Objectives Endovascular surgery has revolutionized the treatment of aortic aneurysms; however these improvements have come at the cost of increased radiation and contrast exposure, particularly for more complex procedures. Three dimensional (3D) fusion computed tomographic (CT) imaging is a new technology that may facilitate these repairs. The purpose of this analysis was to determine the impact of utilizing intraoperative 3D fusion CT on performance of fenestrated endovascular aortic repair. Methods A review of our institutional database was performed to identify patients undergoing fenestrated/branched endovascular aortic repair (FEVAR). Subjects treated using 3D fusion CT were compared to patients treated in the immediate 12-month period prior to implementation of this technology when procedures were performed in a standard hybrid operating room without CT fusion capabilities. Primary endpoints included patient radiation exposure (air kerma area product: milliGray; mGy*cm2), fluoroscopy time (minutes; min), contrast usage (mL) and procedure time (min). Patients were grouped by number of aortic graft fenestrations revascularized with a stentgraft and operative outcomes were compared. Results A total of 72 patients (N = 41 before vs. N = 31 after 3D fusion CT implementation) underwent FEVAR from September 2012 through March 2014. For 2-vessel fenestrated endografts, there was a significant decrease in radiation exposure (3400±1900 vs. 1380±520 mGy*cm2; P=.001), fluoroscopy time (63±29 vs. 41±11min; P=.02), and contrast usage (69±16 vs. 26±8 mL; P=.0002) with intraoperative 3D fusion CT. Similarly, for combined 3 and 4-vessel FEVAR, significantly decreased radiation exposure (5400±2225 vs. 2700±1400 mGy*cm2; P<.0001), fluoroscopy time (89±36 vs 6±21min; P=.02), contrast usage (90±25 vs. 39±17mL; P<.0001), as well as procedure time (330±100 vs. 230±50min; P=.002) was noted. Estimated blood loss was significantly less (P<.0001) and length of stay had a trend (P=.07) toward being lower for all patients in the 3D CT group. Conclusions These results demonstrate that use of intraoperative 3D fusion CT imaging during FEVAR can significantly decrease radiation exposure and procedure time, as well as contrast usage, which may also decrease the overall physiologic impact of the repair.

Object Venous thromboembolism (VTE) represents a significant complication after spine surgery, with reported rates as high as 2%–4%. Published institutional practices for VTE prophylaxis are highly variable. In 2008, the authors implemented a departmental protocol for early VTE prophylaxis consisting of combined compressive devices and subcutaneous heparin initiated either preoperatively or on the same day of surgery. In this study, the authors compared the incidence of VTE in spine surgery patients before and after implementing this protocol. Methods An institutional review board–approved retrospective review of outcomes in patients undergoing spine surgery 2 years before protocol implementation (representing the preprotocol group) and of outcomes in patients treated 2 years thereafter (the postprotocol group) was conducted. Inclusion criteria were that patients were 18 years or older and had been admitted for 1 or more days. Before 2008 (preprotocol), VTE prophylaxis was variable and provider dependent without any uniform protocol. Since 2008 (postprotocol), a new VTE-prophylaxis protocol was administered, starting either preoperatively or on the same day of surgery and continuing throughout hospitalization. The new protocol consisted of 5000 U heparin administered subcutaneously 3 times daily, except in patients older than 75 years or weighing less than 50 kg, who received this dose twice daily. All patients also received sequential compression devices (SCDs). The incidence of VTE in the 2 protocol phases was identified by codes of the International Classification of Diseases, Ninth Revision (ICD-9) codes for deep vein thrombosis (DVT) and pulmonary embolus (PE). Bleeding complications arising from anticoagulation treatments were evaluated by the Current Procedural Terminology (CPT) code for postoperative epidural hematoma (EDH) requiring evacuation. Results In total, 941 patients in the preprotocol group met the inclusion criteria: 25 had DVT (2.7%), 6 had PE (0.6%), and 6 had postoperative EDH (0.6%). In the postprotocol group, 992 patients met the criteria: 10 had DVT (1.0%), 5 had PE (0.5%), and 4 had postoperative EDH (0.4%). This reduction in DVT after the protocol's implementation was statistically significant (p = 0.009). Despite early aggressive prophylaxis, the incidence of postoperative EDH did not increase and compared favorably to the published literature. Conclusions At a high-volume tertiary center, an aggressive protocol for early VTE prophylaxis after spine surgery decreases VTE incidence without increasing morbidity.

We tested the hypotheses that glass-ceramic veneers and overglazes degrade by ion exchange in an acidic environment, and that they degrade by breakdown of the silica network in a basic environment. Disk specimens of glass-ceramic veneer and glaze were fabricated and immersed in pH 2, 7, or 10 buffer solutions, for 1, 3, 5, 10, 15, and 30 days. Each specimen was placed in a shaker bath containing de-ionized distilled water at 80°C. Concentrations of Al(3+), Ca(2+), Zn(2+), Li(2+), and Si(4+) were analyzed by means of inductively coupled plasma atomic emission spectrometry (ICP/AES). Statistical analyses were performed by factorial ANOVA. Significant differences occurred among leached ion concentrations as a function of material type, solution pH, and exposure time. A substantial release of Si occurred at pH 10 over time, leading to a breakdown of the glass phase. At pH 2, dissolution was controlled by an ionic exchange mechanism. We conclude that ceramic veneers and glazes may be susceptible to considerable degradation in low- and high-pH buffer solutions.

Amyotrophic lateral sclerosis (ALS) is a multifactorial, multisystem pro-inflammatory neuromuscular disorder compromising muscle function resulting in death. Neuroinflammation is known to accelerate disease progression and accentuate disease severity, but peripheral inflammatory processes are not well documented. Acute phase proteins (APPs), plasma proteins synthesized in the liver, are increased in response to inflammation. The objective of this study was to provide evidence for peripheral inflammation by examining levels of APPs, and their contribution to disease burden and progression rates. Levels of APPs, including soluble CD14 (sCD14), lipopolysaccharide binding protein (LBP), and C-reactive protein (CRP), were elevated in sera, and correlated positively with increased disease burden and faster progression. sCD14 was also elevated in patients’ CSF and urine. After a 3 year follow-up, 72% of the patients with sCD14 levels above the receiver operating characteristics cutoff were deceased whereas only 28% below the cutoff were deceased. Furthermore, disease onset sites were associated with disease progression rates and APP levels. These APPs were not elevated in sera of patients with Alzheimer’s Disease, frontotemporal dementia, or Parkinson’s Disease. These collective APPs accurately reflect disease burden, progression rates, and survival times, reinforcing the concept of ALS as a disorder with extensive systemic pro-inflammatory responses.