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Background The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or statedesignated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive. Methods Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated. Results Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive. Conclusion Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities. [ABSTRACT FROM AUTHOR]

Background: Islam and Muslims are underrepresented in the medical literature and the influence of physician's cultural beliefs and religious values upon the clinical encounter has been understudied. Objective: To elicit the perceived influence of Islam upon the practice patterns of immigrant Muslim physicians in the USA. Design: Ten face-to-face, in-depth, semistructured interviews with Muslim physicians from various backgrounds and specialties trained outside the USA and practising within the the country. Data were analysed according to the conventions of qualitative research using a modified grounded-theory approach. Results: There were a variety of views on the role of Islam in medical practice. Several themes emerged from our interviews: (1) a trend to view Islam as enhancing virtuous professional behaviour; (2) the perception of Islam as influencing the scope of medical practice through setting boundaries on career choices, defining acceptable medical procedures and shaping social interactions with physician peers; (3) a perceived need for islamic religious experts within Islamic medical ethical deliberation. Limitations: This is a pilot study intended to yield themes and hypotheses for further investigation and is not meant to fully characterise Muslim physicians at large. Conclusions: Immigrant Muslim physicians practising within the USA perceive Islam to play a variable role within their clinical practice, from influencing interpersonal relations and character development to affecting specialty choice and procedures performed. Areas of ethical challenges identified include catering to populations with lifestyles at odds with islamic teachings, end-of-life care and maintaining a faith identity within the culture of medicine. Further study of the interplay between Islam and Muslim medical practice and the manner and degree to which Islamic values and law inform ethical decision-making is needed. [ABSTRACT FROM AUTHOR]

Pakistanis give three kinds of reasons for negative feelings about America. One involves U.S. policies toward Pakistan such as failure to come to Pakistan's aid during the Bangladesh crisis, using Pakistan for its own interests, and opposition to Pakistan's peaceful nuclear program. A second deals with American global policy, including support of Israel, opposition to Iran's present government, and use of force against small Third World nations. The third includes American involvement in Pakistan—for example, support of the military regime, obstructing a settlement of the Afghan issue, and responsibility for the decline in the value of the local currency. Most Pakistanis are uneasy about the relationship with America as opposed to being hostile. American support of Israel, India, and military dictators has undone a lot of the goodwill gained in other ways. Religious, ethnic, and cultural differences are rejected by most people as a basis of anti-American feelings. Speculation about interference in Pakistan's internal affairs and responsibility for former Prime Minister Bhutto's assassination have provided a basis for more ordinary people to develop feelings of anti-Americanism. [ABSTRACT FROM AUTHOR]

Background: The burden of atrial fibrillation (AF) hospitalizations in young patients is not well characterized. We aimed to study the burden, comorbidities, outcomes, and resource utilization of AF hospitalizations in young patients., Methods: We conducted a retrospective analysis of all primary AF hospitalizations in patients 18-45 years of age using the National Inpatient Sample data from January 1, 2008 to December 31, 2019. We collected data on various clinical and socioeconomic features including demographics and clinical outcomes., Results: AF hospitalizations decreased over time from 18.7 per 100,000 in 2008 to 13.0 per 100,000 in 2019 (p < 0.001). AF hospitalizations were higher amongst males compared to females (24.0 vs. 7.5 per 100,000), and higher in Black patients compared to other ethnicities (20.4 for Black vs. 15.6 for White vs. 8.5 Hispanic per 100,000). The utilization of electrical cardioversion increased from 17.6% in 2008 to 21.9% in 2019 (p < 0.001), and catheter ablation decreased from 7.1% in 2008 to 4.3% in 2019 (p < 0.001). Men were more likely to undergo electrical cardioversion than women (20.1% vs. 14.8%, p < 0.001). White patients were more likely to undergo electrical cardioversion (20.8% vs. 14.3% vs. 15.5%, p < 0.001) and catheter ablation (6.1% vs. 3.3% vs. 4.2%, p < 0.001) compared to Black and Hispanic patients, respectively. Patients in the highest income residence quartile were more likely to undergo electrical cardioversion (21.9% vs. 16.4%, p < 0.001) and catheter ablation (8.0% vs. 3.7%, p < 0.001) compared to patients in the lowest income residence quartile., Conclusions: We found significant differences in inpatient AF management based on sex, ethnicity, and SES., (© 2024 Wiley Periodicals LLC.)

Importance: Ultrasonography-guided nerve blocks (UGNBs) have become a core component of multimodal analgesia for acute pain management in the emergency department (ED). Despite their growing use, national adoption of UGNBs has been slow due to a lack of procedural safety in the ED., Objective: To assess the complication rates and patient pain scores of UGNBs performed in the ED., Design, Setting, and Participants: This cohort study included data from the National Ultrasound-Guided Nerve Block Registry, a retrospective multicenter observational registry encompassing procedures performed in 11 EDs in the US from January 1, 2022, to December 31, 2023, of adult patients who underwent a UGNB., Exposure: UGNB encounters., Main Outcomes and Measures: The primary outcome of this study was complication rates associated with ED-performed UGNBs recorded in the National Ultrasound-Guided Nerve Block Registry from January 1, 2022, to December 31, 2023. The secondary outcome was patient pain scores of ED-based UGNBs. Data for all adult patients who underwent an ED-based UGNB at each site were recorded. The volume of UGNB at each site, as well as procedural outcomes (including complications), were recorded. Data were analyzed using descriptive statistics of all variables., Results: In total, 2735 UGNB encounters among adult patients (median age, 62 years [IQR, 41-77 years]; 51.6% male) across 11 EDs nationwide were analyzed. Fascia iliaca blocks were the most commonly performed UGNBs (975 of 2742 blocks [35.6%]). Complications occurred at a rate of 0.4% (10 of 2735 blocks). One episode of local anesthetic systemic toxicity requiring an intralipid was reported. Overall, 1320 of 1864 patients (70.8%) experienced 51% to 100% pain relief following UGNBs. Operator training level varied, although 1953 of 2733 procedures (71.5%) were performed by resident physicians., Conclusions and Relevance: The findings of this cohort study of 2735 UGNB encounters support the safety of UGNBs in ED settings and suggest an association with improvement in patient pain scores. Broader implementation of UGNBs in ED settings may have important implications as key elements of multimodal analgesia strategies to reduce opioid use and improve patient care.

Background: The impact of socioeconomic status on the clinical outcomes of patients admitted to the hospital for atrial fibrillation (AF) is not well described., Objective: The purpose of this study was to determine the association between median neighborhood household income (mNHI) and clinical outcomes among patients admitted to the hospital for AF., Methods: We retrospectively analyzed primary AF hospitalizations from the United States National Inpatient Sample between 2016 and 2020. The analyzed sample was divided into quartiles based on the mNHI in the zip code of the patient's residence. The lowest quartile was used as the reference category. Study outcomes included inpatient procedure utilization (ablation, cardioversion, percutaneous left atrial appendage closure), length of stay, cost, mortality, and disposition. Weighted multivariable logistic and linear regression, adjusting for multiple patient and hospital-level characteristics, was performed., Results: Patients in the highest mNHI quartile had lower comorbidity burden, lower in-hospital mortality (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.7-0.87; P <.001), lower discharges to care facility (OR 0.86; 95% CI 0.83-0.9; P <.001), shorter length of stay (adjusted mean difference -0.26; 95% CI -0.30 to -0.22; P <.001), higher procedure utilization, and higher health care costs ($12,124 vs $10,018) compared to the lowest mNHI quartile patients., Conclusion: We identified significantly higher in-hospital mortality and lower procedural/resource utilization in patients living in lower-income neighborhoods compared to higher-income neighborhoods. Further research is needed to better understand the drivers of these disparities and the strategies to improve health care disparities between socioeconomic groups., Competing Interests: Disclosures The authors have no conflicts to disclose., (Copyright © 2024 Heart Rhythm Society. All rights reserved.)

A growing body of research documents the relevance of parental education as a marker of family socio-economic status for children's later-life health outcomes. A strand of this literature evaluates how the early-life environment shapes mortality outcomes during infancy and childhood. However, the evidence on mortality during the life course and old age is limited. This paper contributes to the literature by analysing the association between paternal education and children's old-age mortality. We use data from Social Security Administration death records over the years 1988-2005 linked to the United States 1940 Census. Applying a family(cousin)- fixed-effects model to account for shared environment, childhood exposures, and common endowments that may confound the long-term links, we find that having a father with a college or high-school education, compared with elementary/no education, is associated with a 4.6- or 2.6-month-higher age at death, respectively, for the child, conditional on them surviving to age 47.

Background: ChatGPT (OpenAI) is a powerful tool for a wide range of tasks, from entertainment and creativity to health care queries. There are potential risks and benefits associated with this technology. In the discourse concerning the deployment of ChatGPT and similar large language models, it is sensible to recommend their use primarily for tasks a human user can execute accurately. As we transition into the subsequent phase of ChatGPT deployment, establishing realistic performance expectations and understanding users' perceptions of risk associated with its use are crucial in determining the successful integration of this artificial intelligence (AI) technology., Objective: The aim of the study is to explore how perceived workload, satisfaction, performance expectancy, and risk-benefit perception influence users' trust in ChatGPT., Methods: A semistructured, web-based survey was conducted with 607 adults in the United States who actively use ChatGPT. The survey questions were adapted from constructs used in various models and theories such as the technology acceptance model, the theory of planned behavior, the unified theory of acceptance and use of technology, and research on trust and security in digital environments. To test our hypotheses and structural model, we used the partial least squares structural equation modeling method, a widely used approach for multivariate analysis., Results: A total of 607 people responded to our survey. A significant portion of the participants held at least a high school diploma (n=204, 33.6%), and the majority had a bachelor's degree (n=262, 43.1%). The primary motivations for participants to use ChatGPT were for acquiring information (n=219, 36.1%), amusement (n=203, 33.4%), and addressing problems (n=135, 22.2%). Some participants used it for health-related inquiries (n=44, 7.2%), while a few others (n=6, 1%) used it for miscellaneous activities such as brainstorming, grammar verification, and blog content creation. Our model explained 64.6% of the variance in trust. Our analysis indicated a significant relationship between (1) workload and satisfaction, (2) trust and satisfaction, (3) performance expectations and trust, and (4) risk-benefit perception and trust., Conclusions: The findings underscore the importance of ensuring user-friendly design and functionality in AI-based applications to reduce workload and enhance user satisfaction, thereby increasing user trust. Future research should further explore the relationship between risk-benefit perception and trust in the context of AI chatbots., (©Avishek Choudhury, Hamid Shamszare. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 27.05.2024.)

