Publications by authors named "Joshua Heller"

50 Publications

Independent Predictors of Revision Lumbar Fusion Outcomes and the Impact of Spine Surgeon Variability: Does It Matter Whether the Primary Surgeon Revises?

Neurosurgery 2021 Aug 14. Epub 2021 Aug 14.

Jefferson Hospital for Neuroscience, Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Background: There is a paucity of information regarding treatment strategies and variables affecting outcomes of revision lumbar fusions.

Objective: To evaluate the influence of primary vs different surgeon on functional outcomes of revisions.

Methods: All elective lumbar fusion revisions, March 2018 to August 2019, were retrospectively categorized as performed by the same or different surgeon who performed the primary surgery. Oswestry Disability Index (ODI) and clinical variables were collected. Multiple logistic regression identified multivariable-adjusted odds ratio (OR) of independent variables analyzed.

Results: Of the 130 cases, 117 (90%) had complete data. There was a slight difference in age in the same (median: 59; interquartile range [IQR], 54-66) and different surgeon (median: 67; IQR, 56-72) groups (P = .02); all other demographic variables were not significantly different (P > .05). Revision surgery with a different surgeon had an ODI improvement (median: 8; IQR, 2-14) greater than revisions performed by the same surgeon (median: 1.5; IQR, -3 to 10) (P < .01). Revisions who achieved minimum clinically important difference (MCID) performed by different surgeon (59.7%) were also significantly greater than the ones performed by the same surgeon (40%) (P = .042). Multivariate analysis demonstrated that a different surgeon revising (OR, 2.37; [CI]: 1.007-5.575, P = .04) was an independent predictor of MCID achievement, each additional 2 years beyond the last surgery conferred a 2.38 ([CI]: 1.36-4.14, P < .01) times greater odds of MCID achievement, and the anterior lumbar interbody fusion approach decreased the chance of achieving MCID (OR, 0.19; [CI]: 0.04-0.861, P = .03).

Conclusion: All revision lumbar spinal fusion approaches may not achieve the same outcomes. This analysis suggests that revision surgeries may have better outcomes when performed by a different surgeon.
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http://dx.doi.org/10.1093/neuros/nyab300DOI Listing
August 2021

Clinical outcomes in revision lumbar spine fusions: an observational cohort study.

J Neurosurg Spine 2021 Aug 6:1-9. Epub 2021 Aug 6.

Objective: The authors compared primary lumbar spine fusions with revision fusions by using patient Oswestry Disability Index (ODI) scores to evaluate the impact of the North American Spine Society (NASS) evidence-based medicine (EBM) lumbar fusion indications on patient-reported outcome measures of revision surgeries.

Methods: This study was a retrospective analysis of a prospective observational cohort of patients who underwent elective lumbar fusion between January 2018 and December 2019 at a single quaternary spine surgery service and had a minimum of 6 months of follow-up. A prospective quality improvement database was constructed that included the data from all elective lumbar spine surgeries, which were categorized prospectively as primary or revision surgeries and EBM-concordant or EBM-discordant revision surgeries based on the NASS coverage EBM policy. In total, 309 patients who met the inclusion criteria were included in the study. The ODIs of all groups (primary, revision, revision EBM concordant, and revision EBM discordant) were statistically compared. Differences in frequencies between cohorts were evaluated using chi-square and Fisher's exact tests. The unpaired 2-tailed Student t-test and the Mann-Whitney U-test for nonparametric data were used to compare continuous variables. Logistic regression was performed to determine the associations between independent variables (surgery status and NASS criteria indications) and functional outcomes.

Results: Primary lumbar fusions were significantly associated with improved functional outcomes compared with revisions, as evidenced by ODI scores (OR 1.85, 95% CI 1.16-2.95 to achieve a minimal clinically important difference, p = 0.01). The percentage of patients whose functional status had declined at the 6-month postoperative evaluation was significantly higher in patients who had undergone a revision surgery than in those who underwent a primary surgery (23% vs 12.3%, respectively). An increase in ODI score, indicating worse clinical outcome after surgery, was greater in patients who underwent revision procedures (OR 2.14, 95% CI 1.17-3.91, p = 0.0014). Patients who underwent EBM-concordant revision surgery had significantly improved mean ODI scores compared with those who underwent EBM-discordant revision surgery (7.02 ± 5.57 vs -4.6 ± 6.54, p < 0.01).

Conclusions: The results of this prospective quality improvement program investigation illustrate that outcomes of primary lumbar fusions were superior to outcomes of revisions. However, revision procedures that met EBM guidelines were associated with greater improvements in ODI scores, which indicates that the use of defined EBM guideline criteria for reoperation can improve clinical outcomes of revision lumbar fusions.
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http://dx.doi.org/10.3171/2020.12.SPINE201908DOI Listing
August 2021

The Impact of Incorporating Evidence-Based Guidelines for Lumbar Fusion Surgery in Neurosurgical Resident Education.

World Neurosurg 2021 Jul 20. Epub 2021 Jul 20.

Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.

Background: Instrumented fusion procedures are essential in the treatment of degenerative lumbar spine disease to alleviate pain and improve neurological function, but they are being performed with increasing incidence and variability. We implemented a training module for neurosurgery residents that is based on evidence-based criteria for lumbar fusion surgery and measured its effectiveness in residents' decision making regarding whether patients should or should not undergo instrumented fusion.

Methods: The study design was a pretest versus posttest experiment conducted from September 2019 until July 2020 to measure improvement after formalized instruction on evidence-based guidelines. Neurosurgery residents of all training levels at our institution participated. A test was administered at the beginning of each academic year. The highest possible score was 18 points in each pretest and posttest.

