Conundrum in surgical management of three-column injuries in sub-axial cervical spine: a systematic review and meta-analysis.

STUDY DESIGN: Systematic Review and Meta-analysis. PURPOSE: Three-column injuries making the spine unstable require adequate fixation which can be achieved by anterior alone, posterior alone or combined anterior-posterior approach. There is no general consensus till date on a single best approach in sub-axial cervical spine trauma. This study comparing the three approaches is an attempt to establish a firmer guideline in this disputed topic. MATERIAL AND METHODS: The protocol was registered with PROSPERO. PubMed, Embase and Google Scholar were searched for relevant literature. For each study, pre-defined data were extracted which included correction of kyphosis, loss of correction, hospital stay, operative time, blood loss during surgery as the outcome variables. Studies were also screened for the complications. RESULTS: Eleven studies were evaluated for qualitative analysis and quantitative synthesis of the data in our review. The result demonstrated significant difference with most correction achieved in combined approach subgroup. Though no significant difference was found, the anterior group was having maximum loss of correction. Combined approach showed significantly more operative time and blood loss followed by posterior approach and then anterior approach alone. The improvement in VAS was significantly more in anterior subgroup when compared to combined approach. CONCLUSION: Cervical alignment is best restored by combined approach compared to the other two. Anterior only approach showed more correction than posterior approach. However, there is no significant difference between all three approaches in loss of correction at long-term follow-up. Anterior only approach is superior to posterior and combined approach on basis of intraoperative and perioperative parameters. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Vessel-specific quantification of absolute myocardial blood flow, myocardial flow reserve and relative flow reserve by means of fused dynamic 13NH3 PET and CCTA: Ranges in a low-risk population and abnormality criteria.

OBJECTIVES: The goal of the present work is to present a novel methodology for the extraction of MBF, MFR and RFR along coronary arteries by means of multimodality image fusion of dynamic PET and CCTA images. BACKGROUND: FFR is the reference standard to identify flow-limiting lesions, but its invasiveness limits broad application. New noninvasive methodologies are warranted to stratify patients and guide treatment. METHODS: A group of 16 low-risk CAD subjects who underwent both 13NH3 PET and CCTA were analyzed. Image fusion techniques were employed to align the studies and CCTA-derived anatomy used to identify coronaries trajectories. MBF was calculated by means of a 1-tissue compartmental model for the standard vascular territories and along patient-specific vessel paths from the base to the apex of the heart. RESULTS: Low-risk ranges for MBF. MFR and RFR for LAD, LCX and rPDA were computed for the entire cohort and separated by gender. Computed low-risk ranges were used to assess a prospective patient with suspected CAD. CONCLUSIONS: Our vessel-specific functional indexes and 3D displays offer promise to more closely replicate what is commonly performed during a catheterization session and have the potential of providing effective noninvasive tools for the identification of flow-limiting lesions and image-guided therapy.

"They're Doing Their Job": Women's Acceptance of Emergency Department Contraception Counseling.

STUDY OBJECTIVE: We explore reproductive-aged women's acceptance of contraception counseling in the emergency department (ED). METHODS: This study is phase 1 of an exploratory sequential mixed methods study. We purposively interviewed 31 participants with the following criteria: black, white, or Latina race/ethnicity; nonpregnant; aged 15 to 44 years; receiving nonemergency care; not using highly effective contraception; and did not intend to become pregnant. We conducted semistructured interviews with a piloted interview guide until reaching thematic saturation. We coded transcripts with an iteratively developed codebook, maintaining intercoder agreement greater than 80%. Qualitative acceptance of ED contraception counseling was grouped into 3 categories: acceptable, unacceptable, and equivocal. We conducted a thematic text analysis to assess themes expressing support and concern for ED contraception counseling. Qualitative findings were stratified by age, race, and frequency of ED use. Using components of grounded theory, we developed a conceptual model. RESULTS: Most participants (81%) accepted ED contraception counseling. Themes expressing support and concern for ED contraception counseling included opportunity to address women's unmet contraception needs, contraception is within the scope of ED practice, the ED is a convenient setting with competent providers, contraception is a sensitive topic, and the ED may be an inappropriate setting for some women. Latina participants had lower acceptance of ED contraception counseling. Dominant subthemes varied slightly by race, age, and frequency of ED use. CONCLUSION: Diverse women had high acceptance of contraception counseling in the ED. Perspectives expressing both support and concern in regard to ED contraception counseling were explored in detail.

Combined Residency Programs in Emergency Medicine.