Objective: Pituitary surgery is a frequent neurosurgical procedure for the management of pituitary adenomas, but little research has been done on the impact of healthcare disparities on surgical results. Healthcare inequity/disparity in terms of race and socioeconomic status (SES), in addition to age and gender, was evaluated in this study to see if they affect the results of pituitary surgery., Methods: A systematic literature search was carried out utilizing the MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic databases from conception to 2023. The Newcastle-Ottawa Scale was used for quality assessment of the included studies., Results: Twenty-one studies yielded a total of 381,643 patients, and removal of the studies with temporal overlap resulted in 134,832 patients with a mean ± SD age of 51.52 ± 0.41 years. Based on the available data, 46.63% of patients were male. Black patients were more likely to be recommended against surgery, while Asian or Pacific Islander patients were more likely to be recommended for surgery. Postoperative course and outcome showed mixed results, with some studies reporting higher rates of transient diabetes insipidus and stroke in racial minority populations. Private hospitals admitted more White patients, and certain racial groups had reduced access to high-volume centers. SES disparities were assessed in terms of insurance and income. Patients with government insurance or without insurance were more likely to be recommended active surveillance instead of definitive treatment. Furthermore, high SES was associated with a higher likelihood of receiving surgical treatment, better treatment outcomes, and better access to high-volume centers. In terms of age and gender disparity, older patients and females were less likely to be recommended for surgical treatment. Age and gender did not consistently impact postoperative course and treatment outcomes, with varying results across studies. No significant age and gender disparities were observed in hospital admissions and charges., Conclusions: This study revealed the presence of disparities in pituitary adenoma surgery based on race, SES, age, and gender. These disparities highlight the need for further research and interventions to ensure equitable access to appropriate surgical treatment and improved outcomes for all patients with pituitary adenomas.

Objective: Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS., Methods: A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS., Results: The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance., Conclusion: These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology., Competing Interests: Competing interests: CA participated in a DSMB for Sobi and OPNA. HB received consulting fees from FirstThought, Guidepoint and Kriya Therapeutics. EMB received research support from AB2Bio and consulting fees from Sobi and Genzyme. SWC received research support from Novartis and AB2Bio, has performed consulting for Simcha and Apollo therapeutics and received travel support from Sobi. RQC has received research support from Sobi, consulting fees from Sironax, speakers’ bureau payments from Sobi and Lilly, participated on the DSMB for Sobi, Pfizer and AbbVie. RG-M has received reseach support from IFM, Lilly, Sobi and Regeneron, and participates on a DSMB for AstraZeneca. AG has received research support from Sobi, Novartis and Novimmune, royalties from UpToDate, consulting fees from Ethos, payments from Novartis for educational materials. LAH has received research support from BMS and Sobi, consulting fees from Sobi, Pfizer and Adaptive Biotechnologies. MH has received research support from Incyte. AH has received honoraria from Sobi and Novartis. RAM has received honoraria for PracticePoint Communications, and participates on the DSMB for Horizon. KEN has received research support from Incyte and owns stock in Incyte. AR has received honoraria from AbbVie, Alexion, Novartis, Pfizer, Reckitt, Benckiser and Sobi. GS has received consulting fees from Sobi and Novartis. SV has received research support from Sobi, consulting fees from Sobi and Novartis., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Erectile dysfunction (ED) is one of the most common urologic problems in men worldwide, with an approximately high incidence rate, significantly affecting patients' quality of life and their sexual partners., Objectives: Due to the association of this disorder with essential diseases such as cardiovascular disease and diabetes, its prevention and treatment are vital for overall human physiologic and psychological health. Along with reviewing the history of treatment and current methods, we seek new approaches to curb this issue in the future., Methods: In this review, investigations were based on the focus of each section's content or conducted on an ad hoc basis. Searches were performed in Scopus and PubMed., Results: In recent years, many treatments for ED have been reported besides oral administration of phosphodiesterase 5 inhibitors such as sildenafil and tadalafil (approved by the Food and Drug Administration). Common oral medications, intracavernous injections, herbal therapies (eg, herbal phosphodiesterase 5 inhibitors), and topical/transdermal medications are routine ED treatment approaches. Moreover, some novel medications are innovative candidates for completing ED's treatment protocols: stem cell injection, low-intensity extracorporeal shock wave therapy, platelet-rich plasma injection, gene therapy, amniotic fluid matrices, rho-kinase inhibitors, melanocortin receptor antagonists, maxi-K channel activators (ie, large-conductance calcium-activated potassium channels), guanylate cyclase activators, and nitric oxide donors., Conclusion: Due to the importance of this complicated problem in men's society, a faster course of treatment trends toward new methods is needed to increase efficiency. Combining the mentioned treatments and attentively examining their efficacy through programmed clinical trials can be a big step toward solving this global problem., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Although surveillance systems used to mitigate disasters serve essential public health functions, communities of color have experienced disproportionate harms (eg, criminalization) as a result of historic and enhanced surveillance., Methods: To address this, we developed and piloted a novel, equity-based scoring system to evaluate surveillance systems regarding their potential and actual risk of adverse effects on communities made vulnerable through increased exposure to policing, detention/incarceration, deportation, and disruption of access to social services or public resources. To develop the scoring system, we reviewed the literature and surveyed an expert panel on surveillance to identify specific harms (eg, increased policing) that occur through surveillance approaches., Results: Scores were based on type of information collected (individual and/or neighborhood level) and evidence of sharing information with law enforcement. Scores were 0 (no risk of harm identified), 1 (potential for risk), 2 (evidence of risk), and U (data not publicly accessible). To pilot the scoring system, 44 surveillance systems were identified between June 2020 and October 2020 through an environmental scan of systems directly related to COVID-19 (n=21), behavioral and health-related services (n=11), and racism and racism-related factors (n=12). A score of 0-2 was assigned to 91% (n=40) of the systems; 9% were scored U; 30% (n=13) scored a 0. Half scored a 1 (n=22), indicating a "potential for the types of harm of concern in this analysis." "Evidence of harm," a score of 2, was found for 12% (n=5)., Conclusions: The potential for surveillance systems to compromise the health and well-being of racialized and/or vulnerable populations has been understudied. This project developed and piloted a scoring system to accomplish this equity-based imperative. The nobler pursuits of public health to improve the health for all must be reconciled with these potential harms., Competing Interests: Conflict of Interest No conflicts of interest reported by authors.

This paper studies the effects of the enactment of birth registration laws, as the official universal and uniform method of recording births, across US states in the first decades of the 20th century on old-age longevity for children affected by these laws. We show that establishing birth registration laws has long-term benefits for old-age health. The benefits are primarily driven by states with an effective child labor policy, suggesting that registering births helps the enforcement of child labor laws which in turn operate as the mechanism channel to improve old-age longevity. A treatment-on-treated calculation suggests an increase of 0.6 years of longevity from not working during childhood due to the birth registration law., (© 2022 The Authors. Health Economics published by John Wiley & Sons Ltd.)

Background: Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment., Methods: We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021., Results: A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process., Conclusion: Our findings highlight the need for having holistic approaches to assess community's health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal-assessment of the community health needs assessment impacts., (© 2023. The Author(s).)

Medical uninsurance (MU) is associated with cancer disparities, particularly among underprivileged and minority sections of the United States. In this cross-sectional study of National Health and Nutritional Examination Survey (NHANES) data from 2013 to 2018, we evaluated sociodemographic attributes of MU disparity in the US cancer population. Those aged ≥20 years with a history of cancer and disclosed MU status were included. We calculated the descriptive statistics of the population stratified by insurance type and performed bivariate and multivariate logistic regression models to assess the association of sociodemographic attributes and MU and reported unadjusted (UOR) and adjusted odds ratios (AOR). Among the 1681 participants (US estimated, 25,982,352), 4.3% ± 0.62 were uninsured. Uninsured individuals were 13.5-year younger, largely female, less educated, and non-US born compared to insured individuals. Age (UOR: 0.94, 95% CI: 0.93-0.96), female sex (UOR: 3.53, 95% CI: 1.73-7.19), Hispanics (UOR: 4.30, 95% CI: 2.45-7.54),

Aspergillus species are capable of causing both invasive disease and chronic infections in immunocompromised patients or those with preexisting lung conditions. Aspergillus fumigatus is the most commonly cultured species, and there is increasing concern regarding resistance to the azoles, which are the mainstays of antifungal therapy against aspergillosis. We evaluated the species distribution and susceptibility profiles of isolates within Aspergillus section Fumigati in the United States over a 52-month period. Species identification was performed by combined phenotypic characteristics and DNA sequence analysis, and antifungal susceptibility testing was performed by CLSI M38 broth microdilution for amphotericin B, the azoles, and the echinocandins. The entire CYP51A gene and its promoter were also sequenced in isolates that were phenotypically resistant to the azoles. During the study time frame, 2,138 isolates were included, representing 11 different species within Aspergillus section Fumigati , of which A. fumigatus was the most prevalent (96.91%). Overall, amphotericin B and the echinocandins demonstrated consistent in vitro activity with very few isolates demonstrating reduced susceptibility to these agents. Voriconazole, isavuconazole, and posaconazole also demonstrated good in vitro activity, and the overall percentages of isolates classified as resistant or non-wild type ranged from 3.33 to 6.58%. Mutations within the CYP51A gene leading to amino acid changes associated with azole resistance were found in 75.3% of isolates that were phenotypically resistant or non-wild type and included both those associated with chronic clinical exposure and environmental exposure to the azoles. Further studies are warranted to continue to monitor for azole-resistant A. fumigatus within the United States.

