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Purpose: Adults over 50 years of age constitute 11% of new AIDS cases reported (CDC, 2007). In addition to consistent rates of infection among older adults, there is a disproportionate impact of HIV/AIDS on ethnic minority older adults. Despite the steady rise and projections of increase, there is still a paucity of education and prevention programs targeting this population. This article addresses these demographic trends by reporting on findings about HIV/AIDS knowledge, attitudes toward sexuality, risk behaviors, and participation in HIV/AIDS education programs from an ethnically diverse sample of adults 50 years and older. Design and Methods: A purposive sample (N = 249) of ethnically and economically diverse adults 50 years and older were selected from 14 organizations in rural and urban settings in California. They were surveyed to determine their HIV/AIDS knowledge, attitudes toward sexuality, high-risk behaviors, and interest in participating in HIV/AIDS education prevention programs. Results: (a) ethnic minority group participants had lower levels of knowledge; (b) over 50% of the sample believed that they do not have to be concerned about HIV/AIDS infection; and (c) participants who self-identified as Hispanic were overrepresented in the group that is likely or very likely to attend HIV/AIDS education programs. Implications: Older adults of color 50 years and older are sexually active, lack accurate information about HIV/AIDS and are in need of HIV/AIDS education. Methodological issues and recommendations are made concerning ethnically diverse older adults and HIV/AIDS. [ABSTRACT FROM AUTHOR]

This article will provide a technique designed to identify and explore areas of countertransference when working with older adults facing HIV/AIDS. It offers instructors and supervisors a way to teach about countertransference toward older adults facing HIV and AIDS. This technique can be utilized in a variety of gerontological settings such as mental health clinics, multipurpose centers for older adults, as well as classrooms and private practice. [ABSTRACT FROM AUTHOR]

Abstract Background SHANK3 is a protein in the core of the postsynaptic density (PSD) and has a critical role in recruiting many key functional elements to the PSD and to the synapse, including components of α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionic acid (AMPA), metabotropic glutamate (mGlu) and N-methyl-D-aspartic acid (NMDA) glutamate receptors, as well as cytoskeletal elements. Loss of a functional copy of the SHANK3 gene leads to the neurobehavioral manifestations of 22q13 deletion syndrome and/or to autism spectrum disorders. The goal of this study was to examine the effects of haploinsufficiency of full-length Shank3 in mice, focusing on synaptic development, transmission and plasticity, as well as on social behaviors, as a model for understanding SHANK3 haploinsufficiency in humans. Methods We used mice with a targeted disruption of Shank3 in which exons coding for the ankyrin repeat domain were deleted and expression of full-length Shank3 was disrupted. We studied synaptic transmission and plasticity by multiple methods, including patch-clamp whole cell recording, two-photon time-lapse imaging and extracellular recordings of field excitatory postsynaptic potentials. We also studied the density of GluR1-immunoreactive puncta in the CA1 stratum radiatum and carried out assessments of social behaviors. Results In Shank3 heterozygous mice, there was reduced amplitude of miniature excitatory postsynaptic currents from hippocampal CA1 pyramidal neurons and the input-output (I/O) relationship at Schaffer collateral-CA1 synapses in acute hippocampal slices was significantly depressed; both of these findings indicate a reduction in basal neurotransmission. Studies with specific inhibitors demonstrated that the decrease in basal transmission reflected reduced AMPA receptor-mediated transmission. This was further supported by the observation of reduced numbers of GluR1-immunoreactive puncta in the stratum radiatum. Long-term potentiation (LTP), induced either with θ-burst pairing (TBP) or high-frequency stimulation, was impaired in Shank3 heterozygous mice, with no significant change in long-term depression (LTD). In concordance with the LTP results, persistent expansion of spines was observed in control mice after TBP-induced LTP; however, only transient spine expansion was observed in Shank3 heterozygous mice. Male Shank3 heterozygotes displayed less social sniffing and emitted fewer ultrasonic vocalizations during interactions with estrus female mice, as compared to wild-type littermate controls. Conclusions We documented specific deficits in synaptic function and plasticity, along with reduced reciprocal social interactions in Shank3 heterozygous mice. Our results are consistent with altered synaptic development and function in Shank3 haploinsufficiency, highlighting the importance of Shank3 in synaptic function and supporting a link between deficits in synapse function and neurodevelopmental disorders. The reduced glutamatergic transmission that we observed in the Shank3 heterozygous mice represents an interesting therapeutic target in Shank3-haploinsufficiency syndromes.

Study Design: Biomechanical analysis., Objective: To evaluate the depth of subsidence resulting from an expandable interbody cage at varying bone foam densities., Summary of Background Data: Expandable interbody cages have been shown to be associated with increased rates of subsidence. It is critical to evaluate all variables which may influence a patient's risk of subsidence following the placement of an expandable interbody cage., Methods: In the first stage of the study, subsidence depth was measured with 1 Nm of input expansion torque. In the second stage, the depth of subsidence was measured following 150 N output force exerted by an expandable interbody cage. Within each stage, different bone foam densities were analyzed, including 5, 10, 15, and 20 pounds per cubic foot (PCF). Five experimental trials were performed for each PCF material, and the mean subsidence depths were calculated. Trials which failed to reach 150 N output force were considered outliers and were excluded from the analysis., Results: There was an overall decrease in subsidence depth with increasing bone foam density. The mean subsidence depths at 150 N output force were 2.0±0.3 mm for 5 PCF, 1.8±0.2 mm for 10 PCF, 1.1±0.2 mm for 15 PCF, and 1.1±0.2 mm for 20 PCF bone foam. The mean subsidence depths at 1 Nm of input torque were 2.3±0.5 mm for 5 PCF, 2.3±0.5 mm for 10 PCF, 1.2±0.2 mm for 15 PCF, and 1.1±0.1 mm for 20 PCF bone foam., Conclusions: Depth of subsidence was negatively correlated with bone foam density at both constant input torque and constant endplate force. Because tactile feedback of cage expansion into the subsiding bone cannot be reliably distinguished from true expansion of disc space height, surgeons should take bone quality into account when deploying expandable cages., Competing Interests: D.N., V.C., and J.R. are employed by Stryker Spine, who helped to conduct this study. The other authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objectives: This study aimed to (1) evaluate for any temporal trends in the rates of VTE, deep venous thrombosis (DVT), pulmonary embolism (PE), and mortality from 2011 to 2020 and (2) identify the predictors of VTE following lumbar fusion surgery., Methods: Annual incidences of 30-day VTE, DVT, PE, and mortality were calculated for each of the operation year groups from 2011 to 2020. Multivariable Poisson regression was utilized to test the association between operation year and primary outcomes, as well as to identify significant predictors of VTE., Results: A total of 121,205 patients were included. There were no statistically significant differences in VTE, DVT, PE, or mortality rates among the operation year groups. Multivariable regression analysis revealed that compared to 2011, operation year 2019 was associated with significantly lower rates of DVT. Age, BMI, prolonged operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking status, functional dependence, and chronic steroid use were identified as independent predictors of VTE following lumbar fusion. Female sex, Hispanic ethnicity, and outpatient surgery setting were identified as protective factors from VTE in this cohort., Conclusions: Rates of VTE after lumbar fusion have remained mostly unchanged between 2011 and 2020. Older age, higher BMI, longer operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking, functional dependence, and steroid use were independent predictors of VTE after lumbar fusion, while female sex, Hispanic ethnicity, and outpatient surgery were the protective factors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Species detections often vary depending on the survey methods employed. Some species may go undetected when using only one approach in community-level inventory and monitoring programs, which has management and conservation implications. We conducted a comparative study of terrestrial mammal and bird detections in the spring and summer of 2021 by placing camera traps at 30 locations across a large military installation in northern Michigan, USA and testing replicate soil samples from these sites for environmental DNA (eDNA) using an established vertebrate metabarcoding assay. We detected a total of 48 taxa from both survey methods: 26 mammalian taxa (excluding humans, 24 to species and two to genus) and 22 avian taxa (21 to species and one to genus). We detected a relatively even distribution of mammalian taxa on cameras (17) and via eDNA analysis (15), with seven taxa detected from both methods. Most medium-to-large carnivores were detected only on cameras, whereas semi-fossorial small mammals were detected only via eDNA analysis. We detected higher bird diversity with camera traps (18 taxa) compared to eDNA analysis (eight taxa; four taxa were detected with both methods), but cameras alone were most effective at detecting smaller birds that frequently occupy arboreal environments. We also used Bayesian spatial occupancy models for two widely distributed game species (white-tailed deer, Odocoileus virginianus , and ruffed grouse, Bonasa umbellus ) that were moderately detected with both survey methods and found species-specific site use (occupancy) estimates were similar between cameras and eDNA analysis. Concordant with similar studies, our findings suggest that a combination of camera trap and eDNA surveys could be most useful for assessing the composition of terrestrial mammal communities. Camera traps may be most efficient for assessing bird diversity but can be complemented with eDNA analysis, particularly for species that spend considerable time on the ground., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). Ecology and Evolution published by John Wiley & Sons Ltd.)

