Assessment of inter- and intraobserver agreement for META score in distinguishing osteoporotic from multiple myeloma vertebral fractures.

PURPOSE: To conduct an independent assessment of inter- and intraobserver agreement for the META score as a tool for differentiating osteoporotic vertebral fractures and multiple myeloma vertebral fractures. METHODS: This is a retrospective observational study. The magnetic resonance imaging analysis was made by two independent spinal surgeons. We designated a Subjective assessment, in which the surgeon should establish a diagnostic classification for each vertebral fracture based on personal experience: secondary to osteoporosis, categorized as a benign vertebral fracture (BVF), or attributed to multiple myeloma, categorized a malign vertebral fracture (MVF). After a 90-day interval, both surgeons repeated the evaluations. For the next step, the observers should establish a diagnosis between BVF and MVF according to the META score system, and both observers repeated the evaluations after a 90-day interval. The intra and interobserver reliability of the Subjective evaluation was studied using the kappa (κ) test. Then, the META evaluations were paralleled using the intraclass correlation coefficient (ICC). RESULTS: A total of 220 patients who had the potential to participate in the study were initially enrolled, but after applying the exclusion criteria, 44 patients were included. Thirty-three patients had BVF, and 12 patients presented MVF. Interobserver agreement for both Subjective evaluations moments (initial and 90-days interval) found a slight agreement for both moments (0.35 and 0.40 respectively). Kappa test for both META evaluations moments (initial and 90-days interval) found a moderate interobserver agreement for both moments (0.54 and 0.48 respectively). It was observed that the ICC calculated for the Initial evaluation using META score was 0.680 and that in the 90-days interval was 0.726, indicating regular to good agreement. Kappa test for intraobserver agreements for the Subjective evaluation presented moderate agreement for both Surgeons. On the other side, Kappa test for intraobserver agreements for the META evaluation presented substantial agreement for both Surgeons. The Intraclass Correlation Coefficient of the META score found presented an almost perfect agreement for both Surgeons. CONCLUSION: Intra and interobserver agreement for both surgeons were unsatisfactory. The lack of consistent reproducibility by the same observer discourages and disfavors the routine use of the META score in clinical decision making, when potentially cases of multiple myeloma may be present.

Efficacy of Dynamic Magnetic Resonance Imaging in the Diagnosis of Degenerative Cervical Myelopathy: Systematic Review Protocol.

Cervical degenerative myelopathy (CDM) is a cervical spine condition resulting in clinical manifestations of spinal cord compression related to the chronic, non-traumatic, and progressive narrowing of the cervical spinal canal. Conventional magnetic resonance imaging (MRI) is the gold standard test to diagnose and assess the severity of CDM. However, the patient is in a neutral and static position during the MRI scan, which may devalue the dynamic factors of CDM, underestimating the risk of spinal cord injury related to cervical spine flexion and extension movements. Dynamic MRI is a promising technique to change this scenario. Therefore, the present review aims to answer the following question: "Is dynamic MRI of the cervical spine more accurate in diagnosing CDM than conventional MRI?". We will search for studies in the MEDLINE (via PubMed), Embase, Scopus, Web of Science, LILACS, and SciELO databases. The search strategy will contain a combination of terms related to cervical myelopathy and magnetic resonance imaging . Two independent reviewers will select studies, extract data, and assess the risk of bias. The synthesis of results will be descriptive, considering the main findings of the studies about the outcomes of interest.

Translation and Cross-cultural Adaptation of the SOSG-OQ 2.0 Questionnaire into Brazilian Portuguese.

Objective: To perform the cross-cultural adaptation and translation into Brazilian Portuguese of the Spine Oncology Study Group - Outcomes Questionnaire 2.0 (SOSG-OQ 2.0) to enable its application to Brazilian patients and to allow Brazilian researchers to use a questionnaire that is on trend in the scientific literature. Materials and Methods: The present is a basic, non-randomized, non-comparative study. The translation followed the proposal by Reichenheime and Moraes, mainly for the semantic equivalence and measurement equivalence sessions, as well as the recommendations by Coster and Mancini mainly in the translation stage. The stages were as follows: first - translation into Brazilian Portuguese; second - back-translation; third - semantic comparison; fourth - validation of the final construct. Results: The translations of the SOSG-OQ 2.0 made by three translators presented a high degree of similarity for most questions. The translators kept all question titles and subtitles, as well as their internal and external orders. Two sworn translators, with native proficiency in English, performed the back-translation of the amalgamated text. Both back-translations were quite similar, and any differences were solved through consensus between the main author and the sworn translators, and the translated text was considered the final version. Conclusion: The present study shows a translated version of the SOSG-OQ 2.0 with semantic validity with the original version published in English. As such, researchers can apply the questionnaire to the Brazilian population, adding another tool for spine surgeons to improve the monitoring of this complex group of patients.

Percutaneous Pedicle Screw for Thoracolumbar Fractures: A Long-term Follow-up.

