Two-Level Anterior Cervical Discectomy and Fusion Performed Using a Three-Dimensional Exoscope

Anterior cervical discectomy and fusion (ACDF) is a common neurosurgical procedure. Portions of the procedure, such as the discectomy, foraminotomy, graft placement, and plate placement, are often performed using operating microscopes to maximize visualization and minimize neurovascular injury. Although standard operating microscopes offer superb visualization, they lack ergonomic and educational utility. With modern advancements in digital imaging and stereopsis, there has been a surge of interest in evaluating modern exoscopes for their utility in cranial and spinal neurosurgery.1-3 In Video 1, we demonstrate the use of a commercial three-dimensional exoscope from skin incision through completion of a two-level ACDF. Both the lead surgeon and the assistant surgeon were able to maintain a neutral, ergonomic, and comfortable position throughout the surgery. Furthermore, we tested the utility of this technique in 15 patients undergoing ACDF (2 one-level, 9 two-level, 3 three-level, and 1 four-level). Mean (SD) overall operative time was 118 (34) minutes (2-level ACDF, 110 [12] minutes), and mean (SD) blood loss was 23 (8.0) mL. The Neck Disability Index score and visual analog scale score for neck pain improved significantly at 6 weeks postoperatively (from 59.6 [1.3] to 27.9 [3.0] and from 6.3 [1.0] to 2.5 [0.92], respectively; P < 0.001 for both). Thus, excellent clinical outcomes can be achieved using three-dimensional exoscopes with comparable operative time and blood loss compared with conventional surgical microscopes or loupes. Given the improved ergonomic and teaching potential of exoscopes, the use of three-dimensional exoscopes for neurosurgical and spine surgeries warrants further investigation.

Management of newborns and healthcare workers exposed to isoniazid-resistant congenital tuberculosis in the neonatal intensive care unit

BACKGROUND

Management of newborns and healthcare workers (HCWs) exposed to congenital tuberculosis (TB) in the neonatal intensive care unit (NICU) has been reported rarely.

AIM

To outline a contact investigation process for individuals exposed to congenital TB in the NICU and investigate nosocomial transmission. Additionally, to assess the efficacy and safety of window prophylaxis in exposed newborns.

METHODS

A baby, born at a gestational age of 28 + 1 weeks, was diagnosed with isoniazid-resistant congenital TB on the 39th day of admission to the level IV NICU. Newborns and HCWs exposed cumulatively for ≥8 h underwent contact investigation and follow-up for a year.

FINDINGS

Eighty-two newborns underwent contact investigation. All newborns displayed normal chest X-rays, and 42 hospitalized newborns tested negative for acid-fast bacilli stain and Xpert® MTB/RIF assay in their endotracheal sputum or gastric juices. Eighty received window prophylaxis: six of 75 on rifampin experienced mild adverse events, and none of the five on levofloxacin. After 12 weeks, five (6.1%) had a positive tuberculin skin test, all of whom had already received the Bacillus Calmette-Guérin vaccine and tested negative on TB interferon-gamma releasing assay. Of 119 exposed HCWs, three (2.5%) were diagnosed with latent TB infection and completed a four-month rifampin therapy. There was no active TB disease among exposed newborns and HCWs during a one-year follow-up.

CONCLUSION

Timely diagnosis of congenital TB is crucial for minimizing transmission among exposed neonates and HCWs in the NICU setting. In cases of isoniazid-resistant index patients, even premature newborns may consider the use of rifampin or levofloxacin for window prophylaxis.

Novel Use of Bilateral Prone Transpsoas Approach for the Treatment of Transforaminal Interbody Fusion Pseudarthrosis and Interbody Cage Subsidence

BACKGROUND AND OBJECTIVES

Pseudarthrosis is a complication after transforaminal lumbar interbody fusion (TLIF) that leads to recurrent symptoms and potential revision surgery. Subsidence of the interbody adds to the complexity of surgical revision. In addition, we report a novel technique for the treatment of TLIF pseudarthrosis with subsidence and propose an approach algorithm for TLIF cage removal.

METHODS

Cases of reoperation for TLIF pseudarthrosis were reviewed. We report a novel technique using a bilateral prone transpsoas (PTP) approach to remove a subsided TLIF cage and place a new lateral cage. An approach algorithm was developed based on the experience of TLIF cage removal. The patient was placed in the prone position with somatosensory evoked potential and electromyography monitoring. A PTP retractor was placed using standard techniques on the ipsilateral side of the previous TLIF. After the discectomy, the subsided TLIF cage was visualized but unable to be removed. The initial dilator was closed, and a second PTP retractor was placed on the contralateral side. After annulotomy and discectomy to circumferentially isolate the subsided cage, a box cutter was used to push and mobilize the TLIF cage from this contralateral side, which could then be pulled out from the ipsilateral side. A standard lateral interbody cage was then placed.

RESULTS

Retractor time was less than 10 minutes on each side. The patient's symptoms resolved postoperatively. We review illustrative cases of various approaches for TLIF cage removal spanning the lumbosacral spine and recommend an operative approach based on the lumbar level, degree of subsidence, and mobility of the interbody.

CONCLUSION

Bilateral PTP retractors for TLIF cage removal may be effectively used in cases of pseudarthrosis with severe cage subsidence. Careful consideration of various factors, including patient surgical history, body habitus, and intraoperative findings, is essential in determining the appropriate treatment for these complex cases.

Complications of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicenter Study

BACKGROUND AND OBJECTIVES

The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date.

METHODS

A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay.

RESULTS

A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms-8.2%, new lower extremity weakness-5.8%, wound infection-1.4%, cage subsidence-0.8%, psoas hematoma-0.5%, small bowel obstruction and ischemia-0.3%, and 90-day readmission-1.9%.

CONCLUSION

In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.

Dehydrated human amnion/chorion membrane use in emergent craniectomies shows minimal dural adhesions

Decompressive craniectomies (DCs) are routinely performed neurosurgical procedures to emergently treat increased intracranial pressure secondary to multiple aetiologies, such as subdural haematoma, epidural haematoma, or malignant oedema in the setting of acute infarction. The DC procedure typically induces epidural fibrosis post-cranial resection, resulting in adherence of the dura to both the brain internally and skin flap externally. This becomes especially problematic in the setting of skull flap replacement for cranioplasty as adherences can lead to bridging vein tear, damage to the underlying brain cortex, and other postoperative complications. Dural adjuvants, which can contribute to decreased rate of adherence formation, can thereby reduce both postoperative cranioplasty complications and operative duration. Dehydrated human amnion/chorion membrane (DHACM) allografts (AMNIOFIX, MIMEDX Group Inc., US) have been shown to reduce the rate of dural scar tissue formation in re-exploration of posterior lumbar interbody fusion operations which require entry into the epidural space. The purpose of this study was to evaluate whether or not the use of DHACM in the setting of emergent craniectomies decreased the rate of dural adhesion formation and subsequent cranioplasty complications. Patients (n=7) who underwent emergent craniectomy and intraoperative placement of DHACM were evaluated during replacement of either an autologous skull cap or a custom-made implant, at which point the degree of adhesions was qualitatively assessed. Placement of DHACM below and on top of the dura resulted in negligible adhesion being found during the defect exposure, and there were no intraoperative complications during cranioplasties. Reported estimated blood loss across the seven patients averaged 64.2ml, total operative time averaged 79.2 minutes, and time dedicated to exposing defect for bone flap placement was <3 minutes.

