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Background: Social determinants of health such as residential segregation have been identified as drivers of disparities in health outcomes; however, this has been understudied for out-of-hospital cardiac arrest (OHCA). We sought to examine whether there were differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander cardiopulmonary resuscitation, using validated measures of racial, ethnic, and economic segregation., Methods: We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival data set. The primary predictor for this study was the Index of Concentration at the Extremes. The primary outcomes were survival to discharge and survival with good neurological status., Results: During the study period, 626 264 had an out-of-hospital cardiac arrest, and patients had a mean age of 62 years (SD 17.2 years). In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in more highly segregated predominately White population and higher-income census tracts as compared with more highly segregated and lower-income Black and Hispanic/Latinx population census tracts. We found that the magnitude of this disparity was 24% for the outcome of survival to discharge as compared with reference (relative risk,1.24 [95% CI, 1.20-1.28])., Conclusions: This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for out-of-hospital cardiac arrest.

Objective: Given the consequences of failed intubation, there is great interest in optimizing airway management success rates. Growing evidence suggests that use of a bougie device is associated with improved airway success. Bougies with a flexible tip may increase intubation success by offering operators greater control. In this study, we performed a feasibility assessment of flexible tip bougies involving clinicians who routinely perform emergency airway management., Methods: We used a feasibility simulation study design with pre- and postsurveys. Participants first completed a presession survey asking about their intubation experience and preferences. They were then given a brief demonstration of the flexible tip bougie with an opportunity to ask questions. They completed 2 intubations on an airway simulator using video laryngoscopy-one with a flexible tip bougie and one with a standard bougie. During these intubations, the time required to pass the bougie through the vocal cords and the time required to pass a tracheal tube through the vocal cords was assessed. Participants finally completed a postsession survey asking about their experiences with the flexible tip bougie., Results: A total of 18 participants took part in the study. All participants rated themselves as familiar with tracheal intubation, and most (72.2%) said that they would consider using a flexible tip bougie on future intubations. Quantitatively, there was no clinically significant difference in the time needed to pass the bougie through the vocal cords (0.38 second) and the time needed to pass a tracheal tube through the vocal cords (8.24 seconds)., Conclusion: Our simulation-based study comparing a flexible tip bougie with a conventional bougie revealed improved operator feedback with the flexible tip bougie and a clinically insignificant temporal difference in intubation metrics. Further study is needed to better assess the benefits of a flexible tip bougie in emergency and nonemergency airway management., Competing Interests: Declaration of competing interest The authors have no relevant disclosures. There was no grant funding or financial support for this manuscript., (Copyright © 2024 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Introduction: Large language models (LLMs) have grown in popularity in recent months and have demonstrated advanced clinical reasoning ability. Given the need to prioritize the sickest patients requesting emergency medical services (EMS), we attempted to identify if an LLM could accurately triage ambulance requests using real-world data from a major metropolitan area., Methods: An LLM (ChatGPT 4o Mini, Open AI, San Francisco, CA, USA) with no prior task-specific training was given real ambulance requests from a major metropolitan city in the United States. Requests were batched into groups of four, and the LLM was prompted to identify which of the four patients should be prioritized. The same groupings of four requests were then shown to a panel of experienced critical care paramedics who voted on which patient should be prioritized., Results: Across 98 groupings of four ambulance requests (392 total requests), the LLM agreed with the paramedic panel in most cases (76.5 %, n = 75). In groupings where the paramedic panel was unanimous in their decision (n = 48), the LLM agreed with the unanimous panel in 93.8 % of groupings (n = 45)., Conclusions: Our preliminary analysis indicates LLMs may have the potential to become a useful tool for triage and resource allocation in emergency care settings, especially in cases where there is consensus among subject matter experts. Further research is needed to better understand and clarify how they may best be of service., Competing Interests: Declaration of competing interest The authors of this document have no relevant conflicts of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Large language models (LLMs) can optimize clinical workflows; however, the economic and computational challenges of their utilization at the health system scale are underexplored. We evaluated how concatenating queries with multiple clinical notes and tasks simultaneously affects model performance under increasing computational loads. We assessed ten LLMs of different capacities and sizes utilizing real-world patient data. We conducted >300,000 experiments of various task sizes and configurations, measuring accuracy in question-answering and the ability to properly format outputs. Performance deteriorated as the number of questions and notes increased. High-capacity models, like Llama-3-70b, had low failure rates and high accuracies. GPT-4-turbo-128k was similarly resilient across task burdens, but performance deteriorated after 50 tasks at large prompt sizes. After addressing mitigable failures, these two models can concatenate up to 50 simultaneous tasks effectively, with validation on a public medical question-answering dataset. An economic analysis demonstrated up to a 17-fold cost reduction at 50 tasks using concatenation. These results identify the limits of LLMs for effective utilization and highlight avenues for cost-efficiency at the enterprise scale., Competing Interests: Competing interests Girish Nadkarni is an Associate Editor for NPJ Digital Medicine. The authors declare no competing interests., (© 2024. The Author(s).)

