Inpatient Outcomes After Elective Lumbar Spinal Fusion for Patients with Human Immunodeficiency Virus in the Absence of Acquired Immunodeficiency Syndrome

Symptomatic HIV infection and in-hospital outcomes for patients with acute myocardial infarction undergoing percutaneous coronary intervention from national inpatient sample

Human immunodeficiency virus (HIV) infection increases the risk of acute myocardial infarction (AMI). However, little is known about its association with in-hospital outcomes and temporal trends in patients with AMI undergoing percutaneous coronary intervention (PCI). We queried patients with AMI who underwent PCI from the National Inpatient Sample Database (2003-2015) and stratified them into three groups: symptomatic, asymptomatic, and HIV-negative. After 1:2 case-control matching (CCM), logistic regression analysis was conducted to determine how HIV infection affected in-hospital outcomes. We also evaluated their recent trends from 2003 to 2015. The total weighted national estimate of 2,191,129 AMI cases included 2,178,995 HIV/AIDS-negative, 4994 asymptomatic, and 7140 symptomatic HIV cases. Symptomatic but not asymptomatic patients with HIV suffered more than triple the in-hospital mortality (adjusted odds ratio (aOR) 3.6, 95% confidence interval (CI) 2.5-5.2), over one-fold incidence of acute kidney injury (aOR 2.6 95% CI 1.9-3.4) and cardiogenic shock risk (aOR 1.9, 95% CI 1.3-2.7), a longer length of hospital stay (beta 1.2, 95% CI 1.0-1.5), and had more procedures (beta 1.3, 95% CI 1.2-1.5). These disparities relating to symptomatic HIV infection persisted from 2003 to 2015. In patients with AMI who underwent PCI, symptomatic HIV infection was associated with higher in-hospital mortality and more severe outcomes.

Temporal Trend and Clinical Outcomes in HIV and Non-HIV Patients following Liposuction: A Propensity-Matched Analysis

BACKGROUND

Because of the availability of highly active antiretroviral therapy, individuals infected with human immunodeficiency virus (HIV) are enjoying greater longevity with chronic conditions including abnormal adipose distribution. However, prior data on postoperative outcomes of liposuction in HIV-positive patients were limited by small sample size. Therefore, the authors aimed to compare differences in temporary trend, clinical characteristics, and outcomes between patients with and without HIV who underwent liposuction.

METHODS

The National Inpatient Sample database from 2010 to 2017 was queried to identify patients who underwent liposuction. Univariate, multivariate logistic regression and 1:4 propensity score-matched analyses were used to assess the primary outcomes (i.e., in-hospital mortality and postoperative outcomes) and secondary outcomes (i.e., discharge disposition, prolonged length of stay, and total cost).

RESULTS

Overall, 19,936 patients who underwent liposuction were identified, among whom 61 patients (0.31%) were infected with HIV. Patients with HIV were more likely to be male, insured by Medicare, and had more comorbidities and lower income. Unadjusted length of stay was longer among patients with HIV (OR, 1.81; 95% CI, 1.09 to 2.99; P = 0.020); nevertheless, multivariable models and propensity score-matched analysis demonstrated that patients with HIV were no more likely to have complications than the general population. This was also the case for length of stay and total costs.

CONCLUSIONS

The authors' findings indicated that patients with HIV who underwent liposuction did not experience an increased risk of major complication or mortality. Liposuction could be safely considered as a surgical treatment for HIV-positive patients with local fat deposition.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Surgical Outcomes of Human Immunodeficiency Virus-positive Patients Undergoing Lumbar Degenerative Surgery

STUDY DESIGN

This was a retrospective cohort studying using a national administrative database.

OBJECTIVE

The objective of this study was to determine the postoperative complications and quality outcomes of the human immunodeficiency virus (HIV)-positive patients undergoing surgical management for lumbar degenerative disease (LDD).

METHODS

This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether they were HIV positive at the time of surgery. Multivariate regression was utilized to reduce the confounding of baseline covariates. Patients who underwent 3 or more levels of surgical correction were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined.

RESULTS

A total of 120,167 patients underwent primary lumbar degenerative surgery, of which 309 (0.26%) were HIV positive. In multivariate regression analysis, the HIV-positive cohort was more likely to be readmitted at 30 days [odds ratio (OR)=1.9, 95% confidence interval (CI): 1.2-2.8], 60 days (OR=1.7, 95% CI: 1.2-2.5), and 90 days (OR=1.5, 95% CI: 1.0-2.2). The HIV-positive cohort was also more likely to experience any postoperative complication (OR=1.7, 95% CI: 1.2-2.3). Of the major drivers identified, HIV-positive patients had significantly greater odds of cerebrovascular disease and postoperative neurological complications (OR=3.8, 95% CI: 1.8-6.9) and acute kidney injury (OR=3.4, 95% CI: 1.3-7.1). Costs of index hospitalization were not significantly different between the 2 cohorts ($30,056 vs. $29,720, P=0.6853). The total costs were also similar throughout the 2-year follow-up period.

