2):44-47

From the British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.

Buprenorphine is an effective treatment for chronic pain and may reduce opioid-induced hyperalgesia. However, its pharmacological properties make its induction challenging, time-consuming, and can precipitate opioid withdrawal. We present the case of a 66-year-old woman with inadequately controlled postoperative pain despite escalating doses of oxycodone and methadone, who was successfully transitioned to buprenorphine/naloxone using a rapid microinduction technique without precipitating opioid withdrawal. Rapid induction provides an alternative method for transitioning patients from other opioids to buprenorphine/naloxone and facilitates transition of patients with chronic pain to buprenorphine therapy within a shorter window compared to currently existing protocols.
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http://dx.doi.org/10.1213/XAA.0000000000001138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147949PMC
January 2020

Predictors and Outcomes of Paramedian Incisional Hernia After Anterior Spine Exposure.

J Surg Res 2020 03 18;247:380-386. Epub 2019 Nov 18.

Division of General Surgery and Minimally Invasive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California. Electronic address:

Background: Anterior exposures for lumbar spine surgery are increasingly common for treating various spinal pathologies. A retroperitoneal approach via a paramedian incision has grown rapidly in popularity, but little is known about the risk of incisional hernia development with this technique. We sought to assess the incidence of paramedian incisional hernia development and identify risk factors that are associated with occurrence.

Materials And Methods: We conducted a retrospective review of all patients who underwent anterior lumbar spine exposure by a paramedian approach between 2012 and 2017 at a single, tertiary medical center. The primary outcome was the development of postoperative paramedian incisional hernia.

Results: Of the 735 patients included in the study, 445 (60.5%) were women, and the mean (standard deviation) age of all patients was 60 y (12.4). Nearly all (97.4%) paramedian approaches were performed with a vascular surgeon present. Median follow-up time was 10 mo (interquartile range 3.5-19.9). Postoperative paramedian hernia developed in 20 patients (2.7%), of which 14 underwent repair. The mean (standard deviation) size of the hernia was 13.5 cm (5.5); 9 of 14 (64%) were repaired with synthetic mesh, whereas 3 of 14 (21%) required bowel resection. On multivariate analysis, risk factors associated with hernia development were male gender (0.045), higher American Society of Anesthesiologists class (0.039), history of abdominal surgery (P = 0.013), and postoperative intensive care unit admission (P = 0.02).

Conclusions: A paramedian approach for anterior lumbar spine exposure resulted in a low rate of incisional hernia with minimal morbidity. Surgeons involved in these collaborative procedures should consider the risk factors that predispose patients to develop these hernias.
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http://dx.doi.org/10.1016/j.jss.2019.10.005DOI Listing
March 2020

Characterizing efficiency in the ambulatory surgery setting: An analysis of operating room time and cost savings in orthopaedic surgery.

J Orthop 2019 Nov-Dec;16(6):534-542. Epub 2019 Sep 11.

George Washington University in Washington, DC, USA.

Changing surgical settings for orthopaedic procedures could drive reductions in operative time and reduce healthcare costs. Time-cost differences were calculated using estimated operating room costs by utilizing the ACS-NSQIP database. Multivariate analyses were generated from propensity-matched cohorts to assess differences between inpatient/outpatient outcomes, and whether surgical length increased risk for complications. Outpatient procedures demonstrated time-cost savings of $1716.06. Generally, inpatient procedures demonstrated increased rates of major/minor complications, reoperation, extended LOS, and unplanned readmission (p < 0.001). Overall, longer operative times increased the risk for postoperative complications (p ≤ 0.001). More elective orthopaedic procedures done on an outpatient basis may result in substantial time-cost savings.
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http://dx.doi.org/10.1016/j.jor.2019.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806637PMC
September 2019

Bulk Anatomical Density Based Dose Calculation for Patient-Specific Quality Assurance of MRI-Only Prostate Radiotherapy.

Front Oncol 2019 2;9:997. Epub 2019 Oct 2.

School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, NSW, Australia.