Background: Lumbar microdiscectomy is a surgical procedure that is frequently used in the treatment of symptomatic lumbar herniation. Differences in outcomes following primary and revision lumbar microdiscectomy have been previously studied, with reports of comparably satisfactory results from the Spine Patient Outcomes Research Trial. In this study, we further investigate these outcomes, including length of stay, bleeding events, and durotomy. We hypothesized that length of stay, incidence of bleeding events, and dural tear would be greater in the revision cohort., Methods: The ACS-National Surgical Quality Improvement Program database was queried for patients undergoing single-level primary and revision lumbar microdiscectomy between 2019 and 2022. Eligibility for inclusion was determined by age >18 years and current procedural terminology codes 63030 and 63042. Patients with preoperative sepsis or cancer were excluded. Length of stay, wound infection, bleeding events requiring transfusion, cerebrospinal fluid leak, dural tear, and neurological injury were compared between the cohorts. Multivariable Poisson regression adjusted for demographics and comorbidities, including age, sex, race, body mass index, diabetes, smoking, and hypertension, was used to determine if revision was predictive of complications., Results: A total of 37,669 patients were included, of whom 3,635 (9.6%) required revision surgery. Patients in the revision cohort were older (54.25 ± 15.7 vs. 50.85 ± 16.0 years, P < 0.001) and had higher proportions of male (59.0% vs. 55.7%, P < 0.001) and non-Hispanic White patients (82.0% vs. 77.4%, P < 0.001). Length of stay (1.11 ± 2.5 vs. 1.58 ± 2.7, P < 0.001) and rates of wound infection (2.1% vs. 1.4%, P = 0.002) and bleeding events requiring transfusion (1.3% vs. 0.7%, P < 0.001) were greater in the revision cohort compared to primary patients. Differences in cerebrospinal fluid leak (0.2% vs. 0.1%, P = 0.116), dural tear complication (0.01% vs. 0.01%, P = 0.092), and neurological injury (0.008% vs. 0.006%, P = 0.691) between the revision and primary cohorts were nonsignificant. Poisson log-linear regression adjusted for demographics and comorbidities demonstrated revision as a significant predictor for length of stay ( χ 2 = 462.95, P < 0.001), wound infection ( χ 2 = 9.22, P = 0.002), and bleeding events ( χ 2 = 9.74, P = 0.002), while it was a nonsignificant predictor of cerebrospinal fluid leak ( χ 2 = 2.61, P = 0.106), dural tear ( χ 2 = 2.37, P = 0.123), and neurological injury ( χ 2 = 0.229, P = 0.632)., Conclusion: Revision surgery was a significant predictor of increased length of stay, wound infection, and bleeding events requiring transfusion. Surgeons and patients alike should be aware of increased risk for complications following revision lumbar microdiscectomy compared to primary discectomy., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Craniovertebral Junction and Spine.)

Spinal fusion is a common method by which surgeons decrease instability and deformity of the spinal segment targeted. Pedicle screws are vital tools in fusion surgeries and advancements in technology have introduced several modalities of screw placement. Our objective was to evaluate the accuracy of pedicle screw placement in robot-assisted (RA) versus fluoroscopic-guided (FG) techniques. The PubMed and Cochrane Library databases were systematically reviewed from January 2007 through to August 8, 2022, to identify relevant studies. The accuracy of pedicle screw placement was determined using the Gertzbein-Robbins (GR) classification system. Facet joint violation (FJV), total case radiation dosage, total case radiation time, total operating room (OR) time, and total case blood loss were collected. Twenty-one articles fulfilled the inclusion criteria. Successful screw accuracy (GR Grade A or B) was found to be 1.02 (95% confidence interval: 1.01 - 1.04) times more likely with the RA technique. In defining accuracy solely based on the GR Grade A criteria, screws placed with RA were 1.10 (95% confidence interval: 1.06 - 1.15) times more likely to be accurate. There was no significant difference between the two techniques with respect to blood loss (Hedges' g: 1.16, 95% confidence interval: -0.75 to 3.06) or case radiation time (Hedges' g: -0.34, 95% CI: -1.22 to 0.53). FG techniques were associated with shorter operating room times (Hedges' g: -1.03, 95% confidence interval: -1.76 to -0.31), and higher case radiation dosage (Hedges' g: 1.61, 95% confidence interval: 1.11 to 2.10). This review suggests that RA may slightly increase pedicle screw accuracy and decrease per-case radiation dosage compared to FG techniques. However, total operating times for RA cases are greater than those for FG cases., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Jung et al.)

Background: The use of shoulder arthroplasty has increased among all age groups, albeit most prominently in older patients. While previous studies have investigated predictors of short-term readmission and reoperation in the general population, there is a paucity of literature available on these in patients under 45 years of age. This study aimed to identify the predictors of 30-day readmission and reoperation following shoulder arthroplasty in patients under 45 years of age., Methods: A retrospective query in the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2019 was used to identify patients who underwent primary reverse and anatomic total shoulder arthroplasty and hemiarthroplasty. Multivariate logistic regression was used to identify predictors of 30-day readmission and reoperation., Results: A total of 530 patients were included. Multivariate regression revealed that Black race and Hispanic ethnicity were independent predictors of readmission. Functional dependence, hypertension requiring medication, and prolonged length of stay predicted reoperation. Finally, low hematocrit and prolonged length of stay predicted morbidity., Discussion: Identifying and accounting for these risk factors for poor outcomes may help improve perioperative risk stratification. As a result, these findings have the potential to reduce healthcare costs associated with readmission and reoperation following shoulder arthroplasty in young patients. Our results also highlight the underlying disparities in healthcare outcomes among racial and ethnic groups that must be considered.

Background: Health literacy is a growing concern because of its effects on communication and health outcomes. One aspect of this communication is the ability of the health care provider to estimate the health literacy of a patient or their caregiver. The objectives of this study are to quantify misestimation of caregiver health literacy by providers and identify potential descriptive or demographic factors that might be related to those misestimations., Methods: Providers were asked to perceive descriptive factors and estimate the health literacy of caregivers in a pediatric Emergency Department. Then, the health literacy of the caregiver was tested using the Short Assessment of Health Literacy, and cross-tabulated with provider estimates., Results: Providers correctly estimated the health literacy of the caregivers 60% of the time, and misestimates were often underestimates (27.7%) rather than overestimates (12.3%). Providers overestimated the health literacy of 24.1% of fathers and only 9.8% of mothers (P = 0.012). They correctly estimated the health literacy of 63.9% of English-speaking caregivers compared with 30.6% of Spanish-speaking caregivers, and underestimated the health literacy of 50% of Spanish-speaking caregivers and 24.8% of English-speaking caregivers (P < 0.001). Providers correctly estimated the health literacy of 34.4% of racially and ethnically diverse caregivers compared with 71.5% of White/non-Hispanic caregivers. They underestimated the health literacy of 52.1% of these racially and ethnically diverse caregivers and 16.8% of White/non-Hispanic caregivers (P < 0.001)., Conclusions: Providers often overestimate and underestimate the health literacy of parents in the pediatric emergency department. Misestimates are related to race, caregiver role, and language spoken by the caregiver. When providers misestimate health literacy, they may use words or phrases that are above or below the health literacy level of the caregiver. These results suggest a need for further health literacy research and interventions in provider education and clinical practice., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background Context: Prior studies have suggested that muscle strength and quality may be associated with low back pain. Recently, a novel magnetic resonance imaging (MRI)-based lumbar muscle health grade was shown to correlate with health-related quality of life scores after spine surgery. However, the potential association between history of lumbar spine surgery and paralumbar muscle health requires further investigation., Purpose: To compare MRI-based paralumbar muscle health parameters between patients with versus without a history of surgery for degenerative lumbar spinal disease., Study Design/setting: Retrospective cohort study., Patient Sample: Consecutive series of patients who presented to the spine surgery clinic of a single surgeon., Outcome Measures: MRI-based measurements of paralumbar cross-sectional area (PL-CSA), Goutallier grade, lumbar indentation value (LIV)., Methods: A retrospective analysis was performed on a consecutive series of patients of a single surgeon, and patients were included based on availability of lumbar MRI. Axial T2-weighted lumbar MRIs were analyzed for PL-CSA, Goutallier classification, and LIV. Measurements were performed at the center of disc spaces from L1 to L5. Patients with and without history of spine surgery were matched based on age, sex, race, ethnicity, and body mass index (BMI) via propensity score matching. Normality of each muscle health variable was assessed using Kolmogorov-Smirnov test. Mann-Whitney U test or independent t-test performed to compare the matched cohorts, as appropriate., Results: A total of 615 patients were assessed. For final analysis, 89 patients with a history of previous spine surgery were matched with 89 patients without a history of spine surgery. There were no statistically significant differences in age, sex, race, ethnicity, or BMI between the matched cohorts. History of spine surgery was generally associated with worse lumbar muscle health. At all 4 intervertebral levels between L1-L5, PL-CSA was significantly smaller among patients with history of spine surgery. At L4-L5, patients with prior spine surgery had significantly smaller PL-CSA/BMI. Patients with prior spine surgery were found to have greater fatty infiltration of the muscles, with higher average Goutallier grades at levels L1-L2, L2-L3, and L4-L5. In addition, history of spine surgery was associated with smaller LIV at L1-L2, L3-L4, and L4-L5., Conclusions: The current study demonstrates that history of lumbar spine surgery is associated with worse paralumbar muscle health based on quantitative and qualitative measurements on MRI. On average, patients with history of spine surgery were found to have smaller cross-sectional areas of the paralumbar muscles, greater amounts of fatty infiltration based on Goutallier classification, and smaller lumbar indentation values., Competing Interests: Declaration of Competing Interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Published by Elsevier Inc.)

Introduction: While there is anecdotal evidence that the coronavirus disease 2019 (COVID-19) pandemic altered perioperative decision-making in patients requiring posterior cervical fusion (PCF), a national-level analysis to examine the significance of this hypothesis has not yet been conducted. This study aimed to determine the potential differences in perioperative variables and surgical outcomes of PCF performed before vs. during the COVID-19 pandemic., Methods: Adults who underwent PCF were identified in the 2019 (prepandemic) and 2020 (intrapandemic) NSQIP datasets. Differences in 30-day readmission, reoperation, and morbidity were evaluated using multivariate logistic regression. On the other hand, differences in operative time and relative value units (RVUs) were estimated using quantile regression. Furthermore, the odds ratios (OR) for length of stay (LOS) were estimated using negative binomial regression. Secondary outcomes included rates of nonhome discharge and outpatient surgery., Results: A total of 3,444 patients were included in this study (50.7% from 2020). Readmission, reoperation, morbidity, operative time, and RVUs per minute were similar between cohorts ( p >0.05). The LOS (OR 1.086, p <0.001) and RVUs-per-case (coefficient +0.360, p =0.037) were significantly greater in 2020 compared to 2019. Operation year 2020 was also associated with lower rates of nonhome discharge (22.3% vs. 25.8%, p =0.017) and higher rates of outpatient surgery (4.8% vs. 3.0%, p =0.006)., Conclusions: During the COVID-19 pandemic, a 28% decreased odds of nonhome discharge following PCF and a 72% increased odds of PCF being performed in an outpatient setting were observed. The readmission, reoperation, and morbidity rates remained unchanged during this period. This is notable given that patients in the 2020 group were more frail. This suggests that patients were shifted to outpatient centers possibly to make up for potentially reduced case volume, highlighting the potential to evaluate rehabilitation-discharge criteria. Further research should evaluate these findings in more detail and on a regional basis., Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest., (Copyright © 2024 The Japanese Society for Spine Surgery and Related Research.)

