Current Disease Classification Research Articles

United States emergency department visits for children with cerebrospinal fluid shunts.

CSF shunt placement is the primary therapy for hydrocephalus; however, shunt malfunctions remain common and lead to neurological deficits if missed. There is a lack of literature characterizing the epidemiology of children with possible shunt malfunctions presenting to United States emergency departments (EDs). A retrospective study was conducted of the 2006-2017 National Emergency Department Sample. The data were queried using an exhaustive list of Current Procedural Terminology and International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes representing children with hydrocephalus diagnoses, diagnostic imaging for shunt malfunctions, and shunt-related surgical revision procedures. In 2017, there were an estimated 16,376 ED visits for suspected shunt malfunction. Children were more commonly male (57.9%), ages 0-4 years (42.2%), and publicly insured (55.8%). Many did not undergo diagnostic imaging (37.2%), and of those who did, most underwent head CT scans (43.7%). Between 2006 and 2017, pediatric ED visits for suspected shunt malfunction increased 18% (95% CI 12.1-23.8). The use of MRI increased substantially (178.0%, 95% CI 176.9-179.2). Visits resulting in discharge home from the ED increased by 76.3% (95% CI 73.1-79.4), and those involving no surgical intervention increased by 32.9% (95% CI 29.2-36.6). Between 2006 and 2017, ED visits for children to rule out shunt malfunction increased, yet there was a decline in surgical intervention and an increase in discharges home from the ED. Possible contributing factors include improved clinical criteria for shunt evaluation, alternative CSF diversion techniques, changing indications for shunt placement, and increased use of advanced imaging in the ED. CPT = Current Procedural Terminology; ED = emergency department; ETV = endoscopic third ventriculostomy; ICD-9 = International Classification of Diseases, Ninth Revision; ICD-10 = International Classification of Diseases, Tenth Revision; NEDS = National Emergency Department Sample.

Trends and Perioperative Outcomes across Elective Benign Hysterectomy Procedures from the ACS-NSQIP 2007-2017

Study Objective To delineate long-term national trends in the frequency of hysterectomy surgical routes, patient demographics, and perioperative morbidity with emphasis on extended length of stay and readmission rates. Design This retrospective cohort study evaluated 224,357 patients who underwent benign hysterectomy between 2007-2017. Setting In-patient hysterectomies performed at one of the participating hospitals in the American College of Surgeons- National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients or Participants The ASC-NSQIP database was used to recognize patients who underwent an elective benign hysterectomy between 2007-2017. Patients were identified using Current Procedural Terminology (CPT) and International Classification of Disease (ICD) codes. Interventions Laparoscopic, transvaginal, and abdominal hysterectomy for benign indications. Measurements and Main Results Summary statistics were used to evaluate shifts in patient characteristics and postoperative outcomes by hysterectomy route and year of surgery. Multivariable logistic regression analysis comparing laparoscopic to transvaginal and abdominal hysterectomies was performed, adjusting for patient characteristics and operative time. Variables of interest included age, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) classification, uterine weight > 250 grams, Extended Length Of Stay (ELOS) and readmission. Our data shows that the rate of laparoscopic hysterectomy increased by more than 200% between 2007-2017 while that of transvaginal and abdominal hysterectomies decreased. Moreover, the mean age and rates of obesity amongst women undergoing hysterectomy increased steadily across all surgical routes, the sharpest increase in obesity noted amongst the laparoscopic hysterectomy group. In 2011, we noted a shift in the laparoscopic hysterectomy group, which by 2017, had 29% lower odds of ELOS as compared to the abdominal group (P Conclusion Although the benign surgical gynecology patient population is becoming increasingly complex, the risk of complications after hysterectomy is lowest when performed laparoscopically.