There are currently 5 combined residencies in emergency medicine (EM), namely EM/pediatrics, EM/internal medicine, EM/internal medicine/critical care, EM/family medicine and EM/anesthesiology. These combined programs vary from 5-6 years in length. Like categorical programs, the decision to enter a 5- or 6-year program should be an informed and comprehensive decision. We describe the history and current status of the combined EM programs, discuss the process of applying to a combined EM program, describe the life of combined EM residents, and explore common career opportunities available to combined EM program graduates.

Pressor support during a Jarisch Herxheimer reaction after initiation of treatment for Weil's disease.

We present a case of Weil's disease complicated by a Jarisch-Herxheimer reaction (JHR) after initiation of antibiotics while in the emergency department requiring invasive monitoring and vasopressor support. The case is followed by a brief review of the JHR which is rarely observed with treatment of leptospirosis. A healthy 28-year-old female who recently returned from the Caribbean presented to the emergency department with flu-like symptoms. The patient appeared jaundiced with conjunctival suffusion and was ultimately treated with the appropriate antibiotics for leptospirosis in the ED. She decompensated subsequently, requiring supplemental oxygen, central and arterial line placement, and vasopressor support with norepinephrine. Although rarely encountered and not well reported throughout the literature, initiation of antibiotics can cause a JHR reaction given that Leptospira interrogans is a spirochete. This JHR may be self-limited and of short duration, or it can be prolonged and severe, requiring invasive therapies such as central line placement for vasopressor support and intubation. It is suggested that patients started on antibiotics for leptospirosis/Weil's disease should be monitored in the emergency department for a short duration prior to discharge or transfer to a regular medical floor for observation given the possibility for decompensation.

ENABLE (Exportable Notation and Bookmark List Engine): an Interface to Manage Tumor Measurement Data from PACS to Cancer Databases.

Oncologists evaluate therapeutic response in cancer trials based on tumor quantification following selected "target" lesions over time. At our cancer center, a majority of oncologists use Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 quantifying tumor progression based on lesion measurements on imaging. Currently, our oncologists handwrite tumor measurements, followed by multiple manual data transfers; however, our Picture Archiving Communication System (PACS) (Carestream Health, Rochester, NY) has the ability to export tumor measurements, making it possible to manage tumor metadata digitally. We developed an interface, "Exportable Notation and Bookmark List Engine" (ENABLE), which produces prepopulated RECIST v1.1 worksheets and compiles cohort data and data models from PACS measurement data, thus eliminating handwriting and manual data transcription. We compared RECIST v1.1 data from eight patients (16 computed tomography exams) enrolled in an IRB-approved therapeutic trial with ENABLE outputs: 10 data fields with a total of 194 data points. All data in ENABLE's output matched with the existing data. Seven staff were taught how to use the interface with a 5-min explanatory instructional video. All were able to use ENABLE successfully without additional guidance. We additionally assessed 42 metastatic genitourinary cancer patients with available RECIST data within PACS to produce a best response waterfall plot. ENABLE manages tumor measurements and associated metadata exported from PACS, producing forms and data models compatible with cancer databases, obviating handwriting and the manual re-entry of data. Automation should reduce transcription errors and improve efficiency and the auditing process.

Relationship between Central and Peripheral Venous Oxygen Saturation and Lactate Levels: A Prospective Study.

BACKGROUND: Optimization of tissue oxygen delivery to meet consumption demands is important in the resuscitation of critically ill patients. Central venous oxygen saturation (ScvO2) and lactate levels are often used to guide resuscitation; however, invasive monitoring is required for the former. Clinicians searching for less invasive alternatives may consider using peripheral venous oxygen saturation (SpvO2) and lactate levels as a substitute. OBJECTIVES: To determine the relationship between SpvO2 and ScvO2 and peripheral and central lactate levels. METHODS: All patients with a central venous catheter in an academic emergency department and intensive care unit were eligible for the study. Blood was obtained simultaneously from a central and peripheral vein and measured for oxygen saturation and lactate levels. Results were analyzed using intraclass correlation coefficient (ICC), Bland-Altman plots, and receiver operating characteristic curves. RESULTS: Seventy-nine paired blood samples were analyzed. SpvO2 and ScvO2 have moderate agreement: ICC = 0.53 (95% confidence interval [CI] 0.35-0.67). A Bland-Altman plot revealed substantial bias (-4.47; limits of agreement -38.6, 29.6). SpvO2 ≥ 85% was 90% specific for ScvO2 ≥ 70%, and SpvO2 of ≤ 55% had a 94% sensitivity for ScvO2 < 70%. Central and peripheral venous lactate levels showed almost perfect agreement: ICC = 0.92 (95% CI 0.87-0.95), bias of 0.46 (limits of agreement -1.78-2.70). CONCLUSION: SpvO2 and ScvO2 have moderate agreement. There was excellent agreement between peripheral and central lactate levels, making them interchangeable. The clinical implications of these substitutions in real-time patient management require further study.

