Spine Surgery in a Geriatric Population. Is it Really Different?

OBJECTIVES: Spinal degenerative disorders are a major cause of morbidity in the elderly resulting in high dependency. Most of them have a trend to be managed conservatively considering age, comorbidities, and apprehensions of surgical complications. Surgical intervention at early stage with appropriate indications can have better outcomes rather than conservative management in fit patients. The objective of the study is to evaluate the functional outcome in geriatric patients > 60 years who have undergone various spinal procedures for degenerative spine. METHODS: The study is retrospective, which includes all cases of spinal degenerative disease operated between 2014 and 2016. They were divided into geriatric (>60 years) and non-geriatric cohorts. These include all patients undergoing spinal decompression and/or instrumentation for degenerative disorders of the spine. Patients were interviewed for their functional outcomes in the follow-up period. RESULTS: A total of 184 spine cases were operated upon by a single surgeon, out of which a total of 139 cases were operated for the spinal degenerative condition. Forty-eight patients underwent lumbar spinal fusion procedures, 67 underwent non-instrumented lumbar decompression, and 24 patients underwent cervical procedures. These were further divided into 65 geriatric cases and 74 non-geriatric cases. The outcome was assessed with improvement and functional outcomes for spinal disability. Statistical analysis was performed using SPSS 20. CONCLUSION: It is concluded that surgical intervention for spinal problems in geriatric patients is not different from the general population. The outcome is also satisfactory provided, the choice of surgical procedure as per its indication is appropriate. The usual preoperative evaluation for the geriatric age group is very important. The performance status before surgery and the comorbidities have a direct bearing on the outcome in these patients.

An Efficient Segmentation and Classification System in Medical Images Using Intuitionist Possibilistic Fuzzy C-Mean Clustering and Fuzzy SVM Algorithm.

The herpesvirus, polyomavirus, papillomavirus, and retrovirus families are associated with breast cancer. More effort is needed to assess the role of these viruses in the detection and diagnosis of breast cancer cases in women. The aim of this paper is to propose an efficient segmentation and classification system in the Mammography Image Analysis Society (MIAS) images of medical images. Segmentation became challenging for medical images because they are not illuminated in the correct way. The role of segmentation is essential in concern with detecting syndromes in human. This research work is on the segmentation of medical images based on intuitionistic possibilistic fuzzy c-mean (IPFCM) clustering. Intuitionist fuzzy c-mean (IFCM) and possibilistic fuzzy c-mean (PFCM) algorithms are hybridised to deal with problems of fuzzy c-mean. The introduced clustering methodology, in this article, retains the positive points of PFCM which helps to overcome the problem of the coincident clusters, thus the noise and less sensitivity to the outlier. The IPFCM improves the fundamentals of fuzzy c-mean by using intuitionist fuzzy sets. For the clustering of mammogram images for breast cancer detector of abnormal images, IPFCM technique has been applied. The proposed method has been compared with other available fuzzy clustering methods to prove the efficacy of the proposed approach. We compared support vector machine (SVM), decision tree (DT), rough set data analysis (RSDA) and Fuzzy-SVM classification algorithms for achieving an optimal classification result. The outcomes of the studies show that the proposed approach is highly effective with clustering and also with classification of breast cancer. The performance average segmentation accuracy for MIAS images with different noise level 5%, 7% and 9% of IPFCM is 91.25%, 87.50% and 85.30% accordingly. The average classification accuracy rates of the methods (Otsu, Fuzzy c-mean, IFCM, PFCM and IPFCM) for Fuzzy-SVM are 79.69%, 92.19%, 93.13%, 95.00%, and 98.85%, respectively.

A Prospective Multicenter Study Evaluating Endoscopy Competence Among Gastroenterology Trainees in the Era of the Next Accreditation System.

PURPOSE: The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy. METHOD: During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis. RESULTS: Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills. CONCLUSIONS: This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.

Effect of individualized feedback on learning curves in EGD and colonoscopy: a cluster randomized controlled trial.

BACKGROUND AND AIMS: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy. METHODS: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills. RESULTS: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77). CONCLUSIONS: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.).

Deep Learning Localizes and Identifies Polyps in Real Time With 96% Accuracy in Screening Colonoscopy.