Objective: This is a retrospective cohort study to analyze the long-term outcomes of thoracolumbar spine fracture patients who underwent minimally invasive percutaneous fixation. Methods: The cases of 17 patients with thoracolumbar spine fractures who had percutaneous fixation between 2009 and 2011 were the subject of a retrospective analysis. Clinical and radiographic variables were collected. For the clinical evaluation the questionnaires SF-36 and Oswestry were used. Radiographic parameters were evaluated using fracture's classification based on Magerls's criteria, the fractured vertebra's wedging angle, and the affected segment's segmental Cobb angle. The measures were made at different stages: before surgery, immediately after surgery, one year later, and at a late follow-up (5 years later). Trauma associated injuries, post-surgical and implant related complications were among the additional information taken into account. Results: The SF-36 questionnaire showed averages above 63,5% in all domains in the late postoperative data (from 5 years after the surgery). Oswestry questionnaire answers showed minimal or no physical limitations in 80% of the patients with a mean score of 10,8%±10,5. The average preoperative Cobb angle value was 5,53° ± 13,80° of kyphosis, the immediate postoperative 2,18° ± 13,38° of kyphosis, one year postoperative 5,26 ± 13,95° of kyphosis, and the late follow-up 8,78° ± 15,06° of kyphosis. The mean correction was 3,35°, and mean loss of correction was 6,6°. There were no complications observed, no case of neurological deficit, infection or implant failure occurred. Conclusion: Thoracolumbar vertebrae fractures can be surgically treated with positive late clinical and radiological outcomes and low complication rates using a minimally invasive percutaneous method.

Molecular alignment-assisted spectral broadening and shifting in the near-infrared with a recycled depleted pump from an optical parametric amplifier.

We demonstrate how the depleted pump of an optical parametric amplifier can be recycled for impulsive alignment of a molecular gas inside a hollow-core fiber and use such alignment for the broadening and frequency shift of the signal pulse at a center wavelength of ∼1300 nm. Our results combine non-adiabatic molecular alignment, self-phase modulation, and Raman non-linearities. We demonstrate spectral shifts of up to 204 nm and a spectral broadening of more than one octave. We also report on the time delays at which broadening occurs, which do not coincide with any of the molecular rotational constants. Further, we encounter that maximum frequency shifts occur when the signal and pump have perpendicular polarization instead of parallel.

29Si Magic Angle Spinning Nuclear Magnetic Resonance, Fourier-Transform Infrared, and Monte Carlo Study of Synthetic Tetrasilicic Magnesium Mica Solid Solutions.

The parallel 29Si magic angle spinning nuclear magnetic resonance (MAS NMR) and Fourier-transform infrared study of synthetic micas made it possible to compare structural features of the tetrasilicic magnesium mica K(Mg2.5□0.5) Si4O10(OH)2 (TMM) and their K(Mg3)(Si3.5Mg0.5)O10(OH)2 (TMMA) and K(Mg3)(Si3.5Be0.5)O10(OH)2 (TMMB) derivatives. In the TMM mica, SiO4 tetrahedra are elongated in the plane ab and shortened along the c* direction with respect to those of the phlogopite (Phl) K(Mg3)(Si3Al)O10(OH)2. The substitution of Si4+ by R2+ (Mg2+ or Be2+) produces, besides the 29Si MAS NMR signal of Si (3Si) at -91.2 ppm, new components at -84.4 or -87.5 ppm that correspond to Si (2Si1Mg) or Si(2Si1Be) environments. Tetrahedral cation distributions in TMM/TMMA, TMM/TMMB solid solutions are investigated with respect to the TMM/Phl series by means of NMR and Monte Carlo simulations, concluding that divalent Mg2+ and Be2+ are further dispersed than trivalent Al3+ cations in tetrahedral sheets of micas. In three analyzed series, cation distributions display features between those of the homogeneous dispersion of charges of phlogopites and the maximum dispersion of charges of TMM derivatives. In three series, the location of charge deficits that compensate K+ cations changes from octahedral in TMM to tetrahedral sheets in phlogopite and TMMA and TMMB derivatives.

Radial Nerve Supracondylar Block Versus Fracture Hematoma Block. Comparison of Their Efficacy in Cases of Fractures of the Distal Third of the Radius.

Objective The present study compares the analgesic efficacy of two techniques to perform non-surgical reduction: fracture hematoma block and radial nerve supracondylar block. Methods Forty patients with fractures of the distal third of the radius, who required reduction, were selected in a quasi-randomized clinical trial to receive one of the anesthetic techniques. All patients signed the informed consent form, except for those who did not wish to participate in the study, had neurological injury, had contraindication to the procedure in the emergency room, or with contraindication to the use of lidocaine. To measure analgesia, the numerical pain rate scale was used at four different moments: preblock, postblock, during reduction, and after reduction; then three differences were calculated: the first between before and after blocking; the second between during reduction and after blockade; and the third between before blocking and after reduction. Results The fracture hematoma and supracondylar block groups showed the following mean values, respectively: 3.90 (1-10) and 3.50 (-6-10) in difference 1; 4.35 (-5-10) and 5.00 (-3-10) in difference 2; and 4.65 (1-10) and 3.80 (-3-10) in difference 3. Conclusion Both techniques proved to be efficient for analgesia, with mild superiority of hematoma block, but without statistical significance.

EARLY COMPLICATIONS OF SURGICAL TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY.

