Robinson Memorial Hospital

Retrospective cohort. We investigated whether postoperative physical therapy (PT) significantly reduces the risk and amount of oral opioid prescriptions in the first year after primary anterior cervical discectomy and fusion (ACDF) and the risk of any opioid prescription/administration. There is a need for nonopioid pain management strategies following ACDF in light of the opioid epidemic. We utilized deidentified medical records from the TriNetX network to identify opioid-naïve adults undergoing their first ACDF from 2014 to 2023. Patients were divided into cohorts by the presence or absence of postoperative PT (≤2mo post-ACDF) and propensity matched for variables related to opioid prescription. Primary outcomes were risk ratio (RR) and the mean number of oral opioid prescriptions in the first postoperative year. Secondary outcomes included the cumulative incidence and risk of any opioid prescription/administration. Each cohort had 4864 patients after propensity matching. Patients receiving PT had a significantly lower risk of oral opioid prescription in the first year after primary ACDF compared with patients not receiving PT [RR: 0.739 (0.714, 0.765); 48.8% vs. 66.1%; P<0.0001]. Patients receiving PT had a statistically significant lower risk of any-route opioid prescription in the first year after primary ACDF as compared with patients who did not receive PT [RR: 0.801 (0.782, 0.821); 65.7% vs. 82.0%; P<0.0001]. In addition, the mean instances of prescriptions per patient were lower for oral opioids (1.9 vs. 2.2; P=0.006) and any-route opioids (2.8 vs. 3.1; P=0.004) among patients receiving PT versus patients not receiving PT within 2 months. Postoperative PT is associated with significantly lowered risk and mean opioid prescriptions in the first year after primary ACDF. Further investigation is needed to understand PT's role in reducing opioid use. Level II.

INTRODUCTION: Sacral neuromodulation (SNM) is a well-established, minimally invasive therapy for the treatment of bowel and urinary dysfunction. SNM implantation carries the risk of postoperative surgical site infections (SSI s), as well as associated device explant or reoperation. Historically, mesh envelopes for antibiotic delivery have been utilized during implantation of cardiac electronic devices. The TYRX envelope, a Medtronic product, is a dissolvable mesh pouch used to locally deliver minocycline and rifampin. TYRX technology has been shown to reduce infection rate when used for cardiac electronic devices, and limited data suggests its utility when used for implantation of SNM devices. OBJECTIVE: The primary objective was to compare the rate of postoperative SSI and device explant in cases with and without TYRX envelope use. METHODS: This was a retrospective cohort study utilizing the Premier Healthcare Database. Patients were identified as having undergone SNM placement between January 2016 and March 2020 using CPT codes. The patients were grouped by those who received a TYRX envelope and those who did not, as identified by TYRX charge code. Patient characteristics, surgical information and postoperative complications within 3 months and 1 year were collected. Antibiotic administration at time of placement was categorized as cephalosporins, current AUA guidelines (Gram positive + broad Gram-negative coverage), or Other. Patients with and without TYRX charge code were matched via greedy nearest neighbor matching using a propensity score calculated from baseline characteristics. RESULTS: The study included 250 patients with TYRX envelopes and 250 matched patients. After propensity score matching, the groups were statistically similar based on demographics, preoperative characteristics and preoperative antibiotics. There were a total of 2 postoperative SSI in the group without TYRX and 0 in the group with TYRX, but no statistically significant difference in SSI noted between groups (p=0.48). Patients without TYRX were more likely to have undergone SNM removal at 3 months (7.6% vs. 1.2%, p=0.001) and 12 months postoperatively (10% vs. 1.6%, p<0.001). CONCLUSIONS: TYRX envelope use at time of SNM implant is not associated with a reduction in surgical site infections but is associated with a reduction in SNM removal within 1 year (Table 1).

Vanadium is a “critical metal” that is predominantly produced from steelmaking slags using a salt-roast leach process that emits corrosive byproduct gases and a contaminated liquid discharge. Here, we describe a clean vanadium extraction method using the environmentally benign lixiviant–carbonated water. This method was found to be highly selective for dissolution of vanadium, manganese, and calcium over iron. By simply using saturated aqueous CO2 solutions produced in a domestic SodaStream, we have extracted vanadium from air-roasted slags with up to 50% efficiency. A modified Parr reactor was then used to achieve higher CO2 saturation pressures, resulting in vanadium extraction efficiencies up to 77%. Vanadium-bearing solids were precipitated from the leachate solutions and further processed to produce both vanadium metal and a V–Mn alloy. Our results demonstrate that carbonated water leaching represents a promising alternative green chemistry route to vanadium extraction from steel slags.

