Cholesteatoma Masquerading as Cerumen

Cerumen is composed of glandular secretions and desquamated epithelial cells. It protects and lubricates the external auditory canal. Impacted cerumen causes canal occlusion and pressure over the tympanic membrane, causing ear discomfort, conductive hearing loss, itching, etc. Up to 6% of the general population are affected with impacted cerumen, which includes 10% of children, more than 30% of the elderly and people with cognitive impairment. Persistent symptoms despite resolution of impaction and patient repeatedly should raise suspicion of alternative diagnosis and prompt for further evaluation. A 20-year-old female patient came with complaints of decreased hearing and ear discharge. On otoscopic examination of left ear, impacted cerumen was seen in the attic region. On removal of wax with the aid of oto-endoscopy, attic region was found to be filled with cholesteatoma debris. On pure tone audiometry, patient had mild conductive hearing loss of 30 db and computed tomography of left temporal bone revealed ill-defined soft tissue density in the middle ear (epitympanum) with erosion of head of malleus and short process of incus. Blunting of scutum was also seen. Attic reconstruction and type III tympanoplasty was performed. On histopathological examination, the section showed keratin flakes with bacterial colonies which were consistent with cholesteatoma. In conclusion, any case of impacted cerumen should not be ignored by otorhinolaryngologist. Further evaluation with thorough examination under otomicroscope/otoendoscope has to be done which can lead to different diagnosis and treatment plan.

The Impact of COVID-19 on Future Orthopaedic Practice

No single event hitherto has stumped the world more significantly than the present Corona pandemic. In a short span of a few months, the world economy, healthcare, livelihood, and human survival have been direly threatened by the rapid increase in the number of COVID-19 cases and fatalities. While dispensations across the world are finding ways to tackle the pestilence, the medical fraternity faces a unique conundrum. On the one side, the health care team is at the forefront fighting the disease and saving patients from the grip of death. On the other side, the healthcare industry is facing a crisis in terms of safety of healthcare personnel, difficulties in online tele-healthcare, economic sustainability, challenges in healthcare education and other problems in safe health care delivery. The authors provide a broad perspective at the current pandemic and its implications on orthopaedic practice in the near future.

Reliability and Validity of the English Version of the AOSpine PROST (Patient Reported Outcome Spine Trauma)

STUDY DESIGN

Multicenter validation study.

OBJECTIVE

The aim of this study was to translate and adapt the AOSpine PROST (Patient Reported Outcome Spine Trauma) into English, and test its psychometric properties among North-American spine trauma patients.

SUMMARY OF BACKGROUND DATA

In the absence of an outcome instrument specifically designed and validated for traumatic spinal column injury patients, it is difficult to measure the effect size of various treatment options. The AOSpine Knowledge Forum Trauma initiated a project and developed the AOSpine PROST consisting of 19 items.

METHODS

Patients were recruited from two level-1 North-American trauma centers. For concurrent validity, next to AOSpine PROST also 36-item Short-Form Health Survey (SF-36) was filled out by patients. Patient characteristics were analyzed using descriptive statistics. Floor and ceiling effects as well as the number of inapplicable and missing questions were analyzed for content validity. Cronbach α and item-total correlation coefficients (ITCCs) were calculated for internal consistency. Spearman correlation tests were performed within AOSpine PROST items and in correlation to SF-36. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs). Factor analysis was performed to explore any dimensions within AOSpine PROST.

RESULTS

The AOSpine PROST was translated adapted into English using established guidelines. Of 196 enrolled patients, 162 (82.7%) met the inclusion criteria and provided sufficient data. Content validity showed good results, and no floor and ceiling effects were seen. The internal consistency was excellent (Cronbach α = 0.97; ITCC 0.50-0.90) as well as test-retest reliability (ICC = 0.97). Spearman correlations were good (0.29-0.85). The strongest correlations of AOSpine PROST with SF-36 were seen with the physical components (0.69-0.82; P < 0.001). Factor analysis revealed two possible dimensions (Eigen values >1), explaining 75.7% of variance.