Objective: To evaluate the early postoperative complications associated with the surgical approach of the cervical spine of patients with cervical spondylotic myelopathy (CSM), comparing the anterior surgical, the posterior surgical, and the combined approaches. Methods: This is a retrospective study based on a database with 169 patients. Demographic data, such as gender and age, and surgical data, such as surgical approach, number of segments with arthrodesis, surgical time, and complications, were evaluated. Complications were divided into major (deep surgical wound infection, intercurrence with the implant, early new compression, and heart failure) and minor (dysphagia, superficial infection, pain, urinary intercurrence, neuropraxia of the C5 root, acute confusional state, and surgical wound hematoma). Results: This included 169 patients, 57 women (33.7%) and 112 men (66.2%). Age ranged from 21 to 87 years, with a mean of 56.48 (± 11) years. Of these, 52 (30.8%) underwent the anterior approach; 111 (65.7%), the posterior approach; and 6 (3.5%), the combined approach. Conclusion: As in the literature, we evinced dysphagia, pain, and superficial infection of the surgical wound as the most frequent postoperative complications. However, it was impossible to establish a statistical relationship between the incidence of complications and surgical time, access route, and number of fixed segments. Level of Evidence III, Retrospective Comparative Study.

Objetivo: Avaliar as complicações pós-operatórias precoces associadas à abordagem cirúrgica da coluna cervical de pacientes portadores de mielopatia cervical espondilótica (MCE), comparando a abordagem cirúrgica anterior, a abordagem cirúrgica posterior e a abordagem combinada. Métodos: Estudo retrospectivo baseado em um banco de dados com 169 pacientes. Foram avaliados dados demográficos, como gênero e idade, e dados cirúrgicos, como abordagem cirúrgica realizada, número de segmentos artrodesados, tempo cirúrgico e complicações. As complicações foram divididas em maiores (infecção profunda da ferida operatória, intercorrência com o implante, nova compressão precoce, insuficiência cardíaca) e menores (disfagia, infecção superficial, dor, intercorrência urinária, neuropraxia da raiz de C5, estado confusional agudo, hematoma de ferida operatória). Resultados: Foram incluídos 169 pacientes, sendo 57 do sexo feminino (33,7%) e 112 do masculino (66,2%). A idade variou de 21 a 87 anos, com média de 56,48 anos (± 11). Destes, 52 (30,8%) foram submetidos à abordagem anterior, 111 (65,7%) à abordagem posterior e 6 (3,5%) à abordagem combinada. Conclusão: Assim como na literatura, evidenciamos a disfagia, a dor e a infecção superficial da ferida operatória como as complicações pós-operatórias mais frequentes. No entanto, não foi possível estabelecer uma relação estatística da incidência de complicações com o tempo cirúrgico, a via de acesso e o número de segmentos fixados. Nível de Evidência III, Estudo Retrospectivo Comparativo.

Radial Nerve Supracondylar Block Versus Fracture Hematoma Block. Comparison of Their Efficacy in Cases of Fractures of the Distal Third of the Radius / Bloqueio supracondilar de nervo radial versus bloqueio de hematoma de fratura. Comparativo de sua eficácia em casos de fraturas do terço distal do rádio

Abstract Objective The present study compares the analgesic efficacy of two techniques to perform non-surgical reduction: fracture hematoma block and radial nerve supracondylar block. Methods Forty patients with fractures of the distal third of the radius, who required reduction, were selected in a quasi-randomized clinical trial to receive one of the anesthetic techniques. All patients signed the informed consent form, except for those who did not wish to participate in the study, had neurological injury, had contraindication to the procedure in the emergency room, or with contraindication to the use of lidocaine. To measure analgesia, the numerical pain rate scale was used at four different moments: preblock, postblock, during reduction, and after reduction; then three differences were calculated: the first between before and after blocking; the second between during reduction and after blockade; and the third between before blocking and after reduction. Results The fracture hematoma and supracondylar block groups showed the following mean values, respectively: 3.90 (1-10) and 3.50 (-6-10) in difference 1; 4.35 (-5-10) and 5.00 (-3-10) in difference 2; and 4.65 (1-10) and 3.80 (-3-10) in difference 3. Conclusion Both techniques proved to be efficient for analgesia, with mild superiority of hematoma block, but without statistical significance.

Resumo Objetivo O estudo compara a eficácia analgésica de duas técnicas para realizar redução incruenta: o bloqueio de hematoma da fratura e o bloqueio supracondilar de nervo radial. Métodos Quarenta pacientes com fraturas do terço distal do rádio, que necessitassem redução, foram selecionados em um ensaio clínico quasi-randomizado, para receber uma das técnicas anestésicas. Todos os pacientes assinaram o termo de consentimento ou assentimento, com exceção daqueles que não desejassem participar do estudo, tivessem lesão neurológica, com contraindicação ao procedimento na sala de emergências, ou com contraindicação ao uso da lidocaína. Para aferir a analgesia foi utilizada a escala numérica da dor em quatro momentos distintos: pré-bloqueio, pós-bloqueio, durante a redução e após a redução; em seguida, foram calculadas três diferenças: a primeira entre antes e após o bloqueio; a segunda entre durante a redução e após o bloqueio; e a terceira entre antes do bloqueio e após a redução. Resultados Os grupos do bloqueio de hematoma de fratura e bloqueio supracondilar apresentaram respectivamente os seguintes valores médios: 3.90 (1-10) e 3.50 (-6-10) na diferença 1; 4.35 (-5-10) e 5.00 (-3-10) na diferença 2; e 4.65 (1-10) e 3.80 (-3-10) na diferença 3. Conclusão As duas técnicas se provaram eficientes para analgesia, com discreta superioridade do bloqueio de hematoma, mas sem significância estatística.