Background: Social determinants of health (SDOH) are critical drivers of health disparities and patient outcomes. However, accessing and collecting patient-level SDOH data can be operationally challenging in the emergency department (ED) clinical setting, requiring innovative approaches., Objective: This scoping review examines the potential of AI and data science for modeling, extraction, and incorporation of SDOH data specifically within EDs, further identifying areas for advancement and investigation., Methods: We conducted a standardized search for studies published between 2015 and 2022, across Medline (Ovid), Embase (Ovid), CINAHL, Web of Science, and ERIC databases. We focused on identifying studies using AI or data science related to SDOH within emergency care contexts or conditions. Two specialized reviewers in emergency medicine (EM) and clinical informatics independently assessed each article, resolving discrepancies through iterative reviews and discussion. We then extracted data covering study details, methodologies, patient demographics, care settings, and principal outcomes., Results: Of the 1047 studies screened, 26 met the inclusion criteria. Notably, 9 out of 26 (35%) studies were solely concentrated on ED patients. Conditions studied spanned broad EM complaints and included sepsis, acute myocardial infarction, and asthma. The majority of studies (n=16) explored multiple SDOH domains, with homelessness/housing insecurity and neighborhood/built environment predominating. Machine learning (ML) techniques were used in 23 of 26 studies, with natural language processing (NLP) being the most commonly used approach (n=11). Rule-based NLP (n=5), deep learning (n=2), and pattern matching (n=4) were the most commonly used NLP techniques. NLP models in the reviewed studies displayed significant predictive performance with outcomes, with F1-scores ranging between 0.40 and 0.75 and specificities nearing 95.9%., Conclusions: Although in its infancy, the convergence of AI and data science techniques, especially ML and NLP, with SDOH in EM offers transformative possibilities for better usage and integration of social data into clinical care and research. With a significant focus on the ED and notable NLP model performance, there is an imperative to standardize SDOH data collection, refine algorithms for diverse patient groups, and champion interdisciplinary synergies. These efforts aim to harness SDOH data optimally, enhancing patient care and mitigating health disparities. Our research underscores the vital need for continued investigation in this domain., (© Ethan E Abbott, Donald Apakama, Lynne D Richardson, Lili Chan, Girish N Nadkarni. Originally published in JMIR Medical Informatics (https://medinform.jmir.org).)

Competing Interests: 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.

