Does intervertebral disc degeneration in adolescent idiopathic scoliosis correlate with patient-reported pain scores? A review of 968 cases

PURPOSE

Report the rate and severity of degenerative disc disease (DDD) in non-surgical adolescent idiopathic scoliosis (AIS) patients and correlate these findings with patient-reported symptomatology scores. Additionally, to quantify the rate of concurrent pathological radiological findings in this group.

METHODS

This was a retrospective chart review study at a single tertiary centre. AIS patients aged 10-16 who had received a whole spine MRI between September 2007 and January 2019 and who had not received surgical intervention to their spine were included. MRI scan reports were screened to extract those who had evidence of DDD. These were then reviewed by a blinded second reviewer who graded every disc using the Pfirrmann grading system. SRS-22 scores were extracted for patients when available.

RESULTS

In total, 968 participants were included in the study. Of these, 93 (9.6%) had evidence of DDD, which was Pfirrmann grade ≥ 3 in 28 (2.9%). The most commonly affected level was L5/S1 (59.1% of DDD cases). A total of 55 patients (5.7%) had evidence of syringomyelia, 41 (3.4%) had evidence of spondylolisthesis (all L5/S1), 14 (1.4%) had bilateral L5 pars defects, and 5 (0.5%) had facet joint degeneration. Spondylolisthesis and bilateral pars defects were more common in patients with DDD identified on MRI scan (p < 0.001 and p = 0.04, respectively). Function (p = 0.048) and pain (p = 0.046) scores were worse in patients with DDD.

CONCLUSION

We present a baseline for the rate and severity of DDD in the non-operative AIS cohort. This should assist in decision-making and counselling of patients prior to surgery.

LEVEL OF EVIDENCE

III.

Effect of institution volume on mortality and outcomes in osteoporotic hip fracture care

Hospitals that treat more patients with osteoporotic hip fractures do not generally have better care outcomes than those that treat fewer hip fracture patients. Institutions that do look after more such patients tend, however, to more consistently perform relevant health assessments.

INTRODUCTION

An inveterate link has been found between institution case volume and a wide range of clinical outcomes; for a host of medical and surgical conditions. Hip fracture patients, notwithstanding the significance of this injury, have largely been overlooked with regard to this important evaluation.

METHODS

We used the UK National Hip Fracture database to determine the effect of institution hip fracture case volume on hip fracture healthcare outcomes in 2019. Using logistic regression for each healthcare outcome, we compared the best performing 50 units with the poorest performing 50 institutions to determine if the unit volume was associated with performance in each particular outcome.

RESULTS

There were 175 institutions with included 67,673 patients involved. The number of hip fractures between units ranged from 86 to 952. Larger units tendered to perform health assessments more consistently and mobilise patients more expeditiously post-operatively. However, patients treated at large institutions did not have any shorter lengths of stay. With regard to most other outcomes there was no association between the unit number of cases and performance; notably mortality, compliance with best practice tariff, time to surgery, the proportion of eligible patients undergoing total hip arthroplasty, length of stay delirium risk and pressure sore risk.

CONCLUSIONS

There is no relationship between unit volume and the majority of health care outcomes. It would seem that larger institutions tend to perform better at parameters that are dependent upon personnel numbers. However, where the outcome is contingent, even partially, on physical infrastructure capacity, there was no difference between larger and smaller units.

The impact of blood conservation techniques on transfusion requirements for posterior adolescent idiopathic scoliosis corrections: do we need a routine cross-match for the operation?

PURPOSE

Various strategies are utilised to reduce blood loss and allogenic blood transfusion for posterior instrumented correction of Adolescent Idiopathic Scoliosis (AIS). The aim of this study was to evaluate post-operative blood transfusion requirements to determine whether routine cross matching of blood is essential.

METHODS

This is a prospective case series of 84 patients who underwent posterior correction of AIS between September 2016 and March 2018. We reviewed demographic, operative, radiological data and transfusion requirements. Results of transfusion requirements in 44 patients who underwent Ponte osteotomies (F:M = 36:8; mean age 14.8 years) were compared with 40 patients (F:M = 9:31; mean age 14.4 years) who did not and provided the control group. A transfusion trigger of 80 mg/dl with clinical caveats was utilised. Cross matching and procurement costs of allogenic blood/unit were ascertained.

RESULTS

Five patients required postoperative blood transfusion on days 2 or 3. Anaesthetic time (p = 0.0003) and preoperative Cobb angle (p = 0.0166) were significant variables between both groups and post-operative Hb (p = 0.0084) and number of levels fused (p = 0.0312) being significant in patients requiring transfusion. Unutilised units on the day of the operation incurred £30,030 (£380/patient or £154/unit) in operational costs.

CONCLUSION

Our audit demonstrates that transfusion on the day of the operation was not required. We recommend that routine crossmatching is not essential for primary posterior correction for AIS with blood conservation techniques. Blood grouping with availability of urgent blood is sufficient at the onset of operation. This has financial implications and cost savings.

LEVELS OF EVIDENCE

III.

Radiation exposure during the treatment of spinal deformities

AIMS

To benchmark the radiation dose to patients during the course of treatment for a spinal deformity.

