The serotonin transporter gene (5-HTT) encodes a transmembrane protein that plays an important role in regulating serotonergic neurotransmission and related aspects of mood and behaviour. The short allele of a 44 bp insertion/deletion polymorphism (S-allele) within the promoter region of the 5-HTT gene (5-HTTLPR) confers lower transcriptional activity relative to the long allele (L-allele) and may act to modify the risk of serotonin-mediated outcomes such as anxiety and substance use behaviours. The purpose of this study was to determine whether (or not) 5-HTTLPR genotypes moderate known associations between attachment style and adolescent anxiety and alcohol use outcomes. Participants were drawn from an eight-wave study of the mental and behavioural health of a cohort of young Australians followed from 14 to 24 years of age (Victorian Adolescent Health Cohort Study, 1992 -present). No association was observed within low-risk attachment settings. However, within risk settings for heightened anxiety (ie, insecurely attached young people), the odds of persisting ruminative anxiety (worry) decreased with each additional copy of the S-allele (B30% per allele: OR 0.77, 95% CI 0.62-0.97, P ¼ 0.029). Within risk settings for binge drinking (ie, securely attached young people), the odds of reporting persisting high-dose alcohol consumption (bingeing) decreased with each additional copy of the S-allele (B35% per allele: OR 0.74, 95% CI 0.64-0.86, Po0.001). Our data suggest that the S-allele is likely to be important in psychosocial development, particularly in those settings that increase risk of anxiety and alcohol use problems. Molecular Psychiatry (2005) 10, 868-876.

Study Design: Retrospective cohort study. Objectives: Racial disparities in postoperative outcomes are unfortunately common. We present data assessing race as an independent risk factor for postoperative complications after spine surgery for Native American (NA) and African American (AA) patients compared with Caucasians (CA). Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for spine procedures performed in 2015. Data was subdivided by surgery, demography, comorbidity, and 30-day postoperative outcomes, which were then compared by race. Regression was performed holding race as an independent risk factor. Results: A total of 4803 patients (4106 CA, 522 AA, 175 NA) were included in this analysis. AA patients experienced longer length of stay (LOS) and operative times ( P < .001) excluding lumbar fusion, which was significantly shorter ( P = .035). AA patients demonstrated higher comorbidity burden, specifically for diabetes and hypertension ( P < .005), while NA individuals were higher tobacco consumers ( P < .001). AA race was an independent risk factor associated with longer LOS across all cervical surgeries (β = 1.54, P <.001), lumbar fusion (β = 0.77, P = .009), and decompression laminectomy (β = 1.23, P < .001), longer operative time in cervical fusion (β = 12.21, P = .032), lumbar fusion (β = -24.00, P = .016), and decompression laminectomy (OR = 20.95, P < .001), greater risk for deep vein thrombosis in lumbar fusion (OR = 3.72, P = .017), and increased superficial surgical site infections (OR = 5.22, P = .001) and pulmonary embolism (OR = 5.76, P = .048) in decompression laminectomy. NA race was an independent risk factor for superficial surgical site infections following cervical fusion (OR = 14.58, P = .044) and decompression laminectomy (OR = 4.80, P = .021). Conclusion: AA and NA spine surgery patients exhibit disproportionate comorbidity burden and greater 30-day complications compared with CA patients. AA and NA race were found to independently affect rates of complications, LOS, and operation time.

Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.

Study Design: Observational cohort study. Objective: To compare 1-year perioperative complications between structural allograft (SA) and synthetic cage (SC) for anterior cervical discectomy and fusion (ACDF) using a national database. Methods: The TriNetX Research Network was retrospectively queried. Patients undergoing initial single or multilevel ACDF surgery between October 1, 2015 and April 30, 2019 were propensity score matched based on age and comorbidities. The rates of 1-year revision ACDF surgery and reported diagnoses of pseudoarthrosis, surgical site infection (SSI), and dysphagia were compared between structural allograft and synthetic cage techniques. Results: A comparison of 1-year outcomes between propensity score matched cohorts was conducted on 3056 patients undergoing single-level ACDF and 3510 patients undergoing multilevel ACDF. In single-level ACDF patients, there was no difference in 1-year revision ACDF surgery ( P = .573), reported diagnoses of pseudoarthrosis ( P = .413), SSI ( P = .620), or dysphagia ( P = .529) between SA and SC groups. In multilevel ACDF patients, there was a higher rate of revision surgery (SA 3.8% vs SC 7.3%, odds ratio = 1.982, P < .001) in the SC group, and a higher rate of dysphagia in the SA group (SA 15.9% vs SC 12.9%). Conclusion: While the overall revision and complication rate for single-level ACDF remains low despite interbody graft selection, SC implant selection may result in higher rates of revision surgery in multilevel procedures despite yielding lower rates of dysphagia. Further prospective study is warranted.

