Background: Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients.Methods: Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients.Results: A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ‡7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index. Conclusions:The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients.
Thymoma associated multiorgan autoimmunity is a rare paraneoplastic disorder, clinicopathologically similar to graft versus host disease, which is thought to be mediated by dysfunctional negative thymocyte selection and abnormally low levels of Tregs. We report a 50 year old Chinese women with a history of malignant thymoma and myasthenia gravis who developed graft versus host disease- like erythroderma after instituting chemotherapy and undergoing myasthenia crisis. Clinically her rash presented as erythematous scaly papules, which evolved to psoriasiform patches and plaques with foci of vitiligo. Histopathologically the biopsy showed a predominantly interface dermatitis with necrotic keratinocytes extending to the upper levels of the epidermis, and florid basket weave orthokeratosis. Clinical and laboratory work-up ruled out common inflammatory or infectious causes, eventually favoring the diagnosis of TAMA with GVHD-like erythroderma. Unfortunately, the patient underwent multi-organ compromise and death due to respiratory failure from myasthenia crisis. Patients with TAMA have a poor clinical outlook; rare successful treatments include high dose oral steroids and additional modalities including bone marrow transplant and chemotherapeutic or biologic agents. As the predominant findings are in the skin, dermatologists and dermatopathologists are in a unique position to enable the early diagnosis and treatment of this unusual disease.
Thymoma associated multiorgan autoimmunity is a rare paraneoplastic disorder, clinicopathologically similar to graft versus host disease, which is thought to be mediated by dysfunctional negative thymocyte selection and abnormally low levels of T regs . We report a 50 year old Chinese women with a history of malignant thymoma and myasthenia gravis who developed graft versus host disease-like erythroderma after instituting chemotherapy and undergoing myasthenia crisis. Clinically her rash presented as erythematous scaly papules, which evolved to psoriasiform patches and plaques with foci of vitiligo. Histopathologically the biopsy showed a predominantly interface dermatitis with necrotic keratinocytes extending to the upper levels of the epidermis, and florid basket weave orthokeratosis. Clinical and laboratory work-up ruled out common inflammatory or infectious causes, eventually favoring the diagnosis of TAMA with GVHD-like erythroderma. Unfortunately, the patient underwent multi-organ compromise and death due to respiratory failure from myasthenia crisis. Patients with TAMA have a poor clinical outlook; rare successful treatments include high dose oral steroids and additional modalities including bone marrow transplant and chemotherapeutic or biologic agents. As the predominant findings are in the skin, dermatologists and dermatopathologists are in a unique position to enable the early diagnosis and treatment of this unusual disease.Thymomas are tumors of thymic epithelial cell origin and are the most common type of thymic neoplasm. They are often diagnosed incidentally on imaging, but can also present with thoracic mass effects such as cough, chest pain, and phrenic nerve palsy. Additionally, thymomas are frequently associated with paraneoplastic autoimmune disorders, the most common of which are myasthenia gravis, pure red cell aplasia, and hypogammaglobulinemia. While rare, several case studies 1-13 have also reported a condition termed thymoma-associated multiorgan autoimmunity (TAMA) affecting the skin, liver, and colon. Interestingly, the histopathologic findings in damaged organs resemble those of graftversus-host disease (GVHD) despite the lack of transplanted lymphocytes. GVHD-like erythroderma is rare and little is understood about its pathogenesis. Additionally, its
Periprosthetic joint infections (PJI) induce an immunosuppressive cytokine profile through an unknown mechanism. Immune checkpoints, like programmed cell death 1 (PD‐1) and its ligand (PD‐L1), initiate innate immunosuppressive pathways essential for self‐tolerance. Several malignancies and chronic infections co‐opt these pathways to derive a survival advantage. This study evaluates PD‐1/PD‐L1 expression in periprosthetic tissue from patients undergoing revision hip or knee arthroplasty for a PJI versus an aseptic failure. PD‐1/PD‐L1 in the global tissue sample and the high‐power microscopic field of maximum expression was analyzed prospectively using immunohistochemistry. Fifteen patients with a PJI (45%) and 16 patients with an aseptic failure (52%) were included. PD‐1 expression was uniformly low. Maximum PD‐L1 expression was upregulated in patients with a PJI (25%, interquartile range [IQR]: 5%–75%) versus an aseptic failure, (8%, IQR: 1%–48%, p = 0.039). In the PJI cohort, maximum PD‐L1 expression was higher among patients who developed a recurrent PJI (68%, IQR: 53%–86% vs. 15%, IQR: 5%–70%, p = 0.039). Patients with global PD‐L1 over 5% trended toward a near 22‐fold increase in the odds of reinfection (odds ratio [OR]: 21.9, 95% confidence interval [CI]: 0.9–523.5, p = 0.057) and patients with maximum PD‐L1 over 20% trended toward a 15‐fold increase in the odds of reinfection (OR: 15.0, 95% CI: 0.6–348.9, p = 0.092). These results support immune checkpoint upregulation as a mechanism of PJI‐induced local immune dysfunction. Future studies should confirm PD‐L1 as a risk factor for reinfection in larger cohorts.
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