Safety and functional outcomes of early antiplatelet therapy within 24 hours following mechanical thrombectomy for secondary prevention in emergent large-vessel occlusion strokes: a registry study

OBJECTIVE

The aim of this study was to demonstrate the safety and functional outcomes of antiplatelet use within 24 hours following mechanical thrombectomy (MT).

METHODS

A retrospective review of prospectively collected data for consecutive patients who underwent MT for acute ischemic stroke (AIS) between 2016 and 2020 was performed. Patient demographics, comorbidities, Alberta Stroke Program Early CT Score (ASPECTS), antiplatelet use, neurological status, and tissue plasminogen activator use were collected. Patients were stratified into two groups, early (< 24 hours) or late (> 24 hours), based on when antiplatelet therapy was initiated post-MT. The primary outcome was safety, determined based on the rate of symptomatic intracranial hemorrhage (sICH) and inpatient mortality. The secondary outcome was functional independence (defined as modified Rankin Scale [mRS] score ≤ 2) at discharge and 30 days and 90 days postoperatively. The two cohorts were compared using univariate analysis. Multiple imputations were used to create complete data sets for missing data. Multivariable analysis was used to identify predictors for sICH and functional outcomes.

RESULTS

A total of 190 patients met inclusion criteria (95 per group). Significant differences between the early and late groups included sex, preoperative intravenous thrombolysis, angioplasty, stent placement, and thrombectomy site. ICH (symptomatic and asymptomatic) and inpatient mortality were not significantly different between the groups. The mRS score was significantly lower at discharge (p < 0.001), 30 days (p = 0.011), and 90 days (p = 0.024) following MT in the early group. Functional independence was significantly higher in the early antiplatelet group at discharge (p = 0.015) and at 30 days (p = 0.006). Early antiplatelet use was independently associated with significantly increased odds of achieving functional independence at discharge (OR 3.07, p = 0.007) and 30 days (OR 5.78, p = 0.004). Early antiplatelet therapy was not independently associated with increased odds of sICH.

CONCLUSIONS

Early antiplatelet initiation after MT in patients with AIS was independently associated with significantly increased odds of improved postoperative functional outcomes without increased odds of developing sICH.

Are There Racial and Ethnic Health Disparities Among Outcomes After Anterior Cranial Fossa Surgery? A Propensity Score-Matched American College of Surgeons National Surgical Quality Improvement Program Study

BACKGROUND

Race-based health care outcomes remain to be described in anterior cranial fossa (ACF) surgery.

OBJECTIVE

To determine whether race predicts worse outcomes after ACF surgery.

METHODS

A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program data for 2005 to 2020. Current Procedural Terminology and International Classification of Diseases-9 codes were used to identify ACF tumor cases. Propensity score matching was performed to compare White and minority patients to assess the robustness of unmatched findings. A subanalysis of pituitary adenoma (PA) resections was also performed.

RESULTS

In an unmatched analysis of 1370 patients who underwent ACF surgery (67.9% White, 17.4% Black, 6.6% Asian/Pacific Islander, and 6.3% Hispanic), minority groups had higher rates of comorbidities. Unmatched multivariate analysis found Hispanic patients bore a 1.86 odds ratio (OR) of minor complications, Black and Asian and Pacific Islander patients bore 1.49 and 1.71 ORs, respectively, for extended length of stay, and Black patients bore a 3.78 OR for urinary tract infection (UTI). Matched analysis found that minority patients had higher UTI rates ( P = .02) and a 4.11 OR of UTI. In PA cases specifically, minority groups had higher comorbidities and length of stay in addition to extended length of stay odds (1.84 OR).

CONCLUSION

Although most ACF surgery outcomes were unaffected by race, minority groups had more minor postoperative complications than White patients, particularly UTI. Similar disparities were observed among PA cases. Higher rates of comorbidities may also have led to longer hospital stays. Further study is needed to understand what actions might be necessary to address any race-associated health disparities in ACF surgery.

951 SETTING UP A GERIATRIC LIAISON SERVICE WITHIN UROLOGY IN A DISTRICT GENERAL HOSPITAL

Introduction

One might refer to urologists as the ‘hidden providers’ of geriatric care, ultimately sought out by many geriatric patients. POPS, the Peri-Operative care of Older People’s Service started at Guys Hospital in London is often quoted as the gold standard for liaison services. Having set up liaison services in Orthopaedics and General Surgery in my previous job, an exciting opportunity arose after the first COVID—19 wave when I found my new office directly under the Urology Assessment Unit.

