BACKGROUND:Surgical site infection in the spine is a serious postoperative complication. Factors such as posterior surgical approach, arthrodesis, use of spinal instrumentation, age, obesity, ...diabetes, tobacco use, operating-room environment, and estimated blood loss are well established in the literature to affect the risk of infection. The goal of this study was to analyze and identify independent risk factors for surgical site infection among spine patients undergoing posterior lumbar instrumented arthrodesis.
METHODS:The medical records of 3218 patients who underwent posterior lumbar instrumented arthrodesis from January 2000 to December 2006 were reviewed to identify those who developed a postoperative infection (eighty-four patients; 2.6%). The size of this single-institution patient group allowed construction of a multivariate logistic regression model to evaluate the independent associations of potential risk factors for surgical site infection in the spine.
RESULTS:In the final regression model, obesity, estimated intraoperative blood loss, ten or more people in the operating room, a dural tear, history of diabetes, chronic obstructive pulmonary disease, coronary heart disease, and osteoporosis were critical risk factors for the onset of spinal surgical site infection. Obesity and a history of chronic obstructive pulmonary disease were the strongest risk factors for postoperative spinal infection after adjusting for all other variables. The most common pathogen was methicillin-resistant Staphylococcus aureus with a prevalence of 34.5%. This study established a single institution infection rate for posterior lumbar instrumented arthrodesis at 2.6%.
CONCLUSIONS:This analysis confirms previously demonstrated risk factors for postoperative infection while reporting on new potential independent risk factors of osteoporosis, chronic obstructive pulmonary disease, and dural tears in the setting of posterior lumbar instrumented arthrodesis. Areas of new research can focus on the roles these novel factors may play in the pathogenesis of surgical site infections in the spine.
LEVEL OF EVIDENCE:Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
Among the myths that are often cited about suicide is that 'people who talk about killing themselves rarely die by suicide', but the evidence seems to contradict this statement. The aim of this study ...was to conduct a meta-analysis of studies reporting a prevalence of suicide communication (SC), and to examine the diagnostic accuracy of SC towards suicide in case-control reports.
Eligible studies had to examine data relative to completed suicides and report the prevalence of SC. Data relative to sample characteristics, study definition, modality and recipient of the SC were coded.
We included 36 studies, conducted on a total of 14 601 completed suicides. The overall proportion of SC was 44.5% 95% confidence interval (CI) 35.4-53.8, with large heterogeneity (I 2 = 98.8%) and significant publication bias. The prevalence of SC was negatively associated with the detection of verbal communication as the sole means of SC and, positively, with study methodological quality. Based on seven case-control studies, SC was associated with an odds ratio of 4.66 for suicide (95% CI 3.00-7.25) and was characterized by sufficient diagnostic accuracy only if studies on adolescents were removed.
Available data suggest that SC occurs in nearly half of subjects who go on to die by suicide, but this figure is likely to be an underestimate given the operational definitions of SC. At present, SC seems associated with overall insufficient accuracy towards subsequent suicide, although further rigorous studies are warranted to draw definite conclusions on this issue.
The prevalence of asthma increased worldwide until the 1990s, but since then there has been no clear temporal pattern. The present study aimed to assess time trends in the prevalence of current ...asthma, asthma-like symptoms and allergic rhinitis in Italian adults from 1990 to 2010. The same screening questionnaire was administered by mail or phone to random samples of the general population (age 20-44 yrs) in Italy, in the frame of three multicentre studies: the European Community Respiratory Health Survey (ECRHS) (1991-1993; n = 6,031); the Italian Study on Asthma in Young Adults (ISAYA) (1998-2000; n = 18,873); and the Gene Environment Interactions in Respiratory Diseases (GEIRD) study (2007-2010; n = 10,494). Time trends in prevalence were estimated using Poisson regression models in the centres that repeated the survey at different points in time. From 1991 to 2010, the median prevalence of current asthma, wheezing and allergic rhinitis increased from 4.1% to 6.6%, from 10.1% to 13.9% and from 16.8% to 25.8%, respectively. The prevalence of current asthma was stable during the 1990s and increased (relative risk 1.38, 95% CI 1.19-1.59) from 1998-2000 to 2007-2010, mainly in subjects who did not report allergic rhinitis. The prevalence of allergic rhinitis has increased continuously since 1991. The asthma epidemic is not over in Italy. During the past 20 yrs, asthma prevalence has increased by 38%, in parallel with a similar increase in asthma-like symptoms and allergic rhinitis.
•Interviewees believe that landscape is an economic resource for Italy.•39% of the sample is not willing to pay for the burial of power lines.•More than 50% of the sample is in favour of a burial ...policy.•The burial finds an economic justification only in areas of relevant environmental interest.