AGREEMENT ON MRI DIAGNOSIS IN COMPRESSIVE MALIGNANT VERTEBRAL FRACTURES.

Objective: Verify interobserver and intraobserver agreement of malignant compressive vertebral fractures (MCVF) diagnosis using magnetic resonance imaging (MRI). Methods: We retrospectively included a lumbar spine MRI of 63 patients with non-traumatic compressive vertebral fracture diagnoses. Each lumbar vertebra was classified as: without fracture, with fracture of benign characteristics, or with fracture of malignant characteristics. Two medical residents in radiology, one musculoskeletal radiologist fellow, one musculoskeletal radiologist, and two spine surgeons evaluated MRI exams, independently and blindly. Each observer performed two readings, with a 15-day interval between evaluations. A simple Kappa coefficient was used to calculate the intra and interobserver agreement. The reference standard classification was based on bone biopsy or clinical, and imaging follow-up of at least two years, for diagnostic performance analysis. Diagnostic performance was assessed by calculating sensitivity, specificity, accuracy, and positive and negative predictive values with a 95% confidence interval (CI). Results: We observed substantial to perfect intraobserver agreement (kappa: 0.80 to 1.00) and substantial interobserver agreement (kappa 0.64 to 0.77). In general, the sensitivity for the detection of MCVF was moderate, except for the second-year radiology resident that achieved a lower sensitivity. The specificity, accuracy, and negative predictive value were high for all observers. Conclusion: MCVF diagnosis using MRI showed substantial interobserver agreement. The second-year medical resident achieved lower sensitivity but high specificity for MCVF. Regarding the seniors, there was no statistical significance between spine surgeons and the musculoskeletal radiologist. Level of Evidence III; Diagnostic.

Objetivo: Verificar a concordância interobservador e intraobservador no diagnóstico de fraturas vertebrais compressivas malignas (MCVF) por meio de ressonância magnética (MRI). Métodos: Incluiu-se retrospectivamente a ressonância magnética da coluna lombar de 63 pacientes com diagnóstico de fratura vertebral compressiva não traumática. Cada vértebra lombar foi classificada da seguinte forma: sem fratura, com fratura de características benignas ou com fratura de características malignas. Dois médicos residentes em radiologia, um pesquisador radiologista musculoesquelético, um radiologista musculoesquelético e dois cirurgiões da coluna vertebral avaliaram os exames de ressonância magnética, independentemente e cegamente. Cada observador realizou duas leituras, com um intervalo de 15 dias entre as avaliações. O coeficiente Kappa simples foi utilizado para calcular o acordo intra e interobservador. A classificação padrão de referência foi baseada em biópsia óssea ou clínica, e acompanhamento por imagem de pelo menos dois anos, para análise de desempenho diagnóstico. O desempenho diagnóstico foi avaliado através do cálculo de sensibilidade, especificidade, precisão, valores preditivos positivos e negativos com um intervalo de confiança de 95% (IC). Resultados: Foi observada concordância substancial a perfeita intraobservador (kappa: 0,80 a 1,00) e concordância substancial interobservador (kappa 0,64 a 0,77). Em geral, a sensibilidade para a detecção de MCVF foi moderada, exceto para o segundo ano de residência radiológica que alcançou uma sensibilidade menor. A especificidade, precisão e valor preditivo negativo foram altos para todos os observadores. Conclusão: O diagnóstico de MCVF por ressonância magnética mostrou uma concordância substancial entre observadores. O residente médico do segundo ano alcançou uma sensibilidade menor, mas alta especificidade para MCVF. Com relação aos veteranos, não houve significância estatística entre os cirurgiões da coluna vertebral e o radiologista músculo-esquelético. Nível de Evidencia III; Diagnóstico .

Impacts of the Delayed Surgical Correction of Adolescent Idiopathic Scoliosis and its Repercussions for the Brazilian Unified Health System: Systematic Review Protocol.

Surgical correction is an effective treatment for adolescent idiopathic scoliosis (AIS) with deformities over 45°. In the Brazilian Unified Health System (SUS, Sistema Único de Saúde), if the surgical procedure is indicated, the patients are placed on a waiting list and wait until the treatment can be performed. An extended waiting period can be harmful due to worsening symptoms and increased treatment costs. Additionally, it has negative effects on the mental health and quality of life of these patients. This paper is a systematic review protocol to answer the following question: "What is the impact of the delayed surgical correction of AIS considering costs and quality of life?" Collecting health status information is the first step to improve high complex public health actions. Future publications from this protocol may serve as a subsidy to point out potential priority criteria to enhance the global health of AIS patients and the management of Brazilian public health financial resources.

Estudo dos determinantes dos custos no atendimento dos pacientes com lesão medular decorrente de trauma raquimedular / Study of cost determinants in the care of subjects with traumatic spinal cord injury

