Bacillus anthracis, Yersinia pestis, and Francisella tularensis are the causative agents of Tier 1 Select Agents anthrax, plague, and tularemia, respectively. Currently, there are no licensed vaccines against plague and tularemia and the licensed anthrax vaccine is suboptimal. Here we report F. tularensis LVS ΔcapB (Live Vaccine Strain with a deletion in capB)- and attenuated multi-deletional Listeria monocytogenes (Lm)-vectored vaccines against all three aforementioned pathogens. We show that LVS ΔcapB- and Lm-vectored vaccines express recombinant B. anthracis, Y. pestis, and F. tularensis immunoprotective antigens in broth and in macrophage-like cells and are non-toxic in mice. Homologous priming-boosting with the LVS ΔcapB-vectored vaccines induces potent antigen-specific humoral and T-cell-mediated immune responses and potent protective immunity against lethal respiratory challenge with all three pathogens. Protection against anthrax was far superior to that obtained with the licensed AVA vaccine and protection against tularemia was comparable to or greater than that obtained with the toxic and unlicensed LVS vaccine. Heterologous priming-boosting with LVS ΔcapB- and Lm-vectored B. anthracis and Y. pestis vaccines also induced potent protective immunity against lethal respiratory challenge with B. anthracis and Y. pestis. The single vaccine platform, especially the LVS ΔcapB-vectored vaccine platform, can be extended readily to other pathogens.

Introduction: Post-total joint arthroplasty (TJA) discharge to a skilled nursing facility (SNF) is associated with higher costs and more complications than home discharge; however, some patients still require postoperative SNF care. To improve outcomes for patients requiring postoperative SNF care, this article analyzed the effect of SNF-surgeon partnerships on TJA postoperative costs and patient outcomes. Methods: This was a retrospective study of primary TJA patients who were part of Medicare's Comprehensive Care for Joint Replacement (CJR) pilot program at our urban, academic medical center. We identified all patients discharged to SNF and designated SNFs as “preferred” if they maintained a partnership with our surgical team. SNF costs, total 90-day postoperative costs, average length of stay in SNF, 90-day readmission rates, and readmission diagnoses were recorded. Data were compared using Student t-tests. Readmission rates and the presence of a readmission diagnosis were analyzed using z-scores. Results: Our search identified 189 patients (22.9%) discharged to SNFs, with 128 (67.8%) discharged to preferred and 61 (32.2%) discharged to nonpreferred facilities. Over the 4-year CJR pilot program, SNF costs ($10,981.23 versus $7,343.34; P < 0.005) and overall postdischarge costs ($23,952.52 versus $18,339.26; P = 0.07) were higher for patients discharged to nonpreferred SNFs versus preferred SNFs. Patients discharged to nonpreferred SNFs also had increased length of stay (14.8 versus 10.1 days; P < 0.005) and increased readmission rates (19.7% versus 3.9%; P < 0.005). These differences became more pronounced across the study period. Conclusion: For patients undergoing primary TJA, hospital partnership with SNFs can improve CJR performance by cost reduction and overall outcomes for TJA patients.

Background: The initial stability of press-fit acetabular components is partially determined by the reaming technique. Nonhemispherical (NHS) acetabular shells, which have a larger radius at the rim than the dome, often require larger reaming preparations than the same-sized hemispherical (HS) shells. Furthermore, deeper central reaming may provide a more stable press fit. Using a reproducible, in vitro protocol, we compared initial shell stability under different reaming techniques with HS and NHS acetabular components. Methods: Cavities for 54-mm NHS and 56-mm HS acetabular components were premachined in 20-pcf Sawbones blocks. Acetabular cavities included diameters of 54, 55, "54þ," and "55þ". "þ" indicates a cavity with a 2-mm smaller diameter that is 2-mm deeper. A 4750N statically applied force seated shells to a height that was comparable with shell height after an orthopaedic surgeon's manual impaction. Force required to dislodge shells was assessed via a straight torque-out with a linear load. Results: Increased preparation depth (þ) was associated with deeper shell seating in all groups. Deeper central reaming increased required lever-out force for all groups. Overall, HS and NHS implants prepared with 55 þ preparation had the highest lever-out forces, although this was not significantly higher than those with 54þ. Conclusions: In 20-pcf Sawbones, representing dense bone, overreaming depth by 1-mm improved initial seating measurements. In both HS and NHS acetabular shells, seating depth and required lever-out force were higher in the "þ" category. It is unclear, however, whether a decreased diameter ream increased seating stability (55þ vs 54þ). Clinically, this deeper central reaming technique may help initial acetabular stability.

Cervical spine deformities (CSD) are complex surgical issues with currently heterogenous management strategies. The classification of CSD is still an evolving field. Rudimentary classification schemas were initially proposed in the late 20th century but were largely informal and based on the underlying etiology (i.e. , postsurgical, traumatic, or inflammatory). The first formal classification schema was proposed by Ames et al. in 2015 who established a standard nomenclature for describing these deformities. This classification system established 5 deformity descriptors based on curve apex location (cervical, cervicothoracic, thoracic, craniovertebral junctional, and coronal deformities) and 5 deformity modifiers which helped surgeons utilize a standard language when discussing CSD patients. Koller et al. in 2019 subsequently established a classification system for patients with rigid cervical kyphosis based on regional and global sagittal alignment. Most recently, Kim et al. in 2020 proposed an updated classification system utilizing dynamic cervical spine imaging to guide surgical treatment of CSD patients. It identified 4 major groups of deformities – (1) those with “flat-neck” deformities caused by cervical lordosis T1 slope mismatch; (2) those with focal kyphotic deformities between 2 cervical vertebrae; (3) those with cervicothoracic deformities caused by large T1 slope; and (4) those with coronal deformities. Group 2 deformities most often required combined anterior-posterior approaches with short constructs, and group 3 deformities most often required posterior-only approaches with 3-column osteotomies.