Background: A growing body of evidence suggests outcomes for cardiac arrest in adults are worse during nights and weekends when compared with daytime and weekdays. Similar research has not yet been carried out in the infant setting., Methods: We examined the National Emergency Medical Services Information System (NEMSIS), a database containing millions of emergency medical services (EMS) runs in the United States. Inclusion criteria were infant out-of-hospital cardiac arrests (patients <1 years old) taking place prior to EMS arrival between January 2021 and December 2022 where EMS documented whether return of spontaneous circulation (ROSC) was achieved. Cardiac arrests were classified as occurring during either the day (defined as 0800-1959) or the night (defined as 2000-0759) and weekends (Saturday/Sunday) or weekdays (Monday-Friday). Rates of ROSC achievement were compared., Results: A total of 8549 infant cardiac arrests met inclusion criteria: 5074 (59.4%) took place during daytime compared with 3475 (40.6%) during nighttime, and 5989 (70.1%) arrests occurred on weekdays compared with 2560 (29.9%) on weekends. Rates of ROSC achievement were significantly lower on weekends versus weekdays (16.8% vs. 14.1%; p = 0.00097). A difference in ROSC rates when comparing daytime and nighttime was seen, but this difference was not statistically significant (16.4% vs. 15.3%; p = 0.08076)., Conclusion: ROSC achievement rates for infant out-of-hospital cardiac arrest are significantly lower on weekends when compared with weekdays. Further study and quality improvement work is needed to better understand this., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Helicopter emergency medical services (HEMS) are used in the United States and globally to respond to patients with critical illness and victims of traumatic injury. Relatively limited research has examined their role in responding to out-of-hospital cardiac arrests (OHCA) in the United States. In this study, we compared OHCA treated by HEMS units with cardiac arrests treated by ground ambulances., Methods: We queried a large national-level database of emergency medical services (EMS) activations in the United States (NEMSIS). Inclusion criteria were OHCA activations between January 1, 2022 and December 31, 2022 treated by either HEMS or ground ambulance. Key arrest data from both groups were then compared. Interfacility transfers and cardiac arrests after EMS arrival were excluded., Results: A total of 1,233 cardiac arrests treated by HEMS and 341,096 cardiac arrests treated by ground ambulances met inclusion criteria. Comparing the two groups, cardiac arrests with HEMS response were more likely to be male (66.7% vs. 62.8%, p < 0.01), White (50.2% vs. 45.7%, p < 0.01), under 18 years old (10.9% vs. 2.7%, p < 0.001), associated with traumatic injury (19.1% vs. 5.7%, p < 0.001), witnessed (72.7% vs. 37.3%, p < 0.001), and initially-shockable (24.7% vs. 11.1%, p < 0.001)., Conclusion: Our comparison of cardiac arrests treated by HEMS with cardiac arrests treated by ground ambulance reveals significant differences between the two groups. Further research is needed to better characterize HEMS' ideal role in the response to OHCA as new prehospital resuscitative techniques for non-traumatic and traumatic cardiac arrest are developed., Competing Interests: 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., (© 2024 The Author(s).)

Background: Residential segregation has been identified as drivers of disparities in health outcomes, but further work is needed to understand this association with clinical outcomes for out-of-hospital cardiac arrest (OHCA). We utilized Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine if there are differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander CPR, using validated measures of racial, ethnic, and economic segregation., Methods: We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine associations among adult OHCA patients. The primary predictor was the Index of Concentration at the Extremes (ICE), a validated measure that includes race, ethnicity, and income across three measures at the census tract level. The primary outcomes were survival to discharge and survival with good neurological status. A multivariable modified Poisson regression modeling approach with random effects at the EMS agency and hospital level was utilized., Results: We identified 626,264 OHCA patients during the study period. The mean age was 62 years old (SD 17.2 years), and 35.7% (n =223,839) of the patients were female. In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in predominately White population census tracts and higher income census tracts as compared to lower income Black and Hispanic/Latinx population census tracts (RR 1.24, CI 1.20-1.28) and a 32% increased likelihood of receiving bystander CPR in higher income census tracts as compared to reference (RR 1.32, CI 1.30-1.34)., Conclusions: In this study examining the association of measures of residential segregation and OHCA outcomes, there was an increased likelihood of survival to discharge, survival with good neurological status, and likelihood of receiving B-CPR for those patients residing in predominately White population and higher income census tracts when compared to predominately Black and/or Hispanic Latinx populations and lower income census tracts. This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for OHCA.

