A Survey of Chemoprophylaxis Techniques in Spine Surgery Among American Neurosurgery Training Programs

The North American Spine Section (NASS) published the Evidence-Based Clinical Guide for the use of antithrombotics in spine surgery. Many of the 14 clinical questions lacked clinical studies to establish evidence-based recommendations, as such expert consensuses were arrived at via a modified nominal group technique. On the clinical inquiry of chemoprophylaxis, the study published that “Unfortunately, scientific scrutiny of chemoprophylaxis in elective spinal surgery has been limited to case series involving discectomy and decompression…safety and efficacy have not been thoroughly studied. This knowledge gap in the optimal prevention of VTE events may be approximated with higher levels of evidence in spine surgery research, which should begin in first understanding chemoprophylaxis techniques across a wide geographical array of neurosurgical training programs. Of the 107 ACGME-approved residencies, contact information for 96 programs were available from ACGME, and responses from 69 unique neurosurgery residencies were collected. Thus, this survey study achieved a 64% respondent rate. Responses appeared equally distributed across the country. The first dose of chemoprophylaxis among patients undergoing surgery for degenerative/ deformity spinal disease started most commonly on postoperative day 1 in 75.3% of neurosurgery programs (n = 52) followed by postoperative day 2 in 10.1% of programs (n = 7), postoperative day 0 – same day of surgery in 8.7% of programs (n = 6), postoperative day 3 in 1.4% of programs (n = 1), and morning of surgery in 1.4% of programs (n = 1). Lastly, 2.9% of programs (n = 2) do not utilize any chemoprophylaxis. Among two of the three indications for spinal surgery, choice of postoperative chemoprophylaxis did not statistically significantly differ between prophylactic UFH versus prophylactic LMWH: 56.5% versus 50.7% in degenerative/ deformity pathologies (p=0.080) and 36.2% versus 43.4% in traumatic pathologies (p-0.535). However, neoplastic pathologies saw a statistically significantly higher proportion of prophylactic UFH (60.8%) compared to prophylactic LMWH (36.2%) (p=0.037). Of those neurosurgeons who documented “other”, one explained that the choice of chemoprophylaxis depends on comorbidities. Similarly, the other mentioned creatinine clearance and “risk factors” as determinants.https://scholarlycommons.henryford.com/merf2019qi/1012/thumbnail.jp

Trends in the Abscopal Effect After Radiation to Spinal Metastases: A Systematic Review

While the abscopal effect has been previously described, the phenomenon has been poorly defined with spinal metastases. This article is unique in that we present the first systematic review of the abscopal effect after radiation therapy to metastatic spinal cancer, especially since the spinal column represents one of the most common metastatic locations. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) resources, a systematic review identified relevant studies via a computer-aided search of MEDLINE and Embase. Ten publications that met the inclusion and exclusion criteria from the PRISMA flow diagram described a total of thirteen patients. Important findings in this review of spinal metastases include (1) abscopal effect is more commonly observed when systemic therapy includes immunomodulators; (2) abscopal effect has a higher likelihood of success when immunomodulators are administered in conjunction with or after radiation therapy to the spine; (3) higher doses of radiation in a smaller number of fractions likely increase the abscopal success; and (4) ionizing radiation to the bone marrow of the spinal column may increase circulating lymphocytes that attack cancerous lesions elsewhere in the body. These trends, however, still require further investigation with experimental and clinical studies.https://scholarlycommons.henryford.com/merf2019clinres/1038/thumbnail.jp

Trends in the Abscopal Effect After Radiation to Spinal Metastases: A Systematic Review

