Design and rationale of the atrial fibrillation occurring transiently with stress (AFOTS) incidence study.

BACKGROUND: Atrial fibrillation (AF) is often detected for the first time in patients hospitalized for medical illness or non-cardiovascular surgery. AF occurring transiently with stress (AFOTS) describes this manifestation of AF, which may either be the result of a non-cardiac stressor, or existing paroxysmal AF that was not previously detected. Current estimates of AFOTS incidence are imprecise: ranging from 1 to 44%, owing to the marked heterogeneity in patient populations, identification and methods used to detect AFOTS. METHODS: The prospective, two-centre epidemiological AFOTS Incidence study will enroll 250 consecutive participants without a history of AF but with at increased risk of AF (Age ≥ 65 or >50 with one risk factor for AF) admitted to intensive care units (ICUs) for medical illness or non-cardiac surgery. Upon admission, participants will wear an ECG patch monitor that will remain in place for 14 days, or until discharge from hospital. Patients' consent to participation is deferred for up to 72 h after admission. The primary endpoint is the incidence of AF lasting ≥30 s. The study is powered to detect an AF incidence of 17% ±â€¯5%. RESULTS: We conducted a vanguard feasibility study, and 55 participants have completed participation. The median duration of monitoring was seven days. AF was detected by the clinical team in 8 participants (14%; 95% Confidence Interval 7-26%). CONCLUSIONS: The AFOTS Incidence study will employ a systematic and highly sensitive protocol for detecting AFOTS in medical illness and non-cardiac surgery ICU patients. This study is feasible and will provide a reliable estimate of the true incidence of AFOTS in this population.

An evaluation of multimodal spinal cord monitoring in scoliosis surgery: a single centre experience of 354 operations.

PURPOSE: To evaluate the effectiveness of multimodal intraoperative neuromonitoring in the early detection of impending spinal cord injury during surgery for spinal deformity. METHOD: A retrospective review of prospectively collected data in 354 consecutive spinal deformity operations from June 2003 to October 2013. Patients were sub-grouped according to demographics, diagnosis and operative features. Post-operative neurological deficit was defined as either spinal cord, nerve root or transient deficit. RESULTS: Combined monitoring with SSEPs and MEPs was possible in 315 cases. The overall incidence of significant alerts was 7.1 % and overall permanent neurological deficit was 1.6 %. When results were collated, the overall combined sensitivity of multimodal monitoring was 100 % with a specificity of 99.3 %. CONCLUSIONS: Multimodal monitoring allows early detection of impending neurological deficit that is superior to a single monitoring modality. To achieve optimal use of monitoring, continuous communication between surgical, anaesthetic and neurophysiology teams are required. As a result of our experience we have incorporated in our consent procedure the discussion of monitoring and the possibility of needing to abandon the procedure, and completing in a staged fashion at a later date. We believe multimodal monitoring is the current gold standard for complex spinal deformity surgery.

Morbidity and mortality in adult spinal deformity surgery: Norwich Spinal Unit experience.

PURPOSE: This study analyses the complications of spinal deformity surgery in adults to highlight pre-disposing factors. METHODS: The clinical records and imaging were reviewed for 48 consecutive patients, 12 males and 36 females, with a mean age of 64 (31-86), who had surgery for spinal deformity. Mean follow-up time was 36 months (24-60). Patient data recorded were age, diagnosis and co-morbidities; deformity assessment: curve type, sagittal and coronal balance, Cobb angle. Operation details: number of instrumented levels, duration and intra-operative complications. OUTCOME: complications, re-operations, balance and Cobb angle. RESULTS: 28 patients (58 %) had at least 1, 15 patients (27 %) had 2 and 5 patients (9.5 %) had more than 2 co-morbidities. Average time between 1st presentation and operation was 13 months (1-41). The mean number of levels fused was 10.8 (4-23). In addition to posterior pedicle screw instrumentation, 40 patients had chevron osteotomies and 8 had pedicle substraction osteotomies. Posterior interbody fusions were performed at one level in 17 of which 7 had 2 level fusion. Two patients had combined anterior and posterior approaches. Fusion to the pelvis was performed in 19 patients. There were a total of 27 major and minor complications in 19/48 (39.5 %) patients. Late complications included 5 patients who had revisions for proximal junctional kyphosis, 1 patient had revision for pseudoarthrosis and 4 patients had removal of mal-positioned screws. CONCLUSIONS: Factors associated with high complication rate in adult spinal deformity surgery are age, co-morbidities and severe sagittal imbalance at the time of presentation.

