Citations

OBJECTIVE Complex tethered spinal cord (cTSC) release in children is often complicated by surgical site infection (SSI). Children undergoing this surgery share many similarities with patients undergoing correction for neuromuscular scoliosis, where high rates of gram-negative and polymicrobial infections have been reported. Similar organisms isolated from SSIs after cTSC release were recently demonstrated in a single-center pilot study. The purpose of this investigation was to determine if these findings are reproducible across a larger, multicenter study. METHODS A multicenter, retrospective chart review including 7 centers was conducted to identify all cases of SSI following cTSC release during a 10-year study period from 2007 to 2017. Demographic information along with specific microbial culture data and antibiotic sensitivities for each cultured organism were collected. RESULTS A total of 44 SSIs were identified from a total of 655 cases, with 78 individual organisms isolated. There was an overall SSI rate of 6.7%, with 43% polymicrobial and 66% containing at least one gram-negative organism. Half of SSIs included an organism that was resistant to cefazolin, whereas only 32% of SSIs were completely susceptible to cefazolin. CONCLUSIONS In this study, gram-negative and polymicrobial infections were responsible for the majority of SSIs following cTSC surgery, with approximately half resistant to cefazolin. Broader gram-negative antibiotic prophylaxis should be considered for this patient population.

ABSTRACT. To date, no study has described the microbiological profile of surgical site infections (SSIs) after spine surgery in a tropical environment. The main objective of this study is to describe the microbiology and the risk factors of SSI after spinal surgery in a tropical climate. Our hypothesis is that the microbiology of SSIs in tropical areas is different to what is mainly described in temperate countries. As a consequence, the recommendation for antibiotic prophylaxis administered in the operative room, which mainly relays on the literature, might not be adequate in such countries. We included 323 consecutive patients who underwent a spinal intervention between 2017 and 2019, with a 2-year minimum follow-up. Objective ISO criteria were established in accordance with the criteria accepted by the Center of Disease Control in Atlanta. The identification of risk factors for SSI was carried out by uni- and multivariate analysis with a significance threshold of P < 0.05. The incidence of SSI was 7.7%. A total of 54.8% were in favor of a predominantly digestive origin of germs with an average of 1.68 bacteria found by ISO. Inadequate antibiotic prophylaxis was found in 54.8%. Age and body mass index were found to be independent risk factors for SSI. We report here an unusual microbiological profile of SSI with a predominance of gram-negative bacteria and a low proportion of Staphylococcus aureus and Staphylococcus epidermidis.

Abstract Aims The aim of our study was to review the surgical literature regarding the relationship between hemoglobin A1c (HbA1c), diagnosis of diabetes mellitus (DM), and risk of postoperative surgical site infection (SSI). Methods A librarian‐assisted literature search was performed with two goals: (1) identify surgical publications related to SSI and HbA1c values, and (2) identify publications reporting infection risk with DM in spinal cord stimulation (SCS), intrathecal drug delivery systems (IDDS), and cardiovascular implantable electronic device (CIED) implantation surgeries. Published guidelines on perioperative management of DM are reviewed. Results We identified 30 studies reporting SSI and HbA1c values. The literature review indicated that for many surgical procedures, elevated HbA1c is not correlated to rate of SSI. We identified 16 studies reporting infection rates within DM cohorts following SCS, IDDS, and CIED implantation surgeries. The data reviewed did not indicate DM as an independent risk factor for SSI. Conclusion Preoperative HbA1c levels in patients with a history of DM is not a singularly sufficient tool to estimate risk of perioperative infection in SCS implantation surgery. Published guidelines on perioperative management of DM do not suggest a specific HbA1c above which surgery should be delayed; intentional perioperative glycemic control is recommended.