Genetically engineered human umbilical cord-derived mesenchymal stem cells expressing human interleukin-12 and in vitro growth inhibition against lung adenocarcinoma cells

INTRODUCTION

Mesenchymal stromal cells (MSCs) are promising vehicles for cancer therapy due to their homing ability and potency to be genetically manipulated through either viral or non-viral methods. Interleukin-12 (IL-12) is one of the key immunomodulatory cytokines which has anti-tumour effect. However, systemic administration of the cytokine at therapeutic dosage can cause serious toxicity in the host system due to the high systemic level of interferon-γ (IFN-γ) induced.

OBJECTIVES

This study aimed to investigate the in vitro growth inhibition of genetically engineered human umbilical cord-derived mesenchymal stromal cells (hUCMSC) expressing IL-12 on H1975 human lung adenocarcinoma cells.

MATERIALS AND METHODS

Both adenoviral method and electroporation which used to generate hUCMSC-IL12 were compared. The method with better outcome was selected to generate hUCMSC-IL12 for the co-culture experiment with H1975 or MRC-5 cells. Characterisation of hUCMSC and hUCMSC-IL12 was performed.

RESULTS

Adenoviral method showed superior results in transfection efficiency (63.6%), post-transfection cell viability (82.6%) and hIL-12 protein expression (1.2 x 107 pg/ml) and thus was selected for the downstream experiments. Subsequently, hUCMSC-IL12 showed significant inhibition effect on H1975 cells after 5 days of co-culture. No significant difference was observed for all other co-culture groups, indicating that the inhibition effect was because of hIL-12. Lastly, the integrity of hUCMSC-IL12 remained unaffected by the transduction through examination of their surface markers and differentiation properties.

CONCLUSION

This study provided proof of concept that hUCMSC can be genetically engineered to express hIL-12 which exerts direct growth inhibition effect on human lung adenocarcinoma cells.

Acute leukemia and lymphoma in pregnancy, a retrospective study from a tertiary center in Malaysia

INTRODUCTION

Most evidence about the management of cancer and hematological malignancy in pregnancy are derived from retrospective observational studies with a small sample size. Availability of sufficiently large data has enabled evidence-based decision-making in this clinical dilemma.

MATERIALS AND METHODS

Retrospective study looking into patients diagnosed with acute leukemia or lymphoma in pregnancy from 1^st January 2014 to 1^st January 2020 in Ampang General Hospital including newly or previously diagnosed and relapsed disease RESULTS: 37 cases of acute leukemia or lymphoma in pregnancy occurred in 34 patients. Majority of acute leukemia or lymphoma in pregnancy diagnosed in 1^st trimester or in the setting of previously established or relapsed disease was therapeutically terminated. Thirteen pregnancies treated with antenatal chemotherapy resulted in livebirths except one stillbirth. More adverse obstetric outcomes are observed in pregnancies that did not receive antenatal chemotherapy, but association did not reach statistical significance. There was no significant difference in fetal outcome between cohort with and without antenatal chemotherapy. No treatment related mortality was observed in pregnancies with antenatal chemotherapy. Overall survival for newly diagnosed acute leukemia in pregnancy is significantly better with antenatal chemotherapy versus no antenatal chemotherapy.

CONCLUSION

Treatment with chemotherapy in 2^nd trimester of pregnancy onwards appears to have tolerable risks with favorable obstetric and fetal outcome. Deferment of treatment for acute leukemia in pregnancy to after delivery may cause increased risk of maternal and fetal adverse outcome.

Radiographic alignment outcomes after the single-position prone transpsoas approach: a multi-institutional retrospective review of 363 cases

OBJECTIVE

The aim of this paper was to evaluate the changes in radiographic spinopelvic parameters in a large cohort of patients undergoing the prone transpsoas approach to the lumbar spine.

METHODS

A multicenter retrospective observational cohort study was performed for all patients who underwent lateral lumber interbody fusion via the single-position prone transpsoas (PTP) approach. Spinopelvic parameters from preoperative and first upright postoperative radiographs were collected, including lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt (PT). Functional indices (visual analog scale score), and patient-reported outcomes (Oswestry Disability Index) were also recorded from pre- and postoperative appointments.

RESULTS

Of the 363 patients who successfully underwent the procedure, LL after fusion was 50.0° compared with 45.6° preoperatively (p < 0.001). The pelvic incidence-lumbar lordosis mismatch (PI-LL) was 10.5° preoperatively versus 2.9° postoperatively (p < 0.001). PT did not significantly change (0.2° ± 10.7°, p > 0.05).

CONCLUSIONS

The PTP approach allows significant gain in lordotic augmentation, which was associated with good functional results at follow-up.

A Retrospective Analysis of the L3-4 Disc and Spinopelvic Parameters on Outcomes in Thoracolumbar Fusion: Was Art Steffee Right?

OBJECTIVE

To determine if the L3-4 disc angle may be a surrogate marker for global lumbar alignment in thoracolumbar fusion surgery. To explore the relationship between radiographic and patient-reported outcomes (PROs) after thoracolumbar fusion surgery.

METHODS

Retrospective chart review was conducted on patients who had undergone a lumbar fusion involving levels from T9 to pelvis. EuroQol-Five Dimension (EQ-5D) scores and adverse events including adjacent segment disease and degeneration, pseudoarthrosis, proximal junctional kyphosis, stenosis, and reoperation were collected. Pre- and postoperative spinopelvic parameters were measured on weight-bearing radiographs, with the L3-4 disc angle of novel interest. Univariate logistic and linear regression were performed to assess the associations of radiographic parameters with adverse event incidence and improvement in EQ-5D, respectively.

RESULTS

182 patients met inclusion criteria. Univariable analysis revealed that increased magnitude of L3-4 disc angle, anterior pelvic tilt, and pelvic incidence measures are associated with increased likelihood of developing postoperative adverse events. Conversely, increased lumbar lordosis demonstrated a decreased incidence of developing a postoperative adverse event. Linear regression showed that radiographic parameters did not significantly correlate with postoperative EQ-5D scores although scores were significantly improved post-fusion in all dimensions except Self-care (P = 0.51).

CONCLUSIONS

L3-4 disc angle magnitude may serve as a surrogate marker of global lumbar alignment. Degree of spinopelvic alignment did not correlate to improvement in EQ-5D score in the present study, suggesting that quality of life metric change may not be a sensitive or specific marker of post-fusion alignment.

Upfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients

BACKGROUND

Laser ablation (LA) is used as an upfront treatment in patients with deep seated newly diagnosed Glioblastoma (nGBM).

OBJECTIVE

To evaluate the outcomes of LA in patients with nGBM and compare them with a matched biopsy-only cohort.

METHODS

Twenty-four nGBM patients underwent upfront LA at Cleveland clinic, Washington University in St. Louis, and Yale University (6/2011-12/2014) followed by chemo/radiotherapy. Also, 24 out of 171 nGBM patients with biopsy followed by chemo/radiotherapy were matched based on age (< 70 vs ≥ 70), gender, tumor location (deep vs lobar), and volume (<11 cc vs ≥11 cc). Progression-free survival (PFS), overall survival (OS), and disease-specific PFS and OS were outcome measures. Three prognostic groups were identified based on extent of tumor ablation by thermal-damage-threshold (TDT)-lines.

RESULTS

The median tumor volume in LA (n = 24) and biopsy only (n = 24) groups was 9.3 cm3 and 8.2 cm3 respectively. Overall, median estimate of OS and PFS in LA cohort was 14.4 and 4.3 mo compared to 15.8 mo and 5.9 mo for biopsy only cohort. On multivariate analysis, favorable TDT-line prognostic groups were associated with lower incidence of disease specific death (P = .03) and progression (P = .05) compared to other groups including biopsy only cohort. Only age (<70 yr, P = .02) and tumor volume (<11 cc, P = .03) were favorable prognostic factors for OS.