Background: Machine learning clustering offers an unbiased approach to better understand the interactions of complex social and clinical variables via integrative subphenotypes, an approach not studied in out-of-hospital cardiac arrest (OHCA)., Objective: We conducted a cluster analysis for a cohort of OHCA survivors to examine the association of clinical and social factors for mortality at 1 year., Methods: We used a retrospective observational OHCA cohort identified from Medicare claims data, including area-level social determinants of health (SDOH) features and hospital-level data sets. We applied k-means clustering algorithms to identify subphenotypes of beneficiaries who had survived an OHCA and examined associations of outcomes by subphenotype., Results: We identified 27,028 unique beneficiaries who survived to discharge after OHCA. We derived 4 distinct subphenotypes. Subphenotype 1 included a distribution of more urban, female, and Black beneficiaries with the least robust area-level SDOH measures and the highest 1-year mortality (2375/4417, 53.8%). Subphenotype 2 was characterized by a greater distribution of male, White beneficiaries and had the strongest zip code-level SDOH measures, with 1-year mortality at 49.9% (4577/9165). Subphenotype 3 had the highest rates of cardiac catheterization at 34.7% (1342/3866) and the greatest distribution with a driving distance to the index OHCA hospital from their primary residence >16.1 km at 85.4% (8179/9580); more were also discharged to a skilled nursing facility after index hospitalization. Subphenotype 4 had moderate median household income at US $51,659.50 (IQR US $41,295 to $67,081) and moderate to high median unemployment at 5.5% (IQR 4.2%-7.1%), with the lowest 1-year mortality (1207/3866, 31.2%). Joint modeling of these features demonstrated an increased hazard of death for subphenotypes 1 to 3 but not for subphenotype 4 when compared to reference., Conclusions: We identified 4 distinct subphenotypes with differences in outcomes by clinical and area-level SDOH features for OHCA. Further work is needed to determine if individual or other SDOH domains are specifically tied to long-term survival after OHCA., (© Ethan E Abbott, Wonsuk Oh, Yang Dai, Cole Feuer, Lili Chan, Brendan G Carr, Girish N Nadkarni. Originally published in JMIR Aging (https://aging.jmir.org).)

Background The national impact of racial residential segregation on out-of-hospital cardiac arrest outcomes after initial resuscitation remains poorly understood. We sought to characterize the association between measures of racial and economic residential segregation at the ZIP code level and long-term survival and readmissions after out-of-hospital cardiac arrest among Medicare beneficiaries. Methods and Results In this retrospective cohort study, using Medicare claims data, our primary predictor was the index of concentration at the extremes, a measure of racial and economic segregation. The primary outcomes were death up to 3 years and readmissions. We estimated hazard ratios (HRs) across all 3 types of index of concentration at the extremes measures for each outcome while adjusting for beneficiary demographics, treating hospital characteristics, and index hospital procedures. In fully adjusted models for long-term survival, we found a decreased hazard of death and risk of readmission for beneficiaries residing in the more segregated White communities  and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes across all 3 indices of concentration at the extremes measures (race: HR, 0.87 [95% CI, 0.81-0.93]; income: HR, 0.75 [95% CI, 0.69-0.78]; and race+income: HR, 0.77 [95% CI, 0.72-0.82]). Conclusions We found a decreased hazard of death and risk for readmission for those residing in the more segregated White communities  and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes when using validated measures of racial and economic segregation. Although causal pathways and mechanisms remain unclear, disparities in outcomes after out-of-hospital cardiac arrest are associated with the structural components of race and wealth and persist up to 3 years after discharge.