Introduction: While the abscopal effect has been previously described, the phenomenon has been poorly defined with spinal metastases. This article presents the first systematic review of the abscopal effect after radiation therapy to metastatic spinal cancer, especially since the spinal column represents one of the most common metastatic locations. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [Figure 1] in the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) resources, a systematic review identified relevant studies via a computer-aided search of MEDLINE and Embase. Ten publications that met the inclusion and exclusion criteria from the PRISMA flow diagram described a total of thirteen patients. Results: Two patients in two separate articles observed the abscopal effect following radiation therapy alone to the spine. The remaining eight articles commented on the abscopal effect in the setting of both systemic and radiation therapy. Conclusion: Important findings in this review of spinal metastases include (1) abscopal effect is more commonly observed when systemic therapy includes immunomodulators; (2) abscopal effect has a higher likelihood of success when immunomodulators are administered in conjunction with or after radiation therapy to the spine; (3) higher doses of radiation in a smaller number of fractions likely increase the abscopal success; and (4) ionizing radiation to the bone marrow of the spinal column may increase circulating lymphocytes that attack cancerous lesions elsewhere in the body. These trends, however, still require further investigation with experimental and clinical studies

Gestational Sac Aspiration of Heterotopic Ectopic Pregnancy in a Cesarean Section Scar

Background: This article describes a case of heterotopic pregnancy that included a normal twin intrauterine pregnancy and one cesarean section (CS) scar pregnancy diagnosed at 6 weeks of gestation. Ultrasound-guided aspiration of the ectopic gestational sac was performed, and the concurrent twin intrauterine pregnancy (IUP) was preserved successfully. The patient was a 50-year-old woman with secondary infertility. Case: The patient underwent in vitro fertilization and embryo transfer using a donor-egg program to achieve pregnancy with her current partner. At 6-weeks' gestation, she underwent a transvaginal ultrasound scan (US) examination showing a viable twin IUP with a third gestational sac with viable embryo located low within the anterior wall of the uterus. The appearance was consistent with a cesarean scar ectopic pregnancy. This was confirmed on a subsequent US 1 week later. She desired to continue the intrauterine pregnancy. US-guided aspiration of the cesarean scar ectopic pregnancy was attempted. The treatment was successful. Results: The twin pregnancy progressed without further complications. Conclusions: Heterotopic CS ectopic pregnancy can be successfully treated with transvaginal US-guided aspiration. (J GYNECOL SURG 29:317)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140090/1/gyn.2012.0026.pd

Randomized, phase II selection study of ramucirumab and paclitaxel versus FOLFIRI in refractory small bowel adenocarcinoma: SWOG S1922

Background: Small bowel adenocarcinoma is a rare malignancy with limited evidence to support the choice of systemic chemotherapy beyond the frontline setting. Though second-line therapy has historically been extrapolated from colorectal cancers, recent molecular data has demonstrated small bowel adenocarcinoma to be genomically unique when compared to either colon or gastric cancer. Retrospective analyses of irinotecan- and taxane-based therapies and one prospective phase II clinical trial of nab-paclitaxel have demonstrated clinical activity in this cancer. Ramucirumab/paclitaxel represents an active combination in the management of gastric cancer. SWOG 1922 evaluates the use of FOLFIRI or ramucirumab/paclitaxel in the second- and later-line setting for small bowel adenocarcinoma. Methods: This is randomized, phase II, selection design clinical trial of FOLFIRI (5-fluorouracil, leucovorin and irinotecan) every two weeks or ramucirumab D1,15 and paclitaxel D1,8,15 every 4 weeks with the primary endpoint of progression-free survival (PFS). Secondary endpoints include response rate, overall survival, and safety. Archived paraffin tumor tissue collection and serial blood collections are included for correlative analyses. Key eligibility criteria include having mismatch repair proficient/microsatellite stable small bowel adenocarcinoma (ampullary location excluded); metastatic or locally advanced unresectable disease; prior fluoropyrimidine and/or oxaliplatin therapy; no prior treatment with irinotecan, ramucirumab, or taxanes; no recent bleeding, blood clots, or bowel perforation/fistula; and Zubrod performance status of 0/1. Measurable disease is not required. The null hypothesis is median PFS of 2.5 months. If a median PFS of at least 3.5 months is observed in one or both arms, the goal is to choose the better regimen with respect to this endpoint. The design provides a 90% probability of selecting the more active arm, assuming a hazard ratio of 1.4, if both arms meet this threshold. This trial is open and, as of September 1, 2021, 21 of 94 planned patients have been enrolled