CONCLUSION

The maximum tumor coverage by LA followed by radiation/chemotherapy is an effective treatment modality in patients with nGBM, compared to biopsy only cohort. The TDT-line prognostic groups were independent predictor of disease specific death and progression after LA.

The effect of Gamma Knife radiosurgery on large posterior fossa metastases and the associated mass effect from peritumoral edema

OBJECTIVE

Gamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM.

METHODS

The authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome.

RESULTS

Fifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4-21.1 cm3), 14.98 cm3 (range 0.6-71.8 cm3), and 1.23 cm3 (range 0.3-3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0-5.07 cm). The median follow-up time was 7.3 months (range 1.6-57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range -96.95% to +48.69%, p < 0.001), median PTE decreased by 78.10% (range -99.92% to +198.35%, p < 0.001), and the fourth ventricle increased by 24.97% (range -37.96% to +545.6%, p < 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment.

CONCLUSIONS

In this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p < 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates.

The efficacy of intraoperative multimodal monitoring in pedicle subtraction osteotomies of the lumbar spine

OBJECTIVE

Iatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors' aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine.

METHODS

All patients older than 18 years who underwent lumbar PSOs at the authors' institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson's Disease Questionnaire-39 (PDQ-39) and Patient Health Questionnaire-9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined.

RESULTS

A total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively).

CONCLUSIONS

In this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.

Redefining lumbar spinal stenosis as a developmental syndrome: an MRI-based multivariate analysis of findings in 709 patients throughout the 16- to 82-year age spectrum

OBJECTIVEUsing an imaging-based prospective comparative study of 709 eligible patients that was designed to assess lumbar spinal stenosis (LSS) in the ages between 16 and 82 years, the authors aimed to determine whether they could formulate radiological structural differences between the developmental and degenerative types of LSS.METHODSMRI structural changes were prospectively reviewed from 2 age cohorts of patients: those who presented clinically before the age of 60 years and those who presented at 60 years or older. Categorical degeneration variables at L1-S1 segments were compared. A multivariate comparative analysis of global radiographic degenerative variables and spinal dimensions was conducted in both cohorts. The age at presentation was correlated as a covariable.RESULTSA multivariate analysis demonstrated no significant between-groups differences in spinal canal dimensions and stenosis grades in any segments after age was adjusted for. There were no significant variances between the 2 cohorts in global degenerative variables, except at the L4-5 and L5-S1 segments, but with only small effect sizes. Age-related degeneration was found in the upper lumbar segments (L1-4) more than the lower lumbar segments (L4-S1). These findings challenge the notion that stenosis at L4-5 and L5-S1 is mainly associated with degenerative LSS.CONCLUSIONSIntegration of all the morphometric and qualitative characteristics of the 2 LSS cohorts provides evidence for a developmental background for LSS. Based on these findings the authors propose the concept of LSS as a developmental syndrome with superimposed degenerative changes. Further studies can be conducted to clarify the clinical definition of LSS and appropriate management approaches.

Assessment of postoperative outcomes in spinal epidural abscess following surgical decompression

BACKGROUND CONTEXT

A spinal epidural abscess (SEA) is a serious condition that may be managed with antibiotics alone or with decompressive surgery combined with antibiotics.

PURPOSE

The objectives of this study were to assess the clinical outcomes of SEA after surgical management and to identify the patient-level factors that are associated with outcomes following surgical decompression and removal of SEA.

STUDY DESIGN/SETTING

Retrospective chart review analysis.

PATIENT SAMPLE

An analysis of 154 consecutive patients who initially presented to a tertiary-care, academic medical center with SEA, and were subsequently treated with surgery between 2010 and 2015 was performed.

OUTCOME MEASURES

Postoperative predischarge American Spinal Injury Association Impairment Scale (AIS) scores, 6-month follow-up encounter AIS scores, need for revision surgery, and mortality during SEA surgery were the primary outcomes.Physiological Measures: AIS scores.

METHOD

Fisher's exact and Wilcoxon rank-sum tests were used to assess the associations between patient-level factors and surgical outcomes. Moreover, an interactive, predictive model for postoperative predischarge AIS score was developed using a proportional odds regression model. There was no funding secured for this study and there is no conflict of interest-associated biases.

RESULTS

One hundred fifty-four patients (mean age of 58 years) were treated using surgical decompression in addition to antibiotics. The majority of patients were Caucasian (81%) and male (61%). No intraoperative mortality was reported. A second SEA surgery was performed in 8% of patients. A comparison of the preoperative and postoperative predischarge AIS scores showed that 49% of patients maintained a score of E or improved, while 45% remained at their preoperative status and 6% worsened. Among a subset of patients (n=36; 23%) for whom a 6-month follow-up encounter occurred, 75% maintained an AIS score of E or improved, 19% remained at their preoperative status, and 6% worsened. Both the presence and longer duration of preoperative paresis was associated with an increased risk of remaining at the same AIS score or worsening at the predischarge encounter (both p< .001). A predictive model for predischarge AIS scores was developed based on several patient characteristics.

CONCLUSIONS

Surgical decompression can contribute to improving or maintaining AIS scores in a high percentage of SEA patients. The presence and duration of preoperative paresis are prognostic for poorer outcomes and suggest that rapid surgical intervention before paresis develops may lead to improved postoperative outcomes. Our modeling tool enables an estimation of probabilities of patients' predischarge condition.

Utility of repeat magnetic resonance imaging in surgical patients with lumbar stenosis without disc herniation

BACKGROUND CONTEXT

Routine use of magnetic resonance imaging (MRI) as a diagnostic tool in lumbar stenosis is becoming more prevalent due to the aging population. Currently, there is no clinical guideline to clarify the utility of repeat MRI in patients with lumbar stenosis, without instability, neurological deficits, or disc herniation.

PURPOSE

To evaluate the utility of routine use of MRI as a diagnostic tool in lumbar stenosis, and to help formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis.

STUDY DESIGN/SETTING

Retrospective radiographic analysis.

PATIENT SAMPLE

Retrospective chart review was performed to review patients with lumbar stenosis, who underwent lumbar decompression without fusion from 2011 to 2015 at a single institution.

OUTCOME MEASURES

Previously established stenosis grading systems were used to measure and compare the initial and the subsequent repeat lumbar MRIs performed preoperatively. If patients were found to have a moderate or severe grade change, and if the surgical plan was altered due to such exacerbated radiographic findings, then their grade changes were considered clinically meaningful.

METHODS

We identified patients with lumbar stenosis without radiographic instability or neurological deficits, who had at least two preoperative lumbar MRIs performed and underwent decompressive surgeries. At each pathologic disc level, the absolute value of the change in grade for central and lateral recess stenosis, right foraminal stenosis, and left foraminal stenosis from the first preoperative MRI to the repeated MRI was calculated. These changed data were then used to calculate the mean and median changes in each of the three types of stenosis for each pathologic disc level. Identical calculations were carried out for the subsample of patients who only underwent discectomy or had a discectomy included as part of their surgery.

RESULTS

Among the 103 patients who met the inclusion criteria, 37 of those patients had more than one level surgically addressed, and a total of 161 lumbar levels were reviewed. Among the subset of patients that had any grade change, the majority of the grades only had a mild change of 1 (36 out of 42 patients, 85.7%, 95% confidence interval [CI]: 73.1%-94.1%); there was a moderate grade change of 2 in two patients (4.8%, CI: 0.8%-14.0%), and a severe change of 3 in one patient (2.4%, CI: 0.2%-10.1%). There were three patients with decreased grade change (7.1%, CI: 1.8%-17.5%). All clinically meaningful grade changes were from the subset of patients who had only discectomy or discectomy as part of the procedure. Lastly, both patients that had a clinically meaningful grade change had their MRIs performed at an interval of greater than 360 days.