Acute mood and thyroid stimulating hormone effects of transcranial magnetic stimulation in major depression.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) has recently been demonstrated to have antidepressant effects. Some work suggests that rTMS over prefrontal cortex administered to healthy individuals produces acute elevations of mood and serum thyroid-stimulating hormone (TSH). We sought to determine whether single rTMS sessions would produce acute mood and serum TSH elevations in subjects with major depressions. METHODS: Under double-blind conditions et al 14 medication-free subjects with major depression received individual sessions of either active or sham rTMS. rTMS was administered over the left prefrontal cortex at 10 Hz et al 100% of motor threshold, 20 trains over 10 min. Immediately before and after rTMS sessions, subjects' mood was rated with the Profile of Mood States (POMS) and the 6-Item Hamilton Depression Scale, and blood was drawn for later analysis of TSH. Subjects and raters were blind to treatment assignment. RESULTS: The group receiving active stimulation manifested significantly greater improvement on the POMS subscale of Depression (p < or = .0055) and a trend toward greater improvement on the modified Hamilton Rating (.05 < p < or =.1). No hypomania was induced. The change in TSH from pre- to post-rTMS was significantly different between active and sham sessions. CONCLUSIONS: This blinded, placebo-controlled trial documents that individual rTMS sessions can acutely elevate mood and stimulate TSH release in patients experiencing major depressive episodes.

Congenital abnormalities of the urogenital tract in association with congenital vertebral malformations.

There is a close link between the embryological development of the musculoskeletal system and all other main organ systems. We report a prospective series of 202 patients with congenital vertebral abnormalities and document the associated abnormalities in other systems. There were 100 boys and 102 girls. In 153 there were 460 associated abnormalities, a mean of 2.27 abnormalities for each patient. Intravenous pyelography was carried out on 173 patients (85.6%) and ultrasonography on the remaining 29 (14.4%). Patients with genitourinary anomalies were more likely to have musculoskeletal (p = 0.002), gastrointestinal (p = 0.02) and cardiac abnormalities (p = 0.008) than those without genitourinary involvement. A total of 54 (26.7%) had at least one genitourinary abnormality, the most frequent being unilateral renal agenesis. There was urinary obstruction in six (3%). There was no association between genitourinary abnormality and the place of birth, parental age, birth order, level of spinal curvature, or the number, type and side of spinal anomaly. There was, however, a statistically significant association (p = 0.04) between costal and genitourinary abnormalities. The incidence of genitourinary abnormalities (26.7%) was similar to that of previously reported series. The diagnosis of a congenital vertebral abnormality should alert the clinician to a wide spectrum of possible associated anomalies most of which are of clinical importance.

"Globus symptoms": a rare case of giant osteochondroma of the axis treated with high cervical extrapharyngeal approach.

Background Osteochondroma is the most common primary bone tumor, composing 35% of benign bone tumors and 9% of all bone tumors; 1.3 to 4.1% of all osteochondromas originate from the spine. A rare differential diagnosis for globus symptoms is an osteochondroma originating from the anterior surface of the axis. We describe a rare case of osteochondroma of the dens resulting in "globus symptoms" (the subjective sensation of a mass in the throat) treated with excision via the high cervical extrapharyngeal approach. Purpose To discuss the surgical management of this problem, with an emphasis on surgical approach used. The clinical history, examination, and investigations are presented and illustrated, along with clinical patient outcome. Study Design/Setting This article is a case report of a patient treated at the Department of Trauma and Orthopaedics in an active university teaching hospital. Methods Case presentation. For the discussion, we used handpicked articles, as well as MEDLINE and PubMed database searches with the keywords "C2," "dens," "osteochondroma," "globus," "extrapharyngeal approach." Results Uncomplicated procedure. Histological analysis confirmed a benign osteochondroma with no evidence of malignancy. The patient underwent an uncomplicated postoperative recovery and was discharged 24 hours after surgery, fully ambulatory and eating and drinking well. Conclusions The high cervical retropharyngeal approach is safe and reproducible for the excision of osteochondromas or osteophytes of the upper cervical spine.

Urine acid output as a test of completeness of vagotomy.

Peak acid output in response to sham feeding and changes in urine acid output 2 and 3 hours after a test meal have been measured in 20 normal volunteers, 17 asymptomatic patients after vagotomy, six patients with recurrent duodenal ulcer after vagotomy and ten normal subjects given a 48-h course of ranitidine, 150 mg 12-hourly. Gastric peak acid output in normal volunteers ranged from 6.9 to 22.1 mmol/h. All asymptomatic patients after vagotomy had a peak acid output less than 7 mmol/h, consistent with complete vagotomy. Five patients with recurrent ulcer had a peak acid output greater than 8 mmol/h, suggesting an incomplete vagotomy. Urine acid output after a test meal, expressed as the change from the basal rate of acid output, was always in a negative direction in normal subjects (fall in acid output = postprandial alkaline tide). This change was abolished in patients with complete vagotomy, in whom urine acid output increased after a meal. In five patients with incomplete vagotomy (and one other with recurrent ulcer and unknown vagal status) the urine acid output changed in a negative direction after a test meal. The relationship of urine acid output to gastric secretion was confirmed by the abolition of the postprandial alkaline tide in normal subjects given ranitidine. The results in patients with incomplete vagotomy did not overlap with those from patients with complete vagotomy. This suggests that this test could be used for the routine postoperative assessment of completeness of vagotomy.