Results: There was a general trend of test score improvement across all levels of training with a greater degree of change for participants with lower compared with higher pretest scores, indicating a possible ceiling effect. Paired t test demonstrated an overall mean score increase of 2 points (P < 0.0001), equivalent to an 11.11% increase (P < 0.0001). Stratified by training group, mean absolute change in test score was 2 (P = 0.0217), 1.67 (P = 0.0108), and 2.25 (P = 0.0173) points for junior, midlevel, and senior training groups, respectively.

Conclusions: Incorporating a targeted evidence-based learning module for lumbar spine fusion surgery can improve neurosurgery residents' clinical decision making toward a more uniform practice supported by published data.
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http://dx.doi.org/10.1016/j.wneu.2021.07.045DOI Listing
July 2021

Operative versus Nonoperative Management of Idiopathic Spinal Cord Herniation: Effect on Symptomatology and Disease Progression.

World Neurosurg 2021 Aug 24;152:e149-e154. Epub 2021 May 24.

Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA. Electronic address:

Background: Idiopathic spinal cord herniation (ISCH) is a rare pathology characterized by extravasation of the spinal cord through a dural defect. The optimal algorithm for choosing operative or nonoperative management is not well elucidated, partially because of the rarity of this pathology. We present the largest single-center series of ISCH and compare operative treatment to conservative management.

Methods: A retrospective case series of all patients evaluated for treatment of ISCH at our institution between 2010 and 2019 was conducted. Demographic variables, presenting symptoms, and imaging characteristics were assessed for all patients. For patients who underwent operative treatment, surgical approach, postoperative course, and discharge outcomes were recorded. Follow-up notes were reviewed for status of symptoms and functional capabilities, which were synthesized into Odom's criteria score.

Results: Sixteen patients met the inclusion criteria for this study, 8 of whom underwent operative treatment. No significant differences were found between operative and nonoperative groups with regard to demographic variables or pathology characteristics. Odom's criteria scores for the operative cohort were 12.5% (1 of 8) Excellent, 62.5% (5 of 8) Good, 12.5% (1 of 8) Fair, and 12.5% (1 of 8) Poor. Odom's criteria scores for the nonoperative cohort were 16.7% (1 of 6) Excellent, 33.3% (2 of 6) Good, 16.7% (1 of 6) Fair, and 33.3% (2 of 6) Poor. There was no significant difference between Odom's criteria score distribution between the operative and nonoperative groups at latest follow up (P = 0.715).

Conclusions: Conservative management of spinal cord herniation is an option that does not preclude symptomatic improvement in patients with idiopathic spinal cord herniation.
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http://dx.doi.org/10.1016/j.wneu.2021.05.046DOI Listing
August 2021

Biomechanics of Circumferential Cervical Fixation Using Posterior Facet Cages: A Cadaveric Study.

Neurospine 2021 Mar 31;18(1):188-196. Epub 2021 Mar 31.

Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.

Objective: Anterior cervical discectomy and fusion (ACDF) is a common procedure for the treatment of cervical disease. Circumferential procedures are options for multilevel pathology. Potential complications of multilevel anterior procedures are dysphagia and pseudarthrosis, whereas potential complications of posterior surgery include development of cervical kyphosis and postoperative chronic neck pain. The addition of posterior cervical cages (PCCs) to multilevel ACDF is a minimally invasive option to perform circumferential fusion. This study evaluated the biomechanical performance of 3-level circumferential fusion with PCCs as supplemental fixation to anteriorly placed allografts, with and without anterior plate fixation.

Methods: Nondestructive flexibility tests (1.5 Nm) performed on 6 cervical C2-7 cadaveric specimens intact and after discectomy (C3-6) in 3 instrumented conditions: allograft with anterior plate (G+P), PCC with allograft and plate (PCC+G+P), and PCC with allograft alone (PCC+G). Range of motion (ROM) data were analyzed using 1-way repeated-measures analysis of variance.

Results: All instrumented conditions resulted in significantly reduced ROM at the 3 instrumented levels (C3-6) compared to intact spinal segments in flexion, extension, lateral bending, and axial rotation (p < 0.001). No significant difference in ROM was found between G+P and PCC+G+P conditions or between G+P and PCC+G conditions, indicating similar stability between these conditions in all directions of motion.

Conclusion: All instrumented conditions resulted in considerable reduction in ROM. The added reduction in ROM through the addition of PCCs did not reach statistical significance. Circumferential fusion with anterior allograft, without plate and with PCCs, has comparable stability to ACDF with allograft and plate.
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http://dx.doi.org/10.14245/ns.2040552.276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021845PMC
March 2021

The Impact of Intraoperative Image-Guidance Modalities and Neurophysiologic Monitoring in the Safety of Sacroiliac Fusions.

Global Spine J 2021 Jan 12:2192568220981977. Epub 2021 Jan 12.

Department of Neurosurgery, 6559Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.

Study Design: Retrospective observational cohort.

Objective: A review of efficiency and safety of fluoroscopy and stereotactic navigation system for minimally invasive (MIS) Sacroiliac (SI) fusion through a lateral technique.

Methods: Retrospective analysis of an observational cohort of 96 patients greater than 18 years old, that underwent MIS SI fusion guided by fluoroscopy or navigation between January 2013 and April 2020 with a minimum of 3 months follow-up. Intraoperative neuromonitoring (IONM) with a variable combination of electromyography (EMG), somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) was also utilized.