Method

A Geriatric Urology liaison service was set up by a Consultant Geriatrician with SpR support. One hour per week was agreed within the department to pilot the service. By May 2021 the service had been running for 8 months. During this period 30 patients had been seen (36 patient visits).

Results

The patient’s mean age was 82 years. The advice given included: O Stopping medication (7 cases) O Recommending iron infusions instead of tablets (5 cases) O Adjusting analgesia (4 cases) O Ordering brain imaging (3 cases) Commonly there was the recognition of the need for palliative care in this frail population. There have been complex cases: O A gentleman with a large perinephric bleed. O A young man with seizures and cognitive issues following renal stones. O A patient with post-operative rhabdomyolysis following nephrectomy. Pre-operative assessments have now been started as part of enhanced care: O Two cystectomy patients (one ward/one telephone) O Two TURBT patients (one with low sodium).

Conclusion

Staff feedback has been excellent especially linking to the Palliative Care Team. We presented our data at the Urology governance meeting in September 2021 and again received excellent feedback. The urology staff have felt increasingly supported. Data collection has helped build a business case for two Consultant posts in surgical liaison.

969 ACUTE FRAILTY MODEL: A DISTRICT GENERAL HOSPITAL EXPERIENCE OF DELIVERING COMPREHENSIVE GERIATRIC ASSESSMENT

Introduction

Under the NHS Long Term Plan1, every hospital with a Type 1 Emergency Department (ED) has been asked to provide Acute Frailty Services for at least 70 hours a week. We have adopted a liaison model to ensure Comprehensive Geriatric Assessment at the front door. The Frailty Team now includes two Frailty Practitioners, a Specialist Registrar based in ED and the Acute Medical Unit (AMU) with Consultant Physician of the Week support.

Method

The team attend multi-disciplinary meetings in ED and AMU on a daily basis. Frail patients are reviewed and Comprehensive Geriatric Assessments are undertaken together with appropriate signposting. The aim being, to enhance the care of frail patients at the earliest opportunity.

Results

High bed utilisation comes at a cost and a longer length of stay (LOS) is associated with an increased risk of deconditioning. Since introducing incremental changes to our working model, the average LOS of patients on AMU has been reduced from a mean of 1.33 days to 0.82 days. This represents a 38.3% reduction from September 2020 to August 2021. This reduction has been sustained, while 30-day readmission rates have not increased. Feedback has been very positive from all the other teams involved.

Conclusion

Our service has established a more positive working culture to efficiently manage frail patients. The AMU team now feel empowered to make patient-centric decisions regarding patient flow and discharges. Since this data was analysed we have implemented a further change to help enhance the care of frail patients. A list of appropriate patients is emailed to the hospital site team every afternoon to aid getting the right patients into the right beds. The impact of LOS on the frailty wards will then be reviewed following this introduction.

Reference

1. nhs-long-term-plan-june-2019.pdf (longtermplan.nhs.uk).

Anterior lumbar interbody fusion: single institutional review of complications and associated variables

BACKGROUND CONTEXT

As more patients undergo anterior lumbar interbody fusion (ALIF) procedures and more devices are created for that purpose, it is important to understand the complications that can arise and the variables that mitigate risk for major and minor complications.

PURPOSE

To assess complication rates after ALIF with or without posterior instrumentation and variables associated with increased likelihood of postoperative complications. We aim to provide this data as benchmarking to improve patient safety and surgical care.

STUDY DESIGN

A single-center retrospective cohort study.

PATIENT SAMPLE

All adult patients who underwent ALIF between 2017 and 2019 was performed OUTCOME MEASURES: Post-operative major and minor complications were evaluated.

METHODS

Complications were recorded and presented as percentages. Patient demographics, perioperative, and postoperative data were also collected and analyzed between patients who had no complications and those that had any complication. Subgroup analysis of surgical complications were performed by nonparametric Chi-square tests. Continuous variables were compared using Mann-Whitney U tests.