23. Natural language processing for automated identification of intraoperative vascular injury in anterior lumbar spine surgery

BACKGROUND CONTEXT Intraoperative vascular injury may be an unavoidable complication of anterior lumbar spine surgery. However, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture. PURPOSE The purpose of this study was to develop natural language processing (NLP) algorithms for automated surveillance of intraoperative vascular injury from free-text notes in anterior lumbar spine surgery. STUDY DESIGN/SETTING Retrospective review of electronic health records at two academic and three community medical centers. PATIENT SAMPLE Adult patients, 18 years or age or older, undergoing anterior lumbar spine surgery OUTCOME MEASURES The primary outcome was unintended vascular injury during anterior lumbar spine surgery. METHODS The training set (n=786) consisted of patients who underwent surgery prior to December 31, 2013. The independent testing set (n=249) consisted of patients who underwent surgery after January 1, 2014. An extreme-gradient boosting supervised machine learning NLP algorithm was trained for detection of intraoperative vascular injury. Performance of this algorithm was compared to current procedural terminology (CPT) and international classification of diseases (ICD) codes. RESULTS In all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative vascular injury was 7.2% (n=75). On temporal validation in the independent testing set, the NLP algorithm achieved c-statistic of 0.92 in comparison to 0.64 for the CPT and ICD codes. At a threshold equal to the Youden index, the NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a vascular injury whereas the CPT and ICD codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64. CONCLUSIONS Relying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative vascular injury in anterior lumbar spine surgery. External and prospective validation of this NLP algorithm may improve quality and safety reporting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Significant Management Variability of Urethral stricture Disease in United States: Data from the AUA Quality (AQUA) Registry

ObjectiveTo determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success. Materials and MethodsThe AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census. ResultsWe identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients. Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p<0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64). ConclusionsRepeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement.

A Retrospective Database Review of the Indications, Complications, and Incidence of Subsequent Spine Surgery in 12,297 Spinal Cord Stimulator Patients

Retrospective review. To analyze the indications, incidence of minor and major complications, and rate of subsequent spinal surgery or revision after spinal cord stimulator (SCS) placement for degenerative spine disease. Despite the application of SCS in various chronic pain conditions, there remains a growing debate on the efficacy and necessity of SCS in degenerative spine disease. A nationally representative sample of Medicare patients who had an open (via laminectomy) SCS placement for degenerative spine disease between 2005 and 2014 were studied. Indications, complications, and the rate of subsequent spinal surgery within 90 days, one year, two years, and three years postoperatively were studied using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. We included 12,297 SCS patients in our study cohort. The most common indications for SCS placement were postlaminectomy syndrome (25.2%) and chronic pain syndrome (20.2%). There was a 4.2 and 17.2% incidence of postoperative back or spine emergency department (ED) visits, and a 0.3 and 3.4% incidence of SCS electrode removal or reimplantation within 90 days and 1 year, respectively. Other reported surgical complications were wound infection (4.3%), hematoma (0.5%), and seroma (0.4%) at one year postoperatively. Within 90 days after SCS implantation, the rate of subsequent spine surgery or revision was 0.9%. This incidence was 7.1, 11.7, and 15.5% at one, two, and three years, respectively. In our retrospective analysis of Medicare patients, the most common indication for SCS implantation was postlaminectomy syndrome. Common postoperative complications included wound infection, and removal of SCS electrodes at one year postoperatively. About 17% patients had an ED visit for spine-related symptoms within one year of device implantation, and 15.5% underwent subsequent spinal decompression and/or fusion within 3 years after primary SCS placement.

The Utility of Obtaining Postmobilization Imaging in Nonsurgical Pelvic Ring Injuries.

Pelvic fractures are diverse injuries with varying degrees of severity. Treatment recommendations are determined by the associated instability. For likely stable patterns, postmobilization imaging is used to assess for occult instability. This study assesses the utility of postmobilization images and determines how often they alter the recommendations for treatment. Records at a single level 1 trauma center from January 2007 through December 2014 were reviewed, and patients with Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for pelvic and acetabular fractures were identified. For those chosen for nonsurgical treatment at presentation, a detailed chart review was performed to identify patients who had postmobilization radiographs and to determine whether this imaging led to a change in treatment recommendations. Inclusion criteria were met by 762 patients whose average age was 50 years. Of 331 patients planned for nonsurgical treatment at presentation, 168 (51%) had postmobilization images. The postmobilization radiographs did not alter treatment recommendations in any of these patients; however, three of these patients underwent surgical stabilization based on the patients' report of pain with attempted mobilization. Routine postmobilization imaging has limited value for patients with pelvic injuries and a low likelihood for instability, such as those with incomplete sacral fractures. Eliminating this step would reduce cost and decrease radiation exposure. The need for change in treatment plan or further imaging should be based on the patient's clinical progress with weight bearing. Level 4.