Background: Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations., Objective: We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians., Methods: This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering., Results: Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period., Conclusions: An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Guidelines recommend outpatient follow-up after emergency department visits for asthma, but factors related to rates of follow-up among the adult population are understudied. We sought to describe patient and community-level predictors of outpatient follow-up after an index ED visit for asthma and evaluate the association between outpatient follow-up visits and subsequent ED revisits. Methods: We conducted a retrospective observational cohort study of adult patients with emergency departments visits for asthma. The primary predictor was time to outpatient follow-up visit within 30 days of the index ED visit. The primary outcome was all-cause ED revisit within 30 days of the index ED visit. Cox proportional hazards regression was utilized to test the association between time to outpatient follow-up and hazard of ED revisit within 30 days. Results: Time to outpatient follow-up visit within 30 days was not significantly associated with hazard of 30-day ED revisit for asthma (HR 1.05; 95% CI 0.69-1.61). However, male patients (HR 1.45; 95% C 1.11-1.89) and smokers (HR 1.67; 95% CI 1.22-2.29) were significantly more likely to have an ED revisit. Conclusion: Younger, Black patients with Medicaid were less likely to receive follow-up care relative to older patients insured by Medicare. While follow-up visits were not associated with 30-day revisit rates, differences by age, race, and insurance status suggest disproportionate barriers to accessing care. Future research may target these subgroups to improve transitions of care after an ED visit for asthma.

Racial and racialized economic residential segregation has been empirically associated with outcomes across multiple health conditions but not yet explored in relation to out-of-hospital cardiac arrest (OHCA). We sought to examine if measures of racial and economic residential segregation are associated with differences in survival to discharge after OHCA for Black and White Medicare beneficiaries. Utilizing age-eligible Medicare fee-for-service claims data from 2013 to 2015, we identified OHCA claims and determined survival to discharge. The primary predictor, residential segregation, was calculated using the index of concentration at the extremes (ICE) for the beneficiary residential ZIP code. Multilevel modified Poisson regression models were used to determine the association of OHCA outcomes and ZIP code level ICE measures. In total, 194,263 OHCA cases were identified among beneficiaries residing in 75% of US ZIP codes. Black beneficiaries exhibited 12.1% survival to discharge, compared with 12.5% of White beneficiaries. In fully adjusted models of the three ICE measures accounting for differences in treating hospital characteristics, there was as high as a 28% (RR 1.28, CI 1.23-1.26) higher relative likelihood of survival to discharge in the most segregated White ZIP codes (Q5) as compared to the most segregated Black ZIP codes (Q1). Racial residential segregation is independently associated with disparities in OHCA outcomes; among Medicare beneficiaries who generated a claim after suffering an OHCA, ICE measures of racial segregation are associated with a lower likelihood of survival to discharge for those living in the most segregated Black and lower income quintiles compared to higher quintiles., (© 2022. The New York Academy of Medicine.)

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost., Methods: We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes., Results: In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001)., Conclusions: The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

Background: There is a movement toward cost savings in healthcare worldwide. Surgeons can affect two main cost variables in an operation (controllable cost): disposables and time. Our hypothesis is that increasing disposable costs do not change outcome or operative time, but simply increases controllable cost., Methods: We retrospectively reviewed patients younger than the age of 18 years undergoing laparoscopic appendectomies for nonperforated appendicitis from January 2013 to November 2016. Data obtained included demographic information in addition to intraoperative details, including disposables used and associated cost, resident participation, operative time, and final pathology. Patients were excluded if perforation was present as confirmed by operative findings or pathology (Kansas City definition). Patients were also excluded if concurrent procedures were performed during the appendectomy., Results: We reviewed 918 patients and excluded 288 for a total of 690. Disposable cost, operative time, and complications were compared between cases with a resident present and those without. Residents did not increase the use of disposables, but did increase operative time and therefore the total controllable cost. Transumbilical laparoscopic-assisted technique was significantly faster with lower controllable cost when compared with all other methods. Using disposable trocars with an endostapler was the second fastest and second lowest controllable cost and retained a significant difference when compared with most other methods. Endoloop methods did not show overall controllable cost savings versus the vast majority of methods., Conclusions: To maximize controllable cost savings, we recommend a transumbilical laparoscopic-assisted appendectomy or a standard three-port laparoscopic appendectomy, with disposable trocars and the endostapler.