RESULTS

Ninty-five of three hundred sixty-two (26.2%) of patients experienced a minor or major complication. Among the most common complications found were surgical site infections (5.8%), neurological complications (4.1%), vascular complications (3.6%), and urinary tract infections (3.3%). Patients undergoing ALIF alone with post-operative complications had higher mean age, higher BMI, higher ASA status, and experienced higher estimated blood loss. Patients undergoing ALIF and posterior instrumentation with post-operative complications were more likely to have diabetes and had a higher ASA status. Patients with any complications from both groups had longer length of stay, discharge to a non-home setting and were more likely to be readmitted or return to the operating room.

CONCLUSION

Our study reveals variables associated with complications at our institution, including age of the patient, BMI, and ASA status leading to higher complications and greater LOS, higher readmission rates, and disposition to skilled facilities.

Global and intertuberal epileptic networks in tuberous sclerosis based on stereoelectroencephalographic (sEEG) findings: a quantitative EEG analysis in pediatric subjects and surgical implications

OBJECTIVE

Recent evidence favors a network concept in tuberous sclerosis (TSC) with seizure generation and propagation related to changes in global and regional connectivity between multiple, anatomically distant tubers. Direct exploration of network dynamics in TSC has been made possible through intracranial sampling with stereoelectroencephalography (sEEG). The objective of this study is to define epileptic networks in TSC using quantitative analysis of sEEG recordings. We also discuss the impact of the definition of these epileptic networks on surgical decision-making.

METHODS

Intracranial sEEG recordings were obtained from four pediatric patients who presented with medically refractory epilepsy secondary to TSC and subjected to quantitative signal analysis methods. Cortical connectivity was quantified by calculating pairwise coherence between all contacts and constructing an association matrix. The global coherence, defined as the ratio of the largest eigenvalue to the sum of all the eigenvalues, was calculated for each frequency band (delta, theta, alpha, beta, gamma). Spatial distribution of the connectivity was identified by plotting the leading principal component (product of the largest eigenvalue and its corresponding eigenvector).

RESULTS

Four pediatric subjects with TSC underwent invasive intracranial monitoring with sEEG, comprising 31 depth electrodes and 250 contacts, for localization of the epileptogenic focus and guidance of subsequent surgical intervention. Quantitative connectivity analysis revealed a change in global coherence during the ictal period in the beta/low gamma (14-30 Hz) and high gamma (31-80 Hz) bands. Our results corroborate findings from existing literature, which implicate higher frequencies as a driver of synchrony and desynchrony.

CONCLUSIONS

Coordinated high-frequency activity in the beta/low gamma and high gamma bands among spatially distant sEEG define the ictal period in TSC. This time-dependent change in global coherence demonstrates evidence for intra-tuberal and inter-tuberal connectivity in TSC. This observation has surgical implications. It suggests that targeting multiple tubers has a higher chance of seizure control as there is a higher chance of disrupting the epileptic network. The use of laser interstitial thermal therapy (LITT) allowed us to target multiple disparately located tubers in a minimally invasive manner with good seizure control outcomes.

Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5-S1: case series and review of the literature

OBJECTIVE

Nerve root injuries associated with anterior lumbar interbody fusion (ALIF) are uncommonly reported in the literature. This case series and review aims to describe the etiology of L5 nerve root injury following ALIF at L5-S1.

METHODS

The authors performed a single-center retrospective review of prospectively collected data of patients who underwent surgery between 2017 and 2019 who had postoperative L5 nerve root injuries after stand-alone L5-S1 ALIF. They also reviewed the literature with regard to nerve root injuries after ALIF procedures.

RESULTS

The authors report on 3 patients with postoperative L5 radiculopathy. All 3 patients had pain that improved. Two of the 3 patients had a neurological deficit, one of which improved.

CONCLUSIONS

Stretch neuropraxia from overdistraction is an important cause of postoperative L5 radiculopathy after L5-S1 ALIF. Judicious use of implants and careful preoperative planning to determine optimal implant sizes are paramount.

Does the Modified Arrhenius Model Reliably Predict Area of Tissue Ablation After Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Pediatric Lesional Epilepsy?

BACKGROUND

Commercial magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) systems utilize a generalized Arrhenius model to estimate the area of tissue damage based on the power and time of ablation. However, the reliability of these estimates in Vivo remains unclear.

OBJECTIVE

To determine the accuracy and precision of the thermal damage estimate (TDE) calculated by commercially available MRgLITT systems using the generalized Arrhenius model.