Anticoagulant Usage Following Anterior Cruciate Ligament Reconstruction is Associated with Increased Rate of Manipulation Under Anesthesia

Objectives:Although uncommon, arthrofibrosis following anterior cruciate ligament reconstruction (ACLR) is considered to be a significant and disabling complication for a young, athletic population. In this study, we aimed to determine: (1) the prevalence of manipulation under anesthesia (MUA) for treatment of arthrofibrosis following ACLR (2) whether anticoagulant use following ACLR is associated with an increased risk of MUA. We anticipate that postoperative use of anticoagulants will be associated with an increased risk of subsequent MUA.Methods:A retrospective cohort study was conducted using data collected from the Humana insurance database using the PearlDiver Patient Records Database from 2007-2017. Subjects were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Patients were initially identified by ACL sprain or tear diagnosis utilizing ICD codes. Patients who underwent a concomitant MCL, PCL or LCL repair or reconstruction were excluded from this analysis. Patients who underwent MUA within one year of ACLR were then identified. Patient demographic characteristics including age, sex, and Charlson Comorbidity Index (CCI) were recorded. In addition, previously identified risk factors for knee stiffness were collected, including history of diabetes mellitus and obesity. Lastly, the time between ACL tear and surgery and ACL reconstruction to MUA were collected and categorized into 2 groups: (1) <4 weeks and (2) >4 weeks. Anticoagulants included in this analysis were warfarin, aspirin, low-molecular-weight heparin, direct factor Xa inhibitors and fondaparinux. Patient demographics, comorbidities, timing to surgery, concomitant meniscal repair, and postoperative complications were analyzed with a logistic multivariate analysis to determine adjusted associations of risk factors of arthrofibrosis. A p-value of < 0.05 was used as the cutoff for statistical significance.Results:There were 7,798 patients who met the inclusion criteria for this analysis. 115 (1.5%) patients received a subsequent MUA within one-year, while 7,683 (98.5%) patients did not. Among patients who underwent ACLR, 234 (3.0%) patients were on anticoagulants postoperatively. Patients who were on anticoagulants following ACLR were more likely to require an MUA (OR: 4.626; 95% CI: 2.462-8.093; p<0.001; Table 1). Other risk factors for MUA are listed in Table 1.Conclusion:The key finding of this study was that the use of anticoagulants is associated with increased rates of MUA following ACLR. One potential mechanism for the effect of anticoagulants may be the increased risk of postoperative hematoma. Recurrent hematoma has been suggested as a risk factor for arthrofibrosis requiring MUA following ACLR due to increased vascular micro-permeability that anticoagulants can produce. The presence of blood products in the joint may stimulate the accumulation of inflammatory mediators and subsequent fibrosis, as it is well-established that unresolved inflammation can initiate and propagate scar tissue formation.In conclusion, arthrofibrosis after ACLR is associated with postoperative use of thromboprophylaxis. Healthcare providers should be cognizant of this risk when considering anticoagulant usage in this patient population.

Rotator cuff repair in HIV-infected patients: an analysis of postoperative complications