Study Design: Retrospective database study., Objective: Navigation has been increasingly used to treat degenerative disease, with positive radiographic and clinical outcomes and fewer adverse events and reoperations, despite increased operative time. However, short-term analysis on treating adult spinal deformity (ASD) surgery with navigation is limited, particularly using large nationally represented cohorts. This is the first large-scale database study to compare 30-day readmission, reoperation, morbidity, and value-per-operative time for navigated and conventional ASD surgery., Methods: Adults were identified in the National Surgical Quality Improvement Program (NSQIP) database. Multivariate regression was used to compare outcomes between navigated and conventional surgery and to control for predictors and baseline differences., Results: 3190 ASD patients were included. Navigated and conventional patients were similar. Navigated cases had greater operative time (405 vs 320 min) and mean RVUs per case (81.3 vs 69.7), and had more supplementary pelvic fixations (26.1 vs 13.4%) and osteotomies (50.3 vs 27.7%) ( P <.001).In univariate analysis, navigation had greater reoperation (9.9 vs 5.2%, P = .011), morbidity (57.8 vs 46.8%, P = .007), and transfusion (52.2 vs 41.8%, P = .010) rates. Readmission was similar (11.9 vs 8.4%). In multivariate analysis, navigation predicted reoperation (OR = 1.792, P = .048), but no longer predicted morbidity or transfusion. Most reoperations were infectious and hardware-related., Conclusions: Despite controlling for patient-related and procedural factors, navigation independently predicted a 79% increased odds of reoperation but did not predict morbidity or transfusion. Readmission was similar between groups. This is explained, in part, by greater operative time and transfusion, which are risk factors for infection. Reoperation most frequently occurred for wound- and hardware-related reasons, suggesting navigation carries an increased risk of infectious-related events beyond increased operative time.

Study Design: Retrospective cohort study., Purpose: To compare the relative value units (RVUs) per minute of operative time between primary and revision surgery for adult spinal deformity (ASD)., Overview of Literature: Surgery for ASD is technically demanding and has high risks of complications and revision rates. This common need for additional surgery can increase the overall cost of care for ASD. RVU is used to calculate reimbursement from Medicare and to determine physician payments nationally. In calculating RVUs, the physician's work, the expenses of the physician's practice, and professional liability insurance. Cost effectiveness of surgeries for ASD have been evaluated, except for RVUs per minute compared between primary and revision surgery., Methods: Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients aged ≥18 years who underwent surgery for spinal deformity between 2011 and 2019 were identified and included. To ensure a homogenous patient cohort, those who underwent anterior-only and concurrent anterior-posterior fusions were excluded. Propensity score matching analysis was performed, and Mann-Whitney U test, Pearson chi-square test, or Fisher's exact test were used to compare matched cohorts as appropriate., Results: A total of 326 patients who underwent revision surgery were matched with 206 primary surgery patients via propensity score matching. Demographic characteristics, comorbidities, preoperative laboratory values, and readmission and reoperation rates were not significantly different between groups. The revision surgery group had significantly higher mean RVUs per minute than that of the primary surgery group (0.331 vs. 0.249, p <0.001), as well as rates of morbidity and blood transfusion., Conclusions: Compared to primary surgery, revision surgery for ASD is associated with significantly higher RVUs per minute and total RVUs and higher rates of 30-day morbidity and blood transfusions. Readmission and reoperation rates are similar between surgeries.

Context: Literature on treating pediatric spinal deformity with navigation is limited, particularly using large nationally represented cohorts. Further, the comparison of single-institution data to national-level database outcomes is also lacking., Aim: (1) To compare navigated versus conventional posterior pediatric deformity surgery based on 30-day outcomes and perioperative factors using the National Surgical Quality Improvement Program (NSQIP) database and (2) to compare the outcomes of the NSQIP navigated group to those of fluoroscopy-only and navigated cases from a single-institution., Settings and Design: Retrospective cohort study., Subjects and Methods: Pediatric patients who underwent posterior deformity surgery with and without navigation were included. Primary outcomes were 30-day readmission, reoperation, morbidity, and complications. The second part of this study included AIS patients < 18 years old at a single institution between 2015 and 2019. Operative time, length of stay, transfusion rate, and complication rate were compared between single-institution and NSQIP groups., Statistical Analysis Used: Univariate analyses with independent t -test and Chi-square or Fisher's exact test was used. Multivariate analyses through the application of binary logistic regression models., Results: Part I of the study included 16,950 patients, with navigation utilized in 356 patients (2.1%). In multivariate analysis, navigation predicted reoperation, deep wound infection, and sepsis. After controlling for operative year, navigation no longer predicted reoperation. In Part II of the study, 288 single institution AIS patients were matched to 326 navigation patients from the NSQIP database. Operative time and transfusion rate were significantly higher for the NSQIP group., Conclusions: On a national scale, navigation predicted increased odds of reoperation and infectious-related events and yielded greater median relative value units (RVUs) per case but had longer operating room (OR) time and fewer RVUs-per-minute. After controlling for operative year, RVUs-per-minute and reoperation rates were similar between groups. The NSQIP navigated surgery group was associated with significantly higher operative time and transfusion rates compared to the single-institution groups., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Craniovertebral Junction and Spine.)

Objective: Paralumbar muscle volume has been indicated as an important factor for patients reporting back pain. Our goal was to determine if there is a statistically significant relationship between the duration of patients' back pain symptoms (>12 weeks or ≤12 weeks) and paralumbar muscle volume., Methods: In this retrospective cohort study, paralumbar muscles on axial T2-weighted lumbar magnetic resonance images were outlined using ImageJ to determine the paralumbar cross-sectional area (PL-CSA) and lumbar indentation value (LIV) at the center of disc spaces from L1 to L5. The Goutallier classification was determined by the primary author. Quantile regression was performed to compare the PL-CSA, PL-CSA normalized by body mass index, and LIV between the 2 cohorts. Cohort A consisted of patients reporting symptoms ≤12 weeks, and cohort B included patients with symptoms >12 weeks. Negative binomial regression was used to compare Goutallier class., Results: A total of 551 patients operated on by a single surgeon with lumbar magnetic resonance imaging within the past 12 months and recorded duration of symptoms were included. Cohort A consisted of 229 patients (41.6%), and cohort B included 322 patients (58.4%). Statistical significance was not found at any lumbar level for PL-CSA, PL-CSA normalized by body mass index, Goutallier class, and LIV., Conclusions: Our results suggest that duration of symptoms may not be an accurate indicator for lumbar muscle volume. These novel findings are clinically valuable because lumbar muscle volume has been shown to be a marker for recovery. With this information, patients previously believed to be inoperable because of long-standing symptoms can be reevaluated., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The coronavirus disease 2019 (COVID-19) pandemic has altered the standard of care for spine surgery in many ways. However, there is a lack of literature evaluating the potential changes in surgical outcomes and perioperative factors for spine procedures performed during the pandemic. In particular, no large database study evaluating the impact of the COVID-19 pandemic on spine surgery outcomes has yet been published. Therefore, the aim of this study was to evaluate the impact of the COVID-19 pandemic on perioperative factors and postoperative outcomes of lumbar fusion procedures., Methods: This retrospective cohort study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, which was queried for all adult patients who underwent primary lumbar fusion in 2019 and 2020. Patients were grouped into cohorts based on 2019 (pre-pandemic) or 2020 (intra-pandemic) operation year. Differences in 30-day readmission, reoperation, and morbidity rates were evaluated using multivariate logistic regression. Differences in total relative value units (RVUs), RVUs per minute, and total operation time were evaluated using quantile (median) regression. Odds ratios (OR) for length of stay were estimated via negative binomial regression., Results: A total of 27,446 patients were included in the analysis (12,473 cases in 2020). Unadjusted comparisons of outcomes revealed that lumbar fusions performed in 2020 were associated with higher rates of morbidity, pneumonia, bleeding transfusions, deep venous thrombosis (DVT), and sepsis. 2020 operation year was also associated with longer length of hospital stay, less frequent non-home discharge, higher total RVUs, and higher RVUs per minute. After adjusting for baseline differences in regression analyses, the differences in bleeding transfusions, length of stay, and RVUs per minute were no longer statistically significant. However, operation year 2020 independently predicted morbidity, pneumonia, DVT, and sepsis. In terms of perioperative variables, operation year 2020 predicted greater operative time, non-home discharge, and total RVUs., Conclusions: Lumbar fusion procedures performed amidst the COVID-19 pandemic were associated with poorer outcomes, including higher rates of morbidity, pneumonia, DVT, and sepsis. In addition, surgeries performed in 2020 were associated with longer operative times and less frequent non-home discharge disposition., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-22-45/coif). The authors have no conflicts of interest to declare., (2023 Journal of Spine Surgery. All rights reserved.)