O trauma raquimedular (TRM) é a principal etiologia relacionada à lesão medular em homens jovens. Em decorrência da complexidade ao atendimento desses pacientes e às suas complicações, os custos envolvidos nesses casos são vultosos. Objetivo: Avaliar os custos associados ao atendimento hospitalar e ambulatorial dos pacientes com lesão medular traumática num serviço universitário. Métodos: Este estudo baseou-se na revisão de informações clínicas sobre a lesão medular e suas complicações, bem como a busca de valores relacionados ao atendimento no período hospitalar e ambulatorial de indivíduos com lesão medular traumática num serviço universitário em 2009. Resultados: Foram contabilizados 51 pacientes com trauma na coluna vertebral, dos quais 14 apresentaram TRM (idade= 38,9 ± 20,8; homens: 86%). Os custos do atendimento foram R$402.908,68 na ausência de lesão medular e R$304.433,77 com lesão medular. Os custos do atendimento estiveram relacionados com o tempo de internação, o número de intercorrências clínicas e procedimentos cirúrgicos. A reabilitação correspondeu a 23% dos custos dos pacientes com TRM. Conclusão: Os custos relacionados ao atendimento do paciente com TRM são maiores que aqueles associados ao trauma de coluna sem lesão neurológica. O número de complicações clínicas correlaciona-se diretamente ao tempo de internação e os custos desse atendimento. A reabilitação corresponde a menor parte das despesas no cuidado aos pacientes com TRM

Spinal cord injury (SCI) is the main etiology related to spinal cord injury in young men. Due to the complexity of health care for these patients and their complications, the costs involved in these cases are high. Objective: To evaluate the costs associated with hospital and outpatient care for patients with traumatic spinal cord injury at a university service. Methods: This study was based on the review of clinical information about spinal cord injury and its complications, as well as the search for monetary amounts related to inpatient and outpatient care of individuals with traumatic SCI in a university service in 2009. Results: There were 51 patients with spinal trauma, of which 14 had SCI (age= 38.9 ± 20.8 years; men: 86%). Costs were R$402,908.68 in the absence of spinal cord injury and R$304,433.77 with spinal cord injury, and were statistically associated to the length of stay, the number of clinical complications and surgical procedures. Rehabilitation accounted for 23% of costs for patients with SCI. Conclusion: The costs related to the care of patients with SCI are higher than those associated with spinal trauma without neurological damage. The number of clinical complications is directly correlated with the length of hospital stay and the costs of this care. Rehabilitation corresponds to a smaller part of the expenses in the care of patients with SCI

A plano-convex thick-lens velocity map imaging apparatus for direct, high resolution 3D momentum measurements of photoelectrons with ion time-of-flight coincidence.

Since their inception, velocity map imaging (VMI) techniques have received continued interest in their expansion from 2D to 3D momentum measurements through either reconstructive or direct methods. Recently, much work has been devoted to the latter of these by relating electron time-of-flight (TOF) to the third momentum component. The challenge is having a timing resolution sufficient to resolve the structure in the narrow (<10 ns) electron TOF spread. Here, we build upon the work in VMI lens design and 3D VMI measurement by using a plano-convex thick-lens (PCTL) VMI in conjunction with an event-driven camera (TPX3CAM) providing TOF information for high resolution 3D electron momentum measurements. We perform simulations to show that, with the addition of a mesh electrode to the thick-lens geometry, the resulting plano-convex electrostatic field extends the detectable electron cutoff energy range while retaining the high resolution. This design also extends the electron TOF range, allowing for a better momentum resolution along this axis. We experimentally demonstrate these capabilities by examining above-threshold ionization in xenon, where the apparatus is shown to collect electrons of energy up to ∼7 eV with a TOF spread of ∼30 ns, both of which are improved compared to a previous work by factors of ∼1.4 and ∼3.75, respectively. Finally, the PCTL-VMI is equipped with a coincident ion TOF spectrometer, which is shown to effectively extract unique 3D momentum distributions for different ionic species in a gas mixture. These techniques have the potential to lend themselves to more advanced measurements involving systems where the electron momentum distributions possess non-trivial symmetries.

Impacts of the Delayed Surgical Correction of Adolescent Idiopathic Scoliosis and its Repercussions for the Brazilian Unified Health System: Systematic Review Protocol / Impactos da espera para correção cirúrgica da escoliose idiopática do adolescente e suas repercussões para o Sistema Único de Saúde: Protocolo de revisão sistemática

Abstract Surgical correction is an effective treatment for adolescent idiopathic scoliosis (AIS) with deformities over 45°. In the Brazilian Unified Health System (SUS, Sistema Único de Saúde), if the surgical procedure is indicated, the patients are placed on a waiting list and wait until the treatment can be performed. An extended waiting period can be harmful due to worsening symptoms and increased treatment costs. Additionally, it has negative effects on the mental health and quality of life of these patients. This paper is a systematic review protocol to answer the following question: "What is the impact of the delayed surgical correction of AIS considering costs and quality of life?" Collecting health status information is the first step to improve high complex public health actions. Future publications from this protocol may serve as a subsidy to point out potential priority criteria to enhance the global health of AIS patients and the management of Brazilian public health financial resources.

Resumo A correção cirúrgica é uma opção efetiva de tratamento para casos de Escoliose Idiopática do Adolescente (EIA) com curvas acima de 45°. No âmbito do Sistema Único de Saúde (SUS), os pacientes avaliados nos centros de referência e com indicação cirúrgica são cadastrados em fila de espera até que o tratamento definitivo possa ser realizado. Um período de espera extenso pode ser prejudicial, do ponto de vista de piora dos sintomas e de aumento do custo de tratamento, além de gerar efeitos negativos na saúde mental e na qualidade de vida do paciente. O presente artigo trata-se do protocolo de uma revisão sistemática que buscará responder o questionamento: "Qual o impacto do tempo de espera para correção cirúrgica da EIA do ponto de vista de custo e qualidade de vida?." O aperfeiçoamento das ações de saúde pública, na esfera da alta complexidade, inicia-se com o levantamento de informações sobre a situação de saúde de determinada condição. Diante disso, as futuras publicações provenientes deste protocolo poderão servir como subsídio para apontar possíveis critérios de prioridade, com o intuito de promover melhoria tanto no âmbito da saúde global de portadores de EIA, quanto na gestão financeira da saúde pública brasileira.