CONCLUSION

The English version of AOSpine PROST showed very good validity and reliability. It is considered as a valuable tool, and has the potential to contribute to the reduction of ongoing controversies in spine trauma care.

LEVEL OF EVIDENCE

2.

Reliability, validity and responsiveness of the Dutch version of the AOSpine PROST (Patient Reported Outcome Spine Trauma)

PURPOSE

To validate the Dutch version of AOSpine PROST (Patient Reported Outcome Spine Trauma).

METHODS

Patients were recruited from two level-1 trauma centers from the Netherlands. Next to the AOSpine PROST, patients also filled out SF-36 for concurrent validity. Descriptive statistics were used to analyze the characteristics. Content validity was assessed by evaluating the number of inapplicable or missing questions. Also floor and ceiling effects were analyzed. Internal consistency was assessed by calculating Cronbach's α and item-total correlation coefficients (itcc). Spearman correlation tests were performed within AOSpine PROST items and in correlation with SF-36. Test-retest reliability was analyzed using Intraclass Correlation Coefficients (ICC). Responsiveness was assessed by calculating effect sizes (ES) and standardized response mean (SRM). Factor analysis was performed to explore any dimensions within AOSpine PROST.

RESULTS

Out of 179 enrolled patients, 163 (91.1%) were included. Good results were obtained for content validity. No floor or ceiling effects were seen. Internal consistency was excellent (Cronbach's α = 0.96, itcc 0.50-0.86), with also good Spearman correlations (0.25-0.79). Compared to SF-36, the strongest correlation was seen for physical functioning (0.79; p < .001). Also test-retest reliability was excellent (ICC = 0.92). Concerning responsiveness analysis, very good results were seen with ES = 1.81 and SRM = 2.03 (p < 0.001). Factor analysis revealed two possible dimensions (Eigenvalues > 1), explaining 65.4% of variance.

CONCLUSIONS

Very satisfactory results were obtained for reliability, validity and responsiveness of the Dutch version of AOSpine PROST. Treating surgeons are encouraged to use this novel and validated tool in clinical setting and research to contribute to evidence-based and patient-centered care.

Management of slipped capital femoral epiphysis: Results of a survey of the members of the Paediatric Orthopaedic Society of India (POSI)

AIM

To determine the preferred practices in the treatment of slipped capital femoral epiphysis (SCFE) among members of the Paediatric Orthopaedic Society of India (POSI).

MATERIALS AND METHODS

A questionnaire with 16 vignettes was made about SCFE and sent to all members of the Paediatric Orthopaedic Society of India (POSI) to study the similarity and variation in the management of SCFE. Specifically, respondents were asked about the role of reduction, methods of fixation, prophylactic fixation of the non-affected hip, postoperative management and their view on the prevalence of Femoro Acetabular Impingement (FAI) and anticipated need for secondary surgery.

RESULTS

The response rate was 94 out of 203 members of Paediatric Orthopaedic Surgeons of India (51.9%). 62 out of 94 (66%) participating surgeons had an exclusive paediatric orthopaedics workload, with 61 surgeons (65%) having more than ten years of experience. Seventy-eight surgeons (83%) were most consistent in their advice for the management of stable slips based on severity. For severe stable slips, 67 surgeons (71%) recommended Modified Dunn procedure. Around 23% of the respondents preferred to do modified Dunn's procedure for all unstable slips while the rest had different approaches to treat this. Single Partially threaded cancellous screw is the preferred implant for in-situ fixation, while a single screw and K wire construct is the preferred construct for in Modified Dunn's procedure. Only 17(16%) of the responders do prophylactic pinning of the opposite hip regularly. Almost 90 responders (96%) do counsel parents about FAI in later stages of life.

CONCLUSION

Our study documents that about 70% of the practising paediatric orthopaedic surgeons prefer to do capital realignment procedure for severe stable slips. The treatment of unstable slips remains controversial without any consensus though about 70% believe that there is a role of gentle reduction or positional reduction or skeletal traction. About 50% of the respondents treat less than five slips a year and thus would not possible to generate high-quality evidence based on meagre numbers. This clearly shows that there is a need for developing a national SCFE registry to pool in all data which would help us to arrive at meaningful conclusions to arrive at the ideal management guidelines for SCFE.