e22509 Background: Chronic inflammatory states are linked with increased cancer risk. However, it is unclear if chronic sinusitis (CS) is involved in the development of certain malignancies. Several observational studies reported conflicting results regarding its association with cancer risk. Methods: We searched MEDLINE, EMBASE, Scopus, and Web of Science from their inception till October 2020. The fully adjusted risk estimates were abstracted independently and pooled using the generic inverse variant random-effects model. The Newcastle Ottawa Scale (NOS) was used to assess the quality of included studies. Results: Of 184 articles meeting our eligibilty criteria, 6 cohort and 6 case-control studies reporting data from USA (n = 2), Japan (n = 3), Singapore (n = 1), Taiwan (n = 5), and France (n = 1) were included in the final analysis. Compared to patients without CS (n = 562818), the RR of overall cancer risk in patients with CS (n = 51436) pooled from two studies was = 1.06 (95% CI: 1.00 - 1.13, P = 0.037). CS was associated with an increased cancer risk of head and neck (RR = 1.42, 95%CI: 1.28 - 1.58, P < 0.001), nasopharyngeal (NP) (RR = 1.62, 95%CI: 1.40 - 1.88, P < 0.001), sinonasal (RR = 1.75, 95% CI: 1.34 - 2.29, P < 0.001), and lung cancers (RR = 1.19, 95% CI: 1.14 - 1.23, P < 0.001). No significant assocation was identified with colorectal (RR = 1.02, 95% CI: 0.72 – 1.45, P = 0.89), liver (RR = 1.06, 95% CI: 0.77 - 1.45, P = 0.73), prostate (RR = 1.43, 95% CI: 0.87 – 2.33, P = 0.16), bladder (RR = 1.20, 95% CI: 0.82 - 1.75, P = 0.36), and stomach cancer (RR = 0.97, 95% CI: 0.88 - 1.06, P = 0.47). On the subgroup analysis, CS was associated with an increased risk of lung cancer in females (HR = 2.32, 95% CI: 1.23–4.39) but not in males (HR = 1.32, 95% CI: 0.79 – 2.21). In addition, the association between CS and NP cancer disappeared 1 year or more after diagnosis with RR = 1.82, 95% CI: 0.98 – 3.39) when pooling results from the three studies reporting the interval between CS diagnosis and cancer occurence. According to the NOS, 8 of the included studies were with low risk of bias, 2 with moderate risk, and 2 with high risk of bias. Conclusions: Our analysis found a significant association between CS and risk of overall, head and neck, nasopharyngeal, sinonasal, and lung cancers. Paradoxically, The risk of CS and NP cancer was significant only in subjects with a shorter duration of CS diagnosis, suggesting that CS is a coexistent complication of yet undiagnosed NP cancer. The results of this meta-analysis should be interpreted carefully due to the high heterogeneity and the small number of included studies in the site-specific cancer analyses. This association warrants further investigation using proper study design taking into consideration the years of follow-up, the interval between CS diagnosis and cancer occurrence, as well as gender disparities.

Abstract Introduction Transnasal access to the anterior skull base provides a minimally invasive approach for sellar and parasellar masses compared with its open counterparts. The unique microbiome of the sinonasal mucosa provides distinct challenges not encountered with other cranial approaches. The use of antibiotics in these cases has not been standardized, and data remain scarce regarding infectious outcomes. Methods We conducted a multicenter retrospective analysis of shared quality data points for the endoscopic endonasal approach (EEA) for pituitary adenomas, along with other sellar and parasellar region masses that were included by participating institutions. Patient and operative characteristics, perioperative and postoperative antibiotic regimens and their durations, intraoperative and postoperative cerebrospinal fluid leak, and onset of postoperative meningitis and sinusitis were compared. Results Fifteen institutions participated and provided 6 consecutive months' worth of case data. Five hundred ninety-three cases were included in the study, of which 564 were pituitary adenomectomies. The incidences of postoperative meningitis and sinusitis were low (0.67 and 2.87% for all pathologies, respectively; 0.35% meningitis for pituitary adenomas) and did not correlate with any specific antibiotic regimen. Immunocompromised status posed an increased odds of meningitis in pituitary adenomectomies (28.6, 95% confidence interval [1.72–474.4]). Conclusions The results show no clear benefit to postoperative antimicrobial use in EEA, with further larger studies needed.

Aim. To assess evidence for an image-guided approach for cardiac resynchronization therapy (CRT) that targets left ventricular (LV) lead placement at the segment of latest mechanical activation. Methods. A systematic review of EMBASE and PubMed was performed for randomized controlled trials (RCTs) and prospective observational studies from October 2008 through October 2020 that compared an image-guided CRT approach with a non-image-guided approach for LV lead placement. Meta-analyses were performed to assess the association between the image-guided approach and NYHA class improvement or changes in end-systolic volume (LVESV), end-diastolic volume (LVEDV), and ejection fraction (LVEF). Results. From 5897 citations, 5 RCTs including 818 patients (426 image-guided and 392 non-image-guided) were identified. The mean age ranged from 66 to 71 years, 76% were male, and 53% had ischemic cardiomyopathy. Speckle tracking echocardiography was the primary image-guided method in all studies. LV lead placement within the segment of the latest mechanical activation (concordant) was achieved in the image-guided arm in 45% of the evaluable patients. There was a statistically significant improvement in the NYHA class at 6 months (odds ratio 1.66; 95% confidence interval (CI) [1.02, 2.69]) with the image-guided approach, but no statistically significant change in LVESV (MD −7.1%; 95% CI [−16.0, 1.8]), LVEDV (MD −5.2%; 95% CI [−15.8, 5.4]), or LVEF (MD 0.68; 95% CI [−4.36, 5.73]) versus the non-image-guided approach. Conclusion. The image-guided CRT approach was associated with improvement in the NYHA class but not echocardiographic measures, possibly due to the small sample size and a low rate of concordant LV lead placement despite using the image-guided approach. Therefore, our meta-analysis was not able to identify consistent improvement in CRT outcomes with an image-guided approach.