CONCLUSION

Patients who are HIV positive at the time of LDD surgery are at a higher risk for postoperative central nervous system and renal complications and unplanned readmissions.

Impact of human immunodeficiency virus on 2-year revision rates following lumbar fusion for degenerative spinal conditions: a retrospective cohort study

BACKGROUND

To our knowledge, no studies exist that evaluate the impact of human immunodeficiency virus (HIV) on long-term revision rates following lumbar fusion. This study aims to understand how HIV impacts 2-year revision rates and 90-day postoperative complication rates following primary lumbar fusion for degenerative spine conditions.

METHODS

Data collection was done using PearlDiver Patient Records Database, a national insurance database from 2010-2019. Patients who underwent primary lumbar fusion for degenerative diseases were divided into a cohort of patients that are HIV positive (HIV), have asymptomatic HIV (AHIV), acquired immune deficiency syndrome (AIDS), and HIV-negative at the time of their procedure. Univariate and multivariable regression analyses were performed to determine rates of revision surgery, surgical site infection (SSI), neurological complications, sensory deficits, bowel/bladder dysfunction and myelopathies within two years of surgery as well as 90-day postoperative complications.

RESULTS

In total, 216,587 patients were included in this study. Of these, 631 patients (0.29%) had HIV including 502 patients (0.23%) with asymptomatic HIV and 129 patients (0.06%) with AIDS. Relative to the control cohort, patients with HIV had no difference in odds of two-year revision surgery, SSI, neurological complications, sensory deficits, bowel/bladder dysfunction and myelopathies. Patients with HIV did have increased odds of postoperative pneumonia (OR 1.592; 95% CI: 1.048-2.314; P=0.021). AIDS patients had greater odds of respiratory complications (OR 2.585; 95% CI: 1.075-5.264; P=0.017) and septic complications (OR 2.702; 95% CI: 1.122-5.514; P=0.013) 90-day postoperatively.

CONCLUSIONS

Our study found that HIV positive status did not significantly affect two-year revision rates compared to the control group. However, there is a higher rate of pneumonia and respiratory complications among HIV positive patients. Before deciding to proceed with surgical intervention in HIV positive individuals, surgeons must carefully consider each patient's specific diagnosis, comorbidities, and risk factors.

HIV and Surgery for Degenerative Spine Disease: A Systematic Review

BACKGROUND AND STUDY AIMS

 The objective of this review is to evaluate the incidence of operative treatment, outcomes, and complications of surgery for degenerative spine disease (DSD) on human immunodeficiency virus (HIV) positive patients. Combined antiretroviral treatment led HIV patients to live long enough to develop many chronic conditions common in the uninfected population. Surgery for DSD is one of the most commonly performed neurosurgical procedures. However, the incidence of spine surgery for DSD in HIV-positive patients seems to be lower than that in uninfected individuals, although this has not been clearly determined.

METHODS

 A systematic search of the Medline, Web of Science, Embase, and SciElo databases was conducted. Only primary studies addressing DSD surgery on HIV-positive patients were included. Evaluated variables were rates of surgical treatment, surgical outcomes and complications, year of publication, country where study was conducted, type of study, and level of evidence.

RESULTS

 Six articles were included in the review from 1,108 records. Significantly lower rates of DSD surgery were identified in HIV-infected patients (0.86 per 1,000 patient-years) when compared with uninfected patients (1.41 per 1,000 patient-years). There was a significant increase in spinal surgery in HIV-positive patients over time, with a 0.094 incidence per 100,000 in the year 2000 and 0.303 in 2009. HIV-positive patients had very similar outcomes when compared with controls, with 66.6% presenting pain relief at a 3-month follow-up. Higher incidences of hospital mortality (1.6 vs. 0.3%; p < 0.001) and complications (12.2 vs. 9.5%, p < 0.001) were observed in HIV carriers.

CONCLUSIONS

 HIV-positive individuals appear to undergo less surgery for DSD than HIV-negative individuals. Improvement rates appear to be similar in both groups, even though some complications appear to be more prevalent in HIV carriers. Larger studies are needed for decisive evidence on the subject.

Hepatitis C Virus Infection as a Predictor of Complications and Increased Costs Following Primary Lumbar Fusion Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to identify whether hepatitis C virus (HCV) diagnosis influences in-hospital lengths of stay (LOS), postoperative complications, readmission rates, or costs following primary posterior lumbar fusions in an elective setting.

SUMMARY OF BACKGROUND DATA

Although joint arthroplasty literature has shown increased complication rates and costs for patients seropositive with HCV without liver disease compared to those without HCV, this comorbidity has not been explored in the spine literature. To our knowledge, this is the first publication in the lumbar spine literature to solely focus on HCV as the disease burden.