CONCLUSIONS

The radiographic evaluation of the utility of routinely repeated MRIs in lumbar stenosis without instability, neurological deficits, or disc herniations demonstrated that there were no significant changes found in the repeated MRI in the preoperative setting, especially if the MRIs were performed less than one year apart. The results of this present study can help to standardize the diagnostic evaluation of lumbar stenosis and to formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis patients.

Combined use of minimal access craniotomy, intraoperative magnetic resonance imaging, and awake functional mapping for the resection of gliomas in 61 patients

OBJECTIVE

Current management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts.

METHODS

The authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed.

RESULTS

A total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p < 0.001). Seventeen of 62 cases achieved an increased EOR > 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months.

CONCLUSIONS

In this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.

The effect of C2–3 disc angle on postoperative adverse events in cervical spondylotic myelopathy

OBJECTIVE

Complete radiographic and clinical evaluations are essential in the surgical treatment of cervical spondylotic myelopathy (CSM). Prior studies have correlated cervical sagittal imbalance and kyphosis with disability and worse health-related quality of life. However, little is known about C2–3 disc angle and its correlation with postoperative outcomes. The present study is the first to consider C2–3 disc angle as an additional radiographic predictor of postoperative adverse events.

METHODS

A retrospective chart review was performed to identify patients with CSM who underwent surgeries from 2010 to 2014. Data collected included demographics, baseline presenting factors, and postoperative outcomes. Cervical sagittal alignment variables were measured using the preoperative and postoperative radiographs. Univariable logistic regression analyses were used to explore the association between dependent and independent variables, and a multivariable logistic regression model was created using stepwise variable selection.

RESULTS

The authors identified 171 patients who had complete preoperative and postoperative radiographic and outcomes data. The overall rate of postoperative adverse events was 33% (57/171), and postoperative C2–3 disc angle, C2–7 sagittal vertical axis, and C2–7 Cobb angle were found to be significantly associated with adverse events. Inclusion of postoperative C2–3 disc angle in the analysis led to the best prediction of adverse events. The mean postoperative C2–3 disc angle for patients with any postoperative adverse event was 32.3° ± 17.2°, and the mean for those without any adverse event was 22.4° ± 11.1° (p < 0.0001).

CONCLUSIONS

In the present retrospective analysis of postoperative adverse events in patients with CSM, the authors found a significant association between C2–3 disc angle and postoperative adverse events. They propose that C2–3 disc angle be used as an additional parameter of cervical spinal sagittal alignment and predictor for operative outcomes.

Prediction of depression and anxiety via patient-assessed tremor severity, not physician-reported motor symptom severity, in patients with Parkinson’s disease or essential tremor who have undergone deep brain stimulation

OBJECTIVE

Deep brain stimulation (DBS) is an effective therapy for movement disorders such as idiopathic Parkinson’s disease (PD) and essential tremor (ET). However, some patients who demonstrate benefit on objective motor function tests do not experience postoperative improvement in depression or anxiety, 2 important components of quality of life (QOL). Thus, to examine other possible explanations for the lack of a post-DBS correlation between improved objective motor function and decreased depression or anxiety, the authors investigated whether patient perceptions of motor symptom severity might contribute to disease-associated depression and anxiety.

METHODS

The authors performed a retrospective chart review of PD and ET patients who had undergone DBS at the Cleveland Clinic in the period from 2009 to 2013. Patient demographics, diagnosis (PD, ET), motor symptom severity, and QOL measures (Primary Care Evaluation of Mental Disorders 9-item Patient Health Questionnaire [PHQ-9] for depression, Generalized Anxiety Disorder 7-item Scale [GAD-7], and patient-assessed tremor scores) were collected at 4 time points: preoperatively, postoperatively, 1-year follow-up, and 2-year follow-up. Multivariable prediction models with solutions for fixed effects were constructed to assess the correlation of predictor variables with PHQ-9 and GAD-7 scores. Predictor variables included age, sex, visit time, diagnosis (PD vs ET), patient-assessed tremor, physician-reported tremor, Unified Parkinson’s Disease Rating Scale part III (UPDRS-III) score, and patient-assessed tremor over time.

RESULTS

Seventy PD patients and 17 ET patients were included in this analysis. Mean postoperative and 1-year follow-up UPDRS-III and physician-reported tremor scores were significantly decreased compared with preoperative scores (p < 0.0001). Two-year follow-up physician-reported tremor was also significantly decreased from preoperative scores (p < 0.0001). Only a diagnosis of PD (p = 0.0047) and the patient-assessed tremor rating (p < 0.0001) were significantly predictive of depression. A greater time since surgery, in general, significantly decreased anxiety scores (p < 0.0001) except when a worsening of patient-assessed tremor was reported over the same time period (p < 0.0013).

CONCLUSIONS

Patient-assessed tremor severity alone was predictive of depression in PD and ET following DBS. This finding suggests that a patient’s perception of illness plays a greater role in depression than objective physical disability regardless of the time since surgical intervention. In addition, while anxiety may be attenuated by DBS, patient-assessed return of tremor over time can increase anxiety, highlighting the importance of long-term follow-up for behavioral health features in chronic neurological disorders. Together, these data suggest that the patient experience of motor symptoms plays a role in depression and anxiety—a finding that warrants consideration when evaluating, treating, and following movement disorder patients who are candidates for DBS.

Biomechanics of L5/S1 in Long Thoracolumbosacral Constructs: A Cadaveric Study

STUDY DESIGN

In vitro cadaveric biomechanical study.

OBJECTIVES

Despite numerous techniques employed to establish solid lumbosacral fixation, there are little biomechanical data correlating fixation methods at L5/S1 to thoracolumbosacral (TLS) construct length. We aimed to determine the optimal construct with the hypothesis that under physiological loads, lumbosacral constructs can be stabilized by L5/S1 anterior lumbar interbody fusion (ALIF) alone, without iliac screw fixation (ISF), and that TLS constructs would require ISF, with or without ALIF.

METHODS

By using a robot capable of motion in 6 axes, force-moment sensor, motion-tracking camera system and software, we simulated the spinal loading effects in flexion-extension, axial rotation, and lateral bending, and compared torques in different construct groups of T4-S1, T10-S1, and L2-S1. By conducting multidirectional flexibility testing we assessed the effects of constructs of various lengths on the L5/S1 segment.

RESULTS

L2-S1 constructs may be equivalently stabilized by L5/S1 ALIF alone without ISF. Longer TLS constructs exerted increasing motion at L5/S1, exhibiting trends in favor of ISF when extending to T10 and statistically improved fixation when extending to T4. Lastly, TLS constructs with ISF exhibited a statistically significant reduction in L5-S1 range of motion from the addition of ALIF when extending to T4-pelvis but not T10-pelvis.

CONCLUSIONS

We found that ALIF alone may sufficiently support the L2-S1 construct, reducing L5/S1 range of motion and transmitting loads instead to the sacropelvis. Furthermore, ALIF was found to add significant stability to the T4-pelvis construct when added to ISF. This difference was not significant for the T10-pelvis construct.

Pregnancy outcomes in women with non-transfusion dependent thalassaemia (NTDT): A haematology centre experience

INTRODUCTION

Non-transfusion dependent thalassaemia (NTDT) is a term used for thalassaemia patients who do not require lifelong regular transfusions for survival. Pregnancy in these women, whether spontaneous or through assisted reproductive technology, represents a challenge for the physician.

