Comparison of medical students' considerations in choosing a specialty: 2020 vs. 2009/10.

BACKGROUND: Workforce shortage in healthcare and particularly in physicians poses a threat to healthcare delivery and its quality. In comparison to other OECD countries, Israel currently has a small number of medical graduates relative to its number of physicians, naturally emphasizing the importance of ensuring that this population chooses to remain in medicine. Understanding what is most important to medical students can help improve working conditions in residency. Such information is particularly needed to facilitate policy planning that will encourage the next generation of physicians to specialize in medical fields that are experiencing shortages. We hypothesized that between 2009/2010 and 2020, there were significant changes in medical students' preferences regarding their considerations for choosing a medical specialty. METHODS: We compared cross-sectional data from questionnaire-based surveys of 5th year medical students performed in 2009-2010 and 2020 at two Israeli universities. RESULTS: Of the 335 medical students who responded (237 and 98 in 2009/2010 and 2020, respectively) those in 2020 were 2.26 less likely vs. those in 2009/2010, to choose a residency for its high-paying potential (P < 0.05), and had significantly more interest in residencies with greater teaching opportunity (98.8% vs 82.9%, P < 0.05), increased responsibility and chances to make clinical decisions on their own (67.9% vs 51.6%, P < 0.05). Criteria important to both the 2009/2010 and 2020 students were choosing a bedside specialty (70.2%vs 67.9%, NS), and an interesting and challenging specialty (95.2%v s 91.3%, NS). CONCLUSIONS: These results partially supported our hypothesis that medical students' preferences have changed over the years, though there are fundamental factors that apparently reflect medical students' nature that do not change over time.

When giants talk; robotic dialog during thoracolumbar and sacral surgery.

BACKGROUND: Spinal trauma patients treated in a specialized hybrid operating room (OR) using two robotic systems communicating during surgery. METHODS: Retrospective review of patients with thoracolumbar or sacral fractures who underwent surgical fixation between Jan 2017 to Jan 2020 with robotic-guided percutaneous pedicle screw insertion in the specialized hybrid OR with Robotic flat panel 3D C-arm (ArtisZeego) for intraoperative interventional imaging connected with the robotic-guidance platform Renaissance (Mazor Robotics). RESULTS: Twenty eight surgeries were performed in 27 patients; 23 with traumatic spinal fractures, 4 with multi-level thoracolumbar compression fractures due to severe osteoporosis. Average patient age 49 (range 12-86). Average radiation exposure time 40 s (range 12-114 s). Average radiation exposure dose 11,584 ± SD uGym2 (range 4454-58,959). Lumber levels operated on were between T5 and S2 (shortest three vertebras and longest eight vertebras). 235 (range 5-11) trajectories were performed. All trajectories were accurate in all cases percutaneous pedicle screws placement was correct, without breach noted at the pedicle in any of the cases. No major complications reported. In all cases, follow-up X-rays showed adequate fracture reduction with restoration. CONCLUSIONS: Merging of surgical robotics technologies increases patient safety and surgeon and patient confidence in percutaneous spine traumatic procedures.

Nanoparticles target early-stage breast cancer metastasis in vivo.

Despite advances in cancer therapy, treating cancer after it has metastasized remains an unmet clinical challenge. In this study we demonstrate that 100 nm liposomes target triple-negative murine breast-cancer metastases post intravenous administration. Metastatic breast cancer was induced in BALB/c mice either experimentally, by a tail vein injection of 4T1 cells, or spontaneously, after implanting a primary tumor xenograft. To track their biodistribution in vivo the liposomes were labeled with multi-modal diagnostic agents, including indocyanine green and rhodamine for whole-animal fluorescent imaging, gadolinium for magnetic resonance imaging (MRI), and europium for a quantitative biodistribution analysis. The accumulation of liposomes in the metastases peaked at 24 h post the intravenous administration, similar to the time they peaked in the primary tumor. The efficiency of liposomal targeting to the metastatic tissue exceeded that of a non-liposomal agent by 4.5-fold. Liposomes were detected at very early stages in the metastatic progression, including metastatic lesions smaller than 2 mm in diameter. Surprisingly, while nanoparticles target breast cancer metastasis, they may also be found in elevated levels in the pre-metastatic niche, several days before metastases are visualized by MRI or histologically in the tissue. This study highlights the promise of diagnostic and therapeutic nanoparticles for treating metastatic cancer, possibly even for preventing the onset of the metastatic dissemination by targeting the pre-metastatic niche.