Background Context: Cervical disc arthroplasty (CDA) is a motion-preserving procedure that is an alternative to fusion. Proponents of arthroplasty assert that it will maintain cervical motion and prevent or reduce adjacent segment degeneration. Accordingly, CDA, compared with fusion, would have the potential to improve clinical outcomes. Published studies have varying conclusions on whether CDA reduces complications and/or improves outcomes. As many of these previous studies have been funded by CDA manufacturers, we wanted to ascertain whether there was a greater likelihood for these studies to report positive results., Purpose: To critically assess the available literature on cervical arthroplasty with a focus on the time of publication and conflict of interest (COI)., Study Design/setting: Review of the literature., Methods: All clinical articles about CDA published in English through August 1, 2013 were identified on Medline. Any article that presented CDA clinical results was included. Study design, sample size, type of disc, length of follow-up, use of statistical analysis, quality-of-life (QOL) outcome scores, COI, and complications were recorded. A meta-analysis was conducted stratifying studies by COI and publication date to identify differences in complication rates reported., Results: Seventy-four studies were included that investigated 8 types of disc prosthesis and 22 met the criteria for a randomized controlled trial (RCT). All Level Ib RCTs reported superior quality-of-life outcomes for CDA versus anterior cervical discectomy and fusion (ACDF) at 24 months. Fifty of the 74 articles (68%) had a disclosure section, including all Level Ib RCTs, which had significant COIs related to the respective studies. Those studies without a COI reported mean weighted average adjacent segment disease rates of 6.3% with CDA and 6.2% with ACDF. In contrast, the reverse was reported by studies with a COI, for which the averages were 2.5% with CDA and 6.3% with ACDF. Those studies with a COI (n=31) had an overall weighted average heterotopic ossification rate of 22%, whereas those studies with no COI (n=43) had a rate of 46%., Conclusions: Associated COIs did not influence QOL outcomes. Conflicts of interest were more likely to be present in studies published after 2008, and those with a COI reported greater adjacent segment disease rates for ACDF than CDA. In addition, heterotopic ossification rates were much lower in studies with COI versus those without COI. Thus, COIs did not affect QOL outcomes but were associated with lower complication rates., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Complete spinal cord lesions and quadriplegia occur in 50%-84% of patients with bilateral facet dislocation. We present a patient who suffered both bilateral facet dislocation and bilateral pedicle fractures while remaining neurologically intact. Based on this case and our literature review, we hypothesize that bilateral facet dislocations without neurological deficits are accompanied by significant associated fractures that facilitate the maintenance of cervical spine canal patency., Case Report: After a fall down a flight of stairs, an 86-year-old woman presented to the hospital complaining of neck pain. She denied numbness and weakness of her extremities. On physical examination she was neurologically intact without focal sensory or motor deficits and with normal reflexes throughout. Computed tomography (CT) of her neck demonstrated bilateral C5-C6 facet dislocation with locking of the C6 superior articular process dorsal to the C5 inferior articular process, as well as corresponding bilateral C6 pedicle fractures. Additional acute fractures were identified on the thoracic CT. Magnetic resonance imaging demonstrated no spinal cord compression, edema, or hemorrhage. The patient had a C6-C7 anterior cervical discectomy and allograft fusion and a C5-T1 anterior cervical plate with screw fixation., Conclusion: Because bilateral facet dislocations without neurological deficits are rare, the most appropriate surgical intervention is not evident. We believe the best choice as a first step is an anterior cervical discectomy and allograft fusion with plating.