Outcomes for high-risk hepatoblastoma in a resource-challenged setting

Background

Outcomes of high‐risk hepatoblastoma have been dismal, especially in resource‐challenged countries where access to chemotherapy and paediatric liver transplantation is limited for the underprivileged. This study aimed to assess the results of treatment of high‐risk hepatoblastoma in a tertiary centre, including patients who had non‐transplant surgical procedures in the form of extended resection.

Methods

A review of patients with high‐risk hepatoblastoma treated between January 2012 and May 2018 was carried out. Perioperative data and long‐term outcomes were analysed.

Results

Of 52 children with hepatoblastoma, 22 were considered to have high‐risk hepatoblastoma (8 girls and 14 boys). The mean(s.d.) age at diagnosis was 35(20) months. Of these 22 children, five died without surgery. Of the remaining 17 who underwent surgery, six had a resection (4 right and 2 left trisectionectomies) and 11 underwent living‐donor liver transplantation. Median follow‐up was 48 (range 12–90) months. Thirteen of the 17 children were alive at last follow‐up and four developed disseminated disease (3 had undergone liver transplantation and 1 liver resection). The overall survival rate at 1, 3 and 5 years was 77, 64 and 62 per cent for the whole cohort with high‐risk hepatoblastoma. In children who had surgery, 1‐, 3‐ and 5‐year survival rates were 91, 82 and 73 per cent for transplantation and 100, 83 and 83 per cent for resection. There was no difference in survival between the two surgical groups.

Conclusion

Excellent results in the treatment of high‐risk hepatoblastoma are possible, even in resource‐challenged countries.

The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities

PURPOSE

Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources.

METHODS

Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders.

RESULTS

Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care.

CONCLUSION

The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: methodology, contributors, and disclosures

PURPOSE

The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations.

METHODS

World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative's mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care.

RESULTS

Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest.

CONCLUSION

The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material.

Critical Values of Facet Joint Angulation and Tropism in the Development of Lumbar Degenerative Spondylolisthesis: An International, Large-Scale Multicenter Study by the AOSpine Asia Pacific Research Collaboration Consortium

STUDY DESIGN

An international, multicenter cross-sectional image-based study performed in 33 institutions in the Asia Pacific region.

OBJECTIVE

The study addressed the role of facet joint angulation and tropism in relation to L4-L5 degenerative spondylolisthesis (DS).

METHODS

The study included 349 patients (63% females; mean age: 61.8 years) with single-level DS; 82 had no L4-L5 DS (group A) and 267 had L4-L5 DS (group B). Axial computed tomography and magnetic resonance imaging were utilized to assess facet joint angulations and tropism (i.e., asymmetry between facet joint angulations) between groups.

RESULTS

There was a statistically significant difference between group A (left mean: 46.1 degrees; right mean: 48.2 degrees) and group B (left mean: 55.4 degrees; right mean: 57.5 degrees) in relation to bilateral L4-L5 facet joint angulations (p < 0.001). The mean bilateral angulation difference was 7.4 and 9.6 degrees in groups A and B, respectively (p = 0.025). A critical value of 58 degrees or greater significantly increased the likelihood of DS if unilateral (adjusted OR: 2.5; 95% CI: 1.2 to 5.5; p = 0.021) or bilateral facets (adjusted OR: 5.9; 95% CI: 2.7 to 13.2; p < 0.001) were involved. Facet joint tropism was found to be relevant between 16 and 24 degrees angulation difference (adjusted OR: 5.6; 95% CI: 1.2 to 26.1; p = 0.027).

CONCLUSIONS

In one of the largest studies assessing facet joint orientation in patients with DS, greater sagittal facet joint angulation was associated with L4-L5 DS, with a critical value of 58 degrees or greater increasing the likelihood of the condition for unilateral and bilateral facet joint involvement. Specific facet joint tropism categories were noted to be associated with DS.