Objectives:Human immunodeficiency virus (HIV) remains a major challenge to global health. However, advances in treatment have transformed HIV infection into a more manageable chronic disease, dramatically increasing the life expectancy of people living with HIV (PLWH). As a result, the range and extent of comorbidities in PLWH have expanded beyond infectious disease, and frequently involves the musculoskeletal system. HIV-positive patients may also suffer from rotator cuff pathology which may require surgical repair. The purpose of this study was to examine the postoperative complications associated with rotator cuff repair (RCR) in HIV-infected patients.Methods:Data was collected from the Medicare Standardized Analytic Files between 2005 – 2015 using thePearlDiver Patient Records Database. Subjects were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Demographics including age, sex, medical comorbidities, and smoking status were collected. Patients were stratified into two groups based upon a history of HIV diagnosis, with the non-infected group serving as the control. Potential confounders were mitigated using propensity score matching to create matched cohorts of patients with and without HIV infection undergoing RCR. Data on patient demographics, comorbidities, and postoperative complications were analyzed with univariate and multivariate analyses. Complications were examined at 7-, 30-, and 90-day postoperative time points.Results:The study included 152,114 patients who underwent RCR, with 24,486 (16.1%) patients who were HIV-positive. Following univariate analysis, patients with HIV were observed to be more likely to develop 7-day, 30-day, and 90-day postoperative complications (Table 1). The multivariate analysis showed patients with HIV were more likely to develop myocardial infarction (OR: 2.494; 95% CI: 1.016-6.121; p<0.001) and sepsis (OR: 2.549; 95% CI: 1.085-5.938, p<0.001) within 7 days; acute renal failure (OR: 1.489; 95% CI: 1.015-2.186; p=0.041), postoperative anemia (OR:2.789; 95% CI: 1.732-4.493, p<0.001), atrial fibrillation (OR: 1.322; 95% CI: 1.079-1.619; p=0.006), blood transfusion (OR: 3.328; 95% CI: 2.005-5.536; p<0.001), heart failure (OR: 2.321; 95% CI: 1.805-2.983; p<0.001), pneumonia (OR: 3.452; 95% CI: 1.054-5.646; p=0.034), sepsis (OR: 2.654; 95% CI: 1.098-6.155; p<0.001), and stroke (OR: 2.007; 95% CI: 1.207-3.337; p=0.007) within 30 days; and mechanical complications (OR: 2.116; 95% CI: 1.232-3.634; p=0.006) and shoulder stiffness (OR: 1.395; 95% CI: 1.312-1.483; p=0.047) within 90 days following surgery (Table 1).Conclusion:To our knowledge, this study is the first to examine postoperative complications following RCR in HIV-infected patients. The rising life expectancy of PLWH has resulted in an increased need for orthopedic treatment of musculoskeletal disorders among HIV-positive individuals, including rotator cuff pathology. The findings of this study inform care regarding RCR in HIV-infected patients, enhancing the ability of practitioners to provide comprehensive care to individuals within this population. We found that complications following RCR occurred at increased rates in the HIV-infected group relative to the non-infected group. Surgeons should be aware PLWH are at elevated risk for postoperative complications in order to optimize care and proactively counsel patients.

Development of machine learning and natural language processing algorithms for preoperative prediction and automated identification of intraoperative vascular injury in anterior lumbar spine surgery

BACKGROUNDIntraoperative vascular injury (VI) may be an unavoidable complication of anterior lumbar spine surgery; however, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture. PURPOSEThe purpose of this study was to (1) develop machine learning algorithms for preoperative prediction of VI and (2) develop natural language processing (NLP) algorithms for automated surveillance of intraoperative VI from free-text operative notes. PATIENT SAMPLEAdult patients, 18 years or age or older, undergoing anterior lumbar spine surgery at two academic and three community medical centers were included in this analysis. OUTCOME MEASURESThe primary outcome was unintended VI during anterior lumbar spine surgery. METHODSManual review of free-text operative notes was used to identify patients who had unintended VI. The available population was split into training and testing cohorts. Five machine learning algorithms were developed for preoperative prediction of VI. An NLP algorithm was trained for automated detection of intraoperative VI from free-text operative notes. Performance of the NLP algorithm was compared to current procedural terminology and international classification of diseases codes. RESULTSIn all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative VI was 7.2% (n=75). Variables used for preoperative prediction of VI were age, male sex, body mass index, diabetes, L4-L5 exposure, and surgery for infection (discitis, osteomyelitis). The best performing machine learning algorithm achieved c-statistic of 0.73 for preoperative prediction of VI (https://sorg-apps.shinyapps.io/lumbar_vascular_injury/). For automated detection of intraoperative VI from free-text notes, the NLP algorithm achieved c-statistic of 0.92. The NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a VI whereas current procedural terminologyand international classification of diseases codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64. CONCLUSIONRelying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative VI in anterior lumbar spine surgery. External and prospective validation of the algorithms presented here may improve quality and safety reporting.