Prompt Diagnosis of an Unusual Cause of Obstructive Shock Using Point-of-Care Ultrasound.

BACKGROUND: The patient presenting in an undifferentiated shock state can produce a diagnostic challenge for even the most seasoned clinician. CASE REPORT: We present an unusual case of an elderly woman in obstructive shock from a large atrial mass that was promptly diagnosed with point-of-care ultrasound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound is a non-invasive tool that can help facilitate the early diagnosis of a patient in undifferentiated shock.

Predictors of a Top Performer During Emergency Medicine Residency.

BACKGROUND: Emergency Medicine (EM) residency program directors and faculty spend significant time and effort creating a residency rank list. To date, however, there have been few studies to assist program directors in determining which pre-residency variables best predict performance during EM residency. OBJECTIVE: To evaluate which pre-residency variables best correlated with an applicant's performance during residency. METHODS: This was a retrospective multicenter sample of all residents in the three most recent graduating classes from nine participating EM residency programs. The outcome measure of top residency performance was defined as placement in the top third of a resident's graduating class based on performance on the final semi-annual evaluation. RESULTS: A total of 277 residents from nine institutions were evaluated. Eight of the predictors analyzed had a significant correlation with the outcome of resident performance. Applicants' grade during home and away EM rotations, designation as Alpha Omega Alpha (AOA), U.S. Medical Licensing Examination (USMLE) Step 1 score, interview scores, "global rating" and "competitiveness" on nonprogram leadership standardized letter of recommendation (SLOR), and having five or more publications or presentations showed a significant association with residency performance. CONCLUSION: We identified several predictors of top performers in EM residency: an honors grade for an EM rotation, USMLE Step 1 score, AOA designation, interview score, high SLOR rankings from nonprogram leadership, and completion of five or more presentations and publications. EM program directors may consider utilizing these variables during the match process to choose applicants who have the highest chance of top performance during residency.

A perioperative predictive model of early mortality in acute cervical spinal cord injury: A prospective cohort study.

Background: Traumatic cervical spine injury is common among spinal cord injury which requires an intensive, multidisciplinary approach which can affect the immediate postoperative hospital survival rate. By identifying the risk factors leading to early mortality in cervical spine trauma patients, the prognosis of patients with TCSCI can be better predicted. Objective: The study aims to analyze the variables influencing in-hospital mortality in cervical spine trauma patients treated at a Level I trauma Center. Methods: Prospective study was conducted on subaxial cervical spine injuries from July 2019 to March 2022. Patients were divided into two groups: Group A, with in-hospital mortality, and Group B, who got discharged from hospital, and mortality predictors were reviewed and analyzed for as potential risk factors for in-hospital mortality. Results: Out of 105 patients, 83.8 % were male with mean age of 40.43 ± 12.62 years. On univariate analysis, AIS (p-value: <0.01), ICU stay (p-value: <0.01), level of injury (p-value: <0.01), and MRI parameters like the extent of Parenchymal damage (p-value: <0.01), MSCC (p-value: <0.01), and MCC (p-value: <0.01) were potential risk factors for in-hospital mortality. On multivariate regression analysis AIS at presentation (p-value: 0.02) was the only significant independent parameter for in-hospital mortality. Conclusions: AIS grading at presentation, duration of ICU stay, level of injury, rate of tracheostomy, and MRI parameters like the extent of parenchymal damage, MCC, and MSCC influence and predicts in-hospital mortality, whereas AIS is the only independent risk factor.

Healing Assessment of Spinal Tuberculosis: A Systematic Review.

OBJECTIVE: Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB. METHODS: A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study. RESULTS: Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing. CONCLUSIONS: Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

Differential survival of systemic B-cell lymphomas initially diagnosed in the skin: a population-based study of 883 patients.

