A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up.

BACKGROUND: Allografts and polyetheretherketone (PEEK) cages are the two most commonly used materials in anterior cervical discectomy and fusion (ACDF). However, their effectiveness in two-level ACDF remains controversial. The primary aim of this retrospective study was to compare the clinical and radiological outcomes of two-level ACDF with plate fixation using either a structural allograft or a PEEK cage. METHODS: From 2010 to 2015, 88 consecutive patients underwent two-level ACDF, of whom 53 received an allograft and 35 patients received a PEEK cage. All PEEK cages were filled with local autografts. All clinical outcomes were prospectively collected before and six months and two years after surgery. Clinical efficacy was evaluated using a visual analogue scale for neck pain and limb pain, the Neck Pain and Disability Score, the Neck Disability Index, the Neurogenic Symptom Score, and the Japanese Orthopedic Association score. Radiological outcomes were assessed preoperatively, immediately after surgery, and at the final follow-up. RESULTS: A preoperative comparison revealed no difference between the two patient groups in terms of age, sex, body mass index, smoking status, preoperative symptoms, operation level, or follow-up (mean = 42.8 months). No differences in the improvements in clinical outcomes were observed between the two groups. Both groups showed significant improvement in mean disc height, segmental height, and segmental lordosis postoperatively. The fusion rate for the PEEK cage was 100% at both levels, while the fusion rate for the allograft group was 98.1% at the cephalad level and 94.2% at the caudad level (p > 0.05). Subsidence at the cephalad level occurred in 22.9% (8/35) of segments in the PEEK group and 7.7% (4/52) of segments in the allograft group (p = 0.057). At the caudal level, a higher incidence of cage subsidence was noted in the PEEK group than in the allograft group [37.1% (13/35) versus 15.4% (8/52)] (p = 0.02). Overall, subsidence was noted in 30% (21/70) of the PEEK group and in 11% (12/104) of the allograft group (p <  0.05). CONCLUSION: The use of PEEK cages resulted in a higher rate of subsidence in two-level ACDF than the use of allografts. Two-level ACDF using either allografts or PEEK cages resulted in similar clinical outcomes, radiological improvements in alignment and fusion rates.

The effect of the comorbidity burden on vitamin D levels in geriatric hip fracture.

BACKGROUND: Elderly patients with hip fractures often have multiple medical comorbidities, and vitamin D deficiency is common in this population. Accumulating evidence links low vitamin D levels to various comorbidities. However, very little is known about the collective impact of comorbidities on vitamin D levels. The Charlson Comorbidity Index (CCI) is a validated comorbidity burden index. We hypothesized that a high CCI score is associated with vitamin D deficiency in elderly patients with hip fracture. METHODS: A retrospective cohort study was conducted among all hospitalized elderly patients aged > 60 years admitted for low-energy hip fracture in a single tertiary hospital from 2013 to 2015. Data regarding patient demographics, fracture type, serum 25-hydroxyvitamin D3 levels and age-adjusted CCI score were collected and analysed. RESULTS: Of the 796 patients included in the study, 70.6% (n = 562) of the patients were women and the mean age was 77.7 ± 8.0 years. The mean vitamin D level was 20.4 ± 7.4 ng/mL, and 91.7% ofhospitalized elderly patients with hip fracture had inadequate vitamin D level. There was no correlation between the individual serum vitamin D level with respect to age-adjusted CCI (Pearson correlation coefficient = 0.01; p = 0.87). After stratifying the CCI scores into low and high comorbidity burden groups (i.e., with scores 1-2 and ≥ 3), there was no relationship between the 2 subgroups for age-adjusted CCI and vitamin D levels (p = 0.497). Furthermore, there was also no association among age, gender, fracture type, and smoking status with the mean 25(OH)D level (p > 0.05). CONCLUSION: Low vitamin D levels were highly prevalent in our hip fracture cohort. There was no relationship between the CCI score and vitamin D levels in the geriatric hip population. The comorbidity burden in geriatric patients with hip fractures did not seem to be a significant factor for vitamin D levels.

Salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty: A network meta-analysis.