Immunological Profiling of Paediatric Inflammatory Bowel Disease Using Unsupervised Machine Learning.

The current classification of inflammatory bowel disease (IBD) is based on clinical phenotypes, which is blind to the molecular basis of the disease. The aim of this study was to stratify a treatment-naïve paediatric IBD cohort through specific innate immunity pathway profiling and application of unsupervised machine learning (UML). In order to test the molecular integrity of biological pathways implicated in IBD, innate immune responses were assessed at diagnosis in 22 paediatric patients and 10 age-matched controls. Peripheral blood mononuclear cells (PBMCs) were selectively stimulated for assessing the functionality of upstream activation receptors including NOD2, toll-like receptor (TLR) 1-2 and TLR4, and the downstream cytokine responses (IL-10, IL-1β, IL-6, and TNF-α) using multiplex assays. Cytokine data generated were subjected to hierarchical clustering to assess for patient stratification. Combined immune responses in patients across 12 effector responses were significantly reduced compared with controls (P = 0.003) and driven primarily by "hypofunctional" TLR responses (P values 0.045, 0.010, and 0.018 for TLR4-mediated IL-10, IL-1β, and TNF-α, respectively; 0.018 and 0.015 for TLR1-2 -mediated IL-10 and IL-1β). Hierarchical clustering generated 3 distinct clusters of patients and a fourth group of "unclustered" individuals. No relationship was observed between the observed immune clusters and the clinical disease phenotype. Although a clinically useful outcome was not observed through hierarchical clustering, our study provides a rationale for using an UML approach to stratify patients. The study also highlights the predominance of hypo-inflammatory innate immune responses as a key mechanism in the pathogenesis of IBD.

Can natural language processing provide accurate, automated reporting of wound infection requiring reoperation after lumbar discectomy?

Surgical site infections are a major driver of morbidity and increased costs in the postoperative period after spine surgery. Current tools for surveillance of these adverse events rely on prospective clinical tracking, manual retrospective chart review, or administrative procedural and diagnosis codes. The purpose of this study was to develop natural language processing (NLP) algorithms for automated reporting of postoperative wound infection requiring reoperation after lumbar discectomy. Adult patients undergoing discectomy at two academic and three community medical centers between January 1, 2000 and July 31, 2019 for lumbar disc herniation. Reoperation for wound infection within 90 days after surgery METHODS: Free-text notes of patients who underwent surgery from January 1, 2000 to December 31, 2015 were used for algorithm training. Free-text notes of patients who underwent surgery after January 1, 2016 were used for algorithm testing. Manual chart review was used to label which patients had reoperation for wound infection. An extreme gradient-boosting NLP algorithm was developed to detect reoperation for postoperative wound infection. Overall, 5,860 patients were included in this study and 62 (1.1%) had a reoperation for wound infection. In patients who underwent surgery after January 1, 2016 (n=1,377), the NLP algorithm detected 15 of the 16 patients (sensitivity=0.94) who had reoperation for infection. In comparison, current procedural terminology and international classification of disease codes detected 12 of these 16 patients (sensitivity=0.75). At a threshold of 0.05, the NLP algorithm had positive predictive value of 0.83 and F1-score of 0.88. Temporal validation of the algorithm developed in this study demonstrates a proof-of-concept application of NLP for automated reporting of adverse events after spine surgery. Adapting this methodology for other procedures and outcomes in spine and orthopedics has the potential to dramatically improve and automatize quality and safety reporting.

Health Care Resource Utilization in Commercially Insured Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Pathology.

Study Design:Retrospective review of an administrative database.Objectives:The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology.Methods:Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission.Results:In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), P < .001.Conclusion:Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.