Using medical specialty and selection criteria clusters to study specialty selection by Israeli medical students.

BACKGROUND: During their final year of medical school, Israeli students must consider which specialty to choose for residency. Based on the vocational counseling literature we presumed that choices are made by selecting from a cluster of related specialties while considering professional and socio-economic issues. METHODS: Questionnaires distributed to final-year medical students at two Israeli medical schools ascertained inclinations toward various medical specialties and the importance of various selection criteria. Analysis focused on seven specialties where >20% of students reported they had positive inclinations. For each such specialty, the specialty and selection criteria query were compared using unpaired two-tailed Student's t-tests to determine differences between students with positive inclinations toward the specialty with those not so inclined. These data were placed in tables, with the significant differences highlighted to facilitate visual recognition of cluster patterns. RESULTS: Completed questionnaires were obtained from 317 of 455 students. Students often had positive inclinations toward more than one specialty (specialty clusters) associated with a group of selection criteria (selection criteria clusters). For example, interest in internal medicine was clustered with interest in internal medicine subspecialties, cardiology and research. Furthermore, there was a "reciprocal" aspect to some specialty cluster patterns. For example, those interested in internal medicine had little interest in surgical specialties. Selection criteria clusters revealed occupational interests and socio-environmental factors associated with the specialty clusters. For example, family medicine, which clustered with pediatrics and psychiatry, had a sub-cluster of: Bedside specialty with family orientation affording long-term patient care. Another sub-cluster was time for childrearing and family, only daytime work and outpatient care. Clusters also revealed students' perceptions that differed from expected: Cardiology is changing from a cognitive to a procedure-oriented subspecialty, clustering not only with internal medicine and its subspecialties but also with emergency medicine, surgical subspecialties and anesthesiology. CONCLUSIONS: The concept that career choice involves selecting from a cluster of related specialties provides information about the specialties students might be considering. Moreover, students are not only looking for individual aspects of a specialty, but for a package including clusters of socio-economic and occupational features. Practically, examining clusters can help in career counseling of medical students and assist residency program directors in marketing their specialties.

The use of local vancomycin powder in degenerative spine surgery.

PURPOSE: Wound infection after spine surgery is a debilitating complication. Local placement of vancomycin powder into the surgical wounds prior to closing of the fascia has been introduced as a method to reduce deep infection rates. METHODS: The infection rates of all the patients who were treated with intra-operative local vancomycin between June 2012 and June 2013 were compared to all cases that were not treated with vancomycin between January 2009 and December 2010. Patients for both groups were operated by four senior, fellowship-trained spine surgeons with a combined experience of 55 years of practice at a referral orthopedic center. Patients' charts and microbiology reports were reviewed. RESULTS: 1224 cases were performed with the use of vancomycin. The average age was 56.3 years (SD -13.2; NS). The male to female ratio was 1:1.12 (NS). 2253 cases were performed without the use of vancomycin. The average patient age was 57.1 years (SD 14.5). The male to female ratio was 1:1.14. There were 30 cases of deep infections needing a surgical irrigation and debridement without vancomycin versus 5 when vancomycin was used (P = 0.04). Infections in patients treated with vancomycin were not vancomycin-resistant bacteria. CONCLUSION: In conclusion, the use of vancomycin reduces the rate of deep wound infections and irrigation and debridement procedures after spine surgery in a referral center among surgeons with a high surgical volume.