Results: The overall complication rate in the study was 9.4%, and there was no difference between the fluoroscopy (10.1%), and navigation groups (8%). Neurological complication rate was 2.1%, without a significant difference between both intraoperative guidance modality groups (p = 0.227). There was a significant difference between the modalities of IONM used and the occurrence of neurological injury (p = 0.01).The 2 patients who had a neurological complication postoperatively were monitored only with EMG and SSEP, but none of the patients (n = 76) in which MEPs were utilized had neurologic complication. The mean pain improvement 3 months after surgery was greater in the navigation group (2.44 ± 2.72), but was not statistically different than the improvement in the fluoroscopy group (1.90 ± 2.07) (p = 0.301).

Conclusions: No difference in the safety of the procedure was found between the fluoroscopy and the stereotactic navigation techniques. The contribution of the IONM to the safety of SI fusions could not be determined, but the data indicates that MEPs provide the highest level of sensitivity.
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http://dx.doi.org/10.1177/2192568220981977DOI Listing
January 2021

Combined Anterior Osteophytectomy and Cricopharyngeal Myotomy for Treatment of DISH-Associated Dysphagia.

Global Spine J 2020 Nov 18:2192568220967358. Epub 2020 Nov 18.

Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Retrospective observational case series.

Objective: To assess the outcome of patients with diffuse idiopathic skeletal hyperostosis (DISH) with dysphagia who underwent cricopharyngeal myotomy (CPM) in conjunction with anterior osteophytectomy (OP).

Methods: This is a retrospective observational study of 9 patients that received combined intervention by neurosurgeons and otolaryngologists. Inclusion criteria for surgery consisted of patients who failed to respond to conservative treatments for dysphagia and had evidence of both upper esophageal dysfunction and osteophyte compression. We present the largest series in literature to date including patients undergoing combined OP and CPM.

Results: A total of 88.9% (8/9) of the patients who underwent OP and CPM showed improvement in their symptoms. Of the aforementioned group, 22.2% of these patients had complete resolution of their symptoms, 11.1% did not improve, and only 2 patients showed recurrence of their symptoms. None of the patients in whom surgery was performed required reoperation or suffered serious complication related to the surgical procedures.

Conclusion: Based on the literature results, high rate of improvements in dysphagia, and low rate of complications, combined OP and CPM procedures may be beneficial to a carefully selected group of patients.
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http://dx.doi.org/10.1177/2192568220967358DOI Listing
November 2020

Cranial Settling Causing Intracranial Hemorrhage Through Violation of the Skull Base by Cervical Spine Instrumentation.

World Neurosurg 2021 01 2;145:178-182. Epub 2020 Sep 2.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Background: Rheumatoid arthritis (RA) is a chronic inflammatory polyarthropathy that affects many synovial joints favoring the hands, knees, and vertebral articulations. Joint laxity manifests as subaxial instability, atlantoaxial instability, and cranial settling (CS).

Case Description: A 70-year-old woman with past medical history of RA, Hashimoto's thyroiditis, osteoporosis, history of C1-2 fusion for instability 15 years prior, with subsequent revision cervicothoracic fusion for degeneration, and trauma 2 years prior presents with new onset headache, nausea, and vomiting of 36-hour duration. Neurologic examination was only notable for mild right dysmetria. Workup revealed acute hemorrhage in the posterior fossa with migration of the right rod implant and screw tulip, as a result of CS. The patient underwent occipital-cervical fusion with removal of the migratory hardware.

Conclusions: Intracranial rod migration and hemorrhage secondary to CS is a rare complication that must be brought to the attention of surgeons operating on patients with RA.
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http://dx.doi.org/10.1016/j.wneu.2020.08.193DOI Listing
January 2021

Robot-Assisted Instrumented Fusion of a T8-9 Extension Distraction Fracture and Epidural Hematoma Evacuation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 Sep;19(4):E420-E421

Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania.

The utilization of robotics has been gaining increased popularity in spine surgery. It can be used to assist in pedicle screw insertion when anatomy is complex in deformity surgery, but is also helpful in degenerative spine as it can minimize tissue dissection and fluoroscopy use.1-6 We present an operative video that demonstrates the use of a robotic system (Globus Excelsius GPS, Audubon, Pennsylvania) for thoracic instrumentation in an unstable fracture. The patient we present is a 64-yr-old male who sustained a T8-9 distraction extension fracture after falling down a flight of stairs. His computed tomography (CT) scan showed ossification of the anterior longitudinal ligament making ankylosing spondylitis the likely underlying condition.7,8 His magnetic resonance imaging showed an epidural hematoma extending from T7 to T11. Due to the unstable nature of this fracture and the presence of the hematoma, informed consent was obtained and the patient underwent thoracic pedicle screw fixation from T7 to T11 and laminectomy for hematoma evacuation. A preoperative CT was done for screw trajectory planning. Paraspinal muscle dissection was limited to the hematoma level to allow for laminectomy and evacuation. After registration of the patient to the robotic system using C-arm fluoroscopy, pilot burr holes are drilled using a rigid robotic arm and with optical tracking in real time. This reduces the degrees of freedom and allows for higher precision of screw placement. To the authors' knowledge, this video is the first one to show the utilization of robotics for thoracic instrumentation in an acute fracture.
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http://dx.doi.org/10.1093/ons/opaa061DOI Listing
September 2020

The Role of Cricopharyngeal Myotomy After Anterior Cervical Decompression and Fusion Operations.

World Neurosurg 2020 05 7;137:146-148. Epub 2020 Feb 7.

Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Background: Anterior cervical spine surgeries have low morbidity, sufficient surgical corridor, and quick recovery times. Although largely considered a safe and effective procedure to address cervical myelopathy, radiculopathy, and deformity, dysphagia is a frequent yet poorly understood adverse event. One treatment is cricopharyngeal myotomy (CPM), which aids in swallowing for patients with refractory issues after anterior cervical decompression and fusion (ACDF).