Development of Learning Objectives to Guide Enhancement of Chronic Disease Prevention and Management Curricula in Undergraduate Medical Education

Phenomenon: Chronic disease is a leading cause of death and disability in the United States. With an increase in the demand for healthcare and rising costs related to chronic care, physicians need to be better trained to address chronic disease at various stages of illness in a collaborative and cost-effective manner. Specific and measurable learning objectives are key to the design and evaluation of effective training, but there has been no consensus on chronic disease learning objectives appropriate to medical student education. Approach: Wagner's Chronic Care Model (CCM) was selected as a theoretical framework to guide development of an enhanced chronic disease prevention and management (CDPM) curriculum. Findings of a literature review of CDPM competencies, objectives, and topical statements were mapped to each of the six domains of the CCM to understand the breadth of existing learning topics within each domain. At an in-person meeting, medical educators prepared a survey for the modified Delphi approach. Attendees identified 51 possible learning objectives from the literature review mapping, rephrased the CCM domains as competencies, constructed possible CDPM learning objectives for each competency with the goal of reaching multi-institutional consensus on a limited number of CDPM learning objectives that would be feasible for institutions to use to guide enhancement of medical student curricula related to CDPM. After the meeting, the group developed a survey which included 39 learning objectives. In the study phase of the modified Delphi approach, 32 physician CDPM experts and educators completed an online survey to prioritize the top 20 objectives. The next step occurred at a CDPM interest group in-person meeting with the goal of identifying the top 10 objectives. Findings: The CCM domains were reframed as the following competencies for medical student education: patient self-care management, decision support, clinical information systems, community resources, delivery systems and teams, and health system practice and improvement. Eleven CDPM learning objectives were identified within the six competencies that were most important in developing curriculum for medical students. Insights: These learning objectives cut across education on the prevention and management of individual chronic diseases and frame chronic disease care as requiring the health system science competencies identified in the CCM. They are intended to be used in combination with traditional disease-specific pathophysiology and treatment objectives. Additional efforts are needed to identify specific curricular strategies and assessment tools for each learning objective.

Management of Tibial Shaft Fractures Distal to TKA Prosthesis by Intramedullary Nail: A Report of Three Cases

INTRODUCTION

Diaphyseal tibial fractures distal to a well-fixed tibial component although rare present a significant challenge and optimal treatment remains controversial. Displaced periprosthetic tibial shaft fractures are ideally treated with open reduction internal fixation with plate osteosynthesis. However, this treatment method is associated with weight-bearing restrictions, which can be difficult for elderly patients with multiple comorbidities and balance impairment. We present our experience of internal fixation with an intramedullary nail that uses an inferior entry point, standard intramedullary tibial nail, and conventional instrumentation.

MATERIALS AND METHODS

Between 2017 and 2018, three patients with acute tibial shaft fractures distal to a TKA (Felix Type 3A) were treated with an intramedullary nail. Preoperative planning involved assessing proximal tibia to ensure adequate room for implant and instrumentation. The average patient age was 66.3 years (range 59-72 years) and all patients were males. All the patients sustained fractures of distal tibial and fibula diaphysis, after a road traffic accident. There were no complications intraoperatively, and all procedures were completed uneventfully. One patient underwent additional fixation of the fibula.

RESULTS

All patients achieved a radiological fracture union after an average of 20.6 weeks. There were no fixation failures, or nonunions postoperatively. There were no new symptoms relative to the TKA that could be attributed to the tibial nailing procedure.

CONCLUSION

We recommend that this technique can be used primarily for this fracture pattern distal to a TKA, provided there is adequate space to accommodate the nail and instrumentation proximally anterior to the tibial tray.

Spinal Melorheostosis: A Rare Cause for Thoracic Radiculopathy

Background

Symptomatic spinal melorheostosis is a rare entity, and its surgical management is even rarer. Our objective is to highlight the importance of considering spinal melorheostosis among the differential diagnosis of thoracic radiculopathy.