The impacts of waiting for surgical correction of Adolescent Idiopathic Scoliosis and its repercussions for publicly funded health systems: systematic review.

PURPOSE: To investigate, through a systematic review, the impact of the waiting time for Adolescent Idiopathic Scoliosis (AIS) surgical correction from the point of view of deformity evolution, treatment cost, and quality of life. METHODS: PubMed, Embase, LILACS, SciELO, Scopus, Web of Science, LIVIVO, and Cochrane Library databases were searched by two researchers to select the articles. The eligibility criteria were: Patients diagnosed with AIS with indication for surgical correction and submitted to waiting lists until treatment. The risks of bias were evaluated using the Risk Of Bias In Non-randomized Studies-Interventions (ROBINS-I) tool, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to classify the level of the evidence for each outcome. The summary of the available evidence is presented in a narrative synthesis. RESULTS: Six observational studies were included. In a Canadian study, the primary outcome was the need for additional spine surgery in patients who had to wait more than three months due to spine deformity progression. American researchers presented a sample of premenarcheal and skeletally immature patients with AIS showing increased Cobb angle and attributed this to a six-month waiting for the surgical treatment. Another study included 177 patients with AIS with a mean waiting time of 225.7 days. There was a worsening average of 7.7° ± 8.6° in Cobb angle, and there was a change in surgical plan in 28 patients, which increased surgical time. Studies that evaluated the treatment cost showed significantly higher mean costs in those who waited longer than six months. Regarding the quality of life, while waiting for surgery, a retrospective study found that patients who underwent surgery earlier showed better results in a questionnaire that assessed their quality of life compared to those who were still waiting. CONCLUSION: Observational studies show that, in individuals who are on waiting lists for AIS surgery, there is a worsening of the spinal deformity (substantial evidence), an increasing cost of treatment (moderate evidence) and it may negatively impact patients' quality of life (insufficient evidence). Performing better methodological quality studies to investigate these outcomes can violate good research practices since randomized clinical trials on this subject have ethical limitations to be carried out. TRIAL REGISTRATION: The authors declare that the systematic review protocol was registered at the international prospective register of systematic reviews (PROSPERO), CRD42020212134, and it was accepted for publication.

Clinical and technical insights of tumour mutational burden in non-small cell lung cancer.

Despite the durable responses provided by the introduction of checkpoint inhibitors in advanced Non-Small Cell Lung Cancer (NSCLC) without actionable targets in a subset of patients, a large proportion of them will progress after immunotherapy. Programmed Death Ligand 1 (PD-L1) was the first biomarker approved for immunotherapy, although it has multiple limitations, thus the development of novel biomarkers is an urgent need. Tumour Mutational Burden (TMB) is an emerging biomarker defined as the total number of mutations per coding area of tumour genome. Targeted gene panels have emerged as a cost-effective approach to estimate TMB. However, there is still an unmet need to fully standardize sample requirements, panel size, and bioinformatic pipelines to ensure that TMB is calculated appropriately. In addition, researchers are also evaluating TMB calculation in liquid biopsy. In this work, we summarize the relevant advances and the clinical utility of TMB in NSCLC.

Association between vertebral fragility fractures, muscle strength and physical performance: A cross-sectional study.

BACKGROUND: Few studies have investigated the association between vertebral fragility fractures and lower limb muscle strength and physical performance in women with low bone mass. OBJECTIVES: To explore whether the presence of vertebral fracture is independently associated with poor physical performance and decreased lower limb muscle strength. To understand whether lower limb muscle strength is associated with physical performance in women with vertebral fracture. METHODS: Older women with low bone mass were divided into 2 groups: no vertebral fracture (NF) and presence of vertebral fragility fracture (VFF). Physical performance was evaluated using the Five Times Sit to Stand (5TSS) test, the Timed Up and Go (TUG) test and a 5m walk test (5MWT). Lower limb muscle strength was assessed using an isokinetic dynamometer. RESULTS: We included 94 women with low bone mass (mean age 71.6 [SD 5.7] years, time since menopause 24.4 [7.1] years, mean BMI 27.5 [5.1] kgm-2). VFF was only associated with low peak hip abductor torque (p = 0.001) after adjustments. In the VFF group (n= 47), each 1 Nmkg-1 increase: in knee extensor torque was associated with improved 5MWT (p = 0.005), TUG (p = 0.002) and 5TSS (p = 0.005) performances; in knee flexor torque was associated with improved 5MWT speed (p = 0.003) and TUG time (p = 0.006); in hip abductor torque was associated with improved 5MWT speed (p = 0.003); and in hip extensor torque with improved TUG time (p = 0.046). CONCLUSION: VFF was associated with reduced hip abductor strength in older women. However, the number of vertebral fractures influenced the association. Additionally, lower limb muscle strength was associated with physical performance, regardless of the clinical characteristics of the fractures. Therefore, strength and power training programs for the lower limbs could improve physical performance.

Internal Chain of Correlation of Sagittal Cervical Alignment in Asymptomatic Subjects.