Study Design: A retrospective cohort study., Purpose: To compare 30-day readmission, reoperation, and morbidity for patients undergoing posterior cervical decompression and fusion (PCDF) in inpatient vs. outpatient settings., Overview of Literature: PCDF has recently been increasingly performed in outpatient settings, often utilizing minimally invasive techniques. However, literature evaluating short-term outcomes for PCDF is scarce. Moreover, no currently large-scale database studies have compared short-term outcomes between PCDF performed in the inpatient and outpatient settings., Methods: Patients who underwent PCDF from 2005 to 2018 were identified using the National Surgical Quality Improvement Program database. Regression analysis was utilized to compare primary outcomes between surgical settings and evaluate for predictors thereof., Results: We identified 8,912 patients. Unadjusted analysis revealed that outpatients had lower readmission (4.7% vs. 8.8%, p =0.020), reoperation (1.7% vs. 3.8%, p =0.038), and morbidity (4.5% vs. 11.2%, p <0.001) rates. After adjusting for baseline differences, readmission, reoperation, and morbidity no longer statistically differed between surgical settings. Outpatients had lower operative time (126 minutes vs. 179 minutes) and levels fused (1.8 vs. 2.2) (p <0.001). Multivariate analysis revealed that age (p =0.008; odds ratio [OR], 1.012), weight loss (p =0.045; OR, 2.444), and increased creatinine (p <0.001; OR, 2.233) independently predicted readmission. The American Society of Anesthesiologists (ASA) classification of ≥3 predicted reoperation (p =0.028; OR, 1.406). Rehabilitation discharge (p <0.001; OR, 1.412), ASA-class of ≥3 (p =0.008; OR, 1.296), decreased hematocrit (p <0.001; OR, 1.700), and operative time (p <0.001; OR, 1.005) predicted morbidity., Conclusions: The 30-day outcomes were statistically similar between surgical settings, indicating that PCDF can be safely performed as an outpatient procedure. Surrogates for poor health predicted negative outcomes. These results are particularly important as we continue to shift spinal surgery to outpatient centers. This importance has been highlighted by the need to unburden inpatient sites, particularly during public health emergencies, such as the coronavirus disease 2019 pandemic.

Study Design: Retrospective cohort study., Objective: The aim of this study was to compare the relative value units (RVUs) and 30-day outcomes between primary and revision pediatric spinal deformity (PSD) surgery., Summary of Background Data: PSD surgery is frequently complicated by the need for reoperation. However, there is limited literature on physician reimbursement rates and short-term outcomes following primary versus revision spinal deformity surgery in the pediatric population., Materials and Methods: This study utilizes data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients between 10 and 18 years of age who underwent posterior spinal deformity surgery between 2012 and 2018 were included. Univariate and multivariate regression were used to assess the independent impact of revision surgery on RVUs and postoperative outcomes, including 30-day readmission, reoperation, morbidity, and complications., Results: The study cohort included a total of 15,055 patients, with 358 patients who underwent revision surgery. Patients in the revision group were more likely to be younger and male sex. Revision surgery more commonly required osteotomy (13.7% vs. 8.3%, P =0.002).Univariate analysis revealed higher total RVUs (71.09 vs. 60.51, P <0.001), RVUs per minute (0.27 vs. 0.23, P <0.001), readmission rate (6.7% vs. 4.0%, P =0.012), and reoperation rate (7.5% vs. 3.3%, P <0.001) for the revision surgery group. Morbidity rates were found to be statistically similar. In addition, deep surgical site infection, pulmonary embolism, and urinary tract infection were more common in the revision group. After controlling for baseline differences in multivariate regression, the differences in total RVUs, RVUs per minute, reoperation rate, and rate of pulmonary embolism between primary and revision surgery remained statistically significant., Conclusions: Revision PSD surgery was found to be assigned appropriately higher mean total RVUs and RVUs per minute corresponding to the higher operative complexity compared with primary surgery. Revision surgery was also associated with poorer 30-day outcomes, including higher frequencies of reoperation and pulmonary embolism., Level of Evidence: Level III., Competing Interests: J.S.: teaching fees: Stryker. D.E.: paid consultant: Stryker, DePuy. S.Q.: editorial or governing board: Clinical Orthopaedics and Related Research , Contemporary Spine Surgery , Global Spine Journal , Spine Journal , Annals of Translational Medicine . Paid consultant: Globus Medical, Paradigm Spine, Stryker. IP royalties: Globus Medical, Stryker. Paid presenter or speaker: Globus Medical. Stock or stock options: Avaz Surgical, Vital 5 (past). Board or committee member: Association of Bone and Joint Surgeons, Cervical Spine Research Society, Healthgrades, International Society for the Advancement of Spine Surgery (ISASS), Lifelink.com, Minimally Invasive Spine Study Group, North American Spine Society, Society of Minimally Invasive Spine Surgery (SMISS), Spinal Simplicity. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The genus Depressaria (Lepidoptera: Depressariidae) mostly comprises specialist herbivores with varying capacity for detoxification of defensive phytochemistry. Depressaria depressana, a Eurasian moth recently introduced into North America, is a family-level specialist of the Apiaceae, whose hosts include more than a dozen species in multiple tribes; Depressaria radiella is a super-specialist of Eurasian origin that feeds exclusively on species in the genera Pastinaca and Heracleum throughout its native and introduced range. In eastern North America, it feeds upon Pastinaca sativa, an invasive European species, and Heracleum maximum, a native species. We determined whether differences in furanocoumarin metabolism exist between D. depressana and two isolated populations of D. radiella, feeding exclusively on either P. sativa or H. maximum. We also compared gravimetric estimates of feeding efficiency to assess D. depressana larval performance on different diets. Both populations of D. radiella metabolized furanocoumarins at a greater rate than D. depressana. Although there was no difference in rates of metabolism of linear furanocoumarins in the two populations of D. radiella, individuals collected from H. maximum metabolized angular furanocoumarins more rapidly. The gravimetric assessments of feeding efficiencies revealed that D. depressana exhibited highest efficiencies consuming Daucus carota; moreover, this species survived to pupation consuming fruits of Zizia aurea, an apiaceous species native to North America. Our preliminary phylogenetic analysis, building on an earlier morphological analysis, incorporates mitochondrial cytochrome oxidase subunit 1 data from the BOLD database and revealed that the presence or absence of furanocoumarins is not a strong predictor of species-level evolution in Depressaria., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Depressaria depressana , the purple carrot seed moth, is a Eurasian species first reported in North America in 2008 and currently undergoing range expansion. This invasion follows that of its Eurasion congener Depressaria radiella (parsnip webworm), first documented in North America 160 years ago. Unlike D. depressana , which utilizes hostplants across multiple tribes of Apiaceae, Depressaria radiella is a "superspecialist" effectively restricted in its native and non-indigenous ranges to two closely related apiaceous genera. We investigated the genetic structure of D. depressana populations across latitudinal and longitudinal gradients in the eastern United States by constructing COI haplotype networks and then comparing these with haplotype networks constructed from available COI sequence data from contemporary European D. depressana populations and from European and North American D. radiella populations. Haplotype data revealed higher genetic diversity in D. depressana , indicating high dispersal capacity, multiple introductions, and/or a genetically diverse founding population. Museum and literature records of D. radiella date back to 1862 and indicate that range expansion to the West Coast required more than 50 years. Higher levels of genetic diversity observed in D. depressana compared to its congener may indicate a greater propensity for dispersal, colonization and establishment in its non-indigenous range.

Introduction: The management of spinal neoplasia consists of surgical, radiation, and systemic options. Little data exist to guide management based on overall health status, which is particularly challenging when patients who could benefit from surgery may be too frail for it. This study's objective was to evaluate the 5-Item Modified Frailty Index (mFI-5) as a predictor of 30-day morbidity in patients undergoing instrumented resection for metastatic extradural spinal tumors., Methods: Adults undergoing extradural tumor resection from the 2011 to 2019 National Surgical Quality Improvement Program datasets were identified by Current Procedural Terminology codes 63275-63278 with an adjunct instrumentation code (22840-22843). Patients were classified into frailty levels 0, 1, or 2+ based on mFI-5 scores of 0, 1, or 2-5, respectively. The primary outcome was morbidity. Secondary outcomes were readmission and reoperation. Multivariate modeling was utilized to analyze mFI-5 as a predictor of outcomes. The Akaike information criterion (AIC) was used to compare relative-model-fit based on frailty versus individual comorbidity variables to determine the optimal model. Chi-squared and Fisher's exact tests were used to establish significance between individual complications and frailty., Results: There were 874 patients. Readmission, reoperation, and morbidity rates were 19.5%, 5.0%, 52.3%, respectively. In multivariate analyses, mFI-5=1 (OR: 1.45, SE: 0.31, p=0.036), mFI-5=2+ (OR: 1.41, SE: 0.40, p=0.036), operative time (OR: 1.18, SE: 0.03, p≤0.001), and chronic steroid use (OR: 1.56, SE: 0.42, p=0.037) independently predicted morbidity. Elective surgery (OR: 0.61) was protective. Frailty did not predict readmission or reoperation. Frailty was found to be significantly associated with respiratory complications, urinary tract infections, cardiac events, and sepsis/septic shock specifically., Conclusions: mFI-5=1 independently predicted 45% increased odds of morbidity. mFI-5=2+ independently predicted 41% increased odds of morbidity. Further, every 30 additional minutes of operative time predicted 18% increased odds of morbidity, suggesting an increased risk of site-related complication events. Taken together, the mFI-5 serves as a valid predictor of morbidity in patients with extradural tumor undergoing instrumented excision., Competing Interests: Conflicts of Interest: Dr. Jeff Silber receives teaching fees for Stryker., (Copyright © 2023 The Japanese Society for Spine Surgery and Related Research.)