Methods

We report a case of melorheostosis involving the T9 vertebra presenting with unilateral radicular pain managed surgically by decompression and posterior stabilization.

Results

Our patient had complete symptomatic relief following surgical resection without any perioperative complications.

Conclusions

Spinal melorheostosis, although rare, forms an important differential diagnosis in patients presenting with thoracic radiculopathy where surgical management can be a viable option in cases refractory to conservative treatment.

Level of Evidence

5.

Shepherd's crook deformity: How to set it straight. A five-step surgical guide

PURPOSE

Fibrous dysplasia (FD) of the proximal femur can result in severe deformity and disability. The results of surgical management in such situations have been reported to be poor. We present a novel, five-step surgical treatment to correct proximal femoral deformity in FD.

MATERIAL AND METHODS

This study is a review of prospectively collected data of cases of proximal femur polyostotic FD managed at our institute from 2012 onward. We managed three patients with FD involving four femora (one patient had bilateral disease). Mean age at presentation was 16 years with an average follow-up of 46 months. All underwent five steps, that is, (1) curettage/excision of the lesion, (2) allograft in intramedullary region, (3) lateral closing wedge valgus osteotomy, (4) fixation with extramedullary implant, and (5) augmentation of osteotomy site with autograft. Functional outcome was assessed using Harris Hip Score preoperatively and at the final follow-up.

RESULTS

The neck shaft angle was corrected from an average of 91.7° to 152.1°, while the Harris Hip Score improved from an average of 59 to 95. There was no clinical or radiological evidence of recurrence of disease or deformity in any patient till the last follow-up.

CONCLUSION

This five-step technique ensures good functional and radiological outcomes in the management of proximal femur FD.

Correlation of radiological parameters to functional outcome in complex proximal humerus fracture fixation: A study of 127 cases

OBJECTIVE

The purpose of this study is to analyze the radiological and functional outcome of complex proximal humerus fractures treated by open reduction and plate fixation, and how radiological parameters correlate with functional outcome.

DESIGN

Retrospective study.

SETTING

Level-1 trauma center.

PATIENTS/METHODS

One hundred twenty-seven patients were analyzed, with a mean follow-up of 5 (3-7) years.

OUTCOME MEASUREMENTS

Radiological parameters studied were neck-shaft angle (NSA), greater tuberosity (GT) to articular surface (AS) distance, medial hinge reduction, and presence (or absence) of calcar screw. Functional outcome evaluated by DASH and Constant-Murley (C-M) score.

RESULTS

The mean age is 53.8 years. All patients had a union in 14 (12-18) weeks. The mean NSA is 135° (112-155°). One hundred and thirteen patients with an NSA of >120° had a good functional outcome. Fourteen patients with NSA ≤120° had shoulder abduction <90°. The mean GT to AS distance is 7.2 mm (-2 to 16). The superior displacement of GT above AS is associated with abduction of <90° (16 patients). The mean medial gap is 3 mm (0-17). In 14 patients with a medial gap of >4 mm and without calcar screw, varus collapse is observed. All patients had a good outcome on DASH score and 122 patients had good to excellent outcome on C-M score. Five patients with poor outcome on C-M score had NSA <120° and displacement of GT above AS.

CONCLUSION

Radiographic indicators for poor outcome are varus angulation with NSA <120°, superior displacement of GT above AS, the presence of medial gap >4 mm, and absence of calcar specific screw. This "terrible triad" of proximal humerus fracture should be avoided during operative fixation.

Modic changes - An evidence-based, narrative review on its patho-physiology, clinical significance and role in chronic low back pain

OBJECTIVE

Lumbar degenerative spinal ailments are the most important causes for chronic low back pain. Modic changes (MC) are vertebral bone marrow signal intensity changes seen on MRI, commonly in association with degenerative disc disease (DDD). Despite being widely studied, majority of issues concerning MC are still controversial. The current narrative, evidence-based review comprehensively discusses the various aspects related to MC.