STUDY DESIGN: Cross-sectional observational study in a prospective cohort. OBJECTIVE: To analyze the cervical alignment characteristics and their chain of correlation in a sample of asymptomatic individuals. METHODS: Asymptomatic adults who had full spinal radiographs performed. Cervical radiographic parameters were measured, including upper cervical curvature (McGregor line-C2), lower cervical curvature (C2-C7), McGregor slope, and sagittal vertical axis from C2-C7 (CSVA) and T1-slope (T1S). Subjects were stratified by age into 3 groups (18-39 years, 40-59 years, and >60 years), and radiographic parameters were compared across age groups and based on sex. RESULTS: 102 asymptomatic subjects (mean age, 50 years) were included. The T1S significantly increased with age, accompanied by an increase in C2-C7 lordosis. The cervical sagittal alignment, represented by CSVA, did not significantly differ based on age. There was a close correlation among the cervical sagittal parameters, such that the CSVA may be predicted based on the T1S and C2-C7 lordosis. Comparisons of the normative values identified in the present study with those reported in previous studies demonstrate variability in what constitutes normal in different populations. CONCLUSION: This analysis of cervical alignment in a sample of asymptomatic volunteers revealed that with increasing age there is an observed increase in the sagittal inclination of the base of the cervical spine (T1S) that is accompanied by an increase in cervical lordosis as a means of maintaining cervical sagittal alignment (CSVA). The variability in what constitutes normal values for cervical parameters suggests that further study is warranted using standardized methodologies across diverse populations.

Impact of surgical treatment on the gait of patients with cervical myelopathy / Impacto do tratamento cirurgico na marcha de pacientes portadores de mielopatia cervical / Impacto del tratamiento quirúrgico en la marcha de pacientes con mielopatía cervical

ABSTRACT: Objective: To analyze the impact of surgery on gait characteristics of individuals with Cervical Spondylotic Myelopathy (CSM) after one month of the procedure. Methods: Observational, cohort type study, with a quantitative analysis approach. Two assessments were performed, the first one week before surgery and the second 30 days after the decompression procedure. The following space-time variables were analyzed: steps per minute, step length, cycle time, speed, steps per minute, support time, swing time, step time. The kinematic variables obtained were analyzed by Gait Profile Score (GPS) and Movement Analysis Profile (MAP). Results: comparing pre and postoperative values, there was a decrease in the number of steps per minute (p=0.006), an increase in support time (p=0.011) and an increase in cycle time (p=0.004). Other variables did not present statistically significant differences. The patients' total GPS average in the pre-surgery assessment was 10.41 and 1 month after the procedure, an average of 10.56 was obtained, which does not characterize a statistical difference between the assessments. When establishing a comparison between the two assessments specifically on each joint movement of the lower limbs using the MAP, it was observed that the obliquity and rotation of the pelvis showed some improvement immediately after the surgical procedure. Knee flexion and extension were significantly (p=0.018) more compromised after the procedure when compared to the value of the same population before surgery. Conclusion: the preliminary analysis of the gait of these patients after one month of intervention did not show immediate benefits of the procedure. Level of Evidence II; Therapeutic studies - Investigation of treatment outcomes.

RESUMO: Objetivo: Analisar o impacto da cirurgia na marcha de indivíduos portadores de Mielopatia Cervical Espondilótica (MCE) após um mês do procedimento. Métodos: Estudo observacional, longitudinal, com abordagem de análise quantitativa. Foram realizadas duas avaliações, a primeira uma semana antes da cirurgia e a segunda 30 dias após o procedimento. Foram analisadas as variáveis de espaço-tempo: avanços por minuto, comprimento do passo, tempo de ciclo, velocidade, passos por minuto, tempo de apoio, tempo de balanço, tempo do passo. As variáveis cinemáticas obtidas foram analisadas pelo Gait Profile Score (GPS) e Movement Analysis Profile (MAP). Resultados: comparando os valores pré e pós-operatórios, houve diminuição do número de passos por minuto (p=0,006), aumento no tempo de apoio (p=0,011) e aumento no tempo de ciclo (p=0,004), outras variáveis não apresentaram diferenças estatisticamente significativas. A média do GPS total dos pacientes na avaliação pré-cirurgia foi de 10,41 e após 1 mês do procedimento obteve-se a pontuação média de 10,56 o que não caracteriza diferença estatística entre as avaliações. Ao estabelecer uma comparação entre as duas avaliações em cada movimento articular dos membros inferiores utilizando o MAP, observa-se que a obliquidade e a rotação da pelve apresentaram alguma melhoria imediatamente após o procedimento cirúrgico. Já a flexão e extensão do joelho mostrou-se significativamente (p=0,018) mais comprometida após o procedimento quando comparada com o valor da mesma população pré cirurgia. Conclusão: a análise preliminar da marcha dos pacientes com MCE após um mês de intervenção não evidenciou benefícios imediatos do procedimento. Nível de Evidência II; Estudos terapêuticos - Investigação dos resultados do tratamento.