BACKGROUND & AIMS: The benefit of colonoscopy for colorectal cancer prevention depends on the adenoma detection rate (ADR). The ADR should reflect the adenoma prevalence rate, which is estimated to be higher than 50% in the screening-age population. However, the ADR by colonoscopists varies from 7% to 53%. It is estimated that every 1% increase in ADR lowers the risk of interval colorectal cancers by 3%-6%. New strategies are needed to increase the ADR during colonoscopy. We tested the ability of computer-assisted image analysis using convolutional neural networks (CNNs; a deep learning model for image analysis) to improve polyp detection, a surrogate of ADR. METHODS: We designed and trained deep CNNs to detect polyps using a diverse and representative set of 8,641 hand-labeled images from screening colonoscopies collected from more than 2000 patients. We tested the models on 20 colonoscopy videos with a total duration of 5 hours. Expert colonoscopists were asked to identify all polyps in 9 de-identified colonoscopy videos, which were selected from archived video studies, with or without benefit of the CNN overlay. Their findings were compared with those of the CNN using CNN-assisted expert review as the reference. RESULTS: When tested on manually labeled images, the CNN identified polyps with an area under the receiver operating characteristic curve of 0.991 and an accuracy of 96.4%. In the analysis of colonoscopy videos in which 28 polyps were removed, 4 expert reviewers identified 8 additional polyps without CNN assistance that had not been removed and identified an additional 17 polyps with CNN assistance (45 in total). All polyps removed and identified by expert review were detected by the CNN. The CNN had a false-positive rate of 7%. CONCLUSION: In a set of 8,641 colonoscopy images containing 4,088 unique polyps, the CNN identified polyps with a cross-validation accuracy of 96.4% and an area under the receiver operating characteristic curve of 0.991. The CNN system detected and localized polyps well within real-time constraints using an ordinary desktop machine with a contemporary graphics processing unit. This system could increase the ADR and decrease interval colorectal cancers but requires validation in large multicenter trials.

Sevoflurane and thiopental preconditioning attenuates the migration and activity of MMP-2 in U87MG glioma cells.

BACKGROUND: Tumor cell migration and diffuse infiltration into brain parenchyma are known causes of recurrence after treatment in glioblastoma (GBM), mediated in part by the interaction of glioma cells with the extracellular matrix, followed by degradation of matrix by tumor cell derived proteases, particularly the matrix metalloproteinases (MMP). Sevoflurane and thiopental are anesthetics commonly used in cancer surgery. However, their effect on the progression of glioma cells remains unclear. The aim of this study was to explore the role of these anesthetics on the migration and activity of MMP-2 in glioma cells. METHODOLOGY: Cultured U87MG cells were pretreated with sevoflurane or thiopental and in vitro wound healing scratch assay was carried out to analyze their effect on migration of these cells. Gelatin zymography was carried out to examine the effect of these anesthetics on tumor cell MMP-2 activity using the conditioned media 24 h after pretreatment. Cell viability was analyzed using 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) assay. RESULTS: U87MG cells exposed to 2.5% sevoflurane or different concentrations of thiopental significantly decreased migration and activity of MMP-2 compared to control. No effect was seen on the viability of these cells after pretreatment with sevoflurane or thiopental. CONCLUSION/SIGNIFICANCE: These results suggest that both sevoflurane and thiopental have inhibitory effect on the migration and MMP-2 activity in glioma cells. Thus, it is important that the choice of anesthetics to be used during glioma surgery takes into account their inhibitory properties against the tumor cells.

Audit of the Functioning of the Elective Neurosurgical Operation Theater in India: A Prospective Study and Review of Literature.

BACKGROUND: Knowledge about the utilization of the operation theater (OT) is essential to improve its efficiency. This study evaluated the neurosurgical operation theater utilization in a neurosciences teaching hospital. METHODS: Data collected included OT start time, delay in start, anesthesia induction time, surgical preparation time, anesthesia recovery time, operating time, time between cases, and theater closing time. RESULTS: Five hundred thirty-seven surgeries were performed during the study period. The percentage of time used for anesthesia induction, actual surgical procedure, recovery from anesthesia, and theater preparation between the two cases were 8%, 70%, 6% and 5%, respectively. Fourteen percent of scheduled cases were cancelled. On 220 occasions (70.51%), theater was over-run. Late start contributed to loss of 8370 minutes (140 hours) of theater time. CONCLUSIONS: This study identified the proportion of time spent on each activity in the neurosurgical OT. This knowledge is likely to facilitate better planning of neurosurgical theater schedule and result in optimal utilization.

First Case of Small Bowel Sarcomatoid Carcinoma Found by Video Capsule Endoscopy.

Sarcomatoid carcinoma of the small bowel is extremely rare. We report the first case of sarcomatoid carcinoma identified by video capsule endoscopy in a patient referred for obscure gastrointestinal bleeding. Computed tomography and small bowel follow through failed to identify the tumor. The tumor was visualized initially on video capsule endoscopy examination and a 6 x 3 cm polypoid, fungating mass with irregular borders was retrieved on surgical resection. Microscopic examination showed sheets of pleomorphic spindled to epitheliod cells staining positive for cytokeritin and vimentin, indicative of sarcomatoid carcinoma. Forty-one months after surgical resection the patient continued to be free of metastatic disease.