Is lumbar facet joint tropism developmental or secondary to degeneration? An international, large-scale multicenter study by the AOSpine Asia Pacific Research Collaboration Consortium

BACKGROUND

Facet joint tropism is asymmetry in orientation of the bilateral facets. Some studies have shown that tropism may increase the risk of disc degeneration and herniations, as well as degenerative spondylolisthesis (DS). It remains controversial whether tropism is a pre-existing developmental phenomena or secondary to progressive remodeling of the joint structure due to degenerative changes. As such, the following study addressed the occurrence of tropism of the lower lumbar spine (i.e. L3-S1) in a degenerative spondylolisthesis patient model.

METHODS

An international, multi-center cross-sectional study that consisted of 349 patients with single level DS recruited from 33 spine institutes in the Asia Pacific region was performed. Axial MRI/CT from L3-S1 were utilized to assess left and right facet joint sagittal angulation in relation to the coronal plane. The angulation difference between the bilateral facets was obtained. Tropism was noted if there was 8° or greater angulation difference between the facet joints. Tropism was noted at levels of DS and compared to immediate adjacent and distal non-DS levels, if applicable, to the index level. Age, sex-type and body mass index (BMI) were also noted and assessed in relation to tropism.

RESULTS

Of the 349 subjects, there were 63.0 % females, the mean age was 61.8 years and the mean BMI was 25.6 kg/m(2). Overall, 9.7, 76.5 and 13.8 % had L3-L4, L4-L5 and L5-S1 DS, respectively. Tropism was present in 47.1, 50.6 and 31.3 % of L3-L4, L4-L5 and L5-S1 of levels with DS, respectively. Tropism involved 33.3 to 50.0 % and 33.3 to 58.8 % of the immediate adjacent and most distal non-DS levels from the DS level, respectively. Patient demographics were not found to be significantly related to tropism at any level (p > 0.05).

CONCLUSIONS

To the authors' knowledge, this is one of the largest studies conducted, in particular in an Asian population, addressing facet joint tropism. Although levels with DS were noted to have tropism, immediate adjacent and distal levels with no DS also exhibited tropism, and were not related to age and other patient demographics. This study suggests that facet joint tropism or perhaps subsets of facet joint orientation may have a pre-disposed orientation that may be developmental in origin or a combination with secondary changes due to degenerative/slip effects. The presence of tropism should be noted in all imaging assessments, which may have implications in treatment decision-making, prognostication of disease progression, and predictive modeling. Having a deeper understanding of such concepts may further elaborate on the precision phenotyping of the facets and their role in more personalized spine care. Additional prospective and controlled studies are needed to further validate the findings.

An International Multicenter Study Assessing the Role of Ethnicity on Variation of Lumbar Facet Joint Orientation and the Occurrence of Degenerative Spondylolisthesis in Asia Pacific: A Study from the AOSpine Asia Pacific Research Collaboration Consortium

Study Design A multinational, multiethnic, cross-sectional image-based study was performed in 33 institutions, representing 10 countries, which were part of the AOSpine Asia Pacific Research Collaboration Consortium. Objective Lumbar facet joint orientation has been reported to be associated with the development of degenerative spondylolisthesis (DS). The role of ethnicity regarding facet joint orientation remains uncertain. As such, the following study was performed across a wide-ranging population base to assess the role of ethnicity in facet joint orientation in patients with DS in the Asia Pacific region. Methods Lateral standing X-rays and axial magnetic resonance imaging scans were obtained for patients with lumbar DS. The DS parameters and facet joint angulations were assessed from L3-S1. Sex, age, body mass index (BMI), and ethnicity were also noted. Results The study included 371 patients with known ethnic origin (mean age: 62.0 years; 64% males, 36% females). The mean BMI was 25.6 kg/m(2). The level of DS was most prevalent at L4-L5 (74.7%). There were 28.8% Indian, 28.6% Japanese, 18.1% Chinese, 8.6% Korean, 6.5% Thai, 4.9% Caucasian, 2.7% Filipino, and 1.9% Malay patients. Variations in facet joint angulations were noted from L3 to S1 and between patients with and without DS (p < 0.05). No differences were noted with regards to sex and overall BMI to facet joint angulations (p > 0.05); however, increasing age was found to increase the degree of angulation throughout the lumbar spine (p < 0.05). Accounting for age and the presence or absence of DS at each level, no statistically significant differences between ethnicity and degree of facet joint angulations from L3-L5 were noted (p > 0.05). Ethnic variations were noted in non-DS L5-S1 facet joint angulations, predominantly between Caucasian, Chinese, and Indian ethnicities (p < 0.05). Conclusions This study is the first to suggest that ethnicity may not play a role in facet joint orientation in the majority of cases of DS in the Asia-Pacific region. Findings from this study may facilitate future comparative studies in other multiethnic populations. An understanding of ethnic variability may assist in identifying those patients at risk of postsurgical development or progression of DS. This study also serves as a model for large-scale multicenter studies across different ethnic groups and cultural boundaries in Asia.