Characteristics and Usefulness of Neurophysiological Monitoring in Corrective Procedures for Abnormally Curved Spine in Young Patients.

PURPOSE: To identify and characterize events of deterioration in intraoperative neuromonitoring data during correction procedures for thoracic and lumbar abnormal spinal curvature in young patients. METHODS: Records of 1,127 cases were retrospectively reviewed to identify events with deterioration of the neuromonitoring data. General etiological and demographic variables were summarized, and neuromonitoring events were studied and characterized. RESULTS: Adolescent idiopathic cases were associated with female dominance and older age. Nonadolescent idiopathic cases were associated with a higher rate of neuromonitoring events. The neuromonitoring events evolved during the different procedural stages, were primarily reflected in the motor-evoked potential data and affected a range of neural structures to varying degrees. Most of the events were resolved, partially or completely, following a corresponding intervention by the surgical team, before the end of the procedure. Significant immediate weakness of the lower extremities was demonstrated in patients with unresolved neuromonitoring events, most of them were nonadolescent idiopathic patients. CONCLUSIONS: Neurophysiological monitoring enables the intraoperative assessment of the integrity of neural pathways and allows the detection of surgery-related impending neural injuries. Neuromonitoring contributes to intraoperative decision making, either when data are uneventful and allow confident continuation or when data deteriorate and lead to corresponding intervention. Further awareness should be paid to the vulnerable characteristics of the patient, surgery course, and neuromonitoring data. Proper interpretation of the neuromonitoring data, together with corresponding intervention by the surgeon when necessary, has the potential to reduce postoperative neurological insults and improve clinical outcomes.

Long-Term Effects on Sexual Function in Women Treated With Scoliosis Correction for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective cohort study with a cross-sectional comparison. OBJECTIVES: To assess sexual function and experience in adult women who had scoliotic correction for adolescent idiopathic scoliosis (AIS). METHODS: Women ages 18-40 years with a history of scoliosis, who were braced or underwent uncomplicated posterior scoliosis correction for AIS, followed for two years or more since treatment were included. Sexual function was assessed using the Female Sexual Distress Scale-Revised (FSDS-R) and the Female Sexual Function Index (FSFI) questionnaires. Participants' scores were compared to those of a control group consisting of age-matched healthy women. RESULTS: Of 115 women who responded to the questionnaires, 40 (35%) had surgical treatment (mean age 25.1; range 19-35 years; mean time since surgery 8.2 years; range 3-12 years) and 35 (30%) were braced (mean age 23.3; range 18-27 years; mean time since treatment 3.6 years; range 3-5 years). The control group consisted of a cohort of 40 (35%) aged-matched healthy women. According to the FSDS-R, significantly more women with scoliotic correction for AIS reported sexual distress compared to healthy controls (25% vs 12%, respectively), and the difference in the total mean scores (7.05 vs 5.34, respectively), was significant (P < .001). Additionally, the mean overall FSFI score for scoliotic-corrected women was 24.2 (range 17.5-29.1) within the pathological range (<26.55) of sexual dysfunction. CONCLUSIONS: High rates of sexual distress and dysfunction were reported in women with a history of AIS, thus, there appears to be long-term consequences years after deformity correction by brace or surgical correction.

Intraoperative Deterioration of Neurophysiological Potentials of the Spinal Tracts in Cervical Spine Surgery: Correlation With Patient-Related and Procedure-Related Variables.