BackgroundCurrently, there is significant variability in bronchoscopy training across pulmonary and critical care medicine (PCCM) programs nationwide, including procedural volume and exposure to simulation training. Despite the increased number of interventional pulmonology (IP) fellowship programs in the United States, their direct educational impact on PCCM fellows’ bronchoscopy training is unknown.ObjectiveTo identify and quantify the differences in flexible bronchoscopy competency among PCCM fellows from institutes with IP fellowships compared with those without IP fellowships.MethodsThis multicenter, prospective cohort study included the assessment of PCCM fellows from two groups, using the Ontario Bronchoscopy Assessment Tool (OBAT): 1) PCCM fellowships with a coexistent IP fellowship program and 2) PCCM fellowships without an IP fellowship program. The primary outcome was the difference in mean score between the two groups; secondary outcomes included the mean OBAT score of first, second, and third-year (or above) fellows in the two groups and the percentage of fellows in the two groups who were capable of independently performing the procedure.ResultsThere were five participating training sites: two with IP fellowships and three without IP fellowships. A total of 50 OBAT assessments were performed (25 in each group) by the supervising attending physician. The mean OBAT score was 3.58 ± 0.65 in the IP group compared with 4.33 ± 0.61 in the non-IP group (P < 0.001). The mean (standard deviation) OBAT scores of the first, second, and third-year (or above) fellows were 3.36 (0.5), 3.48 (0.4), and 4.53 (0.5) in the IP group and 3.75 (0.8), 4.25 (0.5), and 4.7 (0.3) in the non-IP group, respectively. The mean OBAT score was directly proportional to the number of procedures done by the fellows.ConclusionThere was a statistically significant difference in the mean OBAT scores between the two groups; the mean OBAT score was higher in the non-IP fellowship group. Although a more comprehensive study is needed to fully account for the various factors that can impact bronchoscopy training, this study highlights a key difference in basic bronchoscopy training among PCCM trainees. The presence of IP fellowship is one of the many factors that can affect the basic bronchoscopy skills of PCCM fellows.

Persistent mineralocorticoid receptor activation is a pathologic response in type 2 diabetes and chronic kidney disease. Whereas mineralocorticoid receptor antagonists are beneficial in reducing cardiovascular complications, direct mechanistic pathways for these effects in humans are lacking. The MAGMA trial (Mineralocorticoid Receptor Antagonism Clinical Evaluation in Atherosclerosis) was a randomized, double-blind, placebo-controlled trial in patients with high-risk type 2 diabetes with chronic kidney disease (not receiving dialysis) on maximum tolerated renin-angiotensin system blockade. The primary end point was change in thoracic aortic wall volume, expressed as absolute or percent value (ΔTWV or ΔPWV), using 3T magnetic resonance imaging at 12 months. Secondary end points were changes in left ventricle (LV) mass; LV fibrosis, measured as a change in myocardial native T1; and 24-hour ambulatory and central aortic blood pressures. Tertiary end points included plasma proteomic changes in 7596 plasma proteins using an aptamer-based assay. A total of 79 patients were randomized to placebo (n=42) or 25 mg of spironolactone daily (n=37). After a modified intent-to-treat, including available baseline data of study end points, patients who completed the trial protocol were included in the final analyses. At the 12-month follow-up, the average change in PWV was 7.1±10.7% in the placebo group and 0.87±10.0% in the spironolactone group (P=0.028), and ΔTWV was 1.2±1.7 cm3 in the placebo group and 0.037±1.9 cm3 in the spironolactone group (P=0.022). Change in LV mass was 3.1±8.4 g in the placebo group and -5.8±8.4 g in the spironolactone group (P=0.001). Changes in LV T1 values were significantly different between the placebo and spironolactone groups (26.0±41.9 ms in the placebo group versus a decrease of -10.1±36.3 ms in the spironolactone group; P=6.33×10-4). Mediation analysis revealed that the spironolactone effect on thoracic aortic wall volume and myocardial mass remained significant after adjustment for ambulatory and central blood pressures. Proteomic analysis revealed a dominant effect of spironolactone on pathways involving oxidative stress, inflammation, and leukocyte activation. Among patients with diabetes with moderate to severe chronic kidney disease at elevated cardiovascular risk, treatment with spironolactone prevented progression of aortic wall volume and resulted in regression of LV mass and favorable alterations in native T1, suggesting amelioration of left-ventricular fibrosis. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02169089.