Introduction: Compared to anterior cervical discectomy and fusion (ACDF), the motion preservation of cervical disc arthroplasty (CDA) provides an attractive alternative with similar short-term results. However, there is a paucity of the economics of performing CDA over ACDF., Study Design: This was retrospective study., Objective: The objective of this study is to evaluate relative-value-units (RVUs), operative time, and RVUs-per-minute between single-level ACDF and CDA. Secondary outcomes included 30-day readmission, reoperation, and morbidity., Methods: Adults who underwent ACDF or CDA in 2011-2019 National Surgical Quality Improvement Program database datasets. Multivariate quantile regression was utilized., Results: There were 26,595 patients (2024 CDA). ACDF patients were older, more likely to be female, discharged to inpatient rehabilitation, and have a history of obesity, smoking, diabetes, steroid use, and the American Society of Anesthesiologists-class ≥3. ACDF had greater median RVUs-per-case (41.2 vs. 24.1) and RVUs-per-minute (0.36 vs. 0.27), despite greater operative-time (109 min vs. 92 min) ( P < 0.001). ACDF predicted a 16.9 unit increase in median RVUs per case ( P < 0.001, confidence interval [CI] 95 : 16.3-17.5), an 8.81 min increase in median operative time per case ( P < 0.001, CI 95 : 5.69-11.9), and 0.119 unit increase in median RVUs-per-minute ( P < 0.001, CI 95 : 0.108-0.130). ACDF was associated with greater unadjusted rates of readmission (3.2% vs. 1.4%) morbidity (2.3% vs. 1.1%) ( P < 0.001), but similar rates of reoperation (1.3% vs. 0.8%, P = 0.080). After adjusting for significant patient-related and procedural factors, readmission (odds ratio [OR] = 0.695, P = 0.130, CI 95 : 0.434-1.113) and morbidity (OR = 1.102, P = 0.688, CI 95 : 0.685-1.773) was similar between ACDF and CDA., Conclusions: Median RVUs-per-minute increased by 0.119 points for ACDF over CDA, or $257.7/h for each additional-hour of surgery. Adjusted 30-day outcomes were similar between procedures. Reimbursement for CDA does not appear to be in line with ACDF and may be a barrier to widespread usage., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Craniovertebral Junction and Spine.)

Study Design: Retrospective cohort study., Objective: The aim was to compare 30-day readmission and postdischarge morbidity for posterior cervical decompression and fusion (PCDF) in patients who were discharged to home versus rehabilitation., Summary of Background Data: An increasing number of patients are being discharged to postacute inpatient care facilities following spine surgery. However, little research has been performed to evaluate the effect of this trend on short-term outcomes., Materials and Methods: Patients who underwent PCDF from 2011 to 2018 were identified using the National Surgical Quality Improvements Program (NSQIP)-database. Regression was utilized to compare primary outcomes between home and rehabilitation groups and to control for predictors of outcomes., Results: We identified 8912 patients. Unadjusted analysis revealed that rehabilitation-discharge patients had greater readmission (10.4% vs. 8.0%, P=0.002) and postdischarge morbidity (7.1% vs. 4.0%, P<0.001) rates. After controlling for patient-related factors, rehabilitation-discharge independently predicted postdischarge morbidity (P<0.001, odds ratio=2.232). Readmission no longer differed between groups (P=0.071, odds ratio=1.311). Rates of discharge to rehabilitation increased from 23.5% in 2011 to 25.3% in 2018, while postdischarge morbidity rates remained stagnant.Patients discharged to rehabilitation were older (66.9 vs. 59.4 y); more likely to be African American (21.4% vs. 13.8%) and have diabetes (27.1% vs. 17.5%), steroid use (6.4% vs. 4.7%, P=0.002), and American Society of Anaesthesiologists (ASA)-class ≥3 (80.2% vs. 57.7%); less likely to be male (53.9% vs. 57.4%, P=0.004) and smokers (20.3% vs. 26.6%); and had greater operative time (198 vs. 170 min) and length of hospital stay (5.9 vs. 3.3 d) (P<0.001)., Conclusions: Despite controlling for significant factors, discharge to rehabilitation independently predicted a 2.2 times increased odds of postdischarge morbidity. Rates of discharge to rehabilitation increased overtime without an appreciable decrease in postdischarge morbidity, suggesting that greater resources are being utilized in the postacute care period without an obvious justification. Therefore, home-discharge should be prioritized after hospitalization for PCDF when feasible. These findings are notable in light of reform efforts aimed at reducing costs while improving quality of care., Competing Interests: D.E.: receives consulting fees for Stryker and DePuy. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Context: Despite increasing utilization of fusion to treat degenerative pathology, few studies have evaluated outcomes with pelvic fixation (PF). This is the first large-scale database study to compare multilevel fusion with and without PF for degenerative lumbar disease., Aim: The aim of this study was to compare the 30-day outcomes of multilevel lumbar fusion with and without PF., Settings and Design: This was a retrospective cohort study., Subjects and Methods: Lumbar fusion patients were identified using the National Surgical Quality Improvement Program database. Regression was utilized to analyze readmission, reoperation, morbidity, and specific complications and to evaluate for predictors thereof., Statistical Analysis Used: Student's t -test was used for continuous variables and Chi-squared or Fisher's exact test was used for categorical variables. Variables significant in the univariate analyses ( P < 0.05) and PF were then evaluated for significance as independent predictors and control variables in a series of multivariate logistic regression analyses of primary outcomes., Results: We identified 38,413 patients. PF predicted 30-day readmission and morbidity. PF was associated with greater reoperation in univariate analysis, but not in multivariate analyses. PF predicted deep wound infections, organ-space infections, pulmonary complications, urinary tract infection, transfusion, deep venous thrombosis, and sepsis. PF was also associated with a longer hospital stay. Age, obesity, steroids, and American Society of Anesthesiologists (ASA) class ≥ 3 predicted readmission. Obesity, steroids, bleeding disorder, preoperative transfusion, ASA class ≥3, and levels fused predicted reoperation. Age, African American race, decreased hematocrit, obesity, hypertension, dyspnea, steroids, bleeding disorder, ASA class ≥3, levels fused, and interbody levels fused predicted morbidity. Male gender and inclusion of anterior lumbar interbody fusion (ALIF) were protective of reoperation. Hispanic ethnicity, ALIF, and computer-assisted surgery (CAS) were protective of morbidity., Conclusions: Adjunctive PF was associated with a 1.5-times and 2.7-times increased odds of readmission and morbidity, respectively. ASA class and specific comorbidities predicted poorer outcomes, while ALIF and CAS were protective. These findings can guide surgical solutions given specific patient factors., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Craniovertebral Junction and Spine.)

Study Design: This was a retrospective cohort study., Objective: The objective of this study was to compare 30-day postdischarge morbidity for 3-or-more level (multilevel) posterior lumbar fusion in patients who were discharged to home versus rehabilitation., Summary of Background Data: Spine surgery has been increasingly performed in the elderly population, with many of these patients being discharged to rehabilitation and skilled nursing facilities. However, research evaluating the safety of nonhome discharge following spine surgery is limited., Materials and Methods: Patients who underwent multilevel posterior lumbar fusion from 2005 to 2018 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Regression was utilized to compare primary outcomes between discharge disposition and to evaluate for predictors thereof., Results: We identified 5276 patients. Unadjusted analysis revealed that patients who were discharged to rehabilitation had greater postdischarge morbidity (5.6% vs. 2.6%). After adjusting for baseline differences, discharge to rehabilitation no longer predicted postdischarge morbidity [odds ratio (OR)=1.409, confidence interval: 0.918-2.161, P=0.117]. Multivariate analysis also revealed that age (P=0.026, OR=1.023), disseminated cancer (P=0.037, OR=6.699), and readmission (P<0.001, OR=28.889) independently predicted postdischarge morbidity., Conclusions: Thirty days morbidity was statistically similar between patients who were discharged to home and rehabilitation. With appropriate patient selection, discharge to rehabilitation can potentially minimize 30-day postdischarge morbidity for more medically frail patients undergoing multilevel posterior lumbar fusion. These results are particularly important given an aging population, with a great portion of elderly patients who may benefit from postacute care facility discharge following spine surgery., Competing Interests: D.E. receives consulting fees for Stryker and DePuy. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: Spine surgery has been increasingly performed in the outpatient setting, providing greater control over cost, efficiency, and resource utilization. However, research evaluating the safety of this trend is limited. The objective of this study is to compare 30-day readmission, reoperation, and morbidity for patients undergoing lumbar disc arthroplasty (LDA) in the inpatient versus outpatient settings., Methods: Patients who underwent LDA from 2005 to 2018 were identified using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database. Regression was utilized to compare readmission, reoperation, and morbidity between surgical settings, and to evaluate for predictors thereof., Results: We identified 751 patients. There were no significant differences between inpatient and outpatient LDA in rates of readmission, reoperation, or morbidity on univariate or multivariate analyses. There were also no significant differences in rates of specific complications. Inpatient operative time (138 ± 75 minutes) was significantly ( P < .001) longer than outpatient operative time (106 ± 43 minutes). In multivariate analysis, diabetes ( P < .001, OR = 7.365), baseline dyspnea ( P = .039, OR = 6.447), and increased platelet count ( P = .048, OR = 1.007) predicted readmission. Diabetes ( P = .016, OR = 6.533) and baseline dyspnea ( P = .046, OR = 13.814) predicted reoperation. Baseline dyspnea ( P = .021, OR = 8.188) and ASA (American Society of Anesthesiologists) class ≥3 ( P = .014, OR = 3.515) predicted morbidity. Decreased hematocrit ( P = .008) and increased operative time ( P = .003) were associated with morbidity in univariate analysis, but not in multivariate analysis., Conclusions: Readmission, reoperation, and morbidity were statistically similar between surgical setting, indicating that LDA can be safely performed in the outpatient setting. Higher ASA class and specific comorbidities predicted poorer 30-day outcomes. These findings can guide choice of surgical setting given specific patient factors.

Previous estimates of nucleotide substitution rates are routinely applied as secondary or "universal" molecular clock calibrations for estimating evolutionary timescales in groups that lack independent timing information. A major limitation of this approach is that rates can vary considerably among taxonomic groups, but the assumption of rate constancy is rarely evaluated prior to using secondary rate calibrations. Here I evaluate whether an insect mitochondrial DNA clock is appropriate for estimating timescales in Collembola-a group of insect-like arthropods characterized by high levels of cryptic diversity. Relative rates of substitution in cytochrome oxidase subunit 1 (COI) were inferred via Bayesian analysis across a topologically constrained Hexapod phylogeny using a relaxed molecular clock model. Rates for Collembola did not differ significantly from the average rate or from the rates estimated for most other groups (25 of 30), suggesting that (1) their apparent cryptic diversity cannot be explained by accelerated rates of molecular evolution and (2) clocks calibrated using "universal" insect rates may be appropriate for estimating evolutionary timescales in this group. However, of the 31 groups investigated, 10 had rates that deviated significantly from the average (6 higher, 4 lower), underscoring the need for caution and careful consideration when applying secondary insect rate calibrations. Lastly, this study exemplifies a relatively simple approach for evaluating rate constancy within a taxonomic group to determine whether the use of secondary rates are appropriate for molecular clock calibrations.