BACKGROUND: We aim to provide an evidence-based literature review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty with a network meta-analysis. METHODS: A search of PubMed, Embase and Cochrane databases was conducted in December 2016 which identified 12 relevant articles out of 340 articles assessing the efficacy of salvage arthrodesis for failed joint arthroplasty of the first metatarsophalangeal joint. The 12 studies were assigned a level of evidence (I-V) and interventions were graded a level of recommendation (A-C, I) in support of or against the treatment modality. RESULTS: There is fair evidence (grade B) to support salvage arthrodesis with structural bone graft. There is poor evidence (grade C) for salvage arthrodesis without bone graft. There was no good evidence (grade A) to recommend either intervention. Meta-analysis showed that salvage arthrodesis resulted in improved functional outcome over time. CONCLUSIONS: Salvage arthrodesis showed good bone union rates and patient satisfaction. LEVEL OF CLINICAL EVIDENCE: III - Systematic Review of Level III studies.

Randomized trial comparing effects of weight loss by liraglutide with lifestyle modification in non-alcoholic fatty liver disease.

BACKGROUND & AIMS: We compared the effects of weight loss induced with the glucagon-like peptide-1 agonist liraglutide, with that of lifestyle modification, followed by weight maintenance after discontinuing intervention, in obese adults with non-alcoholic fatty liver disease (NAFLD). METHODS: Thirty obese (mean age 40.7 ± 9.1 years, BMI 33.2 ± 3.6 kg/m2 , 90% male) adults with NAFLD defined as liver fat fraction (LFF) > 5% on magnetic resonance imaging without other causes of hepatic steatosis were randomized to a supervised programme of energy restriction plus moderate-intensity exercise to induce ≥ 5% weight loss (DE group, n = 15), or liraglutide 3 mg daily (LI group, n = 15) for 26 weeks, followed by 26 weeks with only advice to prevent weight regain. RESULTS: Diet and exercise and LI groups had significant (P < 0.01) and similar reductions in weight (-3.5 ± 3.3 vs -3.0 ± 2.2 kg), LFF (-8.1 ± 13.2 vs -7.0 ± 7.1%), serum alanine aminotransferase (-39 ± 35 vs -26 ± 33 U/L) and caspase-cleaved cytokeratin-18 (cCK-18) (-206 ± 252 vs -130 ± 158 U/L) at 26 weeks. At 52 weeks, the LI group significantly (P < 0.05) regained weight (1.8 ± 2.1 kg), LFF (4.0 ± 5.3%) and cCK-18 (72 ± 126 U/L), whereas these were unchanged in the DE group. CONCLUSIONS: Liraglutide was effective for decreasing weight, hepatic steatosis and hepatocellular apoptosis in obese adults with NAFLD, but benefits were not sustained after discontinuation, in contrast with lifestyle modification. Continuing the exercise learned in the structured programme contributed to the maintenance of liver fat reduction.

Effects of water stably-enriched with oxygen as a novel method of tissue oxygenation on mitochondrial function, and as adjuvant therapy for type 2 diabetes in a randomized placebo-controlled trial.

BACKGROUND: Diabetes mellitus is associated with inadequate delivery of oxygen to tissues. Cellular hypoxia is associated with mitochondrial dysfunction which increases oxidative stress and hyperglycaemia. Hyperbaric oxygenation therapy, which was shown to improve insulin sensitivity, is impractical for regular use. We evaluated the effects of water which is stably-enriched with oxygen (ELO water) to increase arterial blood oxygen levels, on mitochondrial function in the presence of normal- or high-glucose environments, and as glucose-lowering therapy in humans. METHODS: We compared arterial blood oxygen levels in Sprague-Dawley rats after 7 days of ad libitum ELO or tap water consumption. Mitochondrial stress testing, and flow cytometry analysis of mitochondrial mass and membrane potential, were performed on human HepG2 cells cultured in four Dulbecco's Modified Eagle Medium media, made with ELO water or regular (control) water, at normal (5.5 mM) or high (25 mM) glucose concentrations. We also randomized 150 adults with type 2 diabetes (mean age 53 years, glycated haemoglobin HbA1c 8.9% [74 mmol/mol], average duration of diabetes 12 years) to drink 1.5 litres daