Clinical decision analysis: Incorporating the evidence with patient preferences

Decision analysis has become an increasingly popular decision-making tool with a multitude of clinical applications. Incorporating patient and expert preferences with available literature, it allows users to apply evidence-based medicine to make informed decisions when confronted with difficult clinical scenarios. A decision tree depicts potential alternatives and outcomes involved with a given decision. Probabilities and utilities are used to quantify the various options and help determine the best course of action. Sensitivity analysis allows users to explore the uncertainty of data on expected clinical outcomes. The decision maker can thereafter establish a preferred method of treatment and explore variables which influence the final clinical outcome. The present paper reviews the technique of decision analysis with particular focus on its application to clinical decision making

Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: A meta-Analysis and systematic review of randomized trials

Purpose Displaced femoral neck fractures in healthy elderly patients have traditionally been managed with hemiarthroplasty (HA). Recent data suggest that total hip arthroplasty (THA) may be a better alternative. Methods A systematic review of the English literature was conducted. Randomized controlled trials comparing all forms of THA with HA were included. Three authors independently extracted articles and predefined data. Results were pooled using a random effects model. Results Eight trials totalling 986 patients were retrieved. After THA 4 % underwent revision surgery versus 7 % after HA. The one-year mortality was equal in both groups: 13 % (THA) versus 15 % (HA). Dislocation rates were 9 % after THA versus 3 % after HA. Equal rates were found for major (25 % in THA versus 24 % in HA) and minor complications (13 % THA versus 14 % HA). The weighted mean of the Harris hip score was 81 point

A Matched Cohort Analysis of Drain Usage in Elective Anterior Cervical Discectomy and Fusion: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study

STUDY DESIGN: This is a retrospective, cohort analysis of multi-institutional database. OBJECTIVE: This study was designed to analyze the impact of drain use following elective anterior cervical discectomy and fusion (ACDF) surgeries. SUMMARY OF BACKGROUND DATA: After ACDF, a drain is often placed to prevent postoperative hematoma. However, there has been no high quality evidence to support its use with ACDF despite the theoretical benefits and risks of drain placement. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried to identify all patients undergoing elective ACDF between February 2014 and October 2019. Cases were divided into two cohorts based on drain use. Propensity-score matching was utilized to adjust for inherent differences between the two cohorts. Measured outcomes included surgical site hematoma, length of stay, surgical site infection, dysphagia, home discharge, readmission within 30 days, and unplanned reoperation. RESULTS: We identified 7943 patients during the study period. Propensity-score matching yielded 3206 pairs. On univariate analysis of matched cohorts, there were no differences in rate of postoperative hematoma requiring either return to OR or readmission. We noted patients with drains had a higher rate of dysphagia (4.6% vs. 6.3%; P = 0.003) and had longer hospital stay (P \u3c 0.001). On multivariate analysis, drain use was associated with significantly increased length of stay (relative risk 1.23, 95% confidence interval [CI] 1.13-1.34; P \u3c 0.001). There were no significant differences in other outcomes measured. CONCLUSION: Our analysis demonstrated that drain use is associated with significant longer hospital stay.Level of Evidence: 3

Risk Factors of Not Reaching MCID after Elective Lumbar Spine Surgery: A Case Control Study