LITERATURE SEARCH

An elaborate search was made using keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes", on pubmed and google (scholar.google.com) databases on the 3rd of March 2020. We identified crucial questions regarding Modic changes and included relevant articles pertaining to these topics for this narrative review.

RESULTS

The initial search using the keywords "Modic changes", "lumbar Modic changes", "Modic changes in lumbar spine", and "vertebral Endplate Spinal Changes" on pubmed yielded a total of 568, 412, 394 and 216 articles on "pubmed" database, respectively. A similar search using the aforementioned keywords yielded a total of 3650, 3548, 3726 and 21570 articles on "google scholar" database. The initial screening involved exclusion of duplicate articles, articles unrelated to MC, animal or other non-clinical studies, and articles in non-English literature based on abstracts or the titles of articles. This initial screening resulted in the identification of 405 articles. Full manuscripts were obtained for all these selected articles and thoroughly scrutinised at the second stage of article selection. All articles not concerning Modic changes, not pertaining to concerned questions, articles concerning other degenerative phenomena, articles discussing cervical or thoracic MC, case reports or animal studies, articles in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 69 articles were included in this review.

CONCLUSION

Modic change (MC) is a dynamic phenomenon and its true etiology is still not definitely known. Disc/end plate injury, occult discitis and autoimmune reactions seem to trigger an inflammatory cascade, which leads to their development. Male sex, older age, diabetes mellitus, genetic factors, smoking, obesity, spinal deformities, higher occupational loads and DDD are known risk factors. There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long term outcome in patients with LBP or lumbar disc herniations (LDH). Patients with MC have been reported to have less satisfactory outcome following conservative treatment or discectomy, although the evidence is still unclear.

Adaptive hybrid intelligent MPPT controller to approximate effectual wind speed and optimal rotor speed of variable speed wind turbine

Operating wind power generation system at optimal power point is essential which is achieved by employing a Maximum Power Point Tracking (MPPT) control strategy. This literature focuses on developing a novel particle swarm optimization algorithm enhanced radial basis function neural network supported TSR based MPPT control strategy for Doubly Fed Induction Generator (DFIG) based wind power generation system. The proposed hybrid MPPT control strategy estimates the effective wind speed and estimates the optimal rotor speed of the wind power generation system to track the maximum power. The proposed controller extremely reduces the speed dissimilarity range of wind power generation system, which leads to rationalizing the pulse width inflection of DFIG rotor side converter. This in turn, increases the system's reliability and delivers an effective power tracking with reduced converter losses. Furthermore, by utilizing the proposed MPPT controller, the converter size can be reduced to 40%. Therefore, the overall cost of the system can be gradually decreased. To validate the performance of the proposed MPPT controller, an extensive simulation study has been carried out under medium and high wind speed conditions in MATLAB/Simulink. The obtained results have been justified using experimental analysis.

Inflammaging determines health and disease in lumbar discs-evidence from differing proteomic signatures of healthy, aging, and degenerating discs

BACKGROUND CONTEXT

The true understanding of aging and disc degeneration (DD) is still elusive. MRI has not helped our attempts to understand the health and disease status of the discs as it reflects mainly the end morphologic changes and not the changes at a molecular level. Understanding degeneration at a molecular level through proteomics might allow differentiation from normal aging and also aid in the development of biomarkers for early diagnosis and preventive therapies.

PURPOSE

To utilize proteomics to understand the molecular basis of healthy, aging, and degenerating discs and conclusively differentiate normal aging and degeneration.

STUDY DESIGN

Proteomic analysis of human intervertebral disc samples.

METHODS

L4-L5 disc samples from three groups were acquired and subjected to proteomic analysis. Samples from individuals aged in the second, third, and fourth decades were used to represent young healthy discs (Group A). Those from MRI normal donors aged in the fifth, sixth, and seventh decades represented normal aging (Group B). Five degenerated discs obtained from patients at surgery represented degeneration (Group C). The entire proteome map and alteration in protein expressions were further analyzed using bioinformatics analysis. This was a self-funded project.

