Citations

Study Design. This study retrospectively analyzes prospectively collected data. Objective. Here we aim to develop predictive models for 3-month medical and surgical readmission after elective lumbar surgery, based on a multi-institutional, national spine registry. Summary of Background Data. Unplanned readmissions place considerable stress on payers, hospitals, and patients. Medicare data reveals a 30-day readmission rate of 7.8% for lumbar-decompressions and 13.0% for lumbar-fusions, and hospitals are now being penalized for excessive 30-day readmission rates by virtue of the Hospital Readmissions Reduction Program. Methods. The Quality and Outcomes Database (QOD) was queried for patients undergoing elective lumbar surgery for degenerative diseases. The QOD prospectively captures 3-month readmissions through electronic medical record (EMR) review and self-reported outcome questionnaires. Distinct multivariable logistic regression models were fitted for surgery-related and medical readmissions adjusting for patient and surgery-specific variables. Results. Of the total 33,674 patients included in this study 2079 (6.15%) reported at least one readmission during the 90-day postoperative period. The odds of medical readmission were significantly higher for older patients, males versus females, African Americans versus Caucasion, those with higher American Society of Anesthesiologists (ASA) grade, diabetes, coronary artery disease, higher numbers of involved levels, anterior only or anterior–posterior versus posterior approach; also, for patients who were unemployed compared with employed patients and those with high baseline Oswestry Disability Index (ODI). The odds of surgery-related readmission were significantly greater for patients with a higher body mass index (BMI), a higher ASA grade, female versus male, and African Americans versus Caucasians; also, for patients with severe depression, more involved spinal levels, anterior-only surgical approaches and higher baseline ODI scores. Conclusion. In this study we present internally validated predictive models for medical and surgical readmission after elective lumbar spine surgery. These findings set the stage for targeted interventions with a potential to reduce unnecessary readmissions, and also suggest that medical and surgical readmissions be treated as distinct clinical events. Level of Evidence: 3

Background The 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommended testing low‐density lipoprotein cholesterol ( LDL ‐C) to identify untreated patients with LDL ‐C ≥190 mg/dL, assess lipid‐lowering therapy adherence, and consider nonstatin therapy. We sought to determine whether clinician lipid testing practices were consistent with these guidelines. Methods and Results The PALM (Patient and Provider Assessment of Lipid Management) registry enrolled primary and secondary prevention patients from 140 US cardiology, endocrinology, and primary care offices in 2015 and captured demographic data, lipid treatment history, and the highest LDL ‐C level in the past 2 years. Core laboratory lipid levels were drawn at enrollment. Among 7627 patients, 2787 (36.5%) had no LDL ‐C levels measured in the 2 years before enrollment. Patients without chart‐documented LDL ‐C levels were more often women, nonwhite, uninsured, and non–college graduates (all P <0.01). Patients without prior lipid testing were less likely to receive statin treatment (72.6% versus 76.0%; P =0.0034), a high‐intensity statin (21.5% versus 24.3%; P =0.016), nonstatin lipid‐lowering therapy (24.8% versus 27.3%; P =0.037), and had higher core laboratory LDL ‐C levels at enrollment (median 97 versus 92 mg/dL; P <0.0001) than patients with prior LDL ‐C testing. Of 166 individuals with core laboratory LDL ‐C levels ≥190 mg/dL, 36.1% had no LDL ‐C measurement in the prior 2 years, and 57.2% were not on a statin at the time of enrollment. Conclusions In routine clinical practice, LDL ‐C testing is associated with higher‐intensity lipid‐lowering treatment and lower achieved LDL ‐C levels.

Background Data about anticoagulation in pulmonary arterial hypertension (PAH) patients are inconsistent. The objective of this study was to examine the impact of adjunctive oral anticoagulants in patients with PAH through meta-analysis, and to further assess whether response differs by PAH subtype. Methods and Results Cochrane CENTRAL, Medline, and Scopus databases were searched for randomized or nonrandomized studies that assessed the association between anticoagulation and outcomes in patients with PAH. Hazard ratios (HRs) for mortality were pooled using the random effects model. Subgroup analyses were performed for type of PAH and study design. Twelve nonrandomized studies, at moderate risk of bias, were included. These consisted of 2512 patients (1342 receiving anticoagulation and 1170 controls). Anticoagulation significantly reduced mortality in the overall PAH cohort (HR, 0.73 [0.57, 0.93]; P =0.001; I 2 =64%). On subgroup analysis, a significant mortality reduction was seen in idiopathic PAH patients (HR, 0.73 [0.56, 0.95]; P =0.02; I 2 =46%), whereas no significant difference was observed in connective tissue disease–related PAH (HR, 1.16 [0.58, 2.32]; P =0.67; I 2 =71%). Sensitivity analysis specific to scleroderma-associated PAH demonstrated a significant increase in mortality with anticoagulant use (HR, 1.58 [1.08, 2.31]; P =0.02; I 2 =9%). Conclusions This meta-analysis shows that use of anticoagulation may improve survival in idiopathic PAH patients, while increasing mortality when used in scleroderma-associated-PAH patients. Currently, no randomized clinical trials have been published, and until randomized data are available, anticoagulant use in PAH should be tailored to PAH subtype.

Abstract Several concepts, which in the aggregate get might be used to account for “resilience” against age‐ and disease‐related changes, have been the subject of much research. These include brain reserve, cognitive reserve, and brain maintenance. However, different investigators have use these terms in different ways, and there has never been an attempt to arrive at consensus on the definition of these concepts. Furthermore, there has been confusion regarding the measurement of these constructs and the appropriate ways to apply them to research. Therefore the reserve, resilience, and protective factors professional interest area, established under the auspices of the Alzheimer's Association, established a whitepaper workgroup to develop consensus definitions for cognitive reserve, brain reserve, and brain maintenance. The workgroup also evaluated measures that have been used to implement these concepts in research settings and developed guidelines for research that explores or utilizes these concepts. The workgroup hopes that this whitepaper will form a reference point for researchers in this area and facilitate research by supplying a common language.