Study Design: Retrospective., Objective: The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between Black and White patients undergoing operative treatment for ASD in the United States., Summary of Background Data: Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients., Methods: Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the nationwide inpatient sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for Black patients and White patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status., Results: From 2004 to 2014, ASD utilization for Black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for White patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (P-trend < 0.001). There were no significant differences in complication rates or rates of prolonged hospital stay between Black and White patients across the time period studied (P > 0.05 for both)., Conclusion: Although Black and White patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between White and Black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of SARS-CoV-2 infection. Recommendations are also provided for children with hyperinflammation during COVID-19, the acute, infectious phase of SARS-CoV-2 infection., Methods: The Task Force is composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting., Results: The guidance was approved in June 2020 and updated in November 2020 and October 2021, and consists of 41 final guidance statements accompanied by flow diagrams depicting the diagnostic pathway for MIS-C and recommendations for initial immunomodulatory treatment of MIS-C., Conclusion: Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available., (© 2022 American College of Rheumatology.)

This paper investigates the effects of the introduction of Medicaid during the 1960s on next generations' birth outcomes. A federal mandate that all states must widen the coverage to all cash welfare recipients generated cross-state variations in Medicaid eligibility, specifically among nonwhites who largely overrepresented the target population. I implement a reduced-form difference-in-differences strategy that compares the birth outcomes of mothers born in states with higher cash welfare recipiency versus low welfare recipiency and different years relative to the Medicaid implementation year. Using Natality data (1970-2004), I find that Medicaid significantly improves birth outcomes. The effects are considerably larger among nonwhites, specifically blacks. The effects do not appear to be driven by preexisting trends in birth outcomes, preexisting trends in households' socioeconomic characteristics, changes in other welfare expenditures, and selective fertility. A back-of-an-envelope calculation points to a minimum of 3.9% social externality of Medicaid through income rises due to next generations' improvements in birth outcomes., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Summary of Background: Multiple sclerosis (MS) is a chronic inflammatory disease that can cause physical and neurological dysfunction. Patients with MS are living longer and undergoing more orthopedic procedures, but the risk of patients with MS undergoing posterior lumbar fusion (PLF) has not been studied in literature before., Objective: This study aims to (1) analyze the rates of postoperative complications of MS patients undergoing primary PLF and (2) analyze the economic burden associated with these surgeries in the MS population compared with patients without MS., Methods: A retrospective review of the Medicare database was conducted on all patients who underwent PLF and/or posterior lumbar interbody fusion between the years of 2006 and 2013. Cases involving same-day anterior or revision procedures and patients with a history of spine, infection, and trauma, or neoplasm were excluded from the study. Demographics, comorbidities, 90-day postoperative complications, cost, and length of stay were calculated. All outcomes of interest were analyzed using multivariate logistic regression, adjusting for age, sex, and comorbidity burden. Significance was defined as P-value <0.05., Results: There were 2363 patients with MS and 23,569 matched controlled patients. We found a significant increase in the risk of sepsis [odds ratio (OR)=1.85, P=0.034], urinary tract infection (OR=1.89, P<0.001), deep vein thrombosis (OR=1.4, P=0.044), 90-day emergency room visit (OR=1.14, P=0.027), and 90-day readmissions (OR=1.20, P=0.011) compared with patients without a history of MS. Patients with MS also incurred $4379 extra in total hospital charge, a $1679 increase in the cost of hospitalization, and an increase in length of stay (4.05 vs. 3.61, P<0.001)., Conclusions: A diagnosis of MS is associated with a significant increase in postoperative complications and higher costs after hospitalization. It is imperative for physicians to understand the risk factors of patients undergoing PLF and/or posterior lumbar interbody fusion with MS to better counsel them about postoperative complications before surgery., Level of Evidence: Level III., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background High triglycerides are associated with atherosclerotic cardiovascular disease (ASCVD) risks. Among patients with advanced chronic kidney disease (CKD), the association of elevated triglycerides with mortality is diminished and, thus, we investigated the relationship of triglycerides with ASCVD and non-ASCVD hospitalizations across CKD stages. Methods and Results The cohort comprised 2 963 176 veterans who received care in 2004 to 2006 (baseline) and were followed up to 2014. Using Cox models, we evaluated baseline and time-varying triglycerides with time to ASCVD or non-ASCVD hospitalizations, stratified by baseline CKD stage, and adjusted for demographics and baseline or time-updated clinical characteristics. The cohort mean±SD age was 63±14 years, with a baseline median (interquartile range) triglycerides level of 127 (87-189) mg/dL, and a quarter had prevalent CKD. There was a linear association between baseline triglycerides and ASCVD risk; however, the risk with high triglycerides ≥240 mg/dL attenuated with worsening CKD stages (reference: triglycerides 120 to <160 mg/dL). Baseline triglycerides were associated with a U-shaped relationship for non-ASCVD events in patients with CKD 3A to 3B. Patients with late-stage CKD had lower to null relationships between baseline triglycerides and non-ASCVD events. Time-varying triglycerides associations with ASCVD were similar to baseline analyses. Yet, the time-varying triglycerides relationship with non-ASCVD events was inverse and linear, where elevated triglycerides were associated with lower risks. Conclusions Associations of higher triglycerides with ASCVD and non-ASCVD events declined across advancing CKD stages, where a lower to null risk was observed in patients with advanced CKD. Studies are needed to examine the impact of advanced CKD on triglycerides metabolism and its association with outcomes in this high-risk population.