RESULTS

There were 84 common proteins. Specific proteins numbered 225 in A, 315 in B, and 283 in C. By gene ontology biological process identification, Group A predominated with extracellular matrix organization, cytoskeletal structural and normal metabolic proteins. Group B differed in having additional basal expression of immune response, complement inhibitors, and senescence proteins. Group C was different, with upregulation of proteins associated with oxidative stress response, positive regulators of apoptosis, innate immune response, complement activation and defense response to gram positive bacteria indicating ongoing inflammaging.

CONCLUSIONS

Our study documented diverse proteome signatures between the young, aging and degenerating discs. Inflammaging was the main differentiator between normal biological aging and DD.

CLINICAL SIGNIFICANCE

Multiple inflammatory molecules unique to DD were identified, allowing the possibility of developing specific biomarkers for early diagnosis and thereby provide evidence-based metrics for preventive measures rather than surgical intervention and also to monitor progress of the disease.

Productivity of the Indian non-life insurance sector

Purpose

The purpose of this paper is to analyse the performance of the Indian non-life (general) insurance sector in terms of total factor productivity (TFP) over the period 2005–2016.

Design/methodology/approach

This study utilises Färe‒Primont index (FPI) to access the change in TFP and its components: technical change, technical efficiency and mix and scale efficiency over the observation period. Moreover, it employs the Mann–Whitney U-test to scrutinise the difference between the public and the private insurers in terms of growth in productivity.

Findings

The results reveal that the insurance sector possesses a very low level of TFP. Also, the results divulge an improvement of 11.98 per cent in TFP of the insurance sector at an annual average rate of 12.41 per cent over the observation period. The growth in productivity is mainly attributable to the improvement of 10.81 per cent in the scale‒mix efficiency. The progress in scale‒mix efficiency is mainly the result of improvements in residual scale and residual mix efficiency. The results also show that the privately owned insurers have experienced a high productivity growth rate than the state-owned insurers.

Practical implications

The results hold practical implications for the regulators, policymakers and decision makers of the Indian non-life insurance companies.

Originality/value

This study is the first of its kind to use FPI, which satisfies all economically relevant axioms and tests defined by the index number theory to comprehensively access the change in TFP of the Indian non-life insurance sector.

Vascular injuries due to cerclage passer: Relevant anatomy and note of caution

PURPOSE

The cerclage passer instrument was introduced for aiding percutaneous reduction in spiral femur fractures, thereby overcoming the risk of devascularization of the fracture ends commonly associated with traditional open cerclage wiring techniques. This may, however, predispose to iatrogenic vascular injuries owing to the proximity of the vessels and several other factors. We report four cases with femoral artery (superficial and deep) injuries caused by the cerclage passer in proximal femur and distal femur shaft fractures and incidence of these injuries in our institution.

METHODS

Retrospective analysis of hospital records of femoral fractures from 2011 to 2015. All cases of femoral fractures and periprosthetic femoral fractures with cerclage wiring done using the standard or the Synthes^® cerclage passer were included. Cases with wiring done for trochanteric fractures and other locations were excluded.

RESULTS

Incidence of vascular injuries due to the cerclage passer in proximal femur shaft fractures was 1.59%, whereas in distal femur shaft fractures it was 7.14%. There were two patients with a deep femoral artery (DFA) system injury and two with a superficial femoral artery (SFA) injury caused by the cerclage passer (Synthes) in two proximal femur shaft and two distal femur shaft fractures, respectively. End-to-end anastomosis for the SFA and ligation for DFA system injuries were used, with an uneventful postoperative period in all patients.

CONCLUSION

Caution and accuracy is imperative to avoid vascular injuries while using the cerclage passer in femur fractures, and strict vigilance is essential for early identification and prompt management.

Predictors of Successful Outcomes of Selective Nerve Root Blocks for Acute Lumbar Disc Herniation

STUDY DESIGN

Prospective, observational cohort study.

OBJECTIVE

Selective nerve root block (SNRB) is an effective, standard interventional procedure for failed medical management in lumbar disc herniation (LDH). However, the factors that would predict successful outcomes in patients undergoing SNRB have not been clearly studied.