PURPOSE: To identify characteristics associated with higher incidence of intraoperative deterioration of neurophysiological potentials related to spinal tracts in cervical spine surgeries. METHODS: Electrophysiological raw data and neurophysiological case reports of 1,611 patients from multiple medical centers, who underwent cervical spine surgery for decompression and/or fusion, were retrospectively reviewed. Patient-related and procedure-related variables were identified and analyzed for correlation with intraoperative neurophysiological event of the spinal tracts. The neurophysiological events were analyzed for identification of collective characteristics. RESULTS: The study cohort presented consistent dominancy of male over female patients (67% vs. 33%). Intraoperative deterioration of spinal tract-derived potentials was noted in 10.5% of the total cases, which was not correlated with gender, age, or indication of the surgery. Higher incidence of neurophysiological events was noted in patients with impaired baseline of motor evoked potentials from the thenar muscle ( P = 0.01) or somatosensory evoked potentials of the posterior tibial nerve ( P = 0.0002). Procedures of circumferential approach or procedures that involved ≥3 spinal levels demonstrated higher incidence of neurophysiological events as well ( P = 0.0003 and 0.001, respectively). CONCLUSIONS: Patients with deteriorated neurophysiological baseline and procedures of extensive intervention are at higher risk of intraoperative neurophysiological event in cervical spine surgery. Inclusion of intraoperative neurophysiological monitoring should be encouraged in complicated cases of cervical spine surgeries.

Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: a randomized prospective study.

BACKGROUND: Hyperglycaemia and diabetes mellitus are common in patients hospitalized in the orthopaedic surgery ward. However, glycaemic control obtained during hospitalization is often suboptimal. No method for achieving adequate glycaemic control in this population has been validated in an in-hospital setting. INTERVENTION: An intervention including an intensive subcutaneous insulin protocol in the orthopaedic department. METHODS: All diabetic patients admitted to the Department of Orthopaedic Surgery were prospectively randomized during a 6-month period. One group (n = 30) received standard care with sliding scale insulin and the other group (n = 35) received the intervention protocol. During the intervention period, the staff was briefed on the importance of glucose monitoring and control. An intensive multiple-injection protocol consisting of four daily regular/neutral protamine hagedorn (NPH) insulin injections was initiated in diabetic patients. The programme was followed up by a consulting diabetologist. RESULTS: Mean blood glucose levels throughout the hospitalization were 161.48 ± 3.8 mg/dL in the intervention group versus 175.29 ± 2.3 mg/dL in the control group (p < 0.0005). Hospitalization was shorter by 2 days in the intervention group (p < 0.05). The number of severe hyperglycaemic events (blood glucose level above 400 mg%) was significantly lower (p < 0.05) in the intervention group. There was no significant difference in the number of hypoglycaemic events. CONCLUSIONS: The suggested four-step intervention regimen improved glycaemic control of hospitalized patients in the orthopaedic department and simplified the 'in-house' treatment of the diabetic patient. Hospital stays were reduced on average by two days (p < 0.05).

Awake Percutaneous Fixation for Unstable Fractures of the Spine in High-risk Patients: A Retrospective Study.

INTRODUCTION: Unstable fractures in sick or elderly patients are on the rise. These patients who are at high risk for surgery present a challenge for surgeons and anesthesiologists. In patients with American Society of Anesthesiologists (ASA) scores 3 to 4, the risk is even higher because of the high rate of intraoperative complications. METHODS: All patients with ASA scores 3 to 4 who presented with unstable fractures of the spine to a level-one trauma center were assessed, and they underwent awake spinal percutaneous fixation, with mild sedation and local anesthesia. Demographics, radiology, and the outcome were collected. RESULTS: Nineteen patients were operated between the years 2019 and 2021. Average follow-up was 12 months (range 8 to 24 months); six patients were female and 13 males. The average age was 77.7 years; the ASA score was 3 to 4 in all patients. There were 10 extension-type injuries, six unstable burst injuries, two chance fractures, and one teardrop fracture. All patients underwent unilateral fixation, and just one patient underwent bilateral fixation; cement augmentation was done in 16 of the patients. No neurologic complication was observed. One case of infection presented 4 months after surgery. All patients were discharged ambulating. CONCLUSIONS: Awake fixation in extreme cases is safe and feasible; a dedicated team including an anesthesiologist and radiologist is needed to treat these cases safely and quickly.