Case Description: Here we describe our experience with 6 patients requiring revision ACDF with preoperative dysphagia who were treated with concurrent revision and CPM. Our series demonstrated that CPM is an effective and safe procedure used in combination with an ACDF. In our series, we had 6 patients with dysphagia preoperatively who were all able to undergo ACDF without worsening of their dysphagia despite having risk factors predisposing them to this complication. In our series, 83% of patients either improved or experienced resolution of their symptoms with only 1 patient failing to improve.

Conclusions: Given its efficacy and safety, patients planned for ACDF with preoperative dysphagia should be evaluated by ENT for potential CPM.
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http://dx.doi.org/10.1016/j.wneu.2020.01.180DOI Listing
May 2020

HSV-Encephalitis Reactivation after Cervical Spine Surgery.

Case Rep Surg 2019 10;2019:2065716. Epub 2019 Apr 10.

Jefferson College of Biomedical Sciences, USA.

Background: Herpes simplex virus encephalitis (HSVE) is a viral neurological disorder that occurs when the herpes simplex virus (HSV) enters the brain. The disorder is characterized by the inflammation of the brain and a significant decline in mental status. HSVE reactivation after neurosurgery, although rare, can cause severe neurological deterioration. The high morbidity rate among untreated patients necessitates prompt diagnosis and management.

Case Description: We report a case of a 78-year-old woman with no known prior history of HSVE and declining mental status eleven days after a posterior C3-T1 decompression and instrumented fusion following resection of an intradural extramedullary tumor, confirmed to be meningioma on final pathology. Reactivation of HSV-1 encephalitis was suspected to be the underlying cause of her symptoms, though MRI scans of the brain for HSVE were negative. The patient reacted positively to a 21-day treatment of acyclovir and was discharged with a neurological status comparable to her preoperative baseline. This case contributes to the literature in that it is the first reported instance of HSVE reactivation after intradural cervical spinal surgery with negative MRI findings.

Conclusion: We recommend utilizing multiple tests, including PCR, EEG, and MRI, for postoperative neurosurgery patients that have decreased mental status in order to quickly and correctly diagnose/treat patients who are HSVE positive. Clinicians should consider the possibility of receiving false-negative results from PCR, CSF, EEG, or MRI tests before terminating treatment for HSVE reactivation.
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http://dx.doi.org/10.1155/2019/2065716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481118PMC
April 2019

Comparison of Surgical Outcomes of the Posterior and Combined Approaches for Repair of Cervical Fractures in Ankylosing Spondylitis.

Asian Spine J 2019 Jun 13;13(3):432-440. Epub 2019 Feb 13.

Department of Orthopedic Surgery, Thomas Jefferson University & Rothman Institute, Philadelphia, PA, USA.

Study Design: Retrospective cohort study.

Purpose: To evaluate surgical outcomes and complications of cervical spine fractures in ankylosing spondylitis (CAS) patients who were treated using either the posterior (P) or combined approach (C).

Overview Of Literature: Ankylosing spondylitis typically causes progressive spinal stiffness that makes patients susceptible to spinal fractures. CAS is a highly unstable condition. There is contradictory evidence regarding which treatment option, the posterior or the combined approach, yields superior clinical results.

Methods: A single institution database was reviewed for data in the period 1999 to 2015. All CAS patients who underwent posterior or combined instrumented fusion were enrolled. We analyzed demographic data, radiographic results, perioperative complications, and postoperative results.

Results: Thirty-three patients were enrolled (23 in the P group, 10 in the C group). All patients presented with neck pain after a fall. In the P group, mean operative time was 161.1 minutes (100-327 minutes), and mean estimated blood loss (EBL) was 306.4 mL (50-750 mL). In the C group, 90% of patients underwent a staged procedure, typically with posterior surgery first. Mean EBL was 124 mL (25-337 mL). For posterior surgery, mean EBL was 458.3 mL (400-550 mL). EBL of posterior surgery in the C group was higher but this difference was not significant (p=0.16). Postoperative complication rate was higher in the C group but this difference was not significant (50% vs. 17.4%, p=0.09). In the follow-up period, no late reoperations were performed. Patients who underwent C surgery had a higher rate of neurological improvement but this difference was not significant (p=0.57).

Conclusions: Both P and C provided good clinical results. P surgery had lower EBL, lower postoperative complication rate, and shorter length of stay than C surgery; none of these differences were statistically significant.
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http://dx.doi.org/10.31616/asj.2018.0197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547398PMC
June 2019

Etiology and Surgical Management of Cervical Spinal Epidural Abscess (SEA):: A Systematic Review.

Global Spine J 2018 Dec 13;8(4 Suppl):59S-67S. Epub 2018 Dec 13.

Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Systematic analysis and review.

Objective: Evaluation of the presentation, etiology, management strategies (including both surgical and nonsurgical options), and neurological functional outcomes in patients with cervical spinal epidural abscess (SEA).

Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria were used to create a framework based on which articles pertaining to cervical SEA were chosen for review following a search of the Ovid and PubMed databases using the search terms "epidural abscess" and "cervical." Included studies needed to have at least 4 patients aged 18 years or older, and to have been published within the past 20 years.

Results: Database searches yielded 521 potential articles in PubMed and 974 potential articles in Ovid. After review, 11 studies were ultimately identified for inclusion in this systematic review. Surgery appears to be a well-tolerated management strategy with limited complications for patients with cervical SEA. However, the quantity of data comparing medical and surgical treatment of cervical SEA is limited and the bulk of the data is derived from low quality studies.