MATERIALS AND METHODS

The maternal and foetal outcomes of patients with NTDT followed up in a tertiary haematology centre over 6 months period were studied. A total of 36 pregnancies in 26 pregnant women with NTDT were analysed.

RESULTS

Among these women, all of the pregnancies resulted in successful delivery of singleton live-born neonates. There were four clinically distinct forms of NTDT among these women which include Hb E/β-thalassemia (mild and moderate forms), HbH disease, HbH-Constant Spring, and homozygous δβ-thalassemia. No blood transfusion was needed in 15 of the 36 pregnancies (41.6%). The lowest mean Hb level in which no blood transfusion was given was 8.21 g/dL. The mean of packed-cell units received during pregnancy was 6.95 units per pregnancy. There was no worsening of serum ferritin observed during pregnancy with mean serum ferritin pre- and post-pregnancy of 409.35 ug/L and 418.18 ug/L respectively. The mean gestational age at delivery was 38.6 weeks with no preterm delivery reported. The mean foetal birth weight was 2729 grams. There was no intrauterine growth restriction (IUGR) or congenital malformation. There was a case of small for gestational age (SGA) and a case of oligohydramnios.

CONCLUSION

This study showed that pregnancy was possible, safe and has a favourable outcome in patients with NTDT with multidisciplinary care.

Identification of atopic dermatitis phenotypes with good responses to probiotics (Lactobacillus plantarum CJLP133) in children

The therapeutic effect of probiotics in atopic dermatitis (AD) remains controversial and varies according to the individual patient. We aimed to identify a population of AD patients with a good clinical response to probiotic treatment. We recruited 76 children with a median age of 7.1 years who suffered from moderate to severe AD. After a 2-week washout period, all patients were given Lactobacillus plantarum CJLP133 at a dosage of 1×10¹⁰ colony-forming units once a day for 12 weeks. We measured eosinophil counts in the peripheral blood, the proportion of CD4⁺CD25⁺Foxp3⁺ regulatory T (Treg) cells in CD4⁺ T cells, serum total immunoglobulin E (IgE) levels, and specific IgE against common allergens before the start of the treatment (T1) and at discontinuation (T2). Responders were defined as patients with at least a 30% reduction in the SCORing of AD (SCORAD) index after treatment. There were 36 responders and 40 non-responders after probiotic treatment. The median SCORAD was reduced from 29.5 (range 20.6-46.3) at T1 to 16.4 (range 6.3-30.8) at T2 in the responder group (P<0.001). In multivariable logistic regression analysis, a good clinical response was significantly associated with high total IgE levels (aOR 5.1, 95% CI 1.1-23.6), increased expression of transforming growth factor (TGF)-β (aOR 4.6, 95% CI 1.3-15.9), and a high proportion of Treg cells in CD4⁺ T cells (aOR 3.7, 95% CI 1.1-12.7) at T1. In the responder group, the proportion of Treg cells was significantly increased after 12 weeks of treatment (P=0.004), while TGF-β mRNA expression was decreased (P=0.017). Our results suggest that a subgroup of patients with a specific AD phenotype showing an immunologically active state (high total IgE, increased expression of TGF-β, high numbers of Treg cells) may benefit from probiotic treatment with L. plantarum CJLP133.

Homology between alpha 2(V) and alpha 1(III) collagen promoters and evidence for negatively acting elements in the alpha 2(V) first intron and 5' flanking sequences

We have isolated a 17 kilobase pair (kb) genomic clone containing the 5' portion of the human alpha 2(V) collagen gene. Nucleotide sequence was determined for 1671 base pairs (bp) comprising the promoter region, first exon and 334 bp of the first intron, and the major transcriptional start site determined by primer extension and S1 nuclease analysis. Sequence comparison revealed the alpha 2(V) promoter to be similar in structure to the promoter of the alpha 1(III) collagen gene. This is the first instance of such similarities between promoter regions of genes encoding different fibrillar collagen chains. Homology, in 5' flanking sequences, extends upstream to about nucleotide -120 in each gene and is particularly striking near the TATTTA sequence (TATA box) present in each promoter. Some homology also surrounds the two transcription start sites. The 5' untranslated regions of the two genes also show strong homology. Chimeric chloramphenicol acetyltransferase (CAT) constructs were prepared with various fragments from the 5' portion of the alpha 2(V) gene. Transient expression assays, in human fibroblasts, localized the functional alpha 2(V) promoter to the region of 5' flanking sequence conserved between the alpha 2(V) and alpha 1(III) genes. Expression assays also identified negatively acting elements, in intron and 5' flanking sequences, which inhibit transcription from the alpha 2(V) promoter.

Associations of a social network typology with physical and mental health risks among older adults in South Korea

OBJECTIVES

The objectives of this study were to (1) develop an empirical typology of social networks in older Koreans; and (2) examine its effect on physical and mental health.

METHOD

A sample of 6900 community-dwelling older adults in South Korea was drawn from the 2014 Korean National Elderly Survey. Latent profile analysis (LPA) was conducted to derive social network types using eight common social network characteristics (marital status, living arrangement, the number and frequency of contact with close family/relatives, the number and frequency of contact with close friends, frequency of participation in social activities, and frequency of having visitors at home). The identified typologies were then regressed on self-rated health and depressive symptoms to explore the health risks posed by the group membership.

RESULTS

The LPA identified a model with five types of social network as being most optimal (BIC = 153,848.34, entropy = .90). The groups were named diverse/family (enriched networks with more engagement with family), diverse/friend (enriched networks with more engagement with friends), friend-focused (high engagement with friends), distant (structurally disengaged), and restricted (structurally engaged but disengaged in family/friends networks). A series of regression analyses showed that membership in the restricted type was associated with more health and mental health risks than all types of social networks except the distant type.

CONCLUSION

Findings demonstrate the importance of family and friends as a source of social network and call attention to not only structural but also non-structural aspects of social isolation. Findings and implications are discussed in cultural contexts.

Comparison of the Rotational Stability of Two Toric Intraocular Lenses in 1273 Consecutive Eyes

PURPOSE

To compare the rotational stability of the 2 most commonly used toric intraocular lenses (TIOLs).

DESIGN

Retrospective cohort study in a single private practice.

SUBJECTS

The study included all patients receiving an Acrysof (n = 626) or Tecnis TIOL (n = 647) over an 18-month period from April 2015 to September 2016. Patients were only excluded if their surgery could not be performed using a digital marking system.

METHODS

All patients had cataract surgery performed in the same surgical center with a similar technique. A digital marking system with limbal vessel registration was used to record the axis of the TIOL at the conclusion of surgery. A dilated examination was performed either later on the day of surgery or the next morning, and the postoperative rotation of the 2 TIOL models was compared. Patients who required a return to the operating room for TIOL repositioning were examined to determine risk factors for reoperation and subsequent outcomes.

MAIN OUTCOME MEASURES

The primary outcome measure was the percentage of eyes with TIOL rotation >5 and >10 degrees. The second main outcome was likelihood of requiring return to the operating room to reposition a rotated TIOL.