METHODS

A national database was queried for patients who underwent primary lumbar spine fusion for degenerative lumbar pathology with Medicare insurance from 2005 to 2014. The 90-day postoperative complication rates, readmission rates, and treatment costs were queried. To limit confounding, HCV patients were matched with a control cohort of non-HCV patients using patient demographics, treatment modality, and comorbid conditions, and then analyzed by multivariate logistic regression. Patients with active liver disease were excluded to better isolate HCV as the comorbidity.

RESULTS

A cohort of 28,841 patients were included in the final analysis. Postoperatively, compared to those without HCV infection, those with HCV had significantly higher odds of blood transfusions (odds ratio [OR]: 3.06), pneumonia (OR: 2.49), respiratory failure (OR: 2.49), urinary tract infections (OR: 1.89), wound-/implant-related infections (OR: 1.74), cerebrovascular events (OR: 1.70), or any postoperative complication within 90 days (OR: 2.93; all P < 0.0001). Furthermore, HCV positive patients had higher day of surgery costs ($28,713.26 vs. $25,448.26, P < 0.0001) and 90-day costs ($33,447.39 vs. $29,016.77, P < 0.0001). There was not a significant difference for patients with HCV infection compared to those without in regard to hospital LOS (10 days vs. 8 days, P = 0.332) and rates of a 90-day readmission (0.37% vs. 0.22%; OR: 1.70, 95% confidence interval: 1.00-2.90, P: 0.050).

CONCLUSION

In patients undergoing primary lumbar fusion, a seropositivity for HCV without liver disease is associated with higher costs and complication rates, including higher rates of blood transfusion requirements and pneumonia-related complications. This data shed new light on elective spine surgery in HCV patients and may influence the risks and benefits considerations for surgeons considering lumbar fusion in this population.

LEVEL OF EVIDENCE

3.

Risk Factors for 90-day Readmissions With Fluid and Electrolyte Disorders Following Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study of the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database.

OBJECTIVE

To identify risk factors for 30- and 90-day readmission due to fluid and electrolyte disorders following posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

Thirty- and 90-day readmission rates are important quality and outcome measures for hospitals and physicians. These measures have been tied to financial penalties for abnormally high rates of readmission. Furthermore, complex and high cost surgeries have been increasingly reimbursed in the form of bundled disease resource group payments, where any treatment within 90-day postdischarge is covered within the original bundled payment scheme.

METHODS

A total of 65,121 patients in the Healthcare Cost and Utilization Project Nationwide Readmissions Database met our inclusion criteria, of which 1128 patients (1.7%) were readmitted within 30 days, and 1669 patients (2.6%) were readmitted within 90 days due to fluid and electrolyte abnormalities. A bivariate analysis was performed to compare baseline characteristics between patients readmitted with fluid and electrolyte disorders and the remainder of the cohort. A multivariate regression analysis was then performed to identify independent risk factors for readmission due to fluid and electrolyte disorders at 30 and 90 days.

RESULTS

The strongest independent predictors of 30-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and drug use disorder. The five strongest predictors of 90-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and fluid and electrolyte disorders.

CONCLUSION

Patients with baseline liver disease, previously diagnosed fluid and electrolyte disorders, age older than 55 years, or drug use disorders are at higher risk for readmissions with fluid and electrolyte disorders following posterior lumbar fusion. Close monitoring of fluid and electrolyte balance in the perioperative period is essential to decrease complications and reduce unplanned readmissions.

LEVEL OF EVIDENCE

3.

A Novel lncRNA, AK130181, Contributes to HIV-1 Latency by Regulating Viral Promoter-Driven Gene Expression in Primary CD4+ T Cells

The functions and mechanisms of long non-coding RNAs (lncRNAs) in latent HIV-1 infection are not yet fully understood and warrant further research. In this study, we identified the newly inhibitory lncRNA AK130181 (also named LOC105747689), which is highly expressed in CD4⁺ T lymphocytes latently infected with HIV, using bioinformatics. We also found that AK130181 is involved in HIV-1 latency by inhibiting long terminal repeat (LTR)-driven HIV-1 gene transcription in a nuclear factor κB (NF-κB)-dependent manner. Furthermore, silencing AK130181 significantly reactivates viral production from HIV-1 latently infected Jurkat T cells and primary CD4⁺ T cells. Interestingly, we found that inhibition of AK130181 in resting CD4⁺ T cells from HIV-1-infected individuals treated with highly active antiretroviral therapy significantly increased viral reactivation upon T cell activation in vivo. We provide new insights and a better understanding of lncRNAs that play a role in HIV-1 latency, and suggest that silencing AK130181 expression to activate HIV-1 latently infected cells may be a potential therapeutic target for HIV-infected individuals.