C-Arm Fluoroscope Angle Settings for Fluoroscopically Guided Lumbar Transforaminal Epidural Injections.

BACKGROUND DATA: Minimizing fluoroscopy time in spine interventions is critical for time of procedure as well as radiation safety of the patient and medical personnel. Specific fluoroscopy angle settings for fluoroscopically guided L4-S1 transforaminal epidural injections (TFEIs) have not been described. OBJECTIVES: To describe the most common encountered settings for the C-arm fluoroscope angles for fluoroscopically guided L4-S1 (TFEI). METHODS: Each subject was placed in prone position on a flat fluoroscopy table without utilizing any device to alter innate lumbar spine curvature. The data from 246 consecutive patients at their first encounter in the fluoroscopy suite for a single level subpedicular lumbosacral TFEI was retrospectively analyzed. Most procedures occurred at the L4-5, L5-S1, and S1 levels (227 subjects). The C-arm angles including the oblique, cephalad/caudal were recorded for each subject upon observing final needle positioning for successful completion of the procedure according to ISIS Guidelines. RESULTS: For the L4-5 level, 71% of cases had oblique angle of 30°±5° and 94% of cases had neutral cephalad/caudal tilt (0°±5°) observed. For the L5-S1, 72% of cases had oblique angle of 30°±5° and 62% of cases had cephalad tilt angle of 15°±5° observed. For the S1 level, 73% of cases had oblique angle of 5°±5° and 69% of cases had cephalad tilt angle of 15°±5° observed. DISCUSSION/CONCLUSION: This retrospective descriptive study suggests fluoroscope angles for L4-S1 TFEI as a starting point before fine tuning views accounting for individual anatomy. Angles suggested for each level (oblique/cephalad tilt angles) are as follows: L4-5 (30/0°), L5-S1 (30/15°), and S1 (5/15°). Prospective studies using these guidelines would need to be undertaken to prove reproducibility between interventionalists, time efficiency, and radiation exposure reduction.

Prenatally diagnosed clubfeet: comparing ultrasonographic severity with objective clinical outcomes.

BACKGROUND: Improvements in obstetric sonography (US) have led to an increased prenatal detection of clubfoot, but studies have not been able to correlate sonographic severity to clinical deformity at birth. The purpose of this study was to decrease the false positive (FP) rate for prenatally identified clubfeet, and to predict clinical severity using a new prenatal sonographic classification system. METHODS: We retrospectively identified all pregnant patients referred to the fetal care center at our institution for a diagnosis of clubfoot between 2002 and 2007. A total of 113 fetuses were identified. Follow-up information was available for 107 fetuses (95%). Out of 107 fetuses, 17 were terminated or died shortly after birth. Seven patients had normal studies or were not seen at our center. Out of 83 patients, 42 had an US available for rereview. A novel sonographic severity scale for clubfoot (mild/moderate/severe) was assigned by a radiologist specializing in prenatal US to each fetus based on specific anatomic features. The prenatal sonographic scores were then assessed with respect to final postnatal clinical diagnosis and to clinical severity. RESULTS: None of the pregnancies were terminated because of an isolated diagnosis of clubfoot. Of the remaining 83 fetuses with a prenatal diagnosis of at least 1 clubfoot, 67 had a clubfoot documented at birth (FP=19%). A foot classified as "mild" on prenatal US was significantly less likely to be a true clubfoot at birth than when a "moderate" or "severe" diagnosis was given (Odds Ratio=21, P<0.0001). If "mild" clubfoot patients were removed from the analysis, our FP rate decreased to 3/42. For a subgroup in which postnatal DiMeglio scoring was available, prenatal sonographic stratification of clubfoot did not relate to postnatal clinical severity. CONCLUSIONS: Our initial experience with this novel sonographic scoring system showed improved detection of a true clubfoot prenatally and a decrease in the FP rate. An isolated "mild" clubfoot diagnosed on a prenatal sonogram is less likely to be a clubfoot at birth; this will have substantial impact on prenatal counseling. LEVEL OF EVIDENCE: Level III Diagnostic Study.

Decoding twitter: Surveillance and trends for cardiac arrest and resuscitation communication.

AIM OF THE STUDY: Twitter has over 500 million subscribers but little is known about how it is used to communicate health information. We sought to characterize how Twitter users seek and share information related to cardiac arrest, a time-sensitive cardiovascular condition where initial treatment often relies on public knowledge and response. METHODS: Tweets published April-May 2011 with keywords cardiac arrest, CPR, AED, resuscitation, heart arrest, sudden death and defib were identified. Tweets were characterized by content, dissemination, and temporal trends. Tweet authors were further characterized by: self-identified background, tweet volume, and followers. RESULTS: Of 62,163 tweets (15,324, 25%) included resuscitation/cardiac arrest-specific information. These tweets referenced specific cardiac arrest events (1130, 7%), CPR performance or AED use (6896, 44%), resuscitation-related education, research, or news media (7449, 48%), or specific questions about cardiac arrest/resuscitation (270, 2%). Regarding dissemination (1980, 13%) of messages were retweeted. Resuscitation specific tweets primarily occurred on weekdays. Most users (10,282, 93%) contributed three or fewer tweets during the study time frame. Users with more than 15 resuscitation-specific tweets in the study time frame had a mean 1787 followers and most self-identified as having a healthcare affiliation. CONCLUSION: Despite a large volume of tweets, Twitter can be filtered to identify public knowledge and information seeking and sharing about cardiac arrest. To better engage via social media, healthcare providers can distil tweets by user, content, temporal trends, and message dissemination. Further understanding of information shared by the public in this forum could suggest new approaches for improving resuscitation related education.