RESULTS

The Acrysof TIOL was less likely to rotate postoperatively, with 91.9% of eyes rotated ≤5 degrees at the first postoperative check compared with 81.8% of Tecnis TIOL eyes (P < 0.0001). This difference persisted for rotation ≤10 degrees (97.8% Acrysof vs. 93.2% Tecnis, P = 0.0002) and ≤15 degrees (98.6% Acrysof vs. 96.4% Tecnis, P = 0.02). The mean rotation was 2.72 degrees (95% confidence interval 2.35-3.08 degrees) for Acrysof and 3.79 degrees (95% confidence interval 3.36-4.22 degrees) for Tecnis TIOLs (P < 0.05). The Tecnis TIOL showed a strong predisposition to rotate counterclockwise, unlike the Acrysof. More Tecnis TIOL patients required repositioning (3.1% vs. 1.6%), but this did not reach statistical significance (P = 0.10). Refractive outcomes were similar between the 2 groups.

CONCLUSIONS

The Acrysof TIOL showed significantly greater rotational stability than the Tecnis TIOL.

Treatment of an Anterior Inferior Cerebellar Artery Aneurysm With Microsurgical Trapping and In Situ Posterior Inferior Cerebellar Artery to Anterior Inferior Cerebellar Artery Bypass: Case Report

BACKGROUND

Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can involve microsurgical and/or endovascular techniques. Such treatment can be challenging and may carry a significant risk of neurological morbidity.

OBJECTIVE

To demonstrate a case involving a complex AICA aneurysm that was treated with a unique microsurgical approach involving trapping the aneurysm and performing in Situ bypass from the posterior inferior cerebellar artery (PICA) to the distal AICA. The nuances of AICA aneurysms and revascularization strategies are discussed.

METHODS

The aneurysm and the distal segments of AICA and PICA were exposed with a retrosigmoid and far lateral approach. A side-to-side anastomosis was performed between the adjacent caudal loops of PICA and AICA. The AICA aneurysm was then treated by trapping the aneurysm-bearing segment of the parent vessel between 2 clips.

RESULTS

A postoperative angiogram demonstrated a patent PICA-AICA bypass and complete occlusion of the AICA aneurysm. There were no complications, and the patient made an excellent recovery.

CONCLUSION

The combination of parent vessel sacrifice and bypass remains an excellent option for certain difficult-to-treat aneurysms. This case involving PICA-AICA bypass to treat an AICA aneurysm serves as an example of the neurosurgeon's ability to develop unique solutions that take advantage of individual anatomy.

Early outcomes after intrathecal baclofen therapy in ambulatory patients with multiple sclerosis

OBJECTIVE

Multiple sclerosis (MS) is a chronic autoimmune disease that causes demyelination and axonal loss. Walking difficulties are a common and debilitating symptom of MS; they are usually caused by spastic paresis of the lower extremities. Although intrathecal baclofen (ITB) therapy has been reported to be an effective treatment for spasticity in MS, there is limited published evidence regarding its effects on ambulation. The goal of this study was to characterize ITB therapy outcomes in ambulatory patients with MS.

METHODS

Data from 47 ambulatory patients with MS who received ITB therapy were analyzed retrospectively. Outcome measures included Modified Ashworth Scale, Spasm Frequency Scale, Numeric Pain Rating Scale, and the Timed 25-Foot Walk. Repeated-measures ANOVA was used to test for changes in outcome measures between baseline and posttreatment (6 months and 1 year). Significance was set at p < 0.05. Descriptive data are expressed as the mean ± SD, and results of the repeated-measures ANOVA tests and the Wilcoxon rank-sum test are expressed as the mean ± SEM.

RESULTS

There was a statistically significant reduction in the following variables: 1) aggregate lower-extremity Modified Ashworth Scale scores (from 14.8 ± 1.0 before ITB therapy to 5.8 ± 0.8 at 6 months posttreatment and 6.4 ± 0.9 at 1 year [p < 0.05]); 2) Numeric Pain Rating Scale scores (4.4 ± 0.5 before ITB, 2.8 ± 0.5 at 6 months, and 2.4 ± 0.4 at 1 year [p < 0.05]); 3) spasm frequency (45.7% of the patients reported a spasm frequency of ≥ 1 event per hour before ITB therapy, whereas 15.6% and 4.3% of the patients reported the same at 6 months and 1 year posttreatment, respectively [p < 0.05]); and 4) the number of oral medications taken for spasticity (p < 0.05). Of the 47 patients, 34 remained ambulatory at 6 months, and 32 at 1 year posttreatment. There was no statistically significant change in performance on the Timed 25-Foot Walk test over time for those patients who remained ambulatory.

CONCLUSIONS

In this retrospective study, the authors found that ITB therapy is effective in reducing spasticity and related symptoms in ambulatory patients with MS. Because the use of ITB therapy is increasing in ambulatory patients with MS, randomized, prospective studies are important to help provide a more useful characterization of the effects of ITB therapy on ambulation.

Ophthalmology patients' interest in online access to clinic notes at three US clinics

PURPOSE

This study aimed to understand patients' perceptions about potential benefits and harms of accessing their own ophthalmology clinic notes via an electronic patient portal as part of the OpenNotes initiative.

METHODS

The authors conducted a cross-sectional, in-person survey of ophthalmology patients at three US eye clinics. The paper survey was self-administered or administered with assistance from study staff before or after patients' clinical visits. The authors used descriptive statistics to summarise patient characteristics and patient attitudes about accessing their ophthalmology notes online. Chi-square and t-tests were performed to assess differences in patient responses between clinic locations.

RESULTS

Four hundred and fifty-one patients responded (response rate 65%). Most patients thought that accessing doctors' notes online was a good idea (95%), wanted to view their clinic notes online (94%), and agreed online access would increase their understanding of their eye problems (95%) and help them better remember their care plan (94%); 14% said online access would increase their worry; 43% had privacy concerns; and 96% indicated they would show or discuss their notes with at least one other person. Non-white patients were more likely than white patients to perceive online clinic notes as a useful tool, but they were also more likely to worry and to express greater privacy concerns.

CONCLUSIONS

Patients at three US eye clinics were strongly in favour of online access to ophthalmology notes and were optimistic this access would improve their understanding and self-care. Ophthalmologists should consider offering online access to their notes to enhance doctor-patient communication and improve clinical outcomes.

Management options of non-syndromic sagittal craniosynostosis

There have been various effective surgical procedures for the treatment of non-syndromic sagittal craniosynostosis, but no definitive guidelines for management have been established. We conducted a study to elucidate the current state of practice and establish a warranted standard of care. An Internet-based study was sent to 180 pediatric neurosurgeons across the country and 102 craniofacial plastic surgeons in fourteen different countries, to collect data for primary indication for surgical management, preference for timing and choice of surgery, and pre-, peri-, and post-operative management options. The overall response rate from both groups was 32% (n=90/284). Skull deformity was the primary indication for surgical treatment in patients without signs of hydrocephalus for both neurosurgeons and craniofacial surgeons (80% and 63%, respectively). Open surgical management was most commonly performed at six months of age by neurosurgeons (46%) and also by craniofacial surgeons (35%). Open surgical approach was favored for patients younger than four months of age by neurosurgeons (50%), but endoscopic approach was favored by craniofacial surgeons (35%). When performing an open surgical intervention, most neurosurgeons preferred pi or reversed pi procedure (27%), whereas total cranial vault remodeling was the most commonly performed procedure by craniofacial surgeons (37%). The data demonstrated a discrepancy in the treatment options for non-syndromic sagittal craniosynostosis. By conducting/comparing a wide survey to collect consolidative data from both groups of pediatric neurosurgeons and craniofacial plastic surgeons, we can attempt to facilitate the establishment of standard of care.

Associations of dietary calcium intake with metabolic syndrome and bone mineral density among the Korean population: KNHANES 2008-2011

Excessive amount of calcium intake increased risk for metabolic syndrome in men. However, modest amount decreased the risk of metabolic syndrome and osteoporosis in postmenopausal women. Modest amount of calcium also increased bone mineral density (BMD) in both men and postmenopausal women.