Conclusion: Data reporting was heterogeneous among studies making it difficult to draw discrete conclusions. Early surgical intervention may be appropriate in selected patients with cervical epidural abscess, but it is not clear what distinguishes these patients from those who are successfully managed nonoperatively.
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http://dx.doi.org/10.1177/2192568218772048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6295824PMC
December 2018

Tissue oximetry during cardiac surgery and in the cardiac intensive care unit: A prospective observational trial.

Ann Card Anaesth 2018 Oct-Dec;21(4):371-375

Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, NY, USA.

Background: Cerebral oximetry using near-infrared spectroscopy (NIRS) has well-documented benefits during cardiac surgery. The authors tested the hypothesis that NIRS technology can be used at other sites as a tissue oximeter during cardiac surgery and in the Intensive Care Unit (ICU).

Aims: To establish feasibility of monitoring tissue oximetry during and after cardiac surgery, to examine the correlations between tissue oximetry values and cerebral oximetry values, and to examine correlations between oximetry values and mean arterial pressure (MAP) in order to test whether cerebral oximetry can be used as an index organ.

Settings And Designs: A large, single-center tertiary care university hospital prospective observational trial of 31 patients undergoing cardiac surgery with cardiopulmonary bypass was conducted.

Materials And Methods: Oximetry stickers were applied to both sides of the forehead, the nonarterial line forearm, and the skin above one paraspinal muscle. Data were collected from before anesthesia induction until extubation or for at least 24 h in patients who remained intubated.

Statistical Analysis: Categorical variables were evaluated with Chi-square or Fisher's exact tests, while Wilcoxon rank-sum tests or student's t-tests were used for continuous variables.

Results: The correlation between cerebral oximetry values and back oximetry values ranged from r = 0.37 to 0.40. The correlation between cerebral oximetry values and forearm oximetry values ranged from r = 0.11 to 0.13. None of the sites correlated with MAP.

Conclusions: Tissue oximetry at the paraspinal muscle correlates with cerebral oximetry values while at the arm does not. Further research is needed to evaluate the role of tissue oximetry on outcomes such as acute renal failure, prolonged need for mechanical ventilation, stroke, vascular ischemic complications, prolonged ICU and hospital length of stay, and mortality in cardiac surgery.
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http://dx.doi.org/10.4103/aca.ACA_105_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206809PMC
April 2019

Extradural Arachnoid Cyst Excision.

Clin Spine Surg 2019 12;32(10):E403-E406

Department of Orthopaedic Surgery, Thomas Jefferson University and The Rothman Institute.

Arachnoid cysts are an uncommon postoperative complication and can result in back pain, radiculopathy, and/or cauda equina syndrome. For symptomatic postoperative arachnoid cysts, surgical management is the accepted treatment. While excision of arachnoid cysts is the preferred surgical method, cysts with adhesions to nerve roots and/or dura can be treated with cyst fenestration to reduce morbidity of excision. Surgeons should be prepared for dural defects after cyst excision, which can require dural grafting and lumbar drains for cerebrospinal fluid diversion.
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http://dx.doi.org/10.1097/BSD.0000000000000639DOI Listing
December 2019

In Reply to "Letter to the Editor: Surgical Start Times and Outcomes: It's Not Just the Hour, but the Day as Well".

J Cardiothorac Vasc Anesth 2018 04 15;32(2):e38-e39. Epub 2017 Jun 15.

Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY.

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http://dx.doi.org/10.1053/j.jvca.2017.06.024DOI Listing
April 2018

Robotic-assisted thoracoscopic lung surgery: anesthetic impact and perioperative experience.

Minerva Anestesiol 2018 01 11;84(1):108-114. Epub 2017 Sep 11.

Department of Anesthesiology, the University of North Carolina, Chapel Hill, NC, USA.

Anesthesiologists and the perioperative team have a tremendous impact upon clinical outcomes in robotic-assisted thoracoscopic surgery. As anesthesiology is developing its role outside the operating room, the patient population benefits from an expanded focus on perioperative critical care and pain management. This article focuses upon the preoperative optimization, unique intraoperative considerations for surgeons and anesthesiologists, and postoperative management of patients undergoing robotic-assisted thoracoscopic surgery.
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http://dx.doi.org/10.23736/S0375-9393.17.12168-1DOI Listing
January 2018

Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model.

Clin Spine Surg 2017 Jul;30(6):272-275

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Study Design: Open-label laboratory investigational study; non-animal surgical simulation.

Objective: The authors perform a comparison of dural closure strength in a durotomy simulator across 2 different suture materials.

Summary Of Background Data: Incidental durotomy leading to persistent cerebrospinal fluid leak adds considerable morbidity to spinal procedures, often complicating routine elective lumbar spinal procedures. Using an experimental durotomy simulation, the authors compare the strength of closure using Gore-Tex with other suture types and sizes, using various closure techniques.

Methods: A comparison of dural closures was performed through an analysis of the peak pressure at which leakage occurred from a standardized durotomy closure in an established cerebrospinal fluid repair model with a premade L3 laminectomy. Nurolon was compared with Gore-Tex sutures sizes (for Gore-Tex, CV-6/5-0 and CV-5/4-0 was compared with Nurolon 4-0, 5-0, and 6-0).

Results: Thirty-six trials were performed with Nurolon 4-0, 5-0, and 6-0, whereas 21 trials were performed for 4-0 and 5-0 Gore-Tex. The mean peak pressure at which fluid leakage was observed was 21 cm H2O for Nurolon and 34 cm H2O for Gore-Tex. Irrespective of suture choice, all trials were grouped by closure technique: running suture, locked continuous, and interrupted suture. No significant difference was noted between the groups. For each of the 3 trials groups by closure technique, running, locked continuous, and interrupted, Gore-Tex closures had a significantly higher peak pressure to failure. Interrupted Gore-Tex was significantly higher than Interrupted Nurolon (P=0.007), running Gore-Tex was significantly higher than running Nurolon (P=0.034), and locked Gore-Tex was significantly higher than locked Nurolon (P=0.014).