Purpose: Nearly all men with prostate cancer treated with androgen receptor (AR) signaling inhibitors (ARSIs) develop resistance via diverse mechanisms including constitutive activation of the AR pathway, driven by AR genomic structural alterations, expression of AR splice variants (AR-Vs), or loss of AR dependence and lineage plasticity termed neuroendocrine prostate cancer. Understanding these de novo acquired ARSI resistance mechanisms is critical for optimizing therapy., Materials and Methods: A novel liquid biopsy technology was used to collect mRNA from circulating tumor cells (CTCs) to measure expression of AR-Vs, AR targets, and neuroendocrine prostate cancer markers. An institutional review board-approved prospective cohort (N = 99) was used to identify patterns of gene expression. Two prospective multicenter phase II clinical trials of ARSIs for men with castration-resistant prostate cancer (ClinicalTrials.gov: NCT01942837 [enzalutamide, N = 21] and NCT02025010 [abiraterone, N = 27]) were used to further validate these findings., Results: Hierarchical clustering of CTC transcripts identified two distinct clusters. Cluster 2 (C2) exhibited increased expression of AR-regulated genes and was associated with worse overall survival (median 8.6 v 22.4 months; P < .01; hazard ratio [HR] = 3.45 [1.9 to 6.14]). In multivariable analysis, C2 was prognostic independent of other clinicopathologic variables. AR-V status was not significant when accounting for C2. Upon further validation in pooled multicenter phase II trials, C2 was associated with worse overall survival (15.2 months v not reached; P < .01; HR = 8.43 [2.74 to 25.92]), prostate-specific antigen progression-free survival (3.6 v 12 months; P < .01; HR = 4.64 [1.53 to 14.11]), and radiographic progression-free survival (2.7 v 40.6 months; P < .01; HR = 4.64 [1.82 to 17.41])., Conclusion: We demonstrate that a transcriptional profile detectable in CTCs obtained from liquid biopsies can serve as an independent prognostic marker beyond AR-V7 in patients with metastatic prostate cancer and can be used to identify the emergence of multiple ARSI resistance mechanisms. This is currently being investigated in additional prospective trials., Competing Interests: Hamid EmamekhooConsulting or Advisory Role: Exelixis, Bayer, Bristol Myers Squibb, Cardinal Health, Seattle GeneticsResearch Funding: Bristol Myers Squibb, Exelixis, Replimune, Merck, Calithera Biosciences, Roche/GenentechTravel, Accommodations, Expenses: DAVA Pharmaceuticals Rana R. McKayConsulting or Advisory Role: Janssen, Novartis, Tempus, Exelixis, Pfizer, Bristol Myers Squibb, Astellas Medivation, Dendreon, Bayer, Sanofi, Merck, Vividion Therapeutics, Calithera Biosciences, AstraZenecaResearch Funding: Pfizer, Bayer, Tempus Xiao X. WeiHonoraria: OncLiveConsulting or Advisory Role: NovartisResearch Funding: Bristol Myers SquibbTravel, Accommodations, Expenses: Corvus Pharmaceuticals Rebecca SilverResearch Funding: Bayer Michael J. MorrisConsulting or Advisory Role: Bayer, Endocyte, Advanced Accelerator Applications, ORIC Pharmaceuticals, Johnson & Johnson, Curium Pharma, AthenexResearch Funding: Bayer, Sanofi, Endocyte, Progenics, Corcept Therapeutics, Roche/Genentech, JanssenTravel, Accommodations, Expenses: Endocyte, Fujifilm Felix Y. FengConsulting or Advisory Role: Astellas, Bayer, BlueEarth Diagnostics, Celgene, EMD Serono, Genentech, Janssen, Myovant, Ryovant, Bristol Myers Squibb, Exact Sciences, Varian, Bluestar Genomics, SerimmunResearch Funding: Zenith Epigenetics Howard I. ScherConsulting or Advisory Role: Janssen, Amgen, Janssen Research & Development, Menarini Silicon Biosystems, WIRB-Copernicus Group, ESSA, Ambry Genetics/Konica Minolta, Pfizer, Bayer, Sun PharmaResearch Funding: Janssen, Illumina, Epic Sciences, Menarini Silicon Biosystems, Thermofisher Scientific BiomarkersPatents, Royalties, Other Intellectual Property: BioNTech—Intellectual Property Rights, Elucida Oncology—Intellectual Property Rights, MabVAX—Intellectual Property Rights, Y-mAbs Therapeutics Inc—Intellectual Property RightsTravel, Accommodations, Expenses: Asterias Biotherapeutics, Menarini Silicon Biosystems, Amgen, WIRB-Copernicus Group, Konica Minolta, ESSA, Prostate Cancer Foundation, Sanofi, Bayer, Phosplatin Therapeutics Dana RathkopfConsulting or Advisory Role: Janssen, Genentech, AstraZeneca, Bayer, Myovant SciencesResearch Funding: Janssen Oncology, Medivation, Celgene, Takeda, Millennium, Ferring, Novartis, Taiho Pharmaceutical, AstraZeneca, Genentech/Roche, TRACON Pharma, Bayer, Phosplatin Therapeutics Scott M. DehmConsulting or Advisory Role: Celgene, Oncternal Therapeutics, Janssen Research & DevelopmentResearch Funding: Janssen Research & Development, Medivation/AstellasPatents, Royalties, Other Intellectual Property: Royalties from licensing genome-engineered prostate cancer cell lines Toni K. ChoueiriEmployment: Dana Farber Cancer HospitalLeadership: Dana Farber Cancer Hospital, NCCN, KidneyCAN, ASCOStock and Other Ownership Interests: Pionyr, Tempest TherapeuticsHonoraria: NCCN, UpToDate, Michael J. Hennessy Associates, ASCO, Harborside Press, Analysis Group, AstraZeneca, Alexion Pharmaceuticals, Sanofi/Aventis, Bayer, Bristol Myers Squibb, Genentech/Roche, GlaxoSmithKline, Merck, Novartis, Peloton Therapeutics, Pfizer, Corvus Pharmaceuticals, Ipsen, Foundation Medicine, Eisai, PlatformQ Health, Clinical Care Options, Navinata Health, Kidney Cancer Association, Exelixis, Prometheus, Lpath, The New England Journal of Medicine, Lancet Oncology, Cerulean Pharma, Alligent, EMD Serono, HERON, Lilly, Janssen Oncology, IQvia, Aveo, NCI GU Steering CommitteeConsulting or Advisory Role: Pfizer, Bayer, Novartis, GlaxoSmithKline, Merck, Bristol Myers Squibb, Roche/Genentech, Eisai, Foundation Medicine, Cerulean Pharma, AstraZeneca, Exelixis, Prometheus, Alligent, Ipsen, Corvus Pharmaceuticals, Lpath, Alexion Pharmaceuticals, Sanofi/Aventis, Peloton Therapeutics, UpToDate, NCCN, Michael J. Hennessy Associates, Analysis Group, Kidney Cancer Association, Clinical Care Options, PlatformQ Health, Navinata Health, Harborside Press, ASCO, The New England Journal of Medicine, Lancet Oncology, EMD Serono, HERON, Lilly, ESMOResearch Funding: Pfizer, Novartis, Merck, Exelixis, TRACON Pharma, GlaxoSmithKline, Bristol Myers Squibb, AstraZeneca, Peloton Therapeutics, Roche/Genentech, Celldex, Agensys, Eisai, Takeda, Prometheus, Ipsen, Corvus Pharmaceuticals, Cerulean Pharma, Seattle Genetics/Astellas, Bayer, Foundation Medicine, Roche, Calithera Biosciences, Analysis Group, NCI, Gateway for Cancer Research, Congressionally Directed Medical Research Programs (DOD)Patents, Royalties, Other Intellectual Property: International Patent Application No. PCT/US2018/058430, titled “Biomarkers of Clinical Response and Benefit to Immune Checkpoint Inhibitor Therapy,” and International Patent Application No. PCT/US2018/12209, titled “PBRM1 Biomarkers Predictive of Anti-Immune Checkpoint Response”Travel, Accommodations, Expenses: Pfizer, Bayer, Novartis, GlaxoSmithKline, Merck, Bristol Myers Squibb, Roche/Genentech, Eisai, Foundation Medicine, Cerulean Pharma, AstraZeneca, Exelixis, Prometheus, Alligent, Ipsen, Corvus Pharmaceuticals, Lpath, Alexion Pharmaceuticals, Sanofi/Aventis, UpToDate, Peloton Therapeutics, NCCN, Michael J. Hennessy Associates, Analysis Group, Kidney Cancer Association, Clinical Care Options, PlatformQ Health, Harborside Press, Navinata Health, The New England Journal of Medicine, Lancet Oncology, EMD Serono, HERON, Lilly, ESMOOther Relationship: Medical writing and editorial assistance support might have been funded by Communications companies funded by pharmaceutical companies such as ClinicalThinking, Health Interactions, Envision Pharma Group, Fishawack Group of Companies, Parexel Susan HalabiEmployment: ASCO Andrew J. ArmstrongHonoraria: Astellas Scientific and Medical Affairs IncConsulting or Advisory Role: Bayer, Dendreon, Pfizer, Astellas Scientific and Medical Affairs Inc, Clovis Oncology, AstraZeneca, Merck, Bristol Myers SquibbResearch Funding: Dendreon, Bayer, Pfizer, Novartis, Janssen Oncology, Astellas Pharma, Gilead Sciences, Roche/Genentech, Bristol Myers Squibb, Constellation Pharmaceuticals, Merck, AstraZeneca, BeiGenePatents, Royalties, Other Intellectual Property: Circulating tumor cell novel capture technologyTravel, Accommodations, Expenses: Astellas Scientific and Medical Affairs Inc Alexander W. WyattHonoraria: Janssen, Astellas Pharma, AstraZeneca, Merck, AstraZeneca CanadaConsulting or Advisory Role: AstraZenecaResearch Funding: ESSA Mary-Ellen TaplinHonoraria: Janssen-Ortho, Clovis Oncology, Astellas Pharma, Incyte, UpToDate, Research to Practice, Pfizer, Bayer, Amgen, AstraZeneca, Progenics, Guidepoint Global, Celgene, Merck, GlaxoSmithKline, Myovant Sciences, Roivant, AbbVie, Arcus Biosciences, Constellation PharmaceuticalsConsulting or Advisory Role: Janssen-Ortho, Bayer, Guidepoint Global, Best Doctors Inc, UpToDate, Clovis Oncology, Research to Practice, Myovant Sciences, Incyte, Pfizer, AstraZeneca, Arcus VenturesResearch Funding: Janssen-Ortho, Medivation, Bayer, PfizerTravel, Accommodations, Expenses: Medivation, Janssen Oncology, Tokai Pharmaceuticals, Astellas Pharma, Incyte, Pfizer, Clovis Oncology, Bayer Shuang G. ZhaoEmployment: Exact Sciences (I)Patents, Royalties, Other Intellectual Property: Patent applications pending with Decipher Biosciences, Exact Sciences Joshua M. LangStock and Other Ownership Interests: Salus DiscoveryConsulting or Advisory Role: Sanofi, Immunomedics, Janssen, Pfizer/Astellas, 4D PharmaResearch Funding: Medivation, Agensys, GlaxoSmithKline, Immunomedics, Bristol Myers Squibb, JanssenPatents, Royalties, Other Intellectual Property: I am listed on the patent on a technology for rare cell capture and analysis. This technology has been licensed by Salus Discovery LLC although no commercial products are availableNo other potential conflicts of interest were reported.