Background Context: Lumbar laminectomy and discectomy surgeries are among the most common procedures performed in the United States, and often take place at academic teaching hospitals, involving the care of resident physicians. While academic institutions are critical for the maturation of the next generation of attending surgeons, concerns have been raised regarding the quality of resident-involved care. There is conflicting evidence regarding the effects of resident participation in teaching hospitals on spine surgery patient outcomes. As the volume of lumbar laminectomy and discectomy increases, it is imperative to determine how academic status impacts clinical and economic outcomes., Purpose: The purpose of this study is to determine if lumbar laminectomy and discectomy surgeries for degenerative spine diseases performed at academic teaching centers is associated with more adverse clinical outcomes and increased cost compared to those performed at nonacademic centers., Study Design/setting: This study is a multi-center retrospective cohort study using a New York Statewide database., Patient Sample: We identified 36,866 patients who met the criteria through the New York Statewide Planning and Research Cooperative System who underwent an elective lumbar laminectomy and/or discectomy in New York State between January 1, 2009 and September 30, 2014., Outcome Measures: The primary functional outcomes of interest included: length of stay, cost of the index admission; 30-day and 90-day readmission; 30-day, 90-day, and 1-year return to the operating room., Methods: International Classification of Diseases, Ninth revision codes were utilized to define patients undergoing a laminectomy and/or discectomy who also had a diagnosis code for a lumbar spine degenerative condition. We excluded patients with a procedural code for lumbar fusion, as well as those with a diagnosis of scoliosis, neoplasm, inflammatory disorder, infection or trauma. Hospital academic status was determined by the Accreditation Council for Graduate Medical Education. Unique encrypted patient identifiers allowed for longitudinal follow-up for readmission and re-operation analyses. We extracted charges billed for each admission and calculated costs through cost-to-charge ratios. Logistic regression models compared teaching and nonteaching hospitals after adjusting for patient demographics and comorbidities., Results: Compared to patients at nonteaching hospitals, patients at teaching hospitals were more likely to be younger, male, non-Caucasian, be privately insured and have fewer comorbidities (p<.001). Patients undergoing surgery at teaching hospitals had 10% shorter lengths of stay (2.7 vs. 3.0 days, p<.001), but 21.5% higher costs of admission ($13,693 vs. $11,601 p<.001). Academic institutions had a decreased risk of return to the operating room for revision procedures or irrigation and debridement at 30 days (OR:0.70, 95% confidence interval [CI]: 0.60-0.82, p<.001), 90 days (OR:0.75, 95%CI: 0.66-0.86, p<.001), and 1 year (OR:0.84, 95%CI: 0.77-0.91, p<.001) post index procedure. There was no difference in 30- and 90-day all-cause readmission, or discharge disposition between the two groups., Conclusions: Elective lumbar laminectomy and discectomy for degenerative lumbar conditions at teaching hospitals is associated with higher costs, but decreased length of stay and no difference in readmission rates at 30- and 90-days postoperatively compared to nonteaching hospitals. Teaching hospitals had a decreased risk of return to the operating room at 30 days, 90 days and 1 year postoperatively. Our findings might serve as an impetus for other states or regions to compare outcomes at teaching and nonteaching sites., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The aim of this study was to determine the differences in 30-day readmission, reoperation, and morbidity for patients undergoing multilevel anterior cervical discectomy and fusion (ACDF) or single and multilevel anterior cervical corpectomy and fusion (ACCF)., Summary of Background Data: Despite increasing rates of surgical treatment of cervical spine disease, few studies have compared outcomes by surgical technique. To the best of our knowledge, this is the only large-scale administrative database study that directly evaluates early outcomes between multilevel ACDF and single and multilevel ACCF., Methods: Patients who underwent ACDF and ACCF were identified using the NSQIP database. Multivariate regression was utilized to compare rates of readmission, reoperation, morbidity, and specific complications between surgical techniques, and to evaluate for predictors of primary outcomes., Results: We identified 15,600 patients. ACCF independently predicted (P < 0.001) greater reoperation (odds ratio [OR] = 1.876) and morbidity (OR = 1.700), but not readmission, on multivariate analysis. ACCF was also associated with greater rates of transfusion (OR = 3.273, P < 0.001) and DVT/thrombophlebitis (OR = 2.852, P = 0.001). ACCF had significantly (P < 0.001) greater operative time and length of stay. In the cohort, increasing age (P < 0.001), diabetes (P = 0.025), chronic obstructive pulmonary disease (P = 0.027), disseminated cancer (P = 0.009), and American Society of Anesthesiologists (ASA) class ≥3 (P < 0.001) predicted readmission. Age (P = 0.011), female sex (P = 0.001), heart failure (P = 0.002), ASA class ≥3 (P < 0.001), and increased creatinine (P = 0.044), white cell count (P = 0.033), and length of stay (P < 0.001) predicted reoperation. Age (P < 0.001), female sex (P = 0.002), disseminated cancer (P = 0.010), ASA class ≥3 (P < 0.001), increased white cell count (P = 0.036) and length of stay (P < 0.001), and decreased hematocrit (P < 0.001) predicted morbidity. Within ACDF, three or more levels treated compared to two levels did not predict poorer 30-day outcomes., Conclusion: Compared to multilevel ACDF, ACCF was associated with an 88% increased odds of reoperation and 70% increased odds of morbidity; readmission was similar between techniques. Older age, higher ASA class, and specific comorbidities predicted poorer 30-day outcomes. These findings can guide surgical solution given specific factors., Level of Evidence: 3.

Study Design: Retrospective review of prospective data., Objective: The objective of this study was to describe the clinical, radiographic, and complication-related outcomes through ≥1-year of 27 patients who underwent lateral lumbar interbody fusion (LLIF) with posterior instrumentation to treat ≥3 contiguous levels of degenerative lumbar scoliosis., Summary of Background Data: Multilevel disease has traditionally been treated with open posterior fusion. Literature on multilevel LLIF is limited. We present our experience with utilizing LLIF to treat multilevel degenerative scoliosis., Methods: Clinical outcomes were evaluated using VAS, SF-12, and ODI. Radiographic outcomes included pelvic tilt, pelvic incidence, lumbar lordosis, pelvic incidence-lumbar lordosis mismatch, Cobb angle, and cage subsidence. Perioperative and long-term complications through the ≥1-year final-postoperative visit were reviewed; transient neurological disturbances were assessed independently. Demographic, comorbidity, operative, and recovery variables, including opioid use, were explored for association with primary outcomes., Results: Mean time to final-postoperative visit was 22.5 months; levels treated with LLIF per patient, 3.7; age, 66 years; and lateral operative time, 203 minutes. EBL was ≤100 mL in 74% of cases. Clinical outcomes remained significantly improved at ≥1-year. Cobb angle was corrected from 21.1 to 7.9 degrees (P<0.001), lordosis from 47.3 to 52.6 degrees (P<0.001), and mismatch from 11.4 to 6.4 degrees (P=0.003). High-grade subsidence occurred in 3 patients. Subsidence did not significantly impact primary outcomes. In total, 11.1% returned to the operating room for complication-related intervention over nearly 2-years; 37% experienced complications. Experiencing a complication was associated with having an open-posterior portion (P=0.048), but not with number of LLIF levels treated, or with clinical or radiographic outcomes. No patients experienced protracted neurological deficits; psoas weakness was associated with increased lateral operative time (P=0.049) and decreased surgeon experience (P=0.028)., Conclusions: Patients who underwent multilevel LLIF with adjunctive posterior surgery had significant clinical and radiographic improvements. Complication rates were similar compared to literature on single-level LLIF. LLIF is a viable treatment for multilevel degenerative scoliosis.

Study Design: A retrospective cohort study., Objective: The aim of this study was to determine the difference in 30-day readmission, reoperation, and morbidity for patients undergoing either posterior or anterior lumbar interbody fusion., Summary of Background Data: Despite increasing utilization of lumbar interbody fusion to treat spinal pathology, few studies compare outcomes by surgical approach, particularly using large nationally represented cohorts., Methods: Patients who underwent lumbar interbody fusion were identified using the NSQIP database. Rates of readmission, reoperation, morbidity, and associated predictors were compared between posterior/transforaminal (PLIF/TLIF) and anterior/lateral (ALIF/LLIF) lumbar interbody fusion using multivariate regression. Bonferroni-adjusted alpha-levels were utilized whereby variables were significant if their P values were less than the alpha-level or trending if their P values were between 0.05 and the alpha-level., Results: We identified 26,336 patients. PLIF/TLIF had greater operative time (P = 0.015), transfusion (P < 0.001), UTI (P = 0.008), and stroke/CVA (P = 0.026), but lower prolonged ventilation (P < 0.001) and DVT (P = 0.002) rates than ALIF/LLIF. PLIF/TLIF independently predicted greater morbidity on multivariate analysis (odds ratio: 1.155, P = 0.0019).In both groups, experiencing a complication and, in PLIF/TLIF, ASA-class ≥3 predicted readmission (P < 0.001). Increased age trended toward readmission in ALIF/LLIF (P = 0.003); increased white cell count (P = 0.003), dyspnea (P = 0.030), and COPD (P = 0.005) trended in PLIF/TLIF. In both groups, increased hospital stay and wound/site-related complication predicted reoperation (P < 0.001). Adjunctive posterolateral fusion predicted reduced reoperation in ALIF/LLIF (P = 0.0018). ASA-class ≥3 (P = 0.016) and age (P = 0.021) trended toward reoperation in PLIF/TLIF and ALIF/LLIF, respectively. In both groups, age, hospital stay, reduced hematocrit, dyspnea, ASA-class ≥3, posterolateral fusion, and revision surgery and, in PLIF/TLIF, bleeding disorder predicted morbidity (P < 0.001). Female sex (P = 0.010), diabetes (P = 0.042), COPD (P = 0.011), and disseminated cancer (P = 0.032) trended toward morbidity in PLIF/TLIF; obesity trended in PLIF/TLIF (P = 0.0022) and ALIF/LLIF (P = 0.020)., Conclusion: PLIF/TLIF was associated with a 15.5% increased odds of morbidity; readmission and reoperation were similar between approaches. Older age, higher ASA-class, and specific comorbidities predicted poorer 30-day outcomes, while procedural-related factors predicted only morbidity. These findings can guide surgical approach given specific factors., Level of Evidence: 3.