Safety and Efficacy of Liraglutide, 3.0 mg, Once Daily vs Placebo in Patients With Poor Weight Loss Following Metabolic Surgery: The BARI-OPTIMISE Randomized Clinical Trial

IMPORTANCE: Metabolic surgery leads to weight loss and improved health, but these outcomes are highly variable. Poor weight loss is associated with lower circulating levels of glucagon-like peptide-1 (GLP-1). OBJECTIVE: To assess the efficacy and safety of the GLP-1 receptor agonist, liraglutide, 3.0 mg, on percentage body weight reduction in patients with poor weight loss and suboptimal GLP-1 response after metabolic surgery. DESIGN, SETTING, AND PARTICIPANTS: The Evaluation of Liraglutide 3.0 mg in Patients With Poor Weight Loss and a Suboptimal Glucagon-Like Peptide-1 Response (BARI-OPTIMISE) randomized placebo-controlled trial recruited adult patients at least 1 year after metabolic surgery who had experienced 20% or less body weight loss from the day of surgery and a suboptimal nutrient-stimulated GLP-1 response from 2 hospitals in London, United Kingdom, between October 2018 and November 2019. Key exclusion criteria were type 1 diabetes; severe concomitant psychiatric, gastrointestinal, cardiac, kidney or metabolic disease; and use of insulin, GLP-1 receptor analogues, and medication that can affect weight. The study period was 24 weeks followed by a 4-week follow-up period. Last participant follow-up was completed in June 2020. All participants and clinical study personnel were blinded to treatment allocation. Of 154 assessed for eligibility, 70 met trial criteria and were included in the study, and 57 completed follow-up. INTERVENTIONS: Liraglutide, 3.0 mg, once daily or placebo as an adjunct to lifestyle intervention with a 500-kcal daily energy deficit for 24 weeks, on a 1:1 allocation by computer-generated randomization sequence, stratified by surgery type (Roux-en-Y gastric bypass [RYGB] or sleeve gastrectomy [SG]) and type 2 diabetes status. MAIN OUTCOME AND MEASURES: The primary outcome was change in percentage body weight from baseline to the end of the 24-week study period based on an intention-to-treat analysis. Participant safety was assessed through monitoring of biochemical parameters, including kidney and liver function, physical examination, and assessment for adverse events. RESULTS: A total of 70 participants (mean [SD] age, 47.6 [10.7] years; 52 [74%] female) with a poor weight loss response following RYGB or SG were randomized to receive 3.0-mg liraglutide (n = 35) or placebo (n = 35). All participants received at least 1 dose of the trial drug. Eight participants discontinued treatment (4 per group), and 2 in the 3.0-mg liraglutide group and 1 in the placebo group were lost to follow-up. Due to COVID-19 restrictions, 3 participants in the 3.0-mg liraglutide group and 7 in the placebo group were unable to attend their final in-person assessment. Estimated change in mean (SD) percentage body weight from baseline to week 24 was -8.82 (4.94) with liraglutide, 3.0 mg (n = 31), vs -0.54 (3.32) with placebo (n = 26). The mean difference in percentage body weight change for liraglutide, 3.0 mg, vs placebo was -8.03 (95% CI, -10.39 to -5.66; P < .001). Adverse events, predominantly gastrointestinal, were more frequent with liraglutide, 3.0 mg (28 events [80%]), than placebo (20 events [57%]). There were no serious adverse events and no treatment-related deaths. CONCLUSION AND RELEVANCE: These findings support the use of adjuvant liraglutide, 3.0 mg, for weight management in patients with poor weight loss and suboptimal GLP-1 response after metabolic surgery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03341429

Elucidating the effects of reaction time on the physicochemical characterization of valorized synthesized alumina