Background The therapeutic effect of spine surgery has been traditionally evaluated by physical examination, radiographic findings, and general perception of patient’s health status. However, these assessments are often insufficient to represent surgical outcomes.Patient-reported outcomes (PROs) are tools developed to measures quality outcomes following spinal surgery. Examples include the Patient-Reported Outcomes Measurement Information System Function 4-item Short Form (PROMIS-PF), Visual Analogue Scale (VAS), ODI (Oswestry Disability Index), SF-36 (Short Form Health Survey), and EQ-5D (EuroQuol-5D). The minimum clinically important difference (MCID) is an assessment tool to note the smallest clinical difference in PROs and provides the threshold where patients experience clinical benefit that justifies treatment plans or procedures despite the cost and side effects. MCID results reflect patient-perceived functional improvement, which can be a core metric in lumbar surgery for degenerative disease. Clinical and sociodemographic risk factors may serve to identify high-risk patients via MCID assessment. This study aims to identify risk factors associated with failure of reaching MCID based on PROMIS PF after elective lumbar spine surgery and the data registry from Michigan Spine Surgery Spine Surgery Improvement Collaborative (MSSIC). The results of this study can provide opportunities to optimize medical conditions of patients in prior to any elective lumbar surgery. METHODS MSSIC is a state-wide quality-improvement initiative database including 29 hospitals and 200 orthopedic- and neurosurgeons from various settings. Member hospitals are required to perform an annual minimum of 200 spine surgeries. MSSIC reviews elective spine surgeries for degenerative disease but excludes non-degenerative and/or complex pathology (i.e., spinal cord injury, traumatic fractures, pre-existing infection, grade 3 or 4 spondylolisthesis, scoliosis greater than 25◦, congenital anomalies, or ≥ 4-level fusion). Utilizing MSSIC, 10,922 patients who had undergone elective lumbar spine surgery were selected with 90 day follow up, and 7,200 patients with 1-year follow up. Patients with missing data were excluded from the study. Patient demographics, clinical presentation, medical history, surgical procedure, details of hospital stay, postsurgical adverse events within 90 days of surgery, and patient-reported outcome after surgery were reviewed. A patient was considered to have achieved MCID if there was an increase in ≥4.5 points. RESULTS Of 10,922 patients with 90-day follow-up, 4,453 patients (40.8%) did not reach MCID. Of 7,200 patients with 1-year follow up, 2,361 patients (23.8%) did not achieve MCID. There were significant baseline differences in demographic profiles and operative characteristics for those who had follow-up at 90 days and 1 year after their surgery. At 90 days after surgery, significant factors of not reaching MCID and their relative risk included symptom duration more than 1 year (1.34), previous spine surgery (1.25), African American descent (1.25), chronic opiate use (1.23), less than high school education (1.20), morbid obesity (1.15), ASA class \u3e2 (1.15), current smoking (1.14), chronic obstructive pulmonary disease (COPD) (1.13), depression (1.09), history of DVT (1.08), scoliosis (1.06), anxiety (1.06), baseline PROMIS (1.06), and surgery invasiveness (1.02). At 1 year after surgery, significant factors of not reaching MCID and their relative risk included symptom duration more than 1 year (1.41), less than high school education (1.34), previous spine surgery (1.30), morbid obesity (1.30), chronic opiate use (1.25), age (1.21), current smoking (1.21), African American descent (1.20), ASA class \u3e2 (1.18), history of DVT (1.12), depression (1.10), chronic obstructive pulmonary disease (COPD) (1.09), and baseline PROMIS (1.06). Independent ambulatory status (0.83 and 0.88 for 90-day and 1-year follow-up, respectively) and private insurance (0.83 and 0.85 for 90-day and 1-year follow-up, respectively) were associated with higher likelihood of reaching MCID. CONCLUSION This case control study identifies relevant risk factors of not reaching MCID after elective lumbar spine surgery. The results may assist clinicians in identifying high risk patients and optimizing patients’ medical conditions prior to spinal surgery

What is a clinical decision analysis study?

Decision making in clinical practice often involves the need to make complex and intricate decisions with important long-term consequences. Decision analysis is a tool that allows users to apply evidence-based medicine to make informed and objective clinical decisions when faced with complex situations. A Decision Tree, together with literature-derived probabilities and defined outcome values, is used to model a given problem and help determine the best course of action. Sensitivity analysis allows an exploration of important variables on final clinical outcomes. A decision-maker can thereafter establish a preferred method of treatment and explore variables which influence the final outcome. The present paper is intended to give an overview of decision analysis and its application in clinical decision making

Prehospital care for traumatic spinal cord injury by first responders in 8 sub-Saharan African countries and 6 other low- and middle-income countries: A scoping review

Introduction: Traumatic spinal cord injury (TSCI) constitutes a considerable portion of the global injury burden, disproportionately affecting low- and middle-income countries (LMICs). Prehospital care can address TSCI morbidity and mortality, but emergency medical services are lacking in LMICs. The current standard of prehospital care for TSCI in sub-Saharan Africa and other LMICs is unknown. Methods: This review sought to describe the state of training and resources for prehospital TSCI management in sub-Saharan Africa and other LMICs. Articles published between 1 January 1995 and 1 March 2020 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for TSCI. Two reviewers assessed full texts meeting inclusion criteria for quality using the Newcastle-Ottawa Scale and extracted relevant characteristics to assess trends in the state of prehospital TSCI care in sub-Saharan Africa and other LMICs. Results: Of an initial 482 articles identified, 23 met inclusion criteria, of which ten were set in Africa, representing eight countries. C-spine immobilization precautions for suspected TSCI patients is the most prevalent prehospital TSCI intervention for and is in every LMIC first responder program reviewed, except one. Numerous first responder programs providing TSCI care operate without C-collar access (n = 13) and few teach full spinal immobilization (n = 5). Rapid transport is most frequently reported as the key mortality-reducing factor (n = 11). Despite more studies conducted in the Southeast Asia/Middle East (n = 13), prehospital TSCI studies in Africa are more geographically diverse, but responder courses are shorter, produce fewer professional responders, and have limited C-collar availability. Discussion: Deficits in training and resources to manage TSCI highlights the need for large prospective trials evaluating alternative C-spine immobilization methods for TCSI that are more readily available across diverse LMIC environments and the importance of understanding resource variability to sustainably improve prehospital TSCI care

Taraxacum subcyanolepis M.P.Christ. (BR0000011798590)

Belgium Herbarium image of Meise Botanic Garden

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVEThe Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.METHODSA total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class \u3e II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.RESULTSNinety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p \u3c 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class \u3e II (p \u3c 0.001), while preoperative ambulation (p = 0.001) and private insurance (p \u3c 0.001) were protective. RFs for urinary retention included increasing age (p \u3c 0.001) and male sex (p \u3c 0.001), while anterior-approach surgery (p \u3c 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.CONCLUSIONSA multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events