Conclusions: Durotomy closure in the lumbar spine with Gore-Tex suture may be a reasonable option for providing a watertight closure. In this laboratory study, Gore-Tex suture provided watertight dural closures that withstood higher peak pressures.
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http://dx.doi.org/10.1097/BSD.0000000000000169DOI Listing
July 2017

Cervical Spondylodiscitis: Presentation, Timing, and Surgical Management in 59 Patients.

World Neurosurg 2017 Jul 27;103:664-670. Epub 2017 Apr 27.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Background: Cervical spondylodiscitis is thought to carry a significant risk for rapid neurologic deterioration with a poor response to nonsurgical management.

Methods: A retrospective surgical case series of the acute surgical management of cervical spondylodiscitis is reviewed to characterize the neurologic presentation and postoperative neurologic course in a relatively uncommon disease.

Results: Fifty-nine patients were identified (mean age, 59 years [range, 18-83 years; SD ± 13.2 years]) from a single-institution neurosurgical database. The most common levels of radiographic cervical involvement were C4-C5, C5-C6, and C6-C7, in descending order. Overall, statistically significant clinical improvement was noted after surgery (P < 0.05). Spinal cord hyperintensity on T2-weighted magnetic resonance imaging was significantly associated with a worse preoperative neurologic grade (P = 0.036), but did not correlate with a relatively worse neurologic outcome by discharge. No significant difference was noted between potential preoperative predictors (organism cultured, presence of epidural abscess, tobacco use, early surgery within 24 hours of clinical presentation) and preoperative American Spinal Injury Association injury scale, with the exception of the duration between symptom onset and surgical intervention. A negative correlation between increased preoperative duration of symptoms and magnitude in motor improvement was observed. Relative to anteroposterior decompression and fusion, anterior treatment alone demonstrated a relatively greater effect in neurologic improvement.

Conclusions: Cervical spondylodiscitis is a rare disease that typically manifests with preoperative motor deficits. Surgery was associated with a significant improvement in motor score by hospital discharge. Significant predictors of neurologic improvement were not observed. Prolonged symptomatic duration was correlated with a significantly lower likelihood of motor score improvement.
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http://dx.doi.org/10.1016/j.wneu.2017.04.119DOI Listing
July 2017

Is An Isolated Intervertebral Disk With Significant Degeneration Magnetic Resonance Imaging A Cause of Low Back Pain That Requires No Confirmatory Diagnostic Tests?

Clin Spine Surg 2017 05;30(4):139-141

*Thomas Jefferson University Hospital, Philadelphia, PA †Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, NJ ‡Department of Orthopaedic Surgery, Thomas Jefferson University & Rothman Institute, Philadelphia, PA.

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http://dx.doi.org/10.1097/BSD.0000000000000538DOI Listing
May 2017

Death During Simulation: A Literature Review.

J Contin Educ Health Prof 2016 ;36(4):316-322

Dr. B. J. Heller: House Staff, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY. Dr. DeMaria: Associate Professor, Director of the Division of Liver Transplantation, Department of Anesthesiology, and Co-director of the Mount Sinai Simulation HELPS Center, Icahn School of Medicine at Mount Sinai, New York, NY. Dr. Katz: Assistant Professor, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY. Dr. J. A. Heller: House Staff, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY. Dr. Goldberg: Assistant Professor, Department of Anesthesiology, and Faculty at the Mount Sinai Simulation HELPS Center, Icahn School of Medicine at Mount Sinai, New York, NY.

Introduction: One of the goals of simulation is to teach subjects critical skills and knowledge applicable to live encounters, without the risk of harming actual patients. Although simulation education has surged in medical training over the last two decades, several ethically challenging educational methods have arisen. Simulated death has arisen as one of these challenging issues and currently there is no consensus regarding how to best manage this controversial topic in the simulated environment. The goal of this review is to analyze how simulated mortality has been used and discover whether or not this tool is beneficial to learners.

Methods: In May 2016, the authors performed a literature search on both Pubmed and the Cochrane database using multiple variations of keywords; they then searched bibliographies and related articles.

Results: There were 901 articles acquired in the initial search. The authors eliminated articles that were not relevant to the subject matter. After adding articles from bibliographies and related articles, the authors included the 43 articles cited in this article.

Discussion: As a result, the authors of this article believe that death, when used appropriately in simulation, can be an effective teaching tool and can be used in a responsible manner.
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http://dx.doi.org/10.1097/CEH.0000000000000116DOI Listing
February 2018

Interspinous implants: are the new implants better than the last generation? A review.

Curr Rev Musculoskelet Med 2017 Jun;10(2):189-198

Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut St, 3rd Floor, COB Bldg, Philadelphia, PA, 19107, USA.

Purpose Of Review: Interspinous process devices (IPDs) are used in the surgical treatment of lumbar spinal stenosis. The purpose of this review is to compare the first generation with the next-generation devices in terms of complications, device failure, reoperation rates, symptom relief, and outcome.

Recent Findings: Thirty-seven studies were included from 2011 to 2016. Device failure occurred at a mean of 3.7%, with a lower tendency to happen with next-generation IPDs. Reoperations occurred at a lower rate with the next-generation devices, with a mean follow up of 24 months (3.7% vs. 11.1%). The clinical outcome is not influenced by the type of IPD. The long-term functionality of these devices is questionable, with radiologic changes and recurrence of symptoms often seen by 2 years following implantation. Next-generation devices do not appear to be subject to the same "bounce back" effect of symptom re-emergence after several years.
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http://dx.doi.org/10.1007/s12178-017-9401-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435632PMC
June 2017

Surgery Start Time Does Not Impact Outcome in Elective Cardiac Surgery.