Natural language processing for automated detection of incidental durotomy

BACKGROUNDIncidental durotomy is a common intraoperative complication during spine surgery with potential implications for postoperative recovery, patient-reported outcomes, length of stay, and costs. To our knowledge, there are no processes available for automated surveillance of incidental durotomy. PURPOSEThe purpose of this study was to develop natural language processing (NLP) algorithms for automated detection of incidental durotomies in free-text operative notes of patients undergoing lumbar spine surgery. PATIENT SAMPLEAdult patients 18 years or older undergoing lumbar spine surgery between January 1, 2000 and June 31, 2018 at two academic and three community medical centers. OUTCOME MEASURESThe primary outcome was defined as intraoperative durotomy recorded in free-text operative notes. METHODSAn 80:20 stratified split was undertaken to create training and testing populations. An extreme gradient-boosting NLP algorithm was developed to detect incidental durotomy. Discrimination was assessed via area under receiver-operating curve (AUC-ROC), precision-recall curve, and Brier score. Performance of this algorithm was compared with current procedural terminology (CPT) and international classification of diseases (ICD) codes for durotomy. RESULTSOverall, 1,000 patients were included in the study and 93 (9.3%) had a recorded incidental durotomy in the free-text operative report. In the independent testing set (n=200) not used for model development, the NLP algorithm achieved AUC-ROC of 0.99 for detection of durotomy. In comparison, the CPT/ICD codes had AUC-ROC of 0.64. In the testing set, the NLP algorithm detected 16 of 18 patients with incidental durotomy (sensitivity 0.89) whereas the CPT and ICD codes detected 5 of 18 (sensitivity 0.28). At a threshold of 0.05, the NLP algorithm had specificity of 0.99, positive predictive value of 0.89, and negative predictive value of 0.99. CONCLUSIONSInternal validation of the NLP algorithm developed in this study indicates promising results for future NLP applications in spine surgery. Pending external validation, the NLP algorithm developed in this study may be used by entities including national spine registries or hospital quality and safety departments to automate tracking of incidental durotomies.

Role of inflammasomes in the pathogenesis of periodontal disease and therapeutics.

Inflammasomes are a group of multimolecular intracellular complexes assembled around several innate immune proteins. Recognition of a diverse range of microbial, stress and damage signals by inflammasomes results in direct activation of caspase‐1, which subsequently induces the only known form of secretion of active interleukin‐1β and interleukin‐18. Although the importance of interleukin‐1β in the periodontium is not questioned, the impact of inflammasomes in periodontal disease and its potential for therapeutics in periodontology is still in its very early stages. Increasing evidence in preclinical models and human data strongly implicate the involvement of inflammasomes in a number of inflammatory, autoinflammatory and autoimmune disorders. Here we review: (a) the currently known inflammasome functions, (b) clinical/preclinical data supporting inflammasome involvement in the context of periodontal and comorbid diseases and (c) potential therapies targeting inflammasomes. To clarify further the inflammasome involvement in periodontitis, we present analyses of data from a large clinical study (n = 5809) that measured the gingival crevicular fluid‐interleukin‐1β and grouped the participants based on current periodontal disease classifications. We review data on 4910 European‐Americans that correlate 16 polymorphisms in the interleukin‐1B region with high gingival crevicular fluid‐interleukin‐1β levels. We show that inflammasome components are increased in diseased periodontal tissues and that the caspase‐1 inhibitor, VX‐765, inhibits ~50% of alveolar bone loss in experimental periodontitis. The literature review further supports that although patients clinically present with the same phenotype, the disease that develops probably has different underlying biological pathways. The current data indicate that inflammasomes have a role in periodontal disease pathogenesis. Understanding the contribution of different inflammasomes to disease development and distinct patient susceptibility will probably translate into improved, personalized therapies.

Unplanned Admissions Following Hip Arthroscopy: Incidence and Risk Factors

To determine the rate of and risk factors for 30-day unplanned admissions following hip arthroscopy in a U.S. Patients undergoing hip arthroscopy were identified in the American College of Surgeons National Surgical Quality Improvement Program database using validated Current Procedural Terminology and International Classification of Diseases, Ninth Revision and Tenth Revision codes. Patient demographics, comorbidities, preoperative laboratory values, surgical details, and postoperative outcomes were compared between patients with unplanned admissions and those without. Univariate analysis comparing study cohorts was performed using 2-tailed Student t tests with Levene's test for equality of variance or χ2/Fisher exact tests as appropriate. Using variables that were significant in the univariate analysis, we created Cox proportional hazard models to identify independent predictors for unplanned admission. A total of 1931 cases of hip arthroscopy were identified. There were 18 cases of unplanned admissions within 30days of index procedure (0.9%). The median time to unplanned admission was 14.5days (interquartile range: 3.875-25.125days). The most common reasons for admission were surgical-site infection (11.1%), wound complications (11.1%), and thromboembolic events (11.1%). There were 4 patients who required reoperation (22.2%). There were 7 cases (39.0%) that were readmitted for reasons unrelated to the index hip arthroscopy procedure. Multivariate analysis identified increasing body mass index, chronic corticosteroid use, and perioperative blood transfusion as factors independently associated with increased risk for unplanned admission. There exists a low incidence of 30-day unplanned admission, predominantly secondary to surgical-site infections, wound complications, and thromboembolic events. Independent risk factors for unplanned admission include greater body mass index, chronic corticosteroid use, and perioperative transfusions. Level III Retrospective Cohort Study.