METHODS

A single-center retrospective review of pediatric patients undergoing MRgLITT for lesional epilepsy was performed. The area of each lesion was measured on both TDE and intraoperative postablation, postcontrast T1 magnetic resonance images using ImageJ. Lesions requiring multiple ablations were excluded. The strength of the correlation between TDE and postlesioning measurements was assessed via linear regression.

RESULTS

A total of 32 lesions were identified in 19 patients. After exclusion, 13 pairs were available for analysis. Linear regression demonstrated a strong correlation between estimated and actual ablation areas (R2 = .97, P < .00001). The TDE underestimated the area of ablation by an average of 3.92% overall (standard error (SE) = 4.57%), but this varied depending on the type of pathologic tissue involved. TDE accuracy and precision were highest in tubers (n = 3), with average underestimation of 2.33% (SE = 0.33%). TDE underestimated the lesioning of the single hypothalamic hamartoma in our series by 52%. In periventricular nodular heterotopias, TDE overestimated ablation areas by an average of 13% (n = 2).

CONCLUSION

TDE reliability is variably consistent across tissue types, particularly in smaller or periventricular lesions. Further investigation is needed to understand the accuracy of this emerging minimally invasive technique.

Second nationwide anti-tuberculosis drug resistance survey in Namibia

SETTING: Namibia ranks among the 30 high TB burden countries worldwide. Here, we report results of the second nationwide anti-TB drug resistance survey.OBJECTIVE: To assess the prevalence and trends of multidrug-resistant TB (MDR-TB) in Namibia.METHODS: From 2014 to 2015, patients with presumptive TB in all regions of Namibia had sputum subjected to mycobacterial culture and phenotypic drug susceptibility testing (DST) for rifampicin, isoniazid, ethambutol and streptomycin if positive on smear microscopy and/or Xpert MTB/RIF.RESULTS: Of the 4124 eligible for culture, 3279 (79.5%) had Mycobacterium tuberculosis isolated. 3126 (95%) had a first-line DST completed (2392 new patients, 699 previously treated patients, 35 with unknown treatment history). MDR-TB was detected in 4.5% (95%CI 3.7-5.4) of new patients, and 7.9% (95%CI 6.0-10.1) of individuals treated previously. MDR-TB was significantly associated with previous treatment (OR 1.8, 95%CI 1.3-2.5) but not with HIV infection, sex, age or other demographic factors. Prior treatment failure demonstrated the strongest association with MDR-TB (OR 17.6, 95%CI 5.3-58.7).CONCLUSION: The prevalence of MDR-TB among new TB patients in Namibia is high and, compared with the first drug resistance survey, has decreased significantly among those treated previously. Namibia should implement routine screening of drug resistance among all TB patients.

Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for the Treatment of Nonlesional Insular Epilepsy in Pediatric Patients: Technical Considerations

INTRODUCTION

The insula presents anatomic challenges to surgical exploration and intervention. Open neurosurgical intervention is associated with high rates of complications despite improved seizure control. Minimally invasive techniques using novel energy delivery methods have gained popularity due to their relative safety and ability to overcome access-related barriers. The goal of this paper is to present an operative technical report and methodological considerations on the application of magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) for the treatment of nonlesional, medically refractory, insular epilepsy in pediatric patients.

METHODS

Visualase laser probe(s) were implanted using ROSA robotic stereotactic guidance into the insula using a parasagittal trajectory. After confirmation of placement using intraoperative MRI, thermal energy was delivered under real-time MR guidance. Laser wire pullback was performed when the initial dose of thermal energy was insufficient to ablate the target in its entirety. Thermal ablation within the intended target was confirmed using gadolinium-enhanced brain MRI. Following removal of laser wires, a final T1-weighted axial brain MRI was performed to confirm no evidence of hemorrhage.

RESULTS

Three patients underwent MRgLITT of nonlesional insular epilepsy over an 11-month period. The epileptogenic focus was localized to the insula using stereoelectroencephalography. The anterior and middle portions of the insula were accessed using a parasagittal trajectory. Laser ablation was performed for up to 3 min using an output of 10.5 W. No complications were encountered, and all patients were discharged within 24 h after the surgery. At the most recent follow-up, all patients had an Engel I outcome without any new neurologic deficits.

CONCLUSION

This small cohort shows that insular ablation can be achieved safely with promising seizure outcomes in the short term.