Aluminum waste-can management in Malaysia has recently become a serious environmental and public health issue, particularly in metropolitan areas. This has prompted the need to valorize these waste-cans into value-added products using the most economical and environmentally friendly techniques. In this study, the sol–gel technique was used to synthesize high-quality alumina from the aluminum waste-cans collected. From this method, the observed peaks of the synthesized alumina were identified as diaspore (α-AlO(OH)), boehmite (γ-AlO(OH)), aluminum oxide, or gamma-alumina (γ-Al2O3 ) crystalline structure and corundum. The morphological configuration, microstructure, and functional group properties of the synthesized alumina were evaluated. All the synthesized alumina exhibited a non-spherical shape and appeared to have hexagonal-like shape particles. Moreover, the XRD patterns of the synthesized alumina AL-6-30 and AL-12-30 exhibited a small angle (1–10◦ ) with no XRD peak, which indicated a mesoporous pore structure with no long-range order. The overall results of γ-alumina synthesized from the aluminum waste-cans showed an optimal condition in producing a highly structured γ-alumina with excellent surface-area characteristics. The synthesized alumina exhibited stronger and highly crystalline functional characteristics almost comparable with the commercially available brands on the market

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Return to Operating Room: A National Surgical Quality Improvement Program Study

OBJECTIVE: Because of the health care initiative on quality improvement projects in academic medicine, this study explores the impact of different postgraduate years (PGYs) on unexpected re-operation rates. METHODS: Using the National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open vascular, cranial, and functional. Comparison groups were cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Comorbidity disease burden was measured by frailty index. The primary outcome measure was 30-day unintended return to the operating room. RESULTS: Of the 9782 cases, re-operations were higher for those cases featuring a senior resident (5.6%) compared with mid-level resident (4.1%) and junior resident (3.8%) (P = 0.001). Although senior residents operated on patients with a statistically significantly higher neurologic disease burden, greater relative value units, longer operative times, and more 30-day postoperative adverse events, the level of resident training did not have an impact on revision surgery after multivariable logistical regression. The strongest predictors of return to the operating room included the frailty index (adjusted odds ratio [ORadj] = 5.18, P \u3c 0.001), functional subspecialty (ORadj = 2.65, P \u3c 0.001), and Wound Class 4 - dirty/infected wound (ORadj = 2.33, P = 0.016). CONCLUSIONS: Resident participation in neurosurgical cases does not affect 30-day unplanned re-operation rates, which were affected by frailty index, functional subspecialty, and wound class

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Return to Operating Room: A National Surgical Quality Improvement Program Study

OBJECTIVE: Because of the health care initiative on quality improvement projects in academic medicine, this study explores the impact of different postgraduate years (PGYs) on unexpected re-operation rates. METHODS: Using the National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open vascular, cranial, and functional. Comparison groups were cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Comorbidity disease burden was measured by frailty index. The primary outcome measure was 30-day unintended return to the operating room. RESULTS: Of the 9782 cases, re-operations were higher for those cases featuring a senior resident (5.6%) compared with mid-level resident (4.1%) and junior resident (3.8%) (P = 0.001). Although senior residents operated on patients with a statistically significantly higher neurologic disease burden, greater relative value units, longer operative times, and more 30-day postoperative adverse events, the level of resident training did not have an impact on revision surgery after multivariable logistical regression. The strongest predictors of return to the operating room included the frailty index (adjusted odds ratio [ORadj] = 5.18, P \u3c 0.001), functional subspecialty (ORadj = 2.65, P \u3c 0.001), and Wound Class 4 - dirty/infected wound (ORadj = 2.33, P = 0.016). CONCLUSIONS: Resident participation in neurosurgical cases does not affect 30-day unplanned re-operation rates, which were affected by frailty index, functional subspecialty, and wound class

Clinching the cause: A review of foot drop secondary to lumbar degenerative diseases

Foot drop is defined as weakness on dorsiflexion of the foot. The top two most common etiologies for foot drop include lumbar degenerative disease and common peroneal nerve injury. This review provides updates on understanding the lumbar etiologies of foot drop. Since the publication of Preoperative motor strength and time to surgery are the most important predictors of improvement in foot drop due to degenerative lumbar disease in the Journal of Neurological Sciences, three cohort studies have been published on spinal causes of foot drop. Classification, clinical features, diagnosis, and pathogenesis that may \u27clinch\u27 the cause of foot drop are discussed in the context of these recent publications