High voltage overhead transmission lines are a type of infrastructure with a major impact on landscape quality. As studies have shown, it is sufficient that a pylon occupies even a modest fraction of a view to cause a marked decline in the aesthetic quality of the landscape. Few studies have tried to make a monetary quantification of the landscape damage caused by high voltage transmission power lines. Those few focused attention on urban areas. In this study, by means of a discrete choice experiment, the willingness to pay of the Italian population to eliminate the landscape impact of high voltage overhead transmission lines has been estimated for the entire national territory with reference to four different landscape contexts (protected mountain and hill areas, protected plain and coastal areas, other non-protected hill and mountain areas, non-protected plain areas). The results obtained have demonstrated that the willingness to pay per kilometre of power line eliminated is higher in the mountain and hill natural parks than in the other areas considered. Using a simulation with a two costs hypothesis, the research shows that the social benefit from burying high voltage power lines would exceed the costs only in limited areas of the country.
Purpose
Lateral lumbar interbody fusion (LLIF) is a minimally invasive technique that has gained growing interest in recent years. We performed a retrospective review of the medical records and ...operative reports of patients undergoing LLIF between March 2006 and December 2009. We seek to identify the incidence and nature of neurological deficits following LLIF.
Methods
New occurring sensory and motor deficits were recorded at 6 and 12 weeks as well as 6- and 12 months of follow-up. Motor deficits were grouped according to the muscle weakness and severity and sensory deficits to the dermatomal zone. New events were correlated to the patient demographics, pre-operative diagnosis, operative levels, and duration of surgery. At each post-operative time-point patients were queried regarding the presence of leg pain.
Results
A total of 235 patients (139 F; 96 M) with a total of 444 levels fused were included. Average age was 61.5 and mean BMI 28.3. At 12 months’ follow-up, the prevalence of sensory deficits was 1.6%, psoas mechanical deficit was 1.6% and lumbar plexus related deficits 2.9%. Although there was no significant correlation between the surgical level L4–5 and an increased psoas mechanical flexion or lumbar plexus related motor deficit, a trend was observed. Independent risk factors for both psoas mechanical hip flexion deficit and lumbar plexus related motor deficit was duration of surgery.
Conclusion
LLIF is a valuable tool for achieving fusion through a minimally invasive approach with little risk to neurovascular structures.
Purpose
The vertebral bone quality (VBQ) score based on magnetic resonance imaging (MRI) was introduced as a bone quality marker in the lumbar spine. Prior studies showed that it could be utilized as ...a predictor of osteoporotic fracture or complications after instrumented spine surgery. The objective of this study was to evaluate the correlation between VBQ scores and bone mineral density (BMD) measured by quantitative computer tomography (QCT) in the cervical spine.
Methods
Preoperative cervical CT and sagittal T1-weighted MRIs from patients undergoing ACDF were retrospectively reviewed and included. The VBQ score in each cervical level was calculated by dividing the signal intensity of the vertebral body by the signal intensity of the cerebrospinal fluid on midsagittal T1-weighted MRI images and correlated with QCT measurements of the C2–T1 vertebral bodies. A total of 102 patients (37.3% female) were included.
Results
VBQ values of C2–T1 vertebrae strongly correlated with each other. C2 showed the highest VBQ value Median (range) 2.33 (1.33, 4.23) and T1 showed the lowest VBQ value Median (range) 1.64 (0.81, 3.88). There was significant weak to moderate negative correlations between and VBQ Scores for all levels C2:
p
< 0.001; C3:
p
< 0.001; C4:
p
< 0.001; C5:
p
< 0.004; C6:
p
< 0.001; C7:
p
< 0.025; T1:
p
< 0.001.
Conclusion
Our results indicate that cervical VBQ scores may be insufficient in the estimation of BMDs, which might limit their clinical application. Additional studies are recommended to determine the utility of VBQ and QCT BMD to evaluate their potential use as bone status markers.
Population-based database analysis.
To analyze trends in patient- and healthcare-system-related characteristics, utilization and outcomes associated with anterior cervical spine fusions.
Anterior ...cervical decompression and spine fusion (ACDF) is one of the most commonly performed surgical procedures of the spine. However, few data analyzing trends in patient- and healthcare-system-related characteristics, utilization and outcomes exist.
Data from 1990 to 2004 collected in the National Hospital Discharge Survey were accessed. ACDF procedures were identified. Five-year periods of interest (POI) were created for temporal analysis and changes in the prevalence and utilization of this procedure as well as in patient- and healthcare-system-related variables were examined. The changes in the occurrence of procedure-related complications were evaluated.
An estimated total of 771,932 discharges after ACDF were identified. Temporally, an almost 8-fold increase in total prevalence was accompanied by a similar increase in utilization (23/100.000 civilians/POI to 157/100.000/civilians/POI). The highest increase in utilization was observed in those > or =65 years (28-fold). Average age increased from 47.2 years to 50.5 years over time. Length of hospital stay decreased from 5.17 days to 2.38 days. Overall procedure-related complication rates decreased from 4.6% to 3.03%. The prevalence of hypertension, diabetes mellitus, hypercholesterolemia, obesity, pulmonary, and coronary artery increased over time among patients undergoing ACDF.