Purpose: To provide an assessment of safety regarding high-dose-rate after-loading brachytherapy (HDR-BT) based on adverse events reported to the OpenFDA, an open access database maintained by the United States Food and Drug Administration (FDA)., Methods: OpenFDA was queried for HDR-BT events between 1993 and 2019. A brachytherapist categorized adverse events (AEs) based on disease site, applicator, manufacturer, event type, dosimetry impact, and outcomes. Important findings are summarized., Results: 372 AEs were reported between 1993 and 2019, with a downwards trend after 2014. Nearly half of AEs (48.9%) were caused by a device malfunction, and 27.4% resulted in patient injury. Breast (49.2%) and Gyn (23.7%) were the most common disease sites of AEs. Applicator breaks cause the majority of AEs (64.2%) and breast balloon implants were the most common applicator to malfunction (38.7%). User error contributed to only 16.7% of events. 11.0% of events required repair of the afterloader. There were no reported staff injuries or patient deaths from an AE, however 24.7% of patients received resultant incorrect radiation dose, 16.4% required additional procedures to rectify the AE, and 3.0% resulted in unintended radiation to staff., Conclusion: The OpenFDA database has shown a decreasing trend in AEs since 2014 for HDR-BT. Most AEs are not caused by user error and do not cause patient injury or incorrect radiation dose. Investigation into methods to prevent failures and improve applicators such as the breast balloon could improve safety. These results support the continued use of HDR-BT as a safe treatment modality for cancer., (Copyright © 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

The global incidence of mucormycosis has increased in recent years owing to higher numbers of individuals at risk for these infections. The diagnosis and treatment of this aggressive fungal infection are of clinical concern due to differences in species distribution in different geographic areas and susceptibility profiles between different species that are capable of causing highly aggressive infections. The purpose of this study was to evaluate the epidemiology and susceptibility profiles of Mucorales isolates in the United States over a 52-month period. Species identification was performed by combined phenotypic characteristics and DNA sequence analysis, and antifungal susceptibility testing was performed by CLSI M38 broth microdilution for amphotericin B, isavuconazole, itraconazole, and posaconazole. During this time frame, 854 isolates were included, representing 11 different genera and over 26 species, of which Rhizopus (58.6%) was the predominant genus, followed by Mucor (19.6%). The majority of isolates were cultured from the upper and lower respiratory tracts (55%). Amphotericin B demonstrated the most potent in vitro activity, with geometric mean (GM) MICs of ≤0.25 μg/ml against all genera with the exception of Cunninghamella species (GM MIC of 1.30 μg/ml). In head-to-head comparisons, the most active azole was posaconazole, followed by isavuconazole. Differences in azole and amphotericin B susceptibility patterns were observed between the genera with the greatest variability observed with isavuconazole. Awareness of the epidemiology of Mucorales isolates and differences in antifungal susceptibility patterns in the United States may aide clinicians in choosing antifungal treatment regimens. Further studies are warranted to correlate these findings with clinical outcomes.

Background: Few studies have compared technical success and effectiveness of transradial access (TRA) versus transfemoral access (TFA) for mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We compared the two approaches for technical success, effectiveness, and outcomes., Methods: We retrospectively compared TRA with TFA for AIS MT at our institute. We additionally performed a systematic review and meta-analysis of studies describing the use of TRA alone or in comparison with TFA for MT. Primary outcomes included rate of successful reperfusion (thrombolysis in cerebral infarction (TICI) > 2b), number of passes, access-site complications, and 3- month mortality and favorable functional outcomes (modified Rankin Scale (mRS) score 0-2)., Results: A total of 222 consecutive patients (TRA=93, TFA=129) were included in our case series. The rate of successful reperfusion was significantly higher for the TFA cohort (91.4% vs 79.6%, P=0.01) with lower mean number of passes (1.8±1.2 vs 2.4±1.6, P=0.014). Three-month mortality in the TFA group was lower (22.1% vs 40.9% for the TRA cohort (P=0.004), with a higher rate of favorable functional outcomes (51.3% vs 34.1%, P=0.015). A meta-analysis of 10 studies showed significant heterogeneity in rates of successful reperfusion (57.1% to 95.6%, heterogeneity=67.55%, P=0.001). None of the previous comparative studies reported 3-month mortality and functional outcomes., Conclusions: This case series demonstrate a higher successful reperfusion rate, fewer passes, lower 3-month mortality, and improved 3-month functional outcomes with TFA. The systematic review highlights the inadequacy of existing evidence. Prospective comparative studies are needed before a 'radial-first' approach can be adopted for stroke intervention., Competing Interests: Competing interests: AHS: Financial interest/investor/stock options/ownership: Adona Medical, Inc., Amnis Therapeutics (purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostream Medical Ltd., Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc., Q’Apel Medical Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular Inc., Sense Diagnostics, Inc., Serenity Medical Inc., Silk Road Medical, Spinnaker Medical, Inc., StimMed, Synchron, Three Rivers Medical Inc., Vastrax, LLC, VICIS, Inc., Viseon Inc.; Consultant/advisory board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc., Integra LifeSciences Corp., Medtronic, MicroVention, Minnetronix Neuro, Inc., Northwest University–DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical Inc., Rapid Medical, Rebound Therapeutics Corp. (purchased by Integra LifeSciences Corp.), Serenity Medical Inc., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates; Principal investigator/steering committee for the following trials: Cerenovus NAPA and ARISE II; Medtronic SWIFT PRIME and SWIFT DIRECT; MicroVention FRED & CONFIDENCE; MUSC POSITIVE; and Penumbra 3D Separator, COMPASS, INVEST, TIGER. JMD: Research grant: National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo; Consulting: Medtronic; Honoraria: Neurotrauma Science, LLC; Shareholder/ownership interests: Cerebrotech, RIST Neurovascular. KVS: Consulting and teaching: Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute; Co-Founder: Neurovascular Diagnostics, Inc. EIL: Shareholder/ownership interests: NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical; National principal investigator/steering committees: Medtronic (merged with Covidien Neurovascular) SWIFT Prime and SWIFT Direct Trials; Honoraria: Medtronic (training and lectures); Consultant: Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed; Advisory board: Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical, Endostream Medical; Site principal investigator: CONFIDENCE study (MicroVention), STRATIS Study—Sub I (Medtronic). MW, JZ, JN, RHD, HHR, AM, JMC, RJVC III, AS: no competing interests disclosed., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The aspects of marriage and relationship and their effect on couples' satisfaction are essential and critical aspects to be explored in this globalized and contemporary world. Since there are no reported meta-analysis and systematic reviews conducted in the last two decades in this area, we aimed to investigate the effect of marriage and relationship programs (MRP) on couples' relationship satisfaction (CRS) and couples' relationship communication (CRC) and also to determine the gender differences if any., Method: In this systematic review and meta-analysis, the randomized clinical trials (RCTs) published between 2000 and July 26, 2019, were retrieved from several online electronic databases such as Medline, Embase, ProQuest, and Cochrane Library. Inclusion and exclusion criteria were developed using the PICO (Population, Intervention, Comparison, Outcome) framework of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The mean differences (MDs) and 95% confidence intervals (CIs) were calculated. The reported summary statistics were calculated as random effects models based on the heterogeneity between the studies model. Funnel plots and the Egger regression test was used to confirm the presence of any publication bias., Results: Of the total 12 intervention studies included, five (5) are education/communication skills programs, three (3) enrichment programs, and four (4) therapy programs. The impact of these programs was investigated on CRS and CRC. Therapy programs had a larger effect than other programs (pooled MD: 0.53 (95% CI = 0.35 to 0.71, I 2 = 71.5% p = 0.0001) and had a larger effect size on wives (pooled MD: 0.53 (95% CI 0.25 to 0.80, I 2 = 74.1% p = 0.0001) than husbands RS (pooled MD: 0.26 (95% CI 0.25 to 0.76, I 2 = 72.4% p = 0.0001). In RC (relationship communication) area, the Enhancement programs showed the small to large effect on CRC (pooled MD: 1.31 (95% CI = 0.13 to 2.50, I 2 = 94.7% p = 0.0001)) and educational programs showed small to medium effect (pooled MD: 0.32 (95% CI = 0.13 to 0.50, I 2 = 74.5% p = 0.0001) on women and no effect on men., Conclusion: Due to the high effect of the therapy programs on CRS and enhancement program on CRC in the current meta-analysis, the priority of their utilizations in interventions, especially by psychologists and mental health professionals, should be emphasized. Therefore, mental health planning in communities to develop MRP and care for couples' health should be given special attention to men's health. Due to the high heterogeneity of the results and with scanty literature in this specific domain, we are uncertain about their actual effect. However, well-designed RCTs with a larger sample size would be beneficial in closely examining the effect of MRPs on CRS and CRC.

Background: Rheumatoid arthritis (RA) is a systemic disease with prominent musculoskeletal manifestations that is associated with increased morbidity and mortality in patients undergoing cervical spine surgery; however, few studies have specifically examined postoperative outcomes in patients with RA following lumbar surgery. The aim of this study was to evaluate whether patients with RA who underwent posterior lumbar fusion experienced increased postoperative complications and economic burden compared with patients without RA., Methods: Patients <85 years old who underwent elective 1- or 2-level instrumented posterior lumbar fusion for degenerative lumbar pathology between 2006 and 2012 were identified in the Medicare insurance claims database. Same-day revisions and cases for spinal infection, malignancy, and trauma were excluded. The resulting cohort was divided into patients with RA before fusion and patients without RA (controls). All outcomes of interest were compared using multivariate regression. Reoperation-free survival at 1- and 2-year follow-up was analyzed used log-rank test. Significance was defined as P < 0.05., Results: RA patients had significantly higher risk of 90-day readmission (odds ratio [OR] = 1.27, P < 0.001), thromboembolic events (OR = 1.39, P = 0.010), sepsis (OR = 2.32, P < 0.001), pneumonia (OR = 1.57, P = 0.001), and wound complications (OR = 1.41, P < 0.001). Reoperation-free survival was significantly lower in RA patients at 2-year follow-up (90.4% vs. 92.4%, P < 0.001). Following adjusted regression, RA independently contributed to a $1491 increase in additional 90-day costs (P < 0.001)., Conclusions: Preexisting RA may increase risk for short-term postoperative medical complications following posterior lumbar fusion, specifically infectious events. In addition, patients with RA have higher rates of subsequent reoperation following index surgery. Patients with RA be should counseled regarding these risks., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: Comprehensive training in ultrasound (US) imaging during radiology residency is crucial if radiologists are expected to maintain a substantial role in this widely used imaging modality. This study aimed to evaluate the current curriculum of US training among radiology residency programs across the country via a nationwide survey., Methods: A 28-question survey was distributed among all academic radiology departments in the United States and their radiology residents. The survey consisted of 4 sections: general demographic information, training information, clinical competency, and adequacy of training (perspective). The Student t test and 1-way analyses of variance were performed to assess statistical significance., Results: Overall, 256 residents from 32 states completed the questionnaire. Only 114 (45%) residents reported having a dedicated rotation for performing US studies. Although 228 (89%) of trainees believed they received adequate experience for interpreting US studies, only 66 (26%) of them had the same belief about performing them. Only 116 (45%) of the residents were comfortable operating the US machines in their departments. Higher years of residency training, having a dedicated rotation for performing US studies, and having more than 10 hours per year of didactic lectures and/or more than 5 hours per year of case conferences dedicated to US had a positive impact on the residents' clinical competency and perspective (all P < .05)., Conclusions: Most radiology residents do not feel confident in performing US examinations by themselves. However, higher clinical competency was reported in the residents who had dedicated rotations for performing US studies and received more hours of US lectures and case conferences throughout their residency., (© 2020 American Institute of Ultrasound in Medicine.)