J Cardiothorac Vasc Anesth 2017 Feb 17;31(1):32-36. Epub 2016 Aug 17.

Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY.

Objective: Determine if surgery start time impacts patient outcomes in elective cardiac surgery.

Design: This was a retrospective study.

Setting: This study was based at a single academic institution.

Participants: Patients undergoing elective cardiac surgery over a 3-year period were included.

Interventions: There were no interventions.

Measurements And Main Results: The authors performed a retrospective study of patients undergoing elective cardiac surgery over a 3-year period. They divided their patient groups into those who had an anesthesia start time between 6:00 a.m. and 4:00 p.m. and those who had an anesthesia start time between 4:01 p.m. and 5:59 a.m. In the original sample and propensity-score-matched groups, the authors examined the effects of start time on morbidity, mortality, and several metrics of hospital length of stay. The start time of elective cardiac surgery did not have a statistically significant effect upon mortality, individual or composite morbidity, or hospital length of stay in either the original sample or the propensity-score-matched sample.

Conclusions: The authors' results suggested that elective cardiac surgery may be performed late at night without adverse effects, although institutional support for this effort (such as 24-hour intensivist coverage to facilitate fast-track extubation) may have been integral to their findings.
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http://dx.doi.org/10.1053/j.jvca.2016.08.015DOI Listing
February 2017

Impact of the Zika Virus for Anesthesiologists: A Review of Current Literature and Practices.

J Cardiothorac Vasc Anesth 2017 Dec 2;31(6):2245-2250. Epub 2016 Dec 2.

Department of Anesthesiology, Mount Sinai St. Luke׳s and Mount Sinai Roosevelt, New York, NY.

Zika virus disease is of growing concern to all clinicians. There is a growing concern with regards to the neurologic sequela of the virus, particularly for infants born to women infected while pregnant. The continued spread of this virus throughout North and South America requires all anesthesiologists to maintain vigilance on this issue. This article addresses some of the key issues that pertain to anesthesiologists with regards to the Zika virus including the risks of perioperative management of patients with Zika virus. A discussion of the risks of transfusion and current blood management practices also is included in this review.
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http://dx.doi.org/10.1053/j.jvca.2016.11.042DOI Listing
December 2017

Lateral lumbar retroperitoneal transpsoas approach in the setting of spondylodiscitis: A technical note.

J Clin Neurosci 2017 May 31;39:193-198. Epub 2017 Jan 31.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States. Electronic address:

Thoracolumbar spondylodiscitis is a morbid disease entity, impacting a sick patient population with multiple comorbidities. Wherever possible, surgical measures in this population should limit the extent of soft tissue disruption and overall morbidity that is often associated with anteroposterior thoracolumbar decompression and fusion. The authors describe the rationale, technique, and use of the lateral lumbar transpsoas retroperitoneal approach in tandem with posterior decompression and instrumented fusion in the treatment of circumferential thoracolumbar spondylodiscitis with or without epidural abscesses. The authors have routinely implemented the lateral lumbar transpsoas retroperitoneal approaches to address all pyogenic vertebral abscesses, spondylodiscitis, and ventral epidural abscesses with anterior column debridement and reconstruction with iliac crest autograft, posterior decompression, and pedicle screw instrumentation. In five consecutive patients, the mean blood loss and operative duration was 275mL and 259min, respectively. There were no instances of major vascular injury as this corridor obviates the need for retraction of inflamed retroperitoneal structures. The use of the lumbar lateral retroperitoneal transpsoas approach to the lumbar spine for the treatment of destructive and pyogenic spondylodiscitis is a potential alternative to the traditional anterior lumbar retroperitoneal approach in tandem with posterior spinal decompression and instrumented stabilization.
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http://dx.doi.org/10.1016/j.jocn.2016.12.028DOI Listing
May 2017

Fluoroscopic Confirmation of Sacral Pedicle Screw Placement Utilizing Pelvic Inlet and Outlet Technique: Technical Note.

Clin Spine Surg 2017 05;30(4):150-155

*Department of Neurological Surgery, Thomas Jefferson University Hospital †Neurological Surgery, Division of Spine and Peripheral Nerve, Thomas Jefferson University Hospital, Philadelphia, PA.

Minimally invasive surgical techniques may decrease length of stay, operative duration and blood loss, and postoperative pain. Numerous technical challenges and concerns surround the placement of percutaneous pedicle screws at the lumbosacral level. Maximization of screw triangulation, bicortical purchase, and rostral bias toward the sacral promontory has been shown repeatedly to stabilize lumbosacral segment instrumentation and maximize pullout strength. Because of the unique anatomy, conventional anteroposterior (AP) and lateral radiographic views are relatively less reliable at determining screw depth and penetration of the sacral cortex. Percutaneous sacral pedicle fixation using AP and lateral 2-dimensional fluoroscopy is complicated by the variable contour of the sacral alae and promontory. The pelvic inlet view is ideal for visualization of the ventral screw extent and is obtained by directing 45-degree cephalad and 0-degree mediolateral, with adjustments aligning the patient's pelvic brim. The modified pelvic outlet view is obtained with the trajectory axis being directed 45-degree caudal from the AP plane. This aligns the pubic symphysis with the second sacral vertebrae providing visualization of the superior boundary of the S1-bony neural foramen and any inferior wall pedicle breaches. The authors describe this reliable fluoroscopic technique and their clinical experience with percutaneous S1-screw placement.
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http://dx.doi.org/10.1097/BSD.0000000000000481DOI Listing
May 2017

Teratoma of the spinal cord in an adult: Report of a rare case and review of the literature.