Although the majority of lymphomas are diagnosed in lymph nodes, bone marrow, or other viscera, initial diagnosis of systemic lymphomas in the skin is a rare but important occurrence in dermatology. This study seeks to quantify the incidence of initial skin presentation in patients with systemic B-cell lymphomas (BCL) via examination of data in the Surveillance, Epidemiology, and End Results (SEER)-18 database; cases of primary cutaneous B-cell lymphoma were excluded. We found that an initial diagnosis of lymphoma in the skin is a very rare occurrence for systemic B-cell lymphomas, comprising < 0.3% of cases overall. Follicular lymphoma was the most likely to be diagnosed in the skin (1.47%), followed by marginal zone lymphoma (MZL, 0.5%), mantle cell lymphoma (0.4%), diffuse large B-cell lymphoma (DLBCL, 0.23%), Burkitt lymphoma (0.23%), Hodgkin lymphoma (0.04%), and chronic lymphocytic leukemia (0.006%). While indolent systemic lymphomas (MZL and FL) presenting initially in the skin have a better prognosis than those presenting at other sites, the more aggressive systemic DLBCL presenting in the skin does not demonstrate improved prognosis.

A Practical Review of the Presentation, Diagnosis, and Management of Cutaneous B-Cell Lymphomas.

This review of cutaneous B-cell lymphoma (CBCL) is focused on the clinical presentation, treatment, and workup of each type of lymphoma. Part 1 is an overview of each of the CBCLs, including clinical presentation, recent advances in the pathobiology, and evidence regarding treatment strategies. Part 2 is a detailed guide to the steps in diagnosis and workup of a newly diagnosed CBCL according to the International Society for Cutaneous Lymphoma/European Organization for Research and Treatment of Cancer and NCCN guidelines.

Is it Safe to Save Levels and Choose the Lowest Instrumented Vertebra as Touched Vertebra While Selectively Fusing Lenke 1/2 Curves? A Proportional Meta-Analysis of Existing Evidence.

STUDY DESIGN: Meta-analysis. OBJECTIVE: To compare the clinical and radiological outcomes in patients with Adolescent Idiopathic scoliosis (AIS) treated by selective thoracic fusion (STF) with lowest instrumented vertebra (LIV) at touched vertebra (TV) vs stable vertebra (SV). METHODS: The databases PubMed, Embase and Google Scholar were searched until November 2020.Studies which had Lenke type 1 curves and Lenke type 2 curves in adolescent population treated by STF and which reported pre- and post-operative curve characteristics including correction percentage and complications were included. Studies which did not report the LIV selection, curve correction percentages and whose full text could not be acquired were excluded. RESULTS: Eight studies were included for analysis of which seven were found to be retrospective studies (level III evidence) and one was prospective study (level II evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, total srs-22 scores, and complication rates. CONCLUSION: The evaluation of SV group and TV group as LIV for selective thoracic fusions in AIS reveals a comparable outcome in terms of curve correction, patient satisfaction scores and complication rates. The TV can be chosen safely as the LIV especially in type A and B Lenke 1&2 curves, as it saves more motion segments when compared to SV.

Is Final Fusion Necessary for Growing-Rod Graduates: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: The need for definitive fusion for growing rod graduates is a controversial topic in the management of Early-onset scoliosis (EOS) patients. The authors performed a systematic review and meta-analysis on the available literature to evaluate the outcomes of growing rod graduates undergoing final fusion or observation with implants in-situ. METHODS: An extensive literature search was carried out aimed at identifying articles reporting outcomes in growing rod graduates. Apart from the study characteristics and demographic details, the extracted data included Cobb's correction, trunk height parameters, and revision rate. The extracted data was analyzed and forest plots were generated to draw comparisons between the observation and fusion groups. RESULTS: Of the 11 included studies, 6 were case-control and 5 were case series. The authors did not find any significant difference between the 2 groups with respect to the pre-index and final Cobb's correction, T1-T12 or T1-S1 height gain in either over-all, or sub-analysis with case-control studies. The meta-analysis showed a significantly higher revision rate in patients undergoing a definitive fusion procedure. CONCLUSION: The current analysis revealed comparable outcomes in terms of correction rate and gain in the trunk height but a lesser need of revisions in observation sub-group. The lack of good quality evidence and the need for prospective and randomized trials was also propounded by this review.

Deformity Correction with Interbody Fusion Using Lateral versus Posterior Approach in Adult Degenerative Scoliosis: A Systematic Review and Observational Meta-analysis.