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OBJECTIVEA universal, objective predictor of postoperative resource utilization following inpatient spine surgery has not been clearly established. The Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) risk adjustment model, based on a formula using patient demographics and coded diagnoses, is currently used to prospectively estimate financial risk in Medicare Advantage patients; however, the value of this score as a clinical tool is currently unknown. The authors present an analysis evaluating the utility of the CMS HCC score as a universal predictive tool for patients undergoing inpatient spine surgery.METHODSA total of 1966 consecutive patients (551 with lumbar laminectomy [LL] alone, 592 with lumbar laminectomy and fusion [LF], and 823 with anterior cervical discectomy and fusion [ACDF]) undergoing inpatient spine surgery at a single institution from January 2014 to May 2018 were included in this retrospective outcomes study. Perioperative outcome measures included procedure time, 30-day readmission, reoperation, hospital length of stay (LOS), opioid utilization measured by morphine milligram equivalents (MMEs), and cost of inpatient hospitalization (in US dollars). Published CMS algorithms were incorporated into the electronic health records and used to calculate HCC scores for all patients. Patients were stratified into HCC score quartiles. Linear regression was performed on LOS, procedure time, inpatient opioid consumption, discharge opioid prescriptions, and cost to identify predictors of HCC quartiles when controlling for procedure type. One-way ANOVA and Pearson’s chi-square analysis were used to compare perioperative outcomes stratified by HCC score.RESULTSAcross all procedures, the HCC score demonstrated significant association with 30-day readmission (OR 1.45, 95% CI 1.11–1.91, p = 0.007). The average BMI, median American Society of Anesthesiologists score, and 30-day readmission rate were similar across procedures (LL: 30.6 kg/m2, 2, 3.6%; LF: 30.6 kg/m2, 2, 4.6%; ACDF: 30.2 kg/m2, 2, 3.9%; p = 0.265, 0.061, and 0.713, respectively). LOS (p < 0.0001), duration of procedure (p < 0.0001), discharge MME (p = 0.031), total cost (p < 0.001), daily MME (p < 0.001), reoperation (p < 0.001), and 30-day readmission rate (p < 0.001) were significantly different between HCC quartiles.CONCLUSIONSThe HCC score may hold value as an objective, automated predictor of postoperative resource utilization and outcomes, including readmission and reoperation. This may have value as a universal, reproducible tool to target clinical interventions for higher-risk patients.

Study Design. Retrospective cohort. Objective. We present a universal model of risk prediction for patients undergoing elective cervical and lumbar spine surgery. Summary of Background Data. Previous studies illustrate predictive risk models as possible tools to identify individuals at increased risk for postoperative complications and high resource utilization following spine surgery. Many are specific to one condition or procedure, cumbersome to calculate, or include subjective variables limiting applicability and utility. Methods. A retrospective cohort of 177,928 spine surgeries (lumbar (L) Ln = 129,800; cervical (C) Cn = 48,128) was constructed from the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Cases were identified by Current Procedural Terminology (CPT) codes for cervical fusion, lumbar fusion, and lumbar decompression laminectomy. Significant preoperative risk factors for postoperative complications were identified and included in logistic regression. Sum of odds ratios from each factor was used to develop the Universal Spine Surgery (USS) score. Model performance was assessed using receiver-operating characteristic (ROC) curves and tested on 20% of the total sample. Results. Eighteen risk factors were identified, including sixteen found to be significant outcomes predictors. At least one complication was present among 11.1% of patients, the most common of which included bleeding requiring transfusion (4.86%), surgical site infection (1.54%), and urinary tract infection (1.08%). Complication rate increased as a function of the model score and ROC area under the curve analyses demonstrated fair predictive accuracy (lumbar = 0.741; cervical = 0.776). There were no significant deviations between score development and testing datasets. Conclusion. We present the Universal Spine Surgery score as a robust, easily administered, and cross-validated instrument to quickly identify spine surgery candidates at increased risk for postoperative complications and high resource utilization without need for algorithmic software. This may serve as a useful adjunct in preoperative patient counseling and perioperative resource allocation. Level of Evidence: 3