Carbon monoxide poisoning from gas water heater installed and operated in the bathroom

Two cases of carbon monoxide poisoning involving 3 victims occurred in Cameron Highlands in the months of August and September 1995. Two of the victims were found dead in the bathrooms where they were taking a bath while the other one survived. Blood toxicology from the post mortems revealed high levels of carbon monoxide. The only significant source of carbon monoxide in both cases were the gas water heaters which were installed in the bathrooms. A multigas detector was used to monitor the level of carbon monoxide in one of the bathrooms and carbon monoxide was found to be produced to 1200 ppm in 16 minutes during operation of the heater. Carbon monoxide poisoning from gas water heaters installed in bathroom is a significant hazard.

Prevalence of diabetes in the young in south India

Students from nine schools and one college in Madras city, were screened for diabetes by oral glucose tolerance test. The criteria recommended by the World Health Organization was adopted to classify glucose tolerance. Among 3,515 students, between 5 and 19 years of age, participated in this survey, 1982 (56.4%) were males and 1.533 were (43.6%) females. Family history of diabetes was positive in 302 (8.6%) students. There was no overt case of diabetes of any type. Three (0.09%) males had renal glycosuria. It is therefore concluded that insulin-dependent diabetes, non-insulin dependent diabetes or any other type of diabetes in the young is rare in South India.

Functional status of bio-medical engg. departments in tertiary care hospitals--a comparative study

The Bio-medical Engineering departments of two major hospitals having high-tech equipment needed for routine day to day patient care were compared with respect to their staffing pattern, proficiency, frequency of failure of major and minor equipment and predictable/non-predictable 'Down time' of the selected equipment using non-parametric statistical test. The study shows that Bio-medical Engineering Department (BME) of our Institute though not full fledged as compared to Hospital 'B' however showed better results in bringing down the down time both in major, minor equipment. The major cause of failure of equipment in both the hospitals was found to be rough handling, the need for imparting training to physicians, nurses, paramedical personnel dealing with bio-medical equipment and its role in preventive maintenance is discussed. Based on the study recommendations were made for preventive maintenance, purchase policy and linked to the policy of administration. Recommendations were made to bring down the Down time to acceptable limit though not for complete elimination.

Glycosuria and diabetes mellitus in children and adolescents in south India

In Madras city (India) 10,513 school students between 3 and 20 yr of age were investigated for glycosuria and its causes. While no previously known cases of diabetes mellitus of any type were encountered, four students (0.038%) in the survey population were found to have glycosuria. One (0.009%) had renal glycosuria, two (0.019%) were possibly NIDDY (MODY) and one (0.009%) had transient glycosuria while receiving anti-tuberculous chemotherapy. It is therefore concluded that neither diabetes mellitus nor glycosuria of non-diabetic causes is a crucial health problem in Indian children and adolescents. While the reasons for this are not known, further research in this field could be of global interest.

Postoperative peritoneal lavage in generalised peritonitis. A prospective analysis

Fifty patients with generalised peritonitis were studied in the period between November 1984 and May 1986, 20 with postoperative peritoneal lavage and 30 with only conventional treatment. The study revealed that lavage could not reduce mortality. There was a large number of reperforation and anastomotic leak associated with it. Among patients who survived, lavage did however aid in rendering patients afebrile and in the return of the bowel sound early. Hospital stay was also reduced. We agree with earlier suggestions that the use of peritoneal lavage with its labour, intensiveness and potential complications is restricted to gross peritoneal contamination and its use in lesser degree of peritonitis is questionable.