Post-operative intensive care unit admission after elective non-cardiac surgery: A single-center analysis of the NSQIP database.

Admission to the intensive care unit (ICU) after surgery can be associated with significant morbidity and mortality. This observational cohort study aims to identify perioperative factors associated with post-operative ICU admission in patients undergoing elective non-cardiac surgery. Data from the ACS NSQIP® database at a tertiary care academic medical center were analyzed from January 2011 to September 2016. Univariable and multivariable logistic regression of patient and surgery-specific characteristics was performed to assess association with post-operative ICU admission. The Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) billing codes, as well as associated outcomes, were reviewed. Of 5254 database patient records, 1150 met our inclusion criteria. Elevated body mass index (BMI), longer procedure duration and a diagnosis of disseminated cancer were associated with post-operative ICU admission. Prostatectomy and morbid obesity were the most common CPT and ICD-9 codes identified. Patients who were admitted to the ICU after surgery had a longer hospital length of stay (LOS), had a higher frequency of readmission, re-operation, and in-hospital mortality. Admission to the ICU after elective non-cardiac surgery is common. Our analysis of the ACS NSQIP® database identified elevated BMI, longer duration of surgery and disseminated cancer as predictors of post-operative ICU admissions in patients undergoing elective non-cardiac surgery.

Identifying biological markers for improved precision medicine in psychiatry

Mental disorders represent an increasing personal and financial burden and yet treatment development has stagnated in recent decades. Current disease classifications do not reflect psychobiological mechanisms of psychopathology, nor the complex interplay of genetic and environmental factors, likely contributing to this stagnation. Ten years ago, the longitudinal IMAGEN study was designed to comprehensively incorporate neuroimaging, genetics, and environmental factors to investigate the neural basis of reinforcement-related behaviour in normal adolescent development and psychopathology. In this article, we describe how insights into the psychobiological mechanisms of clinically relevant symptoms obtained by innovative integrative methodologies applied in IMAGEN have informed our current and future research aims. These aims include the identification of symptom groups that are based on shared psychobiological mechanisms and the development of markers that predict disease course and treatment response in clinical groups. These improvements in precision medicine will be achieved, in part, by employing novel methodological tools that refine the biological systems we target. We will also implement our approach in low- and medium-income countries to understand how distinct environmental, socio-economic and cultural conditions influence the development of psychopathology. Together, IMAGEN and related initiatives strive to reduce the burden of mental disorders by developing precision medicine approaches globally.

Long-term Risk of Reoperation After Synthetic Mesh Midurethral Sling Surgery for Stress Urinary Incontinence.