This study was designed to systematically review and meta-analyze the functional and radiological outcomes between lateral and posterior approaches in adult degenerative scoliosis (ADS). Both lateral (lumbar, extreme, and oblique) and posterior interbody fusion (posterior lumbar and transforaminal) are used for deformity correction in patients with ADS with unclear comparison in this cohort of patients in the existing literature. A literature search using three electronic databases was performed to identify studies that reported outcomes of lateral (group L) and posterior interbody fusion (group P) in patients with ADS with curves of 10°-40°. Group P was further subdivided into minimally invasive surgery (MIS-P) and open posterior (Op-P) subgroups. Data on functional, radiological, and operative outcomes, length of hospital stay (LOHS), fusion rates, and complications were extracted and meta-analyzed using the random-effects model. A total of 18 studies (732 patients) met the inclusion criteria. No significant difference was found in functional and radiological outcomes between the two groups on data pooling. Total operative time in the MIS-P subgroup was less than that of group L (233.86 minutes vs. 401 minutes, p <0.05). The total blood loss in group L was less than that in the Op-P subgroup(477 mL vs. 1,325.6 mL, p <0.05). Group L had significantly less LOHS than the Op-P subgroup (4.15 days vs. 13.5 days, p <0.05). No significant difference was seen in fusion rates, but complications were seen except for transient sensorimotor weakness (group L: 24.3%, group P: 5.6%; p <0.05). Complications, such as postoperative thigh pain (7.7%), visceral injuries (2%), and retrograde ejaculation (3.7%), were seen only in group L while adjacent segment degeneration was seen only in group P (8.6%). Lateral approach has an advantage in blood loss and LOHS over the Op-P subgroup. The MIS-P subgroup has less operative time than group L, but with comparable blood loss and LOHS. No significant difference was found in functional, radiological, fusion rates, pseudoarthrosis, and complications, except for transient sensorimotor deficits. Few complications were approach-specific in each group.

Hypertrophic cardiomyopathy - phenotypic variations beyond wall thickness.

Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy (LVH) in the absence of another causal disease. Several morphologic and histologic changes have been described. Given the morbidity and mortality associated with HCM, understanding these anatomic variations is key to interpreting imaging. This is especially important since many patients exhibit these associated findings in the absence of LVH and prompt early detection of these variations may lead to early diagnosis and treatment. This article describes the appearance of morphologic variations seen in HCM beyond myocardial thickening including: papillary muscle and mitral valve variants, myocardial crypts, left ventricular myocardial bands, and dystrophic calcification related to increased wall tension.

Characterization of Primary and Secondary Cutaneous B-Cell Lymphomas: A Population-Based Study of 4758 Patients.

INTRODUCTION/BACKGROUND: Cutaneous B-cell lymphomas are a heterogeneous group of rare malignancies whose specific site tropisms and site-specific survival have not been well documented. In this study, we seek to investigate the frequency and survival for primary and secondary cutaneous MZL (pcMZL and scMZL), primary and secondary cutaneous FCL (pcFCL and scFCL), and primary and secondary cutaneous DLBCL (pcDLBCL and scDLBCL) to better understanding their prognosis and natural history. MATERIALS AND METHODS: A total of 4758 cases of CBCL diagnosed between 1975 and 2016 were identified in the SEER-18 database. Statistical analysis was performed to identify the frequency of location and survival. RESULTS: pcMZL was disproportionately likely to present on the face and upper limb while those of scMZL approximated the expected ratios based on body surface area. pcFCL and scFCL were more likely to present on the face and scalp/neck. pcDLBCL and scDLBCL were more likely to present on the face, scalp/neck, and lower limb. Patients with systemic MZL or FCL, but not DLBCL, had significantly better survival than those diagnosed in the skin than at other sites. CONCLUSIONS: All of these lymphomas demonstrate site-specific tropisms and survival. Molecular characterization of cutaneous lymphomas with analyses of tumor microenvironment are the next steps in understanding disease biology.

The positive-negative mode link between brain connectivity, demographics and behaviour: a pre-registered replication of Smith et al. (2015).

In mental health research, it has proven difficult to find measures of brain function that provide reliable indicators of mental health and well-being, including susceptibility to mental health disorders. Recently, a family of data-driven analyses have provided such reliable measures when applied to large, population-level datasets. In the current pre-registered replication study, we show that the canonical correlation analysis (CCA) methods previously developed using resting-state magnetic resonance imaging functional connectivity and subject measures (SMs) of cognition and behaviour from healthy adults are also effective in measuring well-being (a 'positive-negative axis') in an independent developmental dataset. Our replication was successful in two out of three of our pre-registered criteria, such that a primary CCA mode's weights displayed a significant positive relationship and explained a significant amount of variance in both functional connectivity and SMs. The only criterion that was not successful was that compared to other modes the magnitude of variance explained by the primary CCA mode was smaller than predicted, a result that could indicate a developmental trajectory of a primary mode. This replication establishes a signature neurotypical relationship between connectivity and phenotype, opening new avenues of research in neuroscience with clear clinical applications.