INTRODUCTION

The present study aimed to evaluate the associations of dietary calcium intake with metabolic syndrome and bone mineral density (BMD) in Korean men and women, especially postmenopausal women.

METHODS

The study was performed using data from the Korean National Health and Nutrition Examination Survey (2008-2011) and included 14,705 participants (5953 men, 4258 premenopausal women, and 4494 postmenopausal women). Clinical and other objective characteristics, presence of metabolic syndrome, and the BMD of the femur neck and lumbar spine were evaluated according to dietary calcium intake.

RESULTS

There was a higher tendency for metabolic syndrome in men with a dietary calcium intake of >1200 mg/day than with ≤400 mg of calcium intake; >400 and ≤800 mg of calcium intake was helpful for postmenopausal women to decrease risk for metabolic syndrome. Overall, the group with calcium intake >400 and ≤800 mg daily had significantly increased BMD in both femoral neck and lumbar spine from both men and postmenopausal women. From both femoral neck and lumbar spine, the prevalence of osteoporosis in postmenopausal women significantly decreased in the group whose calcium intake was >400 and ≤800 mg daily.

CONCLUSION

Excessive dietary calcium may increase the prevalence of metabolic syndrome in men. For postmenopausal women, calcium intake does not increase the risk of metabolic syndrome, but modest amount decreases the risk. It may increase the BMD in men and postmenopausal women, and also reduce the prevalence of both osteoporosis and metabolic syndrome in postmenopausal women.

Beta Blockade and Clinical Outcomes in Aneurysmal Subarachnoid Hemorrhage

Background:

Aneurysmal subarachnoid hemorrhages are frequently complicated by hypertension and neurogenic myocardial stunning. Beta blockers may be used for management of these complications. We sought to investigate sympathetic nervous system modulation by beta blockers and their effect on radiographic vasospasm, delayed cerebral infarction, discharge destination and death.

Methods:

Retrospective chart review of 218 adults admitted to the ICU between 8/2004 and 9/2010 was performed. Groups were identified relevant to beta blockade: 77 were never beta blocked (No/No), 123 received post-admission beta blockers (No/Yes), and 18 were continued on their home beta blockers (Yes/Yes). Records were analyzed for baseline characteristics and the development of vasospasm, delayed cerebral infarction, discharge destination and death, expressed as adjusted odds ratio.

Results:

Of the 218 patients 145 patients developed vasospasm, 47 consequently infarcted, and 53 died or required care in a long-term facility. When compared to No/No patients, No/Yes patients had significantly increased vasospasm (OR 2.11 (1.06-4.16)). However, these patients also had significantly fewer deaths or need for long term care (OR 0.17 (0.05-0.64)), with decreased tendency for infarcts (OR 0.70 (0.32-1.55)). When compared to No/No patients, Yes/Yes patients demonstrated a trend toward increased vasospasm (OR 1.61 (0.50-5.29)) that led to infarction (OR 1.51 (0.44-5.13)), but with decreased mortality or need for long term care in a facility (OR 0.13 (0.01-1.30)).

Conclusion:

Post-admission beta blockade in aneurysmal subarachnoid hemorrhage patients was associated with increased incidence of vasospasm. However, despite the increased occurrence of vasospasm, beta blockers were associated with improved discharge characteristics and fewer deaths.

The effect of prolonged breast-feeding on the development of postmenopausal osteoporosis in population with insufficient calcium intake and vitamin D level

Breast-feeding affects bone metabolism and calcium homeostasis, and prolonged breast-feeding may influence the development of postmenopausal osteoporosis, particularly in highly susceptible populations. The study determined that breast-feeding may be a risk factor for postmenopausal osteoporosis, especially in people with low calcium intakes and vitamin D deficiencies.

INTRODUCTION

The purpose of this study was to determine whether breast-feeding is a risk factor in the development of postmenopausal osteoporosis, especially in highly susceptible population.

METHODS

The study was performed using data from the 2010 to 2011 Korea National Health and Nutrition Examination Survey, and it included 1231 postmenopausal women who were aged between 45 and 70 years. Osteoporosis was defined using the World Health Organization's T-score criteria, namely, a T-score of ≤-2.5 at the femoral neck or the lumbar spine. The patients' ages, body mass indexes, daily calcium intakes, serum vitamin D levels, exercise levels, smoking histories, and reproductive factors relating to menarche, menopause, delivery, breast-feeding, hormone treatment, and oral contraceptive use were evaluated. Comparisons between the osteoporosis and non-osteoporosis groups were undertaken using Student's t test and the chi-square test, and logistic regression models were built.

RESULTS

A significant increase in the risk of osteoporosis was apparent in postmenopausal women with prolonged breast-feeding histories (≥24 months) (model 1: odds ratio [OR] = 2.489; 95 % confidence interval [CI] = 1.111 to 5.578, p = 0.027; model 2: OR = 2.503; 95 % CI = 1.118 to 5.602, p = 0.026; model 3: OR = 2.825; 95 % CI = 1.056 to 7.56, p = 0.039), particularly in those with inadequate serum vitamin D levels and calcium intakes (<800 mg/day).

CONCLUSIONS

Breast-feeding seems to increase the risk of postmenopausal osteoporosis; however, its impact may not be definitive in women with sufficient vitamin D levels and calcium intakes. Therefore, sufficient calcium intakes and adequate vitamin D levels may be important to prevent osteoporosis in postmenopausal women that is derived from breast-feeding.

Destruction of Bacillus cereus spores in a thick soy bean paste (doenjang) by continuous ohmic heating with five sequential electrodes

This study selected spores from Bacillus cereus FSP-2 strain (the isolate from a commercial doenjang processing line) as the test strain which showed significantly higher thermal resistance (P < 0·05) than B. cereus reference strain (ATCC 27348). The spores in doenjang were subjected to ohmic heating (OH) at 95, 105, 115 and 125°C for 30, 60 or 90 s using a five sequential electrode system (electrical field: 26·7 V cm(-1) ; alternating current frequency: 25 kHz). OH at 105°C for 30-90 s reduced the B. cereus spore count in doenjang samples to <4 log CFU g(-1) . Since OH treatment at 115 and 125°C caused a perceivable colour change in the product (>1·5 National Bureau of Standards units), treatment at 105°C for 60 s was selected and applied on a large scale (500 kg of product). Reliable and reproducible destruction of B. cereus spores occurred; the reductions achieved (to < 4 log CFU g(-1) ) met the Korean national standards. Scanning electron microscopy revealed microstructural alterations in the spores (shrinkage and a distorted outer spore coat). OH is an effective method for destroying B. cereus spores to ensure the microbiological quality and safety of a thick, highly viscous sauce.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study shows that an ohmic heating (OH) using a five sequential electrode system can effectively destroy highly heat-resistant Bacillus cereus spores which have been frequently found in a commercial doenjang processing line without perceivable quality change in the product. In addition, it may demonstrate high potential of the unique OH system used in this study that will further contribute to ensure microbiological quality and safety of crude sauces containing high levels of electrolyte other than doenjang as well.

Comparison of clinical outcomes in decompression and fusion versus decompression only in patients with ossification of the posterior longitudinal ligament: a meta-analysis

OBJECTIVE

Ossification of the posterior longitudinal ligament (OPLL) is a pathological calcification or ossification of the PLL, predominantly occurring in the cervical spine. Although surgery is often necessary for patients with symptomatic neurological deterioration, there remains controversy with regard to the optimal surgical treatment. In this systematic review and meta-analysis, the authors identified differences in complications and outcomes after anterior or posterior decompression and fusion versus after decompression alone for the treatment of cervical myelopathy due to OPLL.