RESUMEN: Objetivo: Analizar el impacto del tratamiento quirúrgico en las características de la marcha de personas con Mielopatía Cervical Espondilótica (MCE) después de un mes del procedimiento. Métodos: Estudio observacional, longitudinal, con enfoque de análisis cuantitativo. Se realizaron dos evaluaciones, la primera una semana antes de la cirugía y la segunda 30 días después del procedimiento de descompresión. Se analizaron las siguientes variables espacio-temporales: pasos por minuto, longitud de paso, tiempo de ciclo, velocidad, pasos por minuto, tiempo de apoyo, tiempo de balanceo, tiempo de paso. Las variables cinemáticas obtenidas fueron analizadas mediante Gait Profile Score (GPS) y Movement Analysis Profile (MAP). Resultados: Al comparar los valores pre y postoperatorios, hubo una disminución en el número de pasos por minuto (p=0,006), un aumento en el tiempo de soporte (p=0,011) y un aumento en el tiempo de ciclo (p=0,004), otras variables no presentaron diferencias estadísticamente significativas. La media del GPS total de los pacientes en la evaluación prequirúrgica fue de 10,41 y 1 mes después del procedimiento se obtuvo una puntuación promedio de 10,56, lo que no caracteriza diferencia estadística entre las evaluaciones. Al establecer una comparación entre las dos evaluaciones específicamente sobre cada movimiento articular de los miembros inferiores mediante el MAP, se observó que la oblicuidad y rotación de la pelvis mostraron cierta mejoría inmediatamente después del procedimiento quirúrgico. La flexión y extensión de la rodilla estuvieron significativamente (p=0,018) más comprometidas después del procedimiento en comparación con el valor de la misma población antes de la cirugía. Conclusión: Los pacientes con MCE presentan deterioro de la marcha en comparación con la población típica, el análisis preliminar de la marcha de estos pacientes después de un mes de intervención no mostró beneficios inmediatos del procedimiento. Nivel de Evidencia II; Estudios terapéuticos - Investigación de resultados del tratamiento.

Agreement on mri diagnosis in compressive malignant vertebral fractures / Concordância no diagnóstico por rm em fraturas vertebrais malignas compressivas

ABSTRACT Objective: Verify interobserver and intraobserver agreement of malignant compressive vertebral fractures (MCVF) diagnosis using magnetic resonance imaging (MRI). Methods: We retrospectively included a lumbar spine MRI of 63 patients with non-traumatic compressive vertebral fracture diagnoses. Each lumbar vertebra was classified as: without fracture, with fracture of benign characteristics, or with fracture of malignant characteristics. Two medical residents in radiology, one musculoskeletal radiologist fellow, one musculoskeletal radiologist, and two spine surgeons evaluated MRI exams, independently and blindly. Each observer performed two readings, with a 15-day interval between evaluations. A simple Kappa coefficient was used to calculate the intra and interobserver agreement. The reference standard classification was based on bone biopsy or clinical, and imaging follow-up of at least two years, for diagnostic performance analysis. Diagnostic performance was assessed by calculating sensitivity, specificity, accuracy, and positive and negative predictive values with a 95% confidence interval (CI). Results: We observed substantial to perfect intraobserver agreement (kappa: 0.80 to 1.00) and substantial interobserver agreement (kappa 0.64 to 0.77). In general, the sensitivity for the detection of MCVF was moderate, except for the second-year radiology resident that achieved a lower sensitivity. The specificity, accuracy, and negative predictive value were high for all observers. Conclusion: MCVF diagnosis using MRI showed substantial interobserver agreement. The second-year medical resident achieved lower sensitivity but high specificity for MCVF. Regarding the seniors, there was no statistical significance between spine surgeons and the musculoskeletal radiologist. Level of Evidence III; Diagnostic.

RESUMO Objetivo: Verificar a concordância interobservador e intraobservador no diagnóstico de fraturas vertebrais compressivas malignas (MCVF) por meio de ressonância magnética (MRI). Métodos: Incluiu-se retrospectivamente a ressonância magnética da coluna lombar de 63 pacientes com diagnóstico de fratura vertebral compressiva não traumática. Cada vértebra lombar foi classificada da seguinte forma: sem fratura, com fratura de características benignas ou com fratura de características malignas. Dois médicos residentes em radiologia, um pesquisador radiologista musculoesquelético, um radiologista musculoesquelético e dois cirurgiões da coluna vertebral avaliaram os exames de ressonância magnética, independentemente e cegamente. Cada observador realizou duas leituras, com um intervalo de 15 dias entre as avaliações. O coeficiente Kappa simples foi utilizado para calcular o acordo intra e interobservador. A classificação padrão de referência foi baseada em biópsia óssea ou clínica, e acompanhamento por imagem de pelo menos dois anos, para análise de desempenho diagnóstico. O desempenho diagnóstico foi avaliado através do cálculo de sensibilidade, especificidade, precisão, valores preditivos positivos e negativos com um intervalo de confiança de 95% (IC). Resultados: Foi observada concordância substancial a perfeita intraobservador (kappa: 0,80 a 1,00) e concordância substancial interobservador (kappa 0,64 a 0,77). Em geral, a sensibilidade para a detecção de MCVF foi moderada, exceto para o segundo ano de residência radiológica que alcançou uma sensibilidade menor. A especificidade, precisão e valor preditivo negativo foram altos para todos os observadores. Conclusão: O diagnóstico de MCVF por ressonância magnética mostrou uma concordância substancial entre observadores. O residente médico do segundo ano alcançou uma sensibilidade menor, mas alta especificidade para MCVF. Com relação aos veteranos, não houve significância estatística entre os cirurgiões da coluna vertebral e o radiologista músculo-esquelético. Nível de Evidencia III; Diagnóstico.