METHODS

Our radiation dose database identified 25,745 exposures of 6,017 children (under 18 years of age) and adults treated for a spinal deformity between 1 January 2008 and 31 December 2016. Patients were divided into surgical (974 patients) and non-surgical (5,043 patients) cohorts. We documented the number and doses of ionizing radiation imaging events (radiographs, CT scans, or intraoperative fluoroscopy) for each patient. All the doses for plain radiographs, CT scans, and intraoperative fluoroscopy were combined into a single effective dose by a medical physicist (milliSivert (mSv)).

RESULTS

There were more ionizing radiation-based imaging events and higher radiation dose exposures in the surgical group than in the non-surgical group (p < 0.001). The difference in effective dose for children between the surgical and non-surgical groups was statistically significant, the surgical group being significantly higher (p < 0.001). This led to a higher estimated risk of cancer induction for the surgical group (1:222 surgical vs 1:1,418 non-surgical). However, the dose difference for adults was not statistically different between the surgical and non-surgical groups. In all cases the effective dose received by all cohorts was significantly higher than that from exposure to natural background radiation.

CONCLUSION

The treatment of spinal deformity is radiation-heavy. The dose exposure is several times higher when surgical treatment is undertaken. Clinicians should be aware of this and review their practices in order to reduce the radiation dose where possible. Cite this article: Bone Joint J 2021;103-B(4):1-7.

The NORSe: changing the way we communicate

Introduction Rapid, reliable and efficient communication in healthcare systems with finite resources promises to improve patient care. Telephone engagement has effectively monopolised the referral process in the acute setting. Hence, traditional inter-hospital referral networks are potentially time consuming, not expeditious and frustrating. There is often no comprehensive documented communication record or audit trail. Social media, however, suggest that instantaneous, secure and dependable exchanges of information can occur via alternative conduits, potentially transforming the acute clinical referral system. The National On-Call Referral System (NORSe) was established in 2010 as an alternative referral paradigm. We explore the literature evidence surrounding the clinical impact of the NORSe referral system and analogous models. Early evidence suggests that NORSe may minimise delays in obtaining specialist advice and management, particularly in the acute setting. It enables the specialist to receive and address a large number of fact intense referrals that would otherwise be unpalatable and unmanageable. We summarise recent developments with the NORSe and give an overview of its clinical applications and links with clinical governance. NORSe and similar models promise to change the way we communicate as doctors, making the process more efficient, with a robust audit trail facilitating service appraisal and training.

Attitudes of undergraduates towards mental illness: A comparison between nursing and business management students in India

<p><strong>Background.</strong> Mental illness is an important public health issue worldwide; stigmatisation and negative attitudes towards people with mental illness are widespread among the general public. However, little is known about the attitudes of undergraduates to mental illness. </p><p><strong>Purpose.</strong> To compare the attitudes towards mental illness among undergraduates enrolled in nursing courses v. those enrolled in Bachelor of Business Management (BBM) courses. </p><p><strong>Methods.</strong> A cross-sectional descriptive design was adopted for the present study. A total of 268 undergraduates were selected to complete the<em> </em>Attitude Scale for Mental Illness (ASMI) and the Opinions about Mental Illness in the Chinese Community (OMICC) questionnaires. </p><p><span><strong>Results. </strong>We found significant differences between the number of nursing and BBM students who agreed with statements posed by the questionnaires, e.g., that they would move out of their community if a mental health facility was established there (χ²=16.503, <em>p</em>&lt;0.002), that they were not afraid of treated mentally ill people (χ²=15.279, <em>p</em>&lt;0.004), and that people with mental illness tend to be violent (χ²=14.215, <em>p</em>&lt;0.007) and dangerous (χ²=17.808, <em>p</em>&lt;0.001). Nursing students disagreed that people with mental illness are easily identified (χ²=30.094, <em>p</em>&lt;0.000), have a lower IQ (χ²=70.689, <em>p</em>&lt;0.000) and should not have children (χ²=24.531, <em>p</em>&lt;0.000). Nursing students were more benevolent than BBM students, as they agreed that people with mental illness can hold a job (χ²=49.992, <em>p</em>&lt;0.000) and can return to their former position (χ²=11.596, p&lt;0.021), that everyone faces the possibility of becoming mentally ill (χ²=38.726, <em>p</em>&lt;0.000), and that one should not laugh at the mentally ill (χ²=17.407, <em>p</em>&lt;0.002). Nursing students held less pessimistic attitudes, as they felt that the mentally ill should receive the same pay for the same job (χ²=10.669, <em>p</em>&lt;0.031) and that the public are prejudiced towards people with mental illness (χ²=17.604, <em>p</em>&lt;0.001).</span></p><p><strong>Conclusion.</strong> College students’ attitudes towards people with mental illness vary based on the course that they are enrolled in. Attitudes may be positively improved by revising curriculum design to incorporate educational sessions about mental illness. These are essential steps to combat discrimination, and potentially enhance the promotion of human rights for the mentally ill.</p>

Bifrontal ECT for drug-induced psychosis in Parkinson's disease

Psychosis has been documented to occur during treatment for idiopathic Parkinson's disease (PD). This case report describes an elderly male who developed psychosis during the course of treatment for idiopathic PD. He was treated with clozapine but experienced significant adverse effects without clinical improvement. He was prescribed bifrontal electroconvulsive therapy (BF-ECT). Here, we report the efficacy of BF-ECT in treating psychosis and motor symptoms in PD, without producing cognitive side effects in an elderly male.