An Initial Cost-Effectiveness Analysis of Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Epilepsy Surgery

INTRODUCTION

Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new technology that provides a clinically efficacious and minimally invasive alternative to conventional microsurgical resection. However, little data exist on how costs compare to traditional open surgery. The goal of this paper is to investigate the cost-effectiveness of MRgLITT in the treatment of pediatric epilepsy.

METHODS

We retrospectively analyzed the medical records of pediatric patients who underwent MRgLITT via the Visualase® thermal therapy system (Medtronic, Inc., Minneapolis, MN, USA) between December 2013 and September 2017. Direct costs associated with preoperative, operative, and follow-up care were extracted. Benefit was calculated in quality-adjusted life years (QALYs), and the cost-effectiveness was derived from the discounted total direct costs over QALY. Sensitivity analysis on 4 variables was utilized to assess the validity of our results.

RESULTS

Twelve consecutive pediatric patients with medically refractory epilepsy underwent MRgLITT procedures. At the last postoperative follow-up, 8 patients were seizure free (Engel I, 66.7%), 2 demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). The average cumulative discounted QALY was 2.11 over the lifetime of a patient. Adjusting for inflation, MRgLITT procedures had a cost-effectiveness of USD 22,211 per QALY. Our sensitivity analysis of cost variables is robust and supports the procedure to be cost--effective.

CONCLUSION

Our data suggests that MRgLITT may be a cost-effective alternative to traditional surgical resection in pediatric epilepsy surgery.

The role of bacterial skin infections in atopic dermatitis: expert statement and review from the International Eczema Council Skin Infection Group

Patients with atopic dermatitis (AD) have an increased risk of bacterial skin infections, which cause significant morbidity and, if untreated, may become systemic. Staphylococcus aureus colonizes the skin of most patients with AD and is the most common organism to cause infections. Overt bacterial infection is easily recognized by the appearance of weeping lesions, honey‐coloured crusts and pustules. However, the wide variability in clinical presentation of bacterial infection in AD and the inherent features of AD – cutaneous erythema and warmth, oozing associated with oedema, and regional lymphadenopathy – overlap with those of infection, making clinical diagnosis challenging. Furthermore, some features may be masked because of anatomical site‐ and skin‐type‐specific features, and the high frequency of S. aureus colonization in AD makes positive skin swab culture of suspected infection unreliable as a diagnostic tool. The host mechanisms and microbial virulence factors that underlie S. aureus colonization and infection in AD are incompletely understood. The aim of this article is to present the latest evidence from animal and human studies, including recent microbiome research, to define the clinical features of bacterial infections in AD, and to summarize our current understanding of the host and bacterial factors that influence microbial colonization and virulence.

Management of Chiari I malformations: a paradigm in evolution

PURPOSE

Despite decades of experience and research, the etiology and management of Chiari I malformations (CM-I) continue to raise more questions than answers. Controversy abounds in every aspect of management, including the indications, timing, and type of surgery, as well as clinical and radiographic outcomes. This review aims to outline past experiences, consolidate current evidence, and recommend directions for the future management of the Chiari I malformation.

METHODS

A review of recent literature on the management of CM-I in pediatric patients is presented, along with our experience in managing 1073 patients who were diagnosed with CM-I over the past two decades (1998-2018) at Children's National Medical Center (CNMC) in Washington DC.

RESULTS

The general trend reveals an increase in the diagnosis of CM-I at younger ages with a significant proportion of these being incidental findings (0.5-3.6%) in asymptomatic patients as well as a rise in the number of patients undergoing Chiari posterior fossa decompression surgery (PFD). The type of surgical intervention varies widely. At our institution, 104 (37%) Chiari surgeries were bone-only PFD with/without outer leaf durectomy, whereas 177 (63%) were PFD with duraplasty. We did not find a significant difference in outcomes between the PFD and PFDD groups (p = 0.59). An analysis of failures revealed a significant difference between patients who underwent tonsillar coagulation versus those whose tonsils were not manipulated (p = 0.02).

CONCLUSION

While the optimal surgical intervention continues to remain elusive, there is a shift away from intradural techniques in favor of a simple, extradural approach (including dural delamination) in pediatric patients due to high rates of clinical and radiographic success, along with a lower complication rate. The efficacy, safety, and necessity of tonsillar manipulation continue to be heavily contested, as evidence increasingly supports the efficacy and safety of less tonsillar manipulation, including our own experience.