Background Studies of alcohol withdrawal syndrome indicate a higher prevalence in men than in women. However, it is unknown how the condition differs between the sexes. Objective To assess alcohol withdrawal syndrome in women versus men at a single site. Methods All cases of alcohol withdrawal syndrome at a public hospital from 2010 to 2014 were reviewed retrospectively. For all 1496 episodes, age, sex, and admission to a general care unit (ward) versus the medical intensive care unit were ascertained, along with patient survival. A detailed analysis was performed of 437 cases: all 239 patients admitted to the medical intensive care unit, all 99 female patients admitted to the ward, and 99 randomly selected male patients admitted to the ward. Also analyzed were administration of benzodiazepines, disease course, length of stay, and complications. Results Men accounted for 92% of all cases (1378 of 1496; P &lt; .001) and medical intensive care unit admissions (220 of 239; P &lt; .05). Sixteen percent of both men and women were admitted to the medical intensive care unit. Men were older (mean age, 45.6 vs 43.9 years; P &lt; .01), and women required more benzodiazepines. Similar rates of complications occurred in both sexes, although women had a higher rate of pancreatitis and men had higher rates of pneumonia, higher rates of sepsis, and longer stays. Conclusions Men and women with alcohol withdrawal syndrome have similar complications, courses, and intensive care unit admission rates, although men are more prone to pneumonia and have longer stays.

Introduction: CRT outcomes with image-guided left ventricular (LV) lead placement within the LV segment of latest mechanical activation have been assessed in several randomized controlled trials (RCTs) with equivocal results, possibly due to variable achievement of concordant LV lead placement in the image-guided and comparator arms. We conducted meta-analyses to assess CRT outcomes associated with concordant LV lead placement. Methods: A systematic literature review was performed to identify RCTs and prospective observational studies of CRT from October 2008 through October 2020 that reported outcomes in those with LV lead placement at or adjacent to the site of latest mechanical activation (concordant) versus those with LV lead placement distant to the site of latest mechanical activation (discordant) as determined by any imaging method. Two independent reviewers screened titles and abstracts then reviewed full text for inclusion/exclusion. One reviewer abstracted data and a second over-read for accuracy. Meta-analyses for death, death or HF hospitalization, and changes in LVESV and LVEF were performed using random effects models. Results: Among 5715 citations identified, 9 papers from 8 studies (including 4 RCTs) were selected that included 1004 patients with concordant LV lead placement and 380 with discordant LV lead placement. Mean patient age ranged from 66 to 68 years, 82% were male, and 64% had ischemic cardiomyopathy. Segment of latest activation was determined by speckle tracking echocardiography (STE) in 7 (88%) studies. Meta-analyses demonstrated statistically significant lower all-cause mortality or HF hospitalization and reduction in LVESV with a concordant LV lead (Figure). There were trends toward lower all-cause mortality and increased LVEF. Conclusion: A concordant LV lead, as determined primarily by STE, was associated with better CRT outcomes. Further study of feasible methods to achieve concordance in clinical practice is needed.

Abstract Anaplastic thyroid cancer (ATC) is among the most aggressive of human cancers, and currently there are few effective treatments for most patients. YM155, first identified as a survivin inhibitor, was highlighted in a high-throughput screen performed by the National Cancer Institute, killing ATC cells in vitro and in vivo. However, there was no association between survivin expression and response to YM155 in clinical trials, and YM155 has been mostly abandoned for development despite favorable pharmacokinetic and toxicity profiles. Currently, alternative mechanisms are being explored for YM155 by a number of groups. In this study, ATC patient samples show overexpression of topoisomerase Top2α compared with benign thyroid samples and to differentiated thyroid cancers. ATC cell lines that overexpress Top2α are more sensitive to YM155. We created a YM155-resistant cell line, which shows decreased expression of Top2α and is resensitized with Top2α overexpression. Molecular modeling predicts binding for YM155 in the Top2α ATP-binding site and identifies key amino acids for YM155–Top2α interaction. A Top2α mutant abrogates the effect of YM155, confirming the contribution of Top2α to YM155 mechanism of action. Our results suggest a novel mechanism of action for YM155 and may represent a new therapeutic approach for the treatment of ATC.