METHODS

A MEDLINE, SCOPUS, and Web of Science search was performed for studies reporting complications and outcomes after decompression and fusion or after decompression alone for patients with OPLL. A meta-analysis was performed to calculate effect summary mean values, 95% CIs, Q statistics, and I2 values. Forest plots were constructed for each analysis group.

RESULTS

Of the 2630 retrieved articles, 32 met the inclusion criteria. There was no statistically significant difference in the incidence of excellent and good outcomes and of fair and poor outcomes between the decompression and fusion and the decompression-only cohorts. However, the decompression and fusion cohort had a statistically significantly higher recovery rate (63.2% vs 53.9%; p < 0.0001), a higher final Japanese Orthopaedic Association score (14.0 vs 13.5; p < 0.0001), and a lower incidence of OPLL progression (< 1% vs 6.3%; p < 0.0001) compared with the decompression-only cohort. There was no statistically significant difference in the incidence of complications between the 2 cohorts.

CONCLUSIONS

This study represents the only comprehensive review of outcomes and complications after decompression and fusion or after decompression alone for OPLL across a heterogeneous group of surgeons and patients. Based on these results, decompression and fusion is a superior surgical technique compared with posterior decompression alone in patients with OPLL. These results indicate that surgical decompression and fusion lead to a faster recovery, improved postoperative neurological functioning, and a lower incidence of OPLL progression compared with posterior decompression only. Furthermore, decompression and fusion did not lead to a greater incidence of complications compared with posterior decompression only.

Belching during gastroscopy and its association with gastroesophageal reflux disease

Belching may result from transient lower esophageal sphincter relaxation; therefore, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). This study was conducted to investigate the frequency of belching during esophagogastroduodenoscopy (EGD) and its association with GERD. A retrospective review was performed on prospectively collected clinical and endoscopic data from 404 subjects who underwent EGD without sedation from December 2012 to May 2013 in a training hospital in Korea. All detectable belching events during endoscopy were counted. Frequency and severity of belching events were compared between the group with and without GERD using an ordinal logistic regression model. There were 145 GERD patients (26 erosive reflux disease and 119 nonerosive reflux disease [NERD]). In the multivariable analysis, GERD was significantly associated with a higher frequency of belching events (odds ratio = 6.59, P < 0.001). Central obesity, female, and younger age were also risk factors for frequent belching during EGD. Subgroup analyses were performed in subjects without erosive reflux disease (n = 378) and NERD (n = 293). NERD was also a predictive factor for frequent belching during EGD (odds ratio = 6.61, P < 0.001), and the frequency of belching was significantly correlated with GERD severity according to the Los Angeles classification (P < 0.05). Frequent belching during EGD was associated with GERD, including NERD. Future research should focus on its adjuvant role in the diagnosis of GERD/NERD and the necessity for applying differentiated endoscopy strategies for GERD patients, leading to less discomfort during EGD in patients at risk for intolerability.

The effect of electronic health records adoption on patient visit volume at an academic ophthalmology department

BACKGROUND

Electronic health records (EHRs) have become a mandated part of delivering health care in the United States. The purpose of this study is to report patient volume before and after the transition to EHR in an academic outpatient ophthalmology practice.

METHODS

Review of patient visits per half-day and number of support staff for established faculty ophthalmologists between July and October for five consecutive years beginning the year before EHR implementation.

RESULTS

Eight physicians met inclusion criteria for the study. The number of patient visits was lower in each year after EHR adoption compared to baseline p ≤ 0.027). Patient volume per provider was reduced an average of 16.9% over the 4 years (range 15.3-18.5%), and during the final year studied, no provider had returned to the pre-EHR number of patients per clinic session. Support staffing was unchanged (p > 0.2).

CONCLUSIONS

Adoption of EHR was associated with a significantly reduced number of patient visits per clinic session in an academic setting in which support staffing remained stable. Maintaining clinic volume and access in similar settings may require use of additional staffing.

Inactivation of Bacillus cereus spores in a tsuyu sauce using continuous ohmic heating with five sequential elbow-type electrodes

AIMS

The effect of ohmic heating (OH) in a pilot plant system which had a zig-zag shaped (elbow-type) ohmic heater with five sequential voltage electrodes was investigated on Bacillus cereus spores in a commercial tsuyu sauce.

METHODS AND RESULTS

The electrical field was fixed at 26·7 V cm(-1) with an alternating current frequency of 25 kHz. Raw tsuyu sauce (50 l) inoculated with B. cereus spores was submitted in a 4 × 3 factorial design to the OH system and heated at 95, 105, 115, and 125°C each for 30, 60, and 90 s. Survival of B. cereus spores and colour change in the commercial tsuyu sauce were both measured before and after treatment. As the treatment temperature and time increased, the number of surviving B. cereus spores decreased. The OH treatment in a bath-type process at 105°C for more than 30 s resulted in the total inactivation of the inoculated B. cereus spores (average 5·4 log reductions to undetectable levels after treatment). The OH protocol of heating at 105°C for 60 s which ensure complete eradication of the inoculated spores without compromising product quality was chosen and investigated for its suitability for commercial application on bulk quantities of samples (500 l). Reliable and reproducible reductions in B. cereus spore counts of 4·7-5·5 log CFU ml(-1) (mean ± standard deviation = 5·1 ± 0·3 CFU ml(-1) ) were achieved by the selected protocol of the continuous OH treatment (105°C for 60 s).

CONCLUSION

This study suggests that OH treatment with five sequential elbow-type electrodes has great potential as an industrial sterilizing method for liquid food contaminated with B. cereus spores.

SIGNIFICANCE AND IMPACT OF THE STUDY

This procedure will enhance the microbiological quality of liquid foods while minimizing quality deterioration.

Follistatin-like 3 is a mediator of exercise-driven bone formation and strengthening

Exercise is vital for maintaining bone strength and architecture. Follistatin-like 3 (FSTL3), a member of follistatin family, is a mechanosensitive protein upregulated in response to exercise and is involved in regulating musculoskeletal health. Here, we investigated the potential role of FSTL3 in exercise-driven bone remodeling. Exercise-dependent regulation of bone structure and functions was compared in mice with global Fstl3 gene deletion (Fstl3-/-) and their age-matched Fstl3+/+ littermates. Mice were exercised by low-intensity treadmill walking. The mechanical properties and mineralization were determined by μCT, three-point bending test and sequential incorporation of calcein and alizarin complexone. ELISA, Western-blot analysis and qRT-PCR were used to analyze the regulation of FSTL3 and associated molecules in the serum specimens and tissues. Daily exercise significantly increased circulating FSTL3 levels in mice, rats and humans. Compared to age-matched littermates, Fstl3-/- mice exhibited significantly lower fracture tolerance, having greater stiffness, but lower strain at fracture and yield energy. Furthermore, increased levels of circulating FSTL3 in young mice paralleled greater strain at fracture compared to the lower levels of FSTL3 in older mice. More significantly, Fstl3-/- mice exhibited loss of mechanosensitivity and irresponsiveness to exercise-dependent bone formation as compared to their Fstl3+/+ littermates. In addition, FSTL3 gene deletion resulted in loss of exercise-dependent sclerostin regulation in osteocytes and osteoblasts, as compared to Fstl3+/+ osteocytes and osteoblasts, in vivo and in vitro. The data identify FSTL3 as a critical mediator of exercise-dependent bone formation and strengthening and point to its potential role in bone health and in musculoskeletal diseases.