To measure the long-term reoperation risk after synthetic mesh midurethral sling surgery. This retrospective cohort study evaluated all patients who underwent a midurethral sling surgery for stress urinary incontinence (SUI) (2005-2016) within a large managed care organization of 4.5 million members. We queried the system-wide medical record for Current Procedural Terminology and International Classification of Diseases, 9 or 10 Revision codes for patient data, and implant registry coding to assess the sling type. The primary outcome was the overall reoperation rate after midurethral sling, with secondary outcomes being reoperation for mesh revision, or removal and recurrent SUI. We used cumulative incidence to calculate reoperation risk as a function of time at least 1 year, least 5 years, and at least 9 years. We compared demographics, characteristics, and reoperation of patients using χ and Wilcoxon rank sum, and we used a Cox proportional hazards model to calculate adjusted hazard ratios. In this cohort of 17,030 patients treated with primary midurethral slings, the overall reoperation rate was 2.1% (95% CI 1.9-2.4%) at 1 year, 4.5% (95% CI 4.1-4.8%) at 5 years, and 6.0% (95% CI 5.5-6.5%) at 9 years. Risk of reoperation was affected by race (P=.04), with Asian or Pacific Islander patients having a lower reoperation rate when compared with white patients. Reoperation rate for mesh revision or removal was 0.7% (95% CI 0.6-0.8%) at 1 year, 1.0% (95% CI 0.8-1.1%) at 5 years, and 1.1% (95% CI 0.9-1.3%) at 9 years. Reoperation for recurrent SUI was 1.6% (95% CI 1.4-1.8%) at 1 year, 3.9% (95% CI 3.5-4.2%) at 5 years, and 5.2% (95% CI 4.7-5.7%) at 9 years. Risk of reoperation for recurrent SUI was affected by the type of sling, with reoperation more common after single-incision compared with retropubic sling (adjusted hazard ratio 1.5 [95% CI 1.06-2.11] P=.03). Midurethral slings have a low long-term risk of reoperation for mesh revision or removal, and recurrent SUI, adding to the evidence of their safety and efficacy for the treatment of women with SUI.

Implication and Management of Incidental Oropharyngeal Papillomas-A Retrospective Case Series Review.

Incidental papillomas of the pharynx can be found while examining the nasopharynx, oropharynx, and hypopharynx for other disorders of the head and neck. Purpose of the study is to explore the location, biopsy protocol, and decision to perform office-based versus operative management via potassium titanyl phosphate (KTP) laser when an oropharyngeal papilloma is discovered incidentally. A retrospective review of the senior author's patient population was performed using Current Procedural Terminology and/or International Classification of Diseases codes to identify patients who had KTP laser removal of incidental oropharyngeal papillomas. Patients were included based on the incidental nature of the papilloma and confirmed pathology report of squamous papilloma. Demographics, presenting complaint, lesion location, pathological analysis, type of intervention, and outcomes were recorded. When available, human papillomavirus (HPV) subtype was noted. A total of 26 cases were identified, 13 females and 13 males. The median age at time of surgery was 58 years (range: 21-77). The most common presenting symptoms were difficulty swallowing and throat pain. The most common locations were the base of tongue, uvula, tonsils, and the soft palate. Of the 26 patients, 23 patients received KTP laser ablation therapy as an office-based procedure, while the remaining 3 were performed under general anesthesia in the operating room. Only 5 patients had a recorded recurrence that required reoperation. There were no operative or postoperative complications. There were 16 biopsy samples tested for HPV, where 12 were negative for HPV and 4 were positive for HPV. Oropharyngeal papillomas, when present, can be found incidentally during examination of the oropharynx for other symptoms. Office-based biopsy and KTP laser is a safe and efficient means of identifying and removing most oropharyngeal papillomas.

Delayed Healing in Metatarsal Fractures: Role of Low-Intensity Pulsed Ultrasound Treatment

The most common fracture in primary care is metatarsal fracture, but it is controversial whether to treat this fracture conservatively or surgically. We performed a cohort study to contrast metatarsal fractures that heal normally with fractures that show delayed healing. We analyzed 5% Medicare Standard Analytic Files, selecting all metatarsal fractures in 2011 to 2013, excluding patients with multiple fractures. Delayed healing was defined as treatment >14 days postfracture with either low-intensity pulsed ultrasound or surgery. Treatment for delayed healing was identified using the Current Procedural Terminology and International Classification of Diseases, Revision 9, Clinical Modification codes. Among 9482 metatarsal fractures, 256 (2.7%) showed delayed healing. Patients with delayed healing were younger (p < .0001); more likely to receive specialist referral (p < .001); more likely to have obesity (p = .005), psychosis (p = .003), chronic lung disease (p = .012), or iron deficiency anemia (p = .016); and more likely to receive surgery before ultrasound (p < .0001). Patients more likely to be treated with surgery than ultrasound included younger patients (p < .0001), obese patients (p = .02), and patients who first see a specialist (p < .05).