Rigid Cranial Fixation for Robot-Assisted Stereoelectroencephalography in Toddlers: Technical Considerations

BACKGROUND

Stereoelectroencephalography (sEEG) using depth electrodes has become a mainstay of pediatric epilepsy surgery. This technique relies on rigid cranial fixation using skull pins, which forms the basis for accurate stereotactic navigation. The use of cranial fixation pins poses the threat of traumatic skull injuries in young children because of inadequate cranial bone thickness.

OBJECTIVE

To describe a rigid cranial fixation technique involving the integrated Gel Head Ring from the DORO QR3 multipurpose skull clamp set (Pro Med Instruments) with superimposed pin fixation in children below the age of 36 mo undergoing sEEG.

METHODS

Patients were placed in the supine position and the head was fixed using a DORO skull clamp with 3 pediatric cranial pins. The head was supported on the integrated Gel Head Ring, and a pin pressure of 20 pounds was applied. The DORO skull clamp set was then attached to the ROSA neurosurgical robot support telescopic arm for stereotactic navigation.

RESULTS

We present an illustrative series of 2 patients below the age of 3 yr with medically refractory epilepsy who underwent sEEG using our modified cranial fixation technique. Head position and reference registration were stable throughout the surgeries. Postoperative volumetric computed tomography scans of the head showed accurate placement of sEEG depth electrodes and did not reveal any fractures or epidural hematoma. No other complications related to cranial fixation were noted.

CONCLUSION

Concurrent use of rigid and nonrigid cranial fixation using the DORO skull clamp set provides safe and effective cranial fixation in infants and toddlers undergoing sEEG.

Magnetic resonance-guided laser interstitial thermal therapy for the treatment of non-lesional insular epilepsy in pediatric patients: thermal dynamic and volumetric factors influencing seizure outcomes

PURPOSE

To investigate the safety and efficacy of stereoelectroencephalography (sEEG) directed magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) in medically refractory insular epilepsy in pediatric patients, define the relationship between ablation volumes and seizure control, and analyze the relationship between thermal energy and ablation volumes.

METHODS

A single-institution, retrospective review of pediatric patients with insular epilepsy who underwent sEEG directed MRgLITT over a 10-month period was performed. Perioperative, imaging, and outcome data were analyzed. Seizure outcomes were determined based on Engel score (Engel I versus Engel II-IV). Insula and ablation volumes were measured, and the proportion of insula volume ablated was calculated. Thermal energy was calculated in joules.

RESULTS

Four patients underwent sEEG directed MRgLITT of insular epileptogenic foci. The ablation volume was higher in patients with Engel I outcome (3.93 cm³) compared to Engel II-IV outcome (1.02 cm³). The proportion of ablation to insula volume was lowest in patients with Engel II-IV outcome (25.09%). The mean energy requirement to create a unit volume of ablation in the insula is 1205.86 J. A linear trend was noted between thermal ablation energy and ablation volume (R² = 0.884). Over a mean follow-up period of 104 days, three patients were seizure-free (Engel I), and one patient saw significant improvement in seizure frequency (Engel III).

CONCLUSIONS

The proportion of insula ablated, as well as the volume of ablation, are related to seizure outcome with increasing ablation volumes corresponding to improved seizure control. Further analysis of insula laser ablation thermal dynamics and volumes is needed.

C2-C3 spinal fracture subluxation with ligamentous and vascular injury: a case report and review of management

Introduction

Spinal cord injury is one of the leading causes of paralysis and permanent morbidity. High cervical spine injuries, in particular, have the potential to be fatal and debilitating due to injury to multiple components, including but not limited to, discoligamentous disruption, vascular insult and spinal cord injury. To date, no unifying algorithm exists making it challenging to guide treatment decisions.

Case presentation

We present the case of a 29-year-old polytrauma patient with an unstable C2-C3 fracture subluxation secondary to hyperextension and rotation injury with complete ligamentous dissociation and vertebral artery dissection after a high-velocity injury. We review the literature on injury patterns, associated complications and neurological outcomes in subaxial cervical spine injuries.

Discussion

Our patient's injuries had several components including fracture subluxation, ligamentous disruption, central cord syndrome, and vascular insult. The lack of a unifying algorithm to guide treatment decisions highlights the variations in pathology and subsequent limitations in generalizability of current literature. Our patient underwent an open anterior C2-C3 reduction and discectomy with fusion and plating and a subsequent C2-C4 posterior instrumented fusion. The patient regained some motor function postoperatively and through rehabilitation. Careful consideration of multiple components is crucial when treating subaxial spine injuries.