Prostate cancer treatment planning can be performed using magnetic resonance imaging (MRI) only with sCT scans. However, sCT scans are computer generated from MRI data and therefore robust, efficient, and accurate patient-specific quality assurance methods for dosimetric verification are required. Bulk anatomical density (BAD) maps can be generated based on anatomical contours derived from the MRI image. This study investigates and optimizes the BAD map approach for sCT quality assurance with a large patient CT and MRI dataset. 3D T2-weighted MRI and full density CT images of 54 patients were used to create BAD maps with different tissue class combinations. Mean Hounsfield units (HU) of Fat (F: below -30 HU), the entire Tissue [T: excluding bone (B)], and Muscle (M: excluding bone and fat) were derived from the CT scans. CT based BAD maps (BAD and BAD) and a conventional bone and water bulk-density method (BAD) were compared to full CT calculations with bone assignments to 366 HU (measured) and 288 HU (obtained from literature). Optimal bulk densities of Tissue for BAD and Bone for BAD were derived to provide zero mean isocenter dose agreement to the CT plan. Using the optimal densities, the dose agreement of BAD and BAD to CT was redetermined. These maps were then created for the MRI dataset using auto-generated contours and dose calculations compared to CT. The average mean density of Bone, Fat, Muscle, and Tissue were 365.5 ± 62.2, -109.5 ± 12.9, 23.3 ± 9.7, and -46.3 ± 15.2 HU, respectively. Comparing to other bulk-density maps, BAD maps provided the closest dose to CT. Calculated optimal mean densities of Tissue and Bone were -32.7 and 323.7 HU, respectively. The isocenter dose agreement of the optimal density assigned BAD and BAD to full density CT were 0.10 ± 0.65% and 0.01 ± 0.45%, respectively. The isocenter dose agreement of MRI generated BAD and BAD to full density CT were -0.15 ± 0.90% and -0.16 ± 0.65%, respectively. The BAD method with optimal bulk densities can provide robust, accurate and efficient patient-specific quality assurance for dose calculations in MRI-only radiotherapy.
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http://dx.doi.org/10.3389/fonc.2019.00997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783518PMC
October 2019

Hemiarthroplasty versus total hip arthroplasty for femoral neck fractures in patients with chronic obstructive pulmonary disease.

Eur J Trauma Emerg Surg 2021 Apr 25;47(2):547-555. Epub 2019 Sep 25.

Department of Orthopaedic Surgery, The George Washington University, 2300 M St NW, Washington, DC, 20037, USA.

Purpose: This study sought to delineate whether total hip arthroplasty (THA) or hip hemiarthroplasty (HHA) had more complication rates following the treatment of femoral neck fractures (FNF) in chronic obstructive pulmonary disease (COPD) patients.

Materials And Methods: The ACS-NSQIP database was queried for all patients with a history of COPD who had undergone THA and HHA with FNFs, isolated by CPT codes and ICD-9/ICD-10 codes. Propensity score matching without replacement in a 1:1 manner was done to control for patient demographics/preoperative comorbidities. Multivariate logistic regression models were utilized to assess the independent effect of HHA in comparison to THA.

Results: The propensity-matched (PM) HHA cohort was significantly older (76.14 years vs. 73.33 years, p = 0.001) and had significantly higher rates of pneumonia (p = 0.017), extended length of stay (LOS) (p = 0.017), and mortality (p = 0.002), but lower rates of blood transfusions (p = 0.016) and reoperation (p = 0.020). HHA was independently associated with an increased risk of pneumonia (p = 0.043), extended LOS (p = 0.050), and death (p = 0.044) but a decreased risk for blood transfusions (p = 0.008) and reoperation (p = 0.028) when compared to THA.

Discussion: Patients with more comorbidities are more likely to receive HHA than THA, which may explain some of the increased complications and mortality associated with HHA for FNFs compared to THA. Patients undergoing THA were at increased risk for blood transfusion and reoperation. THA does not appear to result in increased morbidity in this population compared to HHA. While THA should be considered in these patients given improved functional outcomes, further prospective studies are needed to establish superiority.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00068-019-01234-xDOI Listing
April 2021
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