Background Context: Numerous advances have been made in the field of spine fusion, such as minimally invasive (MIS) or robotic-assisted spine surgery. However, it is unknown how these advances have impacted the cost of care., Purpose: Compare the economic outcomes of lumbar spine fusion between open, MIS, and robot-assisted surgery patients., Study Design/setting: Retrospective review of a single center spine surgery database., Patient Sample: Three hundred sixty propensity matched patients., Outcome Measures: Costs, EuroQol-5D (EQ5D), cost per quality adjusted life years (QALY)., Methods: Inclusion criteria: surgical patients >18 years undergoing lumbar fusion surgery. Patients were categorized into 3 groups based on procedure type: open, MIS, or robotic. Open patients undergoing poster spinal fusion were considered as the control group. MIS patients included those undergoing transforaminal or lateral lumbar interbody fusion with percutaneous screws. Robotic patients were those undergoing robot-assisted fusion. Propensity score matching was performed between all groups for the number of levels fused. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims for ICD-9 codes. For robotic cases, costs were reflective of operational fees and initial purchase cost. Complications and comorbidities and major complications and comorbidities were assessed according to CMS.gov manual definitions. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs per QALY were calculated for both 1 year and life expectancy, assuming no loss of benefit. A 10,000 trial Monte Carlo simulation with probabilistic sensitivity analysis (PSA) assessed our model parameters and costs., Results: Three hundred sixty propensity matched patients (120 open, 120 MIS, 120 robotic) met inclusion criteria. Descriptive statistics for the cohort were: age 58.8±13.5, 50% women, BMI 29.4±6.3, operative time 294.4±119.0, LOS 4.56±3.31 days, estimated blood loss 515.9±670.0 cc, and 2.3±2.2 average levels fused. Rates of post-op complications were significantly higher in robotic cases versus open and MIS (43% vs. 21% and 22% for open and MIS, p<.05). However, revision rates were comparable between all groups (3% open, 3% MIS, 5% robotic, p>.05). After factoring in complications, revisions, and purchasing and operating fees, the costs of robotic cases was significantly higher than both open and MIS surgery ($60,047.01 vs. $42,538.98 open and $41,471.21 MIS). In a subanalysis of 42 patients with baseline (BL) and 1Y EQ5D data, the cost per QALY at 1Y for open, MIS, and robot-assisted cases was $296,624.48, $115,911.69, and $592,734.30. If utility gained was sustained to life expectancy, the cost per QALY was $14,905.75, $5,824.71, $29,785.64 for open, MIS, and robot-assisted cases. Results of the PSA were consistent with MIS surgery having the most incremental cost effectiveness when compared to open and robotic surgery., Conclusions: Numerous advances have been made in the field of spine surgery, however, there has been limited discussion of the effect these advances have on economic outcomes. When matched for levels fused, robot-assisted surgery patients had significantly higher rates of complications and 30% higher costs of surgery compared to minimally invasive and open spine surgery patients. While 1 year economic outcomes were not optimal for robotic surgery cases, the projected costs per QALYs at life expectancy were well below established acceptable thresholds. The above findings may be reflective of an educational learning curve and emerging surgical technologies undergoing progressive refinement., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF., Methods: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed., Results: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality., Conclusions: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The proportion of neurosurgeons facing a malpractice suit each year is highest among all medical and surgical specialties. It is critical for neurosurgeons to understand local malpractice laws because they vary among states. Sovereign immunity, as described in the 11th constitutional amendment, provides absolute immunity to states from being sued by their residents and by other states. A state may waive its sovereign immunity, however, and substitute itself as the defendant in place of a state-employed physician in the court of law. This means that a physician working for a state-funded hospital may not be liable to a malpractice suit. Further provisions of the law allow the state not to pay indemnity beyond a certain limit, which discourages plaintiff attorneys from pursuing indemnity charges against physicians working for state-funded institutions. In this review, the authors describe the concept of sovereign immunity and its implications for the practice of neurosurgery.

Introduction: Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferentiated patient in the emergency department (ED). Our primary objective in this study was to determine the perceived impact of POCUS in high-risk cases presented at emergency medicine (EM) morbidity and mortality (M&M) conferences. Additionally, we sought to identify in which types of patients POCUS might be most useful, and which POCUS applications were considered to be highest yield., Methods: This was a retrospective survey of cases submitted to M&M at an EM residency program that spans two academic EDs, over one academic year. Postgraduate year 4 (PGY) residents who presented M&M cases at departmental sessions were surveyed on perceived impacts of POCUS on individual patient outcomes. We evaluated POCUS use and indications while the POCUS was used., Results: Over the 12-month period, we reviewed 667 cases from 18 M&M sessions by 15 PGY-4 residents and a supervising EM attending physician who chairs the M&M committee. Of these cases, 75 were selected by the M&M committee for review and presentation. POCUS was used in 27% (20/75) of the cases and not used in 73% (55/75). In cases where POCUS was not used, retrospective review determined that if POCUS had been used it would have "likely prevented the M&M" in 45% (25/55). Of these 25 cases, the majority of POCUS applications that could have helped were cardiac (32%, 8/25) and lung (32%, 8/25) ultrasound. POCUS was felt to have greatest potential in identifying missed diagnoses (92%, 23/25), and decreasing the time to diagnosis (92%, 23/25). Patients with cardiopulmonary chief complaints and abnormal vital signs were most likely to benefit. There were seven cases (35%, 7/20, 95% CI 15-59%) in which POCUS was performed and thought to have possibly adversely affected the outcome of the M&M., Conclusion: POCUS was felt to have the potential to reduce or prevent M&M in 45% of cases in which it was not used. Cardiac and lung POCUS were among the most useful applications, especially in patients with cardiopulmonary complaints and in those with abnormal vital signs.

Study Design: Retrospective review., Objective: To analyze the indications, incidence of minor and major complications, and rate of subsequent spinal surgery or revision after spinal cord stimulator (SCS) placement for degenerative spine disease., Summary of Background Data: Despite the application of SCS in various chronic pain conditions, there remains a growing debate on the efficacy and necessity of SCS in degenerative spine disease., Methods: A nationally representative sample of Medicare patients who had an open (via laminectomy) SCS placement for degenerative spine disease between 2005 and 2014 were studied. Indications, complications, and the rate of subsequent spinal surgery within 90 days, one year, two years, and three years postoperatively were studied using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes., Results: We included 12,297 SCS patients in our study cohort. The most common indications for SCS placement were postlaminectomy syndrome (25.2%) and chronic pain syndrome (20.2%). There was a 4.2 and 17.2% incidence of postoperative back or spine emergency department (ED) visits, and a 0.3 and 3.4% incidence of SCS electrode removal or reimplantation within 90 days and 1 year, respectively. Other reported surgical complications were wound infection (4.3%), hematoma (0.5%), and seroma (0.4%) at one year postoperatively. Within 90 days after SCS implantation, the rate of subsequent spine surgery or revision was 0.9%. This incidence was 7.1, 11.7, and 15.5% at one, two, and three years, respectively., Conclusions: In our retrospective analysis of Medicare patients, the most common indication for SCS implantation was postlaminectomy syndrome. Common postoperative complications included wound infection, and removal of SCS electrodes at one year postoperatively. About 17% patients had an ED visit for spine-related symptoms within one year of device implantation, and 15.5% underwent subsequent spinal decompression and/or fusion within 3 years after primary SCS placement., (© 2019 International Neuromodulation Society.)

Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called "never events." The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients: >18 y/o undergoing elective spine surgery were identified in the American College of Surgeons' NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced >1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p < 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p < 0.001) and UTI (1.3%vs1.1%, p < 0.001) but lower rates of VTE (0.8%vs1.6%, p < 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p < 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Intracerebral hemorrhage (ICH) is associated with a significant mortality of up to 50%, with almost all survivors suffering from debilitating functional compromise. In most cases, open craniotomy has failed to yield significant survival benefit. However, emerging evidence suggests that minimally invasive surgery (MIS) may yield clinically significant improvements in patient survival and quality of life in cases where open craniotomy has not shown benefit., Case Presentation: We report the first documented usage of a side-cutting-aspiration device via an endoscopic approach for the evacuation of a 56cc hematoma, which was a technical modification on previous MIS techniques. The patient is a 50-yr-old female who was transferred emergently to our center with a National Institutes of Health Stroke Scale score of 27 and found to have a large hematoma involving her left basal ganglia. A minimally-invasive approach was elected due to evidence on the risks and suboptimal outcomes of open craniotomy in ICH evacuation. Neuronavigation was used to plan the surgical trajectory for ICH access. Evacuation took place in three main steps: 1) beginning at the center of the clot to remove bulk; 2) mobilizing clots from parenchymal walls to a safe zone via aspiration, followed by clot homogenization; and 3) re-expansion of the cavity via continuous irrigation to allow visualization of further clots. A final inspection was performed to ensure removal of all clots that could be safely removed. The dual functionalities of the device, namely, suction only and suction plus side-cutting functions, enabled key maneuvers, such as clot homogenization and controlled aspiration strength, to be safely performed. A near-total evacuation of the hematoma was achieved without damage to surrounding parenchyma. The patient experienced a rapid clinical course from comatose to discharge-ready in 5 d. At 30-d follow-up, the patient had residual expressive aphasia and was able to ambulate with the assistance of a quad cane. There are no radiographical signs of recurrent hemorrhage or parenchymal injury. Clinical follow-up with this patient is ongoing., Conclusion: This is the first ICH evacuation with a side-cutting-aspiration device via an endoscopic approach. In our patient, this technique proved to be safe and efficacious, suggesting that this technique may be a promising addition to the armamentarium of MIS for ICH evacuation., (Copyright © 2019 by the Congress of Neurological Surgeons.)