Migrating shrapnel: a rare cause of knee synovitis.

UNLABELLED: Shrapnel injuries in soft tissues often do not require surgical excision. Metals that remain embedded in the surrounding tissue are not thought to cause significant damage and the patients are generally asymptomatic. This case presentation describes a patient who sustained a penetrating shrapnel injury to his thigh, where the metal fragment was not removed. However, more than 20 years later, the patient developed knee synovitis. On X-ray the shrapnel was seen in the suprapatellar pouch. An arthroscopy was preformed and the shrapnel was removed with full healing of the patient. CONCLUSION: although nonsurgical treatment of shrapnel in soft tissues is the treatment of choice in many cases, late migration is possible, causing distal symptoms and may require surgical excision.

[Orthopedic care in polytrauma patients in the setting of a multi-casualty event].

Multi-casualty events are characterized by a large number of wounded people arriving at trauma centers in a short period of time. These wounded suffer distinctive injuries in accordance with the cause of the event. Close to 50 percent of all injuries in a multi-casualty event are musculoskeletal injuries. These injuries are not usually isolated and indicate that the patient has suffered severe trauma. Correct management of such an event requires proper management in the pre-hospital, trauma centers, wards and operating galleries. A "damage control" policy should be implemented in all stages of the patient's care. Orthopedic care has been revolutionized several times--developing from delayed care, to early total care and finally to "damage control" orthopedics. "Damage control" orthopedics emphasizes initial stabilization and control of injuries, due to the systemic cytokine storm after polytrauma, prior to final corrective surgery of the patient's fractures. In this article the authors review the orthopedic care in a multi-casualty event, and the specific care given to each of the wounded in such an event.

Robotic assisted fixation of sacral fractures: A pilot study.

OBJECTIVES: Sacral fractures that require fixation are a challenge for the orthopaedic surgeon. Due to anatomical consideration, implant insertion is not risk free, and requires a steep learning curve. A robotic system has been successfully used in pedicle screws insertion and can be also used for iliosacral screws. The aim of the study was to demonstrate the use of the robot in the treatment of unstable sacral fractures. DESIGN: Retrospective case series. SETTING: An academic level I trauma center. PATIENTS: Fourteen patients with sacral fractures were eligible for robotic assisted treatment. These included 9 high-energy fractures, 4 osteoporotic fractures, and 1 pathological fracture. INTERVENTION: Fixation constructs included iliosacral screws, transiliac screws, lumbopelvic fixation, sacroplasty, or a combination of the above techniques. A Renaissance robot was mounted on a multidirectional bridge that was attached to the patients spine and implant trajectories were planned either on preoperative or intraoperative 3D scans. Guide wires were inserted percutaneously and screws were placed subsequently. MAIN OUTCOME MEASUREMENTS: Accuracy of implant placement, operating room and fluoroscopy time. RESULTS: Mean patient age was 36 (17-84), and number of screws, including iliosacral and pedicular ranged 1-14 per patient (average 4.25). Mean operative time was 150 minutes (range 90-300). Average fluoroscopic time was 18 seconds (7-42) for 2D and 40 seconds (12-72) for 3D imaging. All fractures healed, no hardware failure was observed. All hardware was always within bony confines, and no procedure-related neurological deficits were observed. CONCLUSION: Robotic assisted fixation of sacral fracture is a safe and reproduceable method, allowing precise and accurate implant placement.

Tailoring the lipid composition of nanoparticles modulates their cellular uptake and affects the viability of triple negative breast cancer cells.