Aligning sequences for phylogenetic analysis (multiple sequence alignment; MSA) is an important, but increasingly computationally expensive step with the recent surge in DNA sequence data. Much of this sequence data is publicly available, but can be extremely fragmentary (i.e., a combination of full genomes and genomic fragments), which can compound the computational issues related to MSA. Traditionally, alignments are produced with automated algorithms and then checked and/or corrected "by eye" prior to phylogenetic inference. However, this manual curation is inefficient at the data scales required of modern phylogenetics and results in alignments that are not reproducible. Recently, methods have been developed for fully automating alignments of large data sets, but it is unclear if these methods produce alignments that result in compatible phylogenies when compared to more traditional alignment approaches that combined automated and manual methods. Here we use approximately 33,000 publicly available sequences from the hepatitis B virus (HBV), a globally distributed and rapidly evolving virus, to compare different alignment approaches. Using one data set comprised exclusively of whole genomes and a second that also included sequence fragments, we compared three MSA methods: (1) a purely automated approach using traditional software, (2) an automated approach including by eye manual editing, and (3) more recent fully automated approaches. To understand how these methods affect phylogenetic results, we compared resulting tree topologies based on these different alignment methods using multiple metrics. We further determined if the monophyly of existing HBV genotypes was supported in phylogenies estimated from each alignment type and under different statistical support thresholds. Traditional and fully automated alignments produced similar HBV phylogenies. Although there was variability between branch support thresholds, allowing lower support thresholds tended to result in more differences among trees. Therefore, differences between the trees could be best explained by phylogenetic uncertainty unrelated to the MSA method used. Nevertheless, automated alignment approaches did not require human intervention and were therefore considerably less time-intensive than traditional approaches. Because of this, we conclude that fully automated algorithms for MSA are fully compatible with older methods even in extremely difficult to align data sets. Additionally, we found that most HBV diagnostic genotypes did not correspond to evolutionarily-sound groups, regardless of alignment type and support threshold. This suggests there may be errors in genotype classification in the database or that HBV genotypes may need a revision., Competing Interests: The authors declare there are no competing interests.

The processes of vicariance and dispersal are central to our understanding of diversification, yet determining the factors that influence these processes remains a significant challenge in evolutionary biology. Caves offer ideal systems for examining the mechanisms underlying isolation, divergence, and speciation. Intrinsic ecological differences among cavernicolous organisms, such as the degree of cave dependence, are thought to be major factors influencing patterns of genetic isolation in caves. Using a comparative phylogeographic approach, we employed mitochondrial and nuclear markers to assess the evolutionary history of two ecologically distinct groups of terrestrial cave-dwelling springtails (Collembola) in the genera Pygmarrhopalites (Arrhopalitidae) and Pogonognathellus (Tomoceridae) that are codistributed in caves throughout the Salem Plateau-a once continuous karst region, now bisected by the Mississippi River Valley in Illinois and Missouri. Contrasting phylogeographic patterns recovered for troglobiotic Pygmarrhopalites sp. and eutroglophilic Pogonognathellus sp. suggests that obligate associations with cave habitats can restrict dispersal across major geographic barriers such as rivers and valleys, but may also facilitate subterranean dispersal between neighboring cave systems. Pygmarrhopalites sp. populations spanning the Mississippi River Valley were estimated to have diverged 2.9-4.8 Ma, which we attribute to vicariance resulting from climatic and geological processes involved in Mississippi River Valley formation beginning during the late Pliocene/early Pleistocene. Lastly, we conclude that the detection of many deeply divergent, morphologically cryptic, and microendemic lineages highlights our poor understanding of microarthropod diversity in caves and exposes potential conservation concerns.

Four species of Willowsia have been reported from the Americas (W. buski, W. jacobsoni, W. mexicana, and W. nigromaculata), and to date, W. mexicana is the only member of the genus endemic to the New World. Here, Willowsia pyrrhopygia sp. nov. from Florida is described. Like W. mexicana, this new species has a native New World distribution and uninterrupted rib scale type, but can be separated by color pattern and chaetotaxy. Dorsal head chaetotaxy and other descriptive notes are provided to compliment to descriptions for W. buski, W. jacobsoni, W. mexicana, and W. nigromaculata. Comparative morphological analysis also reveals two unique character states among Entomobryinae-the outer maxillary lobe with two (not three) sublobal hairs and the absence of labial triangle seta r-shared only by endemic New World Willowsia and Americabrya, providing preliminary support for their independent evolution from a common New World ancestor.

Bogidiellidae is the most diverse and cosmopolitan family of stygobiotic amphipods, and inhabits a variety of subterranean biotopes, especially interstitial habitats. While the family is characterized by considerable sexual dimorphism, this dimorphism has adversely affected our understanding of the systematics of the group. Most species have restricted geographic ranges and occur in difficult to sample habitats, so it is common for individual species descriptions to be based on a single sex. In this work we revisit an analysis of morphological characters in an attempt to clarify their phylogenetic utility in resolving taxonomic relationships among genera by introducing a new species, two additional characters, and phylogenetic statistical support values. Eobogidiella venkataramani sp. n., from a spring fed brook in the Shirawati River basin along the escarpment of the Western Ghats (Karnataka, India) differs from the only known congener, Eobogidiella purmamarcensis, from Argentina, in the structure of mouthparts, the shape and ornamentation on gnathopods and characters of the telson. Our phylogenetic analyses indicate that the available morphological characters are not sufficient to resolve phylogenetic relationships within Bogidiellidae, thus these characters alone cannot be used to determine the phylogenetic placement of Eobogidiella venkataramani sp. n. within the family. Nevertheless, Eobogidiella venkataramani sp. n. shares diagnostic characters with Eobogidiella, supporting placement of the new species in this genus. Our findings point towards a critical need to resolve relationships within the family using molecular approaches, along with the development of a suite of additional morphological characters for Bogidiellidae. This is the third species of Bogidiellidae from southern India.

The chaetotaxy of 15 species of eastern North American Entomobrya is redescribed in order to determine potential characters for the diagnosis of cryptic lineages and evaluate the diagnostic and phylogenetic utility of chaetotaxy. As a result, four new species (Entomobrya citrensis Katz & Soto-Adames, sp. n., Entomobrya jubata Katz & Soto-Adames, sp. n., Entomobrya neotenica Katz & Soto-Adames, sp. n. and Entomobrya unifasciata Katz & Soto-Adames, sp. n.) are described, and new diagnoses are provided for Entomobrya assuta Folsom, Entomobrya atrocincta Schött, Entomobrya decemfasciata (Packard), Entomobrya ligata Folsom, Entomobrya multifasciata (Tullberg), and Entomobrya quadrilineata (Bueker). Furthermore, previously undocumented levels of intraspecific variation in macrosetal pattern are reported, tempering the exclusive use of chaetotaxy for species delimitation. Phylogenetic relationships, estimated using both morphological and molecular data, indicate that Entomobrya is likely paraphyletic. The phylogenies also suggest that unreliable character homology, likely fostered by Entomobrya's profusion of macrosetae, may limit the phylogenetic utility of chaetotaxy in groups characterized by an abundance of dorsal macrosetae.

The broad goal of this study was to examine multiple potential predictors of anti-Black bias among counselors. Specifically, in an online survey of 173 trainees and professionals in mental health, this study used 3 measures related to cultural sensitivity as predictors of therapists' expectancies for bond and prognosis with African American clients compared with White clients. The Multicultural Counseling Inventory (MCI; Sodowsky, Taffe, Gutkin, & Wise, 1994) was used to measure global multicultural competence. The Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998) served as a measure of automatic prejudice toward Blacks. Additionally, a new self-report measure of anti-Black clinical prejudice was created specifically for this study. The Balanced Inventory of Desirable Responding (Paulhus, 1984) was included to control for socially desirable responding. Each predictor of cultural sensitivity uniquely explained variance in anti-Black bias in bond ratings, with the IAT accounting for more variance than the 2 self-reports. Our novel measure of clinical prejudice accounted for anti-Black bias in prognosis ratings, but the MCI and the IAT did not. Researchers studying cultural competence are encouraged to consider the roles of automatic and deliberate prejudice in determining disparities in clinical expectancies and cross-racial therapeutic alliances. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Research on body image and older women has grown in the past decade. However, there is a gap in the literature regarding body image, older women, and countertransference. This article provides 7 case examples of racially and ethnically diverse women over 60, drawn from MSW student and agency staff supervision, and participant feedback from a national conference on aging workshop. Themes related to loss and grief, adult daughter and aging mother issues, incest, anger, disability, personality disorders, phobic reactions, and shame are discussed. Recommendations and implications for social work practice, education and research are provided.