As healthcare costs continue to increase in the United States, it is important to understand the trends in the allocation of healthcare spending for common orthopaedic surgical procedures. We investigated the recent trends in (1) total net payments (for episode of care), (2) payments to hospitals, (3) payments to physicians, (4) payments to physicians as a percentage of total net payments, and (5) regional variation in hospital and physician payments for four common orthopaedic procedures., Methods: Using a private insurance claims database, we analyzed the payments to US hospitals and physicians from 2010 to 2016 for primary total hip arthroplasty (THA) (n = 128,269), total knee arthroplasty (TKA) (n = 223,319), 1-level anterior cervical diskectomy and fusion (ACDF) (n = 51,477), and 1-level lumbar-instrumented posterior spinal fusion (PSF) (n = 45,680). Regional variations in payments were also assessed. Trends were analyzed using linear regression models adjusting for age, sex, comorbidities, duration of hospital stay, and inflation (alpha = 0.05)., Results: Inflation-adjusted total net payments for the episode of care increased by the following percentages per year: 5.2% for ACDF, 3.2% for PSF, 2.9% for TKA, and 2.6% for THA. Annual inflation-adjusted hospital payments increased significantly for all 4 procedures, whereas annual inflation-adjusted physician payments decreased by -2.2%/year for PSF, -1.5%/year for TKA, -1.1%/year for THA, and -0.4%/year for ACDF (all, P < 0.001). As a percentage of total net payments, physician payments decreased markedly for ACDF (-4.6%), PSF (-3.1%), TKA (-2.1%), and THA (-1.8%). Hospital and physician payments varied significantly by region and were both highest in the West ( P < 0.001)., Conclusions: From 2010 to 2016, inflation-adjusted total net payments for 4 common orthopaedic surgical procedures increased markedly, as did payments to the US hospitals for these procedures. Payments to orthopaedic surgeons for these procedures decreased markedly during the same period., Competing Interests: None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Hassanzadeh; Dr. Srikumaran, Dr. Ficke, Dr. Levy, and Dr. Jain., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background Context: Obesity has risen to epidemic proportions within the United States. As the rates of obesity have increased, so has its prevalence among patients undergoing adult spinal deformity (ASD) surgery. The effect of obesity on the cost efficiency of corrective procedures for ASD has not been effectively evaluated., Purpose: To investigate differences in cost efficiency of ASD surgery for patients stratified by body mass index (BMI)., Study Design/setting: Retrospective review of a single-center ASD database., Patient Sample: Five hundred five ASD patients., Outcome Measures: Complications, revisions, costs, EuroQol-5D (EQ5D), quality-adjusted life years (QALYs), cost per QALY., Methods: ASD patients (scoliosis≥20°, SVA≥5 cm, PT≥25°, or TK ≥60°) ≥18, undergoing ≥4 level fusions were included. Patients were stratified into NIH-defined obesity groups based on their preoperative BMI: underweight 18.5< (U), normal 18.5 to 24.9 (N), overweight 25.0 to 29.9 (O), obese I 30.0 to 34.9 (OI), obese II 35.0 to 39.9 (OII), and obesity class III 40.0+ (OIII). Total surgery costs for each ASD obesity group were calculated. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims. Overall complications and major complications were assessed according to CMS definitions. QALYs and cost per QALY for obesity groups were calculated using an annual 3% discount up to life expectancy (78.7 years)., Results: In all, 505 patients met inclusion criteria. Baseline demographics and surgical details were: age 60.8±14.8, 67.6% female, BMI 28.8±7.30, 81.0% posterior approach, 18% combined approach, 10.1±4.2 levels fused, op time 441.2±146.1 minutes, EBL 1903.8±1594.7 cc, and LOS 8.7±10.7 days. There were 17 U, 154 N patients, 151 O patients, 100 OI, 51 OII, and 32 OIII patients. Revision rates by obesity group were: 0% U, 3% N patients, 3% O patients, 5% OI, 4% OII, and 6% for OIII patients. The total surgery costs by obesity group were: $48,757.86 U, $49,688.52 N, $47,219.93 O, $50,467.66 OI, $51,189.47 OII, and $53,855.79 OIII. In an analysis of patients with baseline and 1 Y EQ5D follow-up, the cost per QALY by obesity group was: $153,737.78 U, $229,222.37 N, $290,361.68 O, $493,588.47 OI, $327,876.21 OII, and $171,680.00 OIII. If that benefit was sustained to life expectancy, the cost per QALY was $8,588.70 U, $12,805.72 N, $16,221.32 O, $27,574.77 OI, $18,317.11 OII, and $9,591.06 for OIII., Conclusions: Among adult spinal deformity patients, those with BMIs in the obesity I, obesity II, or obesity class III range had more expensive total surgery costs. When assessing 1 year cost per QALY, obese patients had costs 32% higher than nonobese patients ($224,440.61 vs. $331,048.23). Further research is warranted on the utility of optimizing modifiable preoperative health factors for patients undergoing corrective adult spinal deformity surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Although inorganic arsenic in drinking water at high levels (100s-1000s μg/L [ppb]) increases cancer risk (skin, bladder, lung, and possibly prostate), the evidence at lower levels is limited. Methods : We conducted an ecologic analysis of the dose-response relationship between prostate cancer incidence and low arsenic levels in drinking water in a large study of U.S. counties ( N = 710). County arsenic levels were <200 ug/L with median <100 ug/L and dependency greater than 10%. Groundwater well usage, water arsenic levels, prostate cancer incidence rates (2009-2013), and co-variate data were obtained from various U.S. governmental agencies. Poisson and negative-binomial regression analyses and stratified analysis were performed. Results : The best fitting polynomial analysis yielded a J-shaped linear-quadratic model. Linear and quadratic terms were significant ( p < 0.001) in the Poisson model, and the quadratic term was significant ( p < 0.05) in the negative binomial model. This model indicated a decreasing risk of prostate cancer with increasing arsenic level in the low range and increasing risk above. Conclusion s : This study of prostate cancer incidence in US counties with low levels of arsenic in their well-water arsenic levels finds a j-shaped model with decreasing risk at very low levels and increasing risk at higher levels., Competing Interests: Authors declare that they have no conflict of interest.