Detection of Apparent Cell-free M. tuberculosis DNA from Plasma

New diagnostics are needed to improve clinicians’ ability to detect tuberculosis (TB) disease in key populations such as children and persons living with HIV and to rapidly detect drug resistance. Circulating cell-free DNA (ccfDNA) in plasma is a diagnostic target in new obstetric and oncologic applications, but its utility for diagnosing TB is not known. Here we show that Mycobacterium tuberculosis complex DNA can be detected in plasma of persons with sputum smear-positive TB, even in the absence of mycobacteremia. Among 40 participants with bacteriologically-confirmed smear-positive TB disease who had plasma tested by quantitative PCR (qPCR), 18/40 (45%) had a positive result on at least one triplicate reaction. Our results suggest that plasma DNA may be a useful target for improving clinicians’ ability to diagnose TB. We anticipate these findings to be the starting point for optimized methods of TB ccfDNA testing and sequence-based diagnostic applications such as molecular detection of drug resistance.

Motor cortex and spinal cord neuromodulation promote corticospinal tract axonal outgrowth and motor recovery after cervical contusion spinal cord injury

Cervical injuries are the most common form of SCI. In this study, we used a neuromodulatory approach to promote skilled movement recovery and repair of the corticospinal tract (CST) after a moderately severe C4 midline contusion in adult rats. We used bilateral epidural intermittent theta burst (iTBS) electrical stimulation of motor cortex to promote CST axonal sprouting and cathodal trans-spinal direct current stimulation (tsDCS) to enhance spinal cord activation to motor cortex stimulation after injury. We used Finite Element Method (FEM) modeling to direct tsDCS to the cervical enlargement. Combined iTBS-tsDCS was delivered for 30min daily for 10days. We compared the effect of stimulation on performance in the horizontal ladder and the Irvine Beattie and Bresnahan forepaw manipulation tasks and CST axonal sprouting in injury-only and injury+stimulation animals. The contusion eliminated the dorsal CST in all animals. tsDCS significantly enhanced motor cortex evoked responses after C4 injury. Using this combined spinal-M1 neuromodulatory approach, we found significant recovery of skilled locomotion and forepaw manipulation skills compared with injury-only controls. The spared CST axons caudal to the lesion in both animal groups derived mostly from lateral CST axons that populated the contralateral intermediate zone. Stimulation enhanced injury-dependent CST axonal outgrowth below and above the level of the injury. This dual neuromodulatory approach produced partial recovery of skilled motor behaviors that normally require integration of posture, upper limb sensory information, and intent for performance. We propose that the motor systems use these new CST projections to control movements better after injury.

Comparison of Mycobacterium tuberculosis complex Yield and Contamination Rates using Lowenstein-Jensen with and without Antibiotics in Western Kenya

BACKGROUND

While molecular methods have been recently endorsed for diagnosis of tuberculosis (TB), mycobacterial culture remains the gold standard. Lowenstein-Jensen (LJ) is often used for the cultivation of Mycobacterium tuberculosis complex (MTBC); however contamination often renders a subset of cultures useless. We compared the MTBC yield and contamination rate of processed sputum inoculated on LJ with antibiotics (LJ PACT) to LJ without antibiotics (LJ).

METHODOLOGY

Sputum samples were obtained from people living with HIV enrolled in a TB screening study in western Kenya, processed using NALC/NaOH-Na citrate, then inoculated on LJ PACT and LJ media. Cultures were evaluated weekly with growth identified as acid-fast bacilli by Ziehl-Neelsen bright-field microscopy. MTBC and nontuberculous mycobacteria (NTM) were identified by immunochromatographic and line probe assays.

RESULTS

A total of 700 sputum samples were cultured on both LJ PACT and LJ between March and June 2012. Of those cultured on LJ PACT, 29 (4.1%) grew MTBC, 613 (87.6%) were negative, 12 (1.7%) grew NTM, and 46 (6.6%) were contaminated; on LJ, 28 (4%) grew MTBC, 553 (79%) were negative, 9 (1.3%) grew NTM, and 110 (15.7%) were contaminated. The difference in contamination on LJ PACT and LJ was statistically significant (p<0.0001), while the difference in MTBC growth was not (p=0.566).