Purpose: Recent data (2002) from the Centers for Disease Control and Prevention indicate that almost 11% of all cases of AIDS were diagnosed in people 50 and older. Despite the steady rise and future projections of increase, there is still a paucity of education and prevention programs targeting this population. This article reports on the development and piloting of an HIV/AIDS education prevention program. It describes an educational curriculum that provides older adults with accurate information about the relevance of HIV/AIDS to their lives., Design and Methods: A purposive sample (n = 249) of ethnically and economically diverse adults 50 years and older was selected from 14 organizations in rural and urban settings in California. They were surveyed to determine their interest in participating in HIV/AIDS education prevention programs., Results: A majority of participants reported interest in an HIV/AIDS prevention program for older people, with female respondents more likely to attend than male respondents. Participants who were moderately or very religious were also more likely to attend. Participants expressed preference for prevention education through presentations at centers serving older adults, and from physicians and other health care providers. On the basis of these findings, a specialized curriculum targeting older adults was developed, presented, and disseminated., Implications: People 50 years and older are sexually active, lack accurate information about HIV/AIDS, and are in need of HIV/AIDS education.

Introduction: Parathyroidectomy via cervical exploration is an effective primary-modality treatment for hyperparathyroidism, with cure rates of greater than 95%. We retrospectively reviewed 866 consecutive parathyroidectomies performed by a single surgeon between 1960 and 1997. We attempted to describe the polymorphic variation in multiglandular disease, the anatomic locations of pathologic glands, and the operative strategy and techniques which we believed were important to minimizing morbidity and maximizing curative success., Methods: The cases of 329 males and 537 females (age, 1-88 years) were reviewed. There were 766 operations performed: primary hyperparathyroidism (713), tertiary hyperparathyroidism (100), reoperations (53). The strategy for primary exploration includes a bilateral neck exploration, early recurrent laryngeal nerve skeletonization, and identification of at least four glands., Results: Normocalcemia was achieved in 98.2% of cases after initial cervical exploration. Persistent hypercalcemia occurred in 7 patients (<1%). Nine patients (1%) suffered persistent postoperative hypocalcemia. Unilateral recurrent laryngeal nerve injury occurred in two patients (<1%). Other perioperative complications included: reoperation for hematoma, repaired carotid artery injury, unexplained dysphagia, pneumothorax, deep venous thrombosis, and aspiration pneumonia. There were two mortalities (<1%) attributable to severe, comorbid disease. Ectopic glands were found in 120 cases. The frequency of glands at these sites were as follows: mediastinal (4.9%), intrathymic (8.4%), intrathyroid (6.7%), and retroesophageal/retrotracheal (3.5%). Thyroid resections provided diagnosis of concomitant thyroid carcinoma in 8.0% of resected patients. The pathology of patients with primary hyperparathyroidism (PHPT) consisted of single adenomas (77.2%), hyperplasia (21.0%), normal glands (1%), double adenomas (<1%), and parathyroid carcinoma (<1%). The distribution of adenomas was as follows: left upper, 25.3%; left lower, 27.3%; right upper, 26.8%; right lower, 20.6%. Hyperplastic glands were found in ectopic positions as follows: intrathymic (7.5%), intrathyroid (11.3%), mediastinal (2.5%), and retroesophageal/retrotracheal (0%). The average volume difference between the largest and smallest hyperplastic gland of each case was 1.80 + 4.40 cm3. Reoperations were performed upon 53 referred patients and 7 patients after failed exploration. Normocalcemia was attained in 98.3% of cases. Glandular pathology was identified in the previous operative field in 52 patients (86.7%). Adenomas were identified in 56.0% (n = 23) and hyperplasia in 39.0% (n = 16)., Conclusions: In our series, we were able to attain normocalcemia in 98.2% of cases after initial cervical exploration. We believe that identification of four glands, an exhaustive search of ectopic sites, bilateral exploration, and liberal use of biopsy and intraoperative frozen section were essential to curative success. The pathologist should identify parathyroid tissue in the specimen and differentiate the "abnormal" from "normal" gland. Morphologic criteria alone cannot be used because of polymorphic variation in hyperplasia in which pathologic glands may appear normal. Early identification of the recurrent laryngeal nerve allows for a safer neck exploration by alerting the surgeon to the location and course of the nerve. A bilateral approach does not contribute increased morbidity from recurrent laryngeal nerve injury.

Surgeons should be aware that any mass in the region of the cranial nerves, brachial plexus, cervical sympathetic plexus, or a major peripheral nerve can be of neurogenic origin. Solitary neurogenic tumors of the head and neck can simulate metastatic masses or congenital lesions. If they are resected unrecognized and/or without regard to their nerve origin, major and permanent nerve defects can unnecessarily occur. Thirty-two patients, 16 males and 16 females, ranging in age from 5 to 69 years, had 33 extracranial solitary neurogenic neoplasms resected. The nerves involved were the cervical sympathetic plexus in 7 patients, branchial plexus in 6, spinal accessory nerve in 5, vagus nerve in 4, hypoglossal nerve in 3, facial nerve in 2, and 6 other nerves in 1 patient each. The technique is to dissect out the neurilemoma without destroying the nerve sheath or nerve trunk. Despite careful dissection, the four patients with masses of the vagus nerve had permanent ipsilateral cord paralysis.

One thousand seventy-seven recurrent laryngeal nerves were observed in 719 patients. Seven hundred forty-seven nerves bifurcated or trifurcated over 0.5 cm inferior to the cricoid cartilage (63%). Of these, 170 patients had bilateral nerve bifurcations. Thirty-nine per cent of the patients had bilateral bifurcations when one side bifurcated. Eleven patients had direct laryngeal nerves, two of which bifurcated. Five of these 11 patients also had a recurrent and direct laryngeal nerve. Seven patients had recurrent laryngeal nerves, all on the right side, receiving branches directly from the vagus nerve 6-14 cm from the cricoid. Damage to any filaments to or from the recurrent laryngeal nerve can cause vocal cord paralysis. Damage to branches to the esophagus from the recurrent laryngeal nerve can cause dysphagia.

The entity of preclinical hyperparathyroidism has never been clearly investigated. The authors believe that the incidence of pathologic abnormalities of the parathyroid glands before the development of any symptoms or hypercalcemia (serum calcium > 12.0 mg/dl) is more frequent than has been reported. Over a 14-year period, parathyroid glands were examined during thyroid operations in over 800 patients. Serum calcium and phosphorous levels were measured in all patients preoperatively. Thirty-six patients had additional parathyroid operations for a preclinical form of hyperparathyroidism, defined by abnormal appearing parathyroid glands at the time of thyroid surgery. None of the 36 patients had symptoms of hyperparathyroidism preoperatively. Nine patients had borderline hypercalcemia (serum calcium 10.6 to 12.0 mg/dl), and the remainder were considered normocalcemic. The average age was 53 (range 21 to 75) with a male to female ratio of 1:3. Nine of the 36 patients had thyroid cancer. There were eight patients with parathyroid adenoma and 28 patients with parathyroid hyperplasia. Of 13 patients who had a history of neck irradiation, five had parathyroid adenoma and eight had parathyroid hyperplasia. Only two patients with parathyroid hyperplasia remain on calcium medication. Since preoperative normocalcemia does not preclude the presence of parathyroid pathology, the authors urge careful identification and examination of the parathyroid glands during thyroid operations. It adds little time to the procedure. Excision of parathyroid disease along with the thyroid gland can be performed safely and prevents the need for further operation with its associated morbidity.

Parathyroid autotransplantation is a known and increasingly utilized procedure. It is indicated in patients with primary parathyroid hyperplasia, in patients with primary hypercalcemia who have normal parathyroid tissue devascularized during surgery, in patients with secondary and tertiary parathyroid hyperplasia, and in patients with total thyroidectomy when normal parathyroid tissue is accidentally or unavoidably removed or completely devascularized. No normal viable parathyroid tissue should be autotransplanted. This procedure was performed in 13 dialysis patients, 27 primary hypercalcemic patients and 77 patients with thyroidectomy. The hypercalcemic patients had autotransplantations into muscle pockets in the volar surface of the forearm, while the thyroidectomy patients had autotransplantation into the sternocleidomastoid muscles. The application of parathyroid autotransplantation is a major technical and physiologic breakthrough in the field of thyroid and parathyroid surgery. It should greatly reduce the morbidity associated with permanent hypocalcemia in this type of extensive surgery.

Fifty-three patients, 35 with persistent and 7 with recurrent hyperparathyroidism, had parathyroid surgery. There were 11 patients who had prior thyroid surgery before being identified as having hyperparathyroidism. Forty patients had parathyroid adenomas and 13 (8 dialysis patients) had parathyroid hyperplasia. Thallium-210-iodine 123 subtraction scanning proved to be the most accurate in localizing parathyroid adenomas (60 percent) but not parathyroid hyperplasia. Resection of 3 3/4 parathyroid glands in primary parathyroid hyperplasia and total parathyroidectomy with parathyroid autotransplantation in tertiary parathyroid hyperplasia are the treatments of choice and would have prevented reoperation in this group. Careful neck exploration, resection of the thymus, and even thyroidectomy would probably have led to the correct location of the missed parathyroid adenomas. Mediastinotomy should not be performed at initial surgery. A careful history and preoperative calcium and phosphorus determinations in all thyroid surgery patients will reveal occult hyperparathyroidism. Twenty-one such patients were identified in our overall parathyroid series.

Seven hundred twenty-one recurrent laryngeal nerves were visualized in 400 patients having thyroid or parathyroid surgery. Four hundred twenty-one nerves (58 percent) bifurcated or trifurcated more than 0.5 cm from the cricoid cartilage. Ninety-seven patients had bilateral bifurcations, and 10 patients had trifurcations. Six patients had direct laryngeal nerves, all on the right side. One patient had a direct laryngeal and a recurrent laryngeal nerve simultaneously, and one patient had a bifurcated recurrent laryngeal nerve with an accessory vagus nerve joining it 13.5 cm from the cricoid cartilage. Damage to any of the filaments of the recurrent laryngeal nerve to the cricothyroid musculature or to or from a variant direct laryngeal nerve or variant vagus nerve connection can cause vocal cord paralysis. Damage to any branches of the recurrent laryngeal nerve to the esophagus can cause dysphagia. Therefore, if possible, all branches of the recurrent laryngeal nerve, no matter how small, should be preserved.