Background: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery., Methods: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported., Results: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02)., Conclusions: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: In 2008, it was reported that 19.5% of service members previously deployed experienced a mild traumatic brain injury (mTBI). Fifty-seven percent of those did not seek medical care. It was suggested that concerns with seeking care involved confidentiality and career issues. Objective: This study addressed mTBI history, medical treatment history, and stigmas associated with mTBI/concussion., Materials and Methods: An anonymous questionnaire was developed. Data collection occurred throughout March 2018 in conjunction with Brain Injury Awareness Month activities., Results: All 5,174 volunteers were Army; 86% male; 87% were between 18 and 34 years old; 89% had <14 years in the military; 35% had a combat deployment; and 10% reported having one or more mTBIs in their military careers. Of the Soldiers who reported a concussion, 52% sought medical care. Of those not seeking care, 64% reported they did not think the injury required care, followed by 18% fearing negative impact on their career. Twenty-eight percent who experienced an mTBI versus 11% who have not reported that there is a stigma associated with an mTBI., Conclusions: Soldiers sometimes failed to report their suspected concussions and did not seek medical care. Educational efforts may increase reporting of and medical screening for potentially concussive events. Future research to determine the ramifications of unreported and untreated mTBIs/concussions is recommended., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background Context: Although prescribing opioid medication on a limited basis for postoperative pain control is common practice, few studies have focused on chronic opioid use following anterior cervical discectomy and fusion (ACDF)., Purpose: To determine the prevalence of and risk factors for chronic opioid use following one and two-level ACDF for degenerative cervical pathology., Design: Retrospective cohort., Patient Sample: Using an insurance claims database, we identified patients aged 18-64 who underwent one or two-level primary ACDF from 2010 to 2015 for degenerative cervical pathology., Outcome Measures: Opioid prescription strength at various timepoints pre- and postoperatively and development of chronic postoperative opioid use., Methods: Prescription opioid use was examined during the following periods: 90 days before 7 days preceding surgery (preoperative), 6 days preceding surgery to 90 days following surgery (perioperative) and from 91 to 365 days following surgery (postoperative). The primary outcome was chronic postoperative opioid use, defined as ≥120 days' supply of opioid prescriptions filled or ≥10 opioid prescriptions between 3 and 12 months postoperatively. Secondary outcomes were high-dose (>90 morphine milligram equivalents [MME]/day) and very high-dose (>200 MME/day) opioid prescriptions. A multivariate logistic model (area under the ROC curve 0.75, p<.001) was built to predict long-term opioid use., Results: Among 28,813 patients who underwent ACDF, most were female (55%) and underwent single-level ACDF (68%), with mean age of 50±8.0 years. Fifty-two percent of patients filled an opioid prescription in the preoperative period, 95% of patients filled a prescription in the perioperative period, and 39% of patients filled a prescription in the postoperative period. High-dose and very high-dose opioid prescriptions in the perioperative period were identified in 45% and 24% of patients, respectively, whereas 17% met criteria for chronic postoperative opioid use. The odds of chronic opioid use were highest in the Western US (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.3, 1.6). Duration of opioids prescribed was also highest in the Western US (median 111 days, interquartile range 11-336), p<.001. Factors associated with the highest risk for chronic opioid use were preoperative opioid use (OR 5.7, 95% CI 5.3, 56.2), drug abuse (OR 3.5, 95% CI 2.6, 4.5), depression (OR 1.7, 95% CI 1.6, 1.9), anxiety (OR 1.5, 95% CI 1.4, 1.6), and surgery in the western region of the United States (OR 1.5, 95% CI 1.3, 1.6)., Conclusions: Patients undergoing ACDF commonly receive high-dose opioid prescriptions after surgery, and certain patient factors increase risk for chronic opioid use following ACDF. Intervention focusing on patients with these factors is essential to reduce long-term use of prescription opioids and postoperative care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In the general population, elevated triglyceride (TG) levels are an important risk factor for cardiovascular disease and mortality. However, in chronic kidney disease, the association of serum TGs with mortality is less clear., Objective: We sought to examine the association of TGs with mortality across chronic kidney disease (CKD) stages in a large cohort of U.S. veterans., Methods: We examined 2,086,904 U.S. veterans with a TG measurement obtained between a baseline period of October 2004 and September 2006, with follow-up until December 2014 (median [interquartile range {IQR}]: 9.2 [6.5, 9.9] years). Associations of TGs with all-cause and cardiovascular mortality across CKD stages were evaluated using Cox proportional hazard models., Results: Patients were 64 ± 14 years old with a median (IQR) baseline TG of 129 [88, 193] mg/dL and estimated glomerular filtration rate of 76 [61, 91] mL/min/1.73 m 2 . More advanced CKD was associated with higher odds of TGs ≥ 240 mg/dL. Low levels of TGs < 80 mg/dL were associated with a higher risk of mortality across all stages, whereas TG levels ≥ 240 mg/dL were only associated with a higher risk of all-cause mortality in non-CKD and CKD stages 3A, 3B, and 4 (reference: TG 120 to <160 mg/dL). The relationship of higher TGs with mortality incrementally attenuated across worsening stages of CKD and attenuated to the null among patients with CKD stage 5/end-stage renal disease. Similar results were observed for cardiovascular mortality, in strata by age and diabetes, and further adjustment for high-density lipoprotein and low-density lipoprotein., Conclusion: Associations of elevated TGs with all-cause and cardiovascular mortality were incrementally attenuated across more advanced stages of CKD., (Published by Elsevier Inc.)

Pharmacological therapy options for spinal cord injury (SCI) in acute phase have so far been limited, thus we focused on Calcitriol, FDA-approved biologically active form of vitamin D whose neuroprotective effects are increasingly recognized, to ameliorating damage following acute SCI in rats. Calcitriol (1 μg/kg) treatment for 7 consecutive days after SCI was compared SCI control and Sham control rat groups. Calcitriol-treated group had significantly improved outcome in standard functional recovery evaluation test (BBB) 12 weeks after SCI compared to SCI control, which was confirmed by increased ventral horn motor neurons in Calcitriol-treated group. In addition, proliferation test performed on lymphocytes from spleen and lymph nodes one week after SCI showed that calcitriol injection has a significant regulatory effect on Division Index (DI) in response to MBP stimulation compared to control SCI groups, which was associated with significant reduction in IFN-γ and IL-17A secretion and leukocyte infiltration into injury site. Along with confirmation of immunoregulatory aspects of Calcitriol treatment against myelin antigens in SCI, this study has shown that reducing the extent of progressive tissue loss by Calcitriol therapy in acute phase, could result in better recovery after SCI., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: It is not clear if antiarrhythmic drug therapy (AAD) after catheter ablation (CA) of atrial fibrillation (AF) increases mortality., Objective: To determine whether there is an association between AAD therapy and mortality after CA of AF., Methods: There were 3624 consecutive patients with AF (mean age: 59 ± 11 years, women: 27%, paroxysmal AF: 58%). An AAD was used in 2253 patients (62%, AAD group) for a mean duration of 1.3 ± 0.8 years, during a mean follow-up of 6.7 ± 2.2 years after CA of AF. Using propensity score matching, with every 2 patients using an AAD matched to 1 patient who did not use AAD (NO-AAD group), Cox regression models were utilized to assess the association between AAD use (as a time-variable covariate) and all-cause mortality., Results: There were a total of 50 deaths (2.2%) in the AAD and 62 deaths (4.5%) in the NO-AAD groups, respectively (P = .02). At the time of death, 46 of 50 patients (92%) who died in the AAD cohort were still using an AAD (P = .21, compared to baseline use). On multivariate analysis, although the risk of death was not statistically significant between the AAD and NO-AAD cohorts, there was a trend towards mortality benefit with AAD therapy (hazard ratio [HR]: 0.66, 95% confidence interval [CI]: 0.43-1.00, P = .05), regardless of the rhythm or anticoagulation status., Conclusion: AAD use after CA of AF is not associated with an increased risk of mortality, suggesting that when carefully chosen and monitored, AADs appear to be safe after CA of AF., (Copyright © 2019 Heart Rhythm Society. All rights reserved.)

The Department of Defense (DoD) and Department of Veterans Affairs (VA) Infrastructure for Clinical Intelligence (DaVINCI) creates an electronic network between the two United States federal agencies that provides a consolidated view of electronic medical record data for both service members and Veterans. This inter-agency collaboration has created new opportunities for supporting transitions in clinical care, reporting to Congress, and longitudinal research.

Objective: Serum albumin is a marker of malnutrition and inflammation and has been demonstrated as a strong predictor of mortality in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. Yet, whether serum albumin levels in late-stage CKD are associated with adverse outcomes after the transition to ESRD is unknown. We hypothesize that lower levels and a decline in serum albumin in late-stage CKD are associated with higher risk of mortality and hospitalization rates 1 year after transition to ESRD., Design and Methods: This retrospective cohort study included 29,124 US veterans with advanced CKD transitioning to ESRD between 2007 and 2015. We evaluated the association of pre-ESRD (91 days before transition) serum albumin with 12-month post-ESRD all-cause, cardiovascular, and infection-related mortalities and hospitalization rates as well as the association of 1-year pre-ESRD albumin slope and 12-month post-ESRD mortality using hierarchical multivariable adjustments., Results: There was a negative linear association between serum albumin and all-cause mortality, such that risk doubled (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.87, 2.28) for patients with the lowest serum albumin <2.8 g/dL (ref: ≥4.0 g/dL) after full adjustment. A consistent relationship was observed between serum albumin and cardiovascular and infection-related mortality, and hospitalization outcomes. An increase in serum albumin of >0.25 g/dL/year was associated with reduced mortality risk (HR: 0.76, 95% CI: 0.63, 0.91) compared with a slight decline in albumin (ref: >-0.25 to 0 g/dL/year), whereas a decline more than 0.5 g/dL/year was associated with a 55% higher risk in mortality (HR: 1.55, 95% CI: 1.43, 1.68) in fully adjusted models., Conclusions: Lower pre-ESRD serum albumin was associated with higher post-ESRD all-cause, cardiovascular, and infection-related mortalities and hospitalization rates. Declining serum albumin levels in the pre-ESRD period were also associated with worse 12-month post-ESRD mortality., (Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Study Design: A retrospective database analysis among Medicare beneficiaries OBJECTIVE.: The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion., Summary of Background Data: Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail., Methods: The PearlDiver insurance-based database (2005-2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated., Results: Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality [OR = 2.06, 95% confidence interval (95% CI) 1.13-3.78, P = 0.018] and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33-1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41-2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61-9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20-28.46, P < 0.001) but did not significantly impact mortality., Conclusion: Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion., Level of Evidence: 3.

Background Although studies have shown that statin therapy in patients with non-dialysis-dependent chronic kidney disease was associated with a lower risk of death, this was not observed in dialysis patients newly initiated on statins. It is unclear if statin therapy benefits administered during the predialysis period persist after transitioning to end-stage renal disease. Methods and Results In 47 720 veterans who transitioned to end-stage renal disease during 2007 to 2014, we examined the association of statin therapy use 1 year before transition with posttransition all-cause and cardiovascular mortality and hospitalization incidence rates over the first 12 months of follow-up. Associations were examined using multivariable adjusted Cox proportional hazard models and negative binomial regressions. Sensitivity analyses included propensity score and subgroup analyses. The cohort's mean± SD age was 71±11 years, and the cohort included 4% women, 23% blacks, and 66% diabetics. Over 12 months of follow-up, there were 13 411 deaths, with an incidence rate of 35.3 (95% CI , 34.7-35.8) deaths per 100 person-years. In adjusted models, statin therapy compared with no statin therapy was associated with lower risks of 12-month all-cause (hazard ratio [95% CI], 0.79 [0.76-0.82]) and cardiovascular (hazard ratio [95% CI ], 0.83 [0.78-0.88]) mortality, as well as with a lower rate of hospitalizations (incidence rate ratio [95% CI ], 0.89 [0.87-0.92]) after initiating dialysis. These lower outcome risks persisted across strata of clinical characteristics, and in propensity score analyses. Conclusions Among veterans with non-dialysis-dependent chronic kidney disease, treatment with statin therapy within the 1 year before transitioning to end-stage renal disease is associated with favorable early end-stage renal disease outcomes.