METHODS

Patients with failed conservative treatment for acute LDH, treated with SNRB were periodically followed till 1 year. Patients who failed to have pain relief or had recurrent pain after SNRB, underwent surgery. The pattern of radiculogram during SNRB was classified into 4 types-"arm," "arrow," "linear," and "splash." Various clinical factors, radiological factors, and radiculograms were compared between patients who had consistent pain relief (group A) and those patients who did not (group B).

RESULTS

A total of 91 patients underwent SNRB. Sixty-nine had good pain relief maintained till 1 year (75.8% success). Twenty-two patients underwent surgery after failed NRB at a mean of 6.3 weeks. Patients with sensory symptoms (P = .01), higher mean preinjection Oswestry Disability Index (ODI) score (P = .02), higher mean postinjection ODI score at 3 weeks (P = .004), nonmanual job (P = .01), lumbosacral transitional segment (P = .00 005), and splash pattern of radiculogram (P = .005) were predictive of failed NRB. Logistic regression analysis showed that lumbosacral transitional segment at the level of LDH is the most significant factor predicting poor outcome.

CONCLUSIONS

SNRB is an effective technique to provide consistent symptom relief at least till 1 year in patients with acute LDH. The study identified several factors that predicted poor outcomes of SNRB and such patients can be forewarned about need for later surgery.

INFIX/EXFIX: Innovation managing pelvic fractures in difficult scenarios

Pelvic fractures complicated by the presence of visceral injuries, open fractures and urethral or bladder injuries pose a significant challenge to treat. In these conditions internal fixation is usually contraindicated. External fixators, though a potential solution, have disadvantages like loss of reduction, pin tract infection and loosening. INFIX, a novel technique has been effective in managing anterior ring fractures and can be used as a substitute for internal fixation. We describe use of INFIX as EXFIX in three case scenarios where passing INFIX rod internally was precluded with favorable outcomes.

An empirical investigation of efficiency and productivity in the Indian non-life insurance market

Purpose

The purpose of this paper is to analyse the performance of the Indian non-life (general) insurance sector in terms of efficiency, productivity and returns-to-scale economies. In addition to this, it identifies the determinants of efficiency.

Design/methodology/approach

This study employs a two-stage data envelopment analysis (DEA) bootstrap approach to estimate the level and determinants of efficiency. In the first stage, the DEA bootstrap approach is employed to estimate bias-corrected efficiency scores. In the second stage, the truncated bootstrapped regression is used to identify the effect of firm-level characteristics on the efficiency of insurers. Moreover, the bootstrapped Malmquist index is used to examine the productivity growth over the observation period 2005–2016.

Findings

The bootstrapped DEA results show that the Indian non-life insurance sector is moderately technical, scale, cost and allocative efficient, and there is a large opportunity for improvement. Moreover, the results reveal that the public insurers are more cost efficient than the private insurers. It is also evident that all the insurers irrespective of size and ownership type are operating under increasing returns to scale. Malmquist index results divulge an improvement in productivity of insurers, which is attributable to the employment of the best available technology. Bootstrapped DEA and bootstrapped Malmquist index results also show that the global financial crisis of 2008 has not severely affected the efficiency and productivity of the Indian non-life insurance sector. The truncated regression results spell that size and reinsurance have a statistically significant negative relationship with efficiency. It also shows a statistically significant positive age–efficiency relationship.

Practical implications

The results hold practical implications for the regulators, policy makers, practitioners and decision makers of the Indian non-life insurance companies.

Originality/value

This study is the first of its kind that comprehensively investigates different types of robust efficiency measures, determinants of efficiency, productivity growth and returns-to-scale economies in the Indian non-life insurance market for an extended time period.

Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies

INTRODUCTION

Conventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies.

METHODOLOGY

We reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups-CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups.

RESULTS

Among 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p < 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse > 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three.

CONCLUSION

Our study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis. These slides can be retrieved under Electronic Supplementary Material.