J Clin Neurosci 2017 Feb 1;36:59-63. Epub 2016 Nov 1.

Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States.

Teratomas of the spinal cord are incredibly rare, comprising less than 0.5% of all spinal cord tumors. These tumors are exceptionally rare in adults, with only a handful of cases reported in the literature. We present the case of a 49-year-old gentleman with new onset urinary incontinence who presented with a large intradural tumor of the thoracolumbar spine. The patient underwent a laminectomy with midline durotomy for subtotal tumor resection. Surgical pathology diagnosed the tumor as a mature teratoma, exhibiting the presence of all three germ layers. These tumors tend to present with an indolent onset of symptoms characteristic of the tumor location within the spinal cord and the affected surrounding nerve roots. Magnetic resonance imaging (MRI) is useful in determining the location and nature of these tumors, but final diagnosis ultimately rests on histopathological analysis. Surgical resection is the preferred treatment, with subtotal resection being favored if there is a high risk of intraoperative neurological damage due to adherent or infiltrative tumor. In general, the prognosis for these tumors is good, with most patients exhibiting stable or improved neurological status after resection.
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http://dx.doi.org/10.1016/j.jocn.2016.10.022DOI Listing
February 2017

Heparin-Induced Thrombocytopenia: A Comprehensive Clinical Review.

J Am Coll Cardiol 2016 05;67(21):2519-32

Department of Anesthesiology, Mount Sinai Medical Center, New York, New York.

Heparin-induced thrombocytopenia is a profoundly dangerous, potentially lethal, immunologically mediated adverse drug reaction to unfractionated heparin or, less commonly, to low-molecular weight heparin. In this comprehensive review, the authors highlight heparin-induced thrombocytopenia's risk factors, clinical presentation, pathophysiology, diagnostic principles, and treatment. The authors place special emphasis on the management of patients requiring procedures using cardiopulmonary bypass or interventions in the catheterization laboratory. Clinical vigilance of this disease process is important to ensure its recognition, diagnosis, and treatment. Misdiagnosis of the syndrome, as well as misunderstanding of the disease process, continues to contribute to its morbidity and mortality.
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http://dx.doi.org/10.1016/j.jacc.2016.02.073DOI Listing
May 2016

Lumbar paraganglioma.

J Clin Neurosci 2016 Aug 28;30:149-151. Epub 2016 Mar 28.

Thomas Jefferson University, Department of Neurosurgery, 909 Walnut Street, Philadelphia, PA 19107, USA.

Spinal paragangliomas (SP) are benign and overall rare extra-adrenal neuroendocrine tumors often diagnosed during workup for lower back pain. Complete surgical resection achieves both symptomatic relief and cure. We present a 32-year-old man with a longstanding history of lumbago and bilateral lower extremity pain found to have a lumbar paraganglioma at the level of the L3 vertebrae. The clinical, histopathological, and radiological characteristics are described, including the rare finding of superficial siderosis on MRI of the brain. A laminectomy with microscopic dissection of the intradural mass achieved complete debulking without evidence of residual tumor. Excellent prognosis can be achieved with complete surgical resection of SP without the need for adjuvant therapy. Therefore, care should be taken to distinguish these spinal tumors from those that appear similar but are more aggressive. As such, the radiological finding of superficial siderosis should raise the suspicion for SP when a vascular intradural extramedullary spinal tumor is observed.
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http://dx.doi.org/10.1016/j.jocn.2016.01.019DOI Listing
August 2016

Cervical Spine Spondylodiscitis After Esophageal Dilation in Patients With a History of Laryngectomy or Pharyngectomy and Pharyngeal Irradiation.

JAMA Otolaryngol Head Neck Surg 2016 05;142(5):467-71

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.

Importance: Dysphagia is a frequently reported sequela of treatment for head and neck cancer and is often managed with esophageal dilation in patients with dysphagia secondary to hypopharyngeal or esophageal stenosis. Reported complications of esophagoscopy with dilation include bleeding, esophageal perforation, and mediastinitis. These, though rare, can lead to substantial morbidity or mortality. In patients who have undergone irradiation, tissue fibrosis and devascularization may contribute to a higher incidence of these complications.

Objectives: To describe the occurrence of cervical spine spondylodiscitis (CSS) following esophageal dilation in patients with a history of laryngectomy or pharyngectomy and irradiation with or without chemotherapy.

Design, Setting, And Participants: Medical records from a 5-year period (January 1, 2009, through December 31, 2014) in an academic tertiary care center were searched for patients with a history of laryngopharyngeal irradiation and a diagnosis of CSS following esophageal dilation. Four eligible patients were identified.

Main Outcomes And Measures: Recognition and treatment of CSS in the study population.

Results: A total of 1221 patients underwent esophageal dilation for any reason. Of these, 247 patients carried a diagnosis of head and neck cancer at the following sites: piriform sinus, larynx, hypopharynx, epiglottis, oropharynx, base of the tongue, and tonsil. Of these, 4 patients with a diagnosis of CSS following esophageal dilation were included in this assessment. Prompt diagnosis and multidisciplinary management of CSS with intravenous antibiotics as well as spinal surgical debridement and stabilization led to recovery of full ability to take food by mouth in 3 of the 4 included patients. One patient remained dependent on the feeding tube.

Conclusion And Relevance: In patients with a history of laryngopharyngeal irradiation and esophageal dilation, complaints of neck pain or upper extremity weakness should trigger immediate evaluation for CSS; if present, prompt therapy is essential for prevention of substantial morbidity and mortality.
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http://dx.doi.org/10.1001/jamaoto.2015.3038DOI Listing
May 2016
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