For transmasculine spectrum individuals, there is a lack of validated surveys to assess sexual well-being (SWB) post-genital gender-affirming surgery. Currently, either providers are designing their own SWB surveys or surveys designed for cisgender men are being used. This study investigated the applicability of SWB surveys validated for cisgender men to transmasculine spectrum individuals post-genital gender-affirming surgery (TMSX). Recognizing the paucity of validated tools for assessing SWB in transmasculine individuals post-genital gender-affirming surgery (TMSX), we evaluated current surveys for their inclusiveness and relevance to this population. Our methodology involved analyzing surveys validated in English-speaking North American cisgender men. We conducted a systematic review, yielding 31 surveys, out of which 12 met our inclusion criteria. These were then assessed against the 10 domains of holistic SWB as identified by Özer etal. Each survey was scored based on its reflection of these domains, thus generating an SWB score. Additionally, we performed a thematic analysis to identify areas needing modification for better applicability to TMSX. Our findings indicate an average SWB score of 5.17 out of 10 across the surveys. The surveys predominantly addressed sexual function, with a marked underrepresentation of domains like quality of life, sexuality, and sexual pleasure. This underscores the tendency of these surveys to focus more on the biological mechanisms of sex, rather than on a nuanced biopsychosocial understanding. Thematic analysis revealed significant gaps, such as the irrelevance of questions about erections and ejaculations for TMSX, and the need for greater emphasis on psychosocial factors. Given these gaps and the inadequacy of most cisnormative surveys, we recommend the creation of a novel, validated SWB survey specifically for TMSX. This should be developed in collaboration with a multidisciplinary panel and TMSX community advisory board, ensuring a tool that truly reflects the unique SWB needs of this population.

A thyroid storm is a life-threatening endocrine emergency characterized by severe hyperthyroidism and many systemic manifestations. Prompt recognition and treatment are essential for patient survival. This study evaluates the utility of existing diagnostic criteria and scoring systems for thyroid storm. A comprehensive literature review encompassed articles published up to December 2023. Various diagnostic criteria and scoring systems, such as the Burch-Wartofsky Point Scale and the Japanese Thyroid Association criteria, were critically assessed based on their sensitivity, specificity, and clinical applicability. Our findings reveal that existing diagnostic criteria and scoring systems, although valuable tools, exhibit limitations. They may lack sensitivity in identifying milder cases of thyroid storm or fail to differentiate it from other critical conditions. Furthermore, some criteria rely heavily on subjective clinical Judgment, which can vary among healthcare providers. Future research should focus on refining existing criteria and developing more objective and universally applicable diagnostic tools to address these limitations. Incorporating advanced laboratory markers and modern imaging techniques may enhance diagnostic accuracy. Additionally, a standardized scoring system approach could improve clinical practice consistency. In conclusion, while current diagnostic criteria and scoring systems provide a foundation for identifying thyroid storm, their utility has shortcomings. Advancements in diagnostic methods and a collaborative effort to establish standardized criteria are imperative to enhance the accuracy and reliability of thyroid storm diagnosis, ultimately improving patient outcomes.

Stroke is defined as a syndrome of rapidly developing clinical signs of focal or global disturbance of cerebral function with symptoms lasting 24 hours or longer or leading to death with no apparent cause other than of vascular origin. In the current management of stroke in developed countries, stroke units form a vital part of the care pathway. Stroke units save lives, reduce disability, mitigate against complications such as aspiration pneumonitis, facilitate early discharge home with timely interventions by a Multidisciplinary Team. Whilst the burden of stroke has decreased in high income countries, this decrease is lowest in sub-Saharan Africa.