Improved diagnostic yield with severity of bleeding.

OBJECTIVE: Video capsule endoscopy (VCE) is an important tool for non-invasive imaging of the small bowel. Whether there is a dose-related effect of anemia severity on the diagnostic yield of VCE is unknown. The aim of this study was to determine the influence of anemia severity on VCE outcome measures. METHODS: VCE studies from the Sacramento Veterans Affairs Medical Center for 300 consecutive patients were retrospectively screened. Those with anemia were selected. Patients were grouped as mildly, moderately or severely bleeding. Outcomes data including completion of study, diagnostic yield and further intervention were compared. RESULTS: Of the 300 patients, 210 (70%) were found to have anemia. Overall 32 (15.24%) patients were mildly, 145 (69.05%) were moderately and 33 (15.71%) were severely bleeding. The diagnostic yield was significantly higher in severe (72.73%) relative to moderate (32.41%) and mild bleeding (12.50%); P = 0.0001. Significantly more angioectasias were detected in severely bleeding patients (42.42%) than in those bleeding moderately (14.48%) and mildly (0.00%), P = 0.0001. The ability of VCE to guide further intervention was significantly higher in patients bleeding severely (69.70%, P = 0.006). CONCLUSIONS: Our data showed a significant increase in diagnostic yield with the increasing degree of anemia. Relative difference in hemoglobin rather than absolute values may be a better predictor. The ability of VCE to guide further intervention reached significance in severely bleeding patients. The hypothesis that use of VCE prior to esophagogastroduodenoscopy or colonoscopy in the severely bleeding group deserves to be evaluated.

Maxillary labial fraenectomy: indications and technique.

UNLABELLED: A labial fraenectomy is indicated in various clinical situations and is performed to facilitate orthodontic closure of a maxillary midline diastema. In these clinical situations, timing of surgery during the phase of orthodontic treatment is important. Labial fraenectomy can be performed before, during or after the orthodontic closure of the maxillary midline diastema, depending on the individual case. It is important to understand how to perform the procedure efficiently and effectively. Success relies as much on accurate diagnosis of the fleshy, prominent or persistent fraenum as it does on meticulous technique to ensure its complete elimination. This article presents the indications for labial fraenectomy. The appropriate timing of the labial fraenectomy procedure to facilitate orthodontic treatment is discussed. CLINICAL RELEVANCE: A surgical technique to perform maxillary labial fraenectomy procedure in an effective and efficient manner is a useful addition to the clinician's armamentarium.

Incomplete capsule endoscopy examinations after Roux-en-Y gastric bypass.

BACKGROUND: Video capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel. Optimization of this imaging modality has focused on minimizing the rate of incomplete studies through appropriate patient selection. Recent data have shown an increased incidence of incomplete examinations in those with surgically altered gastrointestinal anatomy. METHODS: We present 4 consecutive cases of post Roux-en-Y gastric bypass patients undergoing video capsule endoscopy. RESULTS: Three patients were referred for obscure gastrointestinal bleeding and one for diagnosis of Crohn's disease; all 4 patients had incomplete studies. One patient experienced capsule retention in the gastric pouch. Two patients had repeated poor small bowel preparation despite compliance with preparatory methods. The fourth patient experienced delayed gastrointestinal transit despite satisfactory small bowel preparation. CONCLUSION: Patients with a history of Roux-en-Y surgery appear to be at increased risk for incomplete examination due to capsule retention and delayed gastric transit. Endoscopists may consider additional precursory testing or the use of alternative imaging methods in this population.

Golimumab and certolizumab: the two new anti-tumor necrosis factor kids on the block.

Anti-tumor necrosis factor (anti-TNF) agents have revolutionized treatment of psoriasis and many other inflammatory diseases of autoimmune origin. They have considerable advantages over the existing immunomodulators. Anti-TNF agents are designed to target a very specific component of the immune-mediated inflammatory cascades. Thus, they have lower risks of systemic side-effects. In a brief period of 10 years, a growing number of biological therapies are entering the clinical arena while many more biologicals remain on the horizon. With time, the long-term side-effects and efficacies of these individual agents will become clearer and help to determine which ones are the most suitable for long-term care. Golimumab (a human monoclonal anti-TNF-α antibody) and Certolizumab (a PEGylated Fab fragment of humanized monoclonal TNF-α antibody) are the two latest additions to the anti-TNF regimen. Here, we are providing a brief description about these two drugs and their uses.