Lipid nanoparticles are used widely as anticancer drug and gene delivery systems. Internalizing into the target cell is a prerequisite for the proper activity of many nanoparticulate drugs. We show here, that the lipid composition of a nanoparticle affects its ability to internalize into triple-negative breast cancer cells. The lipid headgroup had the greatest effect on enhancing cellular uptake compared to other segments of the molecule. Having a receptor-targeted headgroup induced the greatest increase in cellular uptake, followed by cationic amine headgroups, both being superior to neutral (zwitterion) phosphatidylcholine or to negatively-charged headgroups. The lipid tails also affected the magnitude of cellular uptake. Longer acyl chains facilitated greater liposomal cellular uptake compared to shorter tails, 18:0 > 16:0 > 14:0. When having the same lipid tail length, unsaturated lipids were superior to saturated ones, 18:1 > 18:0. Interestingly, liposomes composed of phospholipids having 14:0 or 12:0-carbon-long-tails, such as DMPC and DLPC, decreased cell viability in a concertation dependent manner, due to a destabilizing effect these lipids had on the cancer cell membrane. Contrarily, liposomes composed of phospholipids having longer carbon tails (16:0 and 18:0), such as DPPC and HSPC, enhanced cancer cell proliferation. This effect is attributed to the integration of the exogenous liposomal lipids into the cancer-cell membrane, supporting the proliferation process. Cholesterol is a common lipid additive in nanoscale formulations, rigidifying the membrane and stabilizing its structure. Liposomes composed of DMPC (14:0) showed increased cellular uptake when enriched with cholesterol, both by endocytosis and by fusion. Contrarily, the effect of cholesterol on HSPC (18:0) liposomal uptake was minimal. Furthermore, the concentration of nanoparticles in solution affected their cellular uptake. The higher the concentration of nanoparticles the greater the absolute number of nanoparticles taken up per cell. However, the efficiency of nanoparticle uptake, i.e. the percent of nanoparticles taken up by cells, decreased as the concentration of nanoparticles increased. This study demonstrates that tuning the lipid composition and concentration of nanoscale drug delivery systems can be leveraged to modulate their cellular uptake.

Ambulation and survival following surgery in elderly patients with metastatic epidural spinal cord compression.

BACKGROUND AND CONTEXT: Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management. PURPOSE: Evaluate the duration of ambulation and survival in elderly patients following surgical decompression of MESCC. STUDY DESIGN/SETTING: Retrospective file review of a prospective database, under institutional review board (IRB) waiver of informed consent, of consecutive patients treated in an academic tertiary care medical center from August 2008 to March 2015. PATIENT SAMPLE: Patients ≥65 years presenting neurological and/or radiological signs of cord compression because of metastatic disease, who underwent surgical decompression. OUTCOME MEASURES: Duration of ambulation and survival. METHODS: Patients underwent urgent multidisciplinary evaluation and surgery. Ambulation and survival were compared with age, pre-, and postoperative neurological (American Spinal Injury Association [ASIA] Impairment Scale [AIS]) and performance status (Karnofsky Performance Status [KPS]), and Tokuhashi Score using Kruskal-Wallis and Wilcoxon signed rank tests, Pearson correlation coefficient, Cox regression model, log-rank analysis, and Kaplan-Meier analysis. RESULTS: Forty patients were included (21 male, 54%; mean age 74 years, range 65-87). Surgery was performed a mean 3.8 days after onset of motor symptoms. Mean duration of ambulation and survival were 474 (range 0-1662) and 525 days (range 11-1662), respectively; 53% of patients (21 of 40) survived and 43% (17 of 40) retained ambulation for ≥1 year. There was no significant relationship between survival and ambulation for patients aged 65-69, 70-79, or 80-89 years, although Kaplan-Meier analysis suggested stratification. There was a significant relationship between duration of ambulation and pre- and postoperative AIS (p=.0342, p=.0358, respectively) and postoperative KPS (p=.0221). Tokuhashi score was not significantly related to duration of survival or ambulation, and greatly underestimated life expectancy in 22 of 37 (59%) patients with scores 0-11. CONCLUSIONS: Decompressive surgery led to marked improvement in neurological function and performance status. More than 50% of patients survived for >1 year, some for 3 years or more after surgery.