Despite limitations inherent to secondary analysis of large databases, we identified a number of significant changes in the utilization, demographics, and outcomes associated with ACDF, which can be used to assess the effect of changes in medical care, direct health care resources, and future research. The effect of the increased prevalence of comorbidities on medical practice remains to be evaluated. Further studies are necessary to evaluate causal relationships.
Abstract Apathy is the most common neuropsychiatric syndrome in Alzheimer's disease (AD) affecting 19–76% of patients, but is difficult to distinguish from depression, because of the frequent ...comorbidities and a considerable overlap in key symptoms. A structured clinical interview and a specific set of diagnostic criteria to diagnose apathy in dementia have been recently validated, but so far its nosological position is still a debated issue, even if several studies tend to consider apathy a discrete and specific syndrome. The pathopshysiology of apathy in neuropsychiatric disorders is still unknown, however, recent studies suggest that an important role is played by dysfunctions of the frontal lobe and basal ganglia. Both apathy and depression can have a negative impact on the progression of AD, therefore, an accurate differential diagnosis is fundamental to reach an appropriate family education and to obtain a possibly effective treatment.
STUDY DESIGN.Longitudinal cohort.
OBJECTIVE.Measure concordance between patients’ and surgeons’ preoperative expectations of lumbar surgery; determine which member of the dyad more closely predicted ...fulfillment of expectations, defined as patient-reported status postoperatively.
SUMMARY OF BACKGROUND DATA.Concordant patient-surgeon expectations reflect effective communication and should foster better outcomes.
METHODS.Preoperatively patients and surgeons completed identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function. Responses ranged from “complete improvement” to “do not have this expectation”; scores for each survey ranged from 0–100 (greatest expectations). Concordance between pairs of patient-surgeon scores was measured with the intraclass correlation coefficient (ICC). Postoperatively fulfillment of expectations was measured from patient-reported amount of improvement received and was calculated as the proportion of patient-reported postoperative score relative to 1) patient-reported preoperative score, and 2) surgeon-reported preoperative score; (range 0 (no expectations fulfilled) to >1 (expectations surpassed)). Clinical measures included patient-reported spine-related disability.
RESULTS.For 402 patient-surgeon pairs, mean survey scores were 73 ± 19 (patients) and 57 ± 16 (surgeons); 84% of patients had higher scores than surgeons, mainly due to expecting complete improvement while surgeons expected a lot/moderate/little improvement. The ICC for the entire sample was .31 (fair agreement); for sub-groups the greatest difference in ICC was for patients with more spine-related disability (ICC = .10, 95%CI .00-.23) versus less disability (ICC = .46, 95%CI .34-.56). 96% of patients were contacted ≥2.0 years postoperatively. Proportions of expectations fulfilled were .79 (0–3.00) (patients) and 1.01 (0–2.29) (surgeons). Thus patients were less likely to anticipate subsequent postoperative status (OR 0.34, 95%CI 0.25–0.45) versus surgeons who were more likely to anticipate patient-reported postoperative status (OR 2.98, 95% CI 2.22–4.00).
CONCLUSIONS.Concordance between patients’ and surgeons’ expectations was fair; due mostly to patients expecting complete improvement while surgeons expected a lot/moderate/little improvement. Compared to patients’ expectations, surgeons’ expectations more closely coincided with patient-reported fulfillment of expectations 2 years postoperatively.Level of Evidence1
Purpose
This study aimed to investigate the changes of the posterior paraspinal muscles (PPM) and psoas muscle in patients with low back pain (LBP) over time.
Methods
Patients with LBP who had a ...repeat lumbar MRI with a minimum of 3-years apart at a tertiary referral center were analyzed. MRI-based quantitative assessments of the PPM and the psoas muscle were conducted for the baseline and follow-up MRI. The cross sectional area (CSA), the functional cross sectional area (fCSA) and the fat area (FAT) were calculated using a dedicated software program. The fatty infiltration (FI,%) of the regions of interest was calculated. Differences between the 1st and 2nd MRI were calculated for all assessed muscular parameters.
Results
A total of 353 patients (54.4%female) with a median age of 60.1 years and BMI of 25.8 kg/m
2
at baseline were analyzed. The mean time between the 1st and 2nd MRI was 3.6 years. The fCSA
PPM
declined in both sexes significantly from the 1st to the 2nd MRI, whereas the FAT
PPM
increased. In line with this result, the FI
PPM
increased in both males (29.9%) and females (19.4%). Females had a higher FI
PPM
and FI
Psoas
than males in both MRIs. In females, no significant changes were found for the psoas muscle. The CSA
Psoas
and fCSA
Psoas
in males were significantly smaller in the 2nd MRI. With increasing age, a significant trend in a decrease in ∆FI
PPM
was observed for both sexes.
Conclusion
The study revealed significant quantitatively muscular changes in males and females, especially in the posterior paraspinal muscles in only three years’ time.
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