Blood Transfusion and Postoperative Infection in Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: Allogeneic blood transfusion-related immunomodulation may relatively suppress the immune system, heightening the risk of infection following spine surgery. This systematic review seeks to determine whether allogeneic blood transfusion increases the risk of postoperative infection and whether there are any factors that modify this association. METHODS: PubMed, Cochrane Central Register of Controlled Trials, and reference lists from included studies were searched from inception to April 20, 2017 to identify studies examining the risk of infection following allogeneic blood transfusion in adult patients receiving surgery for degenerative spine disease. RESULTS: Eleven retrospective cohort or case-control studies, involving 8428 transfusion patients and 43 242 nontransfusion patients, were identified as meeting the inclusion criteria. Regarding surgical site infection (SSI), the results were mixed with roughly half reporting a significant association. There was an association between allogeneic transfusion and urinary tract infection (UTI) and any infection, but not respiratory tract infection. There was no statistical modifying effect of lumbar versus thoracic surgery on the association of allogeneic transfusion and SSI, though subgroup analyses in 3 of 4 studies reported a statistical association between transfusion and postoperative infections, including SSI, UTI, and any infection within the lumbar spine. CONCLUSIONS: This systematic review failed to find a consistent association between allogeneic transfusion and postoperative infection in spine surgery patients. However, these studies were all retrospective with a high or moderately high risk of bias. To properly examine this association an observational prospective study of sufficient power, estimated as 2400 patients, is required.

Value of repeat CT scans in low back pain and radiculopathy.

We assessed the clinical value of repeat spine CT scan in 108 patients aged 18-60 years who underwent repeat lumbar spine CT scan for low back pain or radiculopathy from January 2008 to December 2010. Patients with a neoplasm or symptoms suggesting underlying disease were excluded from the study. Clinical data was retrospectively reviewed. Index examinations and repeat CT scan performed at a mean of 24.3 ± 11.3 months later were compared by a senior musculoskeletal radiologist. Disc abnormalities (herniation, sequestration, bulge), spinal stenosis, disc space narrowing, and bony changes (osteophytes, fractures, other changes) were documented. Indications for CT scan were low back pain (60 patients, 55%), radiculopathy (46 patients, 43%), or nonspecific back pain (two patients, 2%). A total of 292 spine pathologies were identified in 98 patients (90.7%); in 10 patients (9.3%) no spine pathology was seen on index or repeat CT scan. At repeat CT scan, 269/292 pathologies were unchanged (92.1%); 10/292 improved (3.4%), 8/292 worsened (2.8%, disc herniation or spinal stenosis), and five new pathologies were identified. No substantial therapeutic change was required in patients with worsened or new pathology. Added diagnostic value from repeat CT scan performed within 2-3 years was rare in patients suffering chronic or recurrent low back pain or radiculopathy, suggesting that repeat CT scan should be considered only in patients with progressive neurologic deficits, new neurologic complaints, or signs implying serious underlying conditions.

Erratum: Adolescent Idiopathic Scoliosis and Pregnancy: An Unsolved Paradigm.

[This corrects the article DOI: 10.1055/s-0035-1552987.].

Evidence for the adverse effect of starvation on bone quality: a review of the literature.

Malnutrition and starvation's possible adverse impacts on bone health and bone quality first came into the spotlight after the horrors of the Holocaust and the ghettos of World War II. Famine and food restrictions led to a mean caloric intake of 200-800 calories a day in the ghettos and concentration camps, resulting in catabolysis and starvation of the inhabitants and prisoners. Severely increased risks of fracture, poor bone mineral density, and decreased cortical strength were noted in several case series and descriptive reports addressing the medical issues of these individuals. A severe effect of severely diminished food intake and frequently concomitant calcium- and Vitamin D deficiencies was subsequently proven in both animal models and the most common cause of starvation in developed countries is anorexia nervosa. This review attempts to summarize the literature available on the impact of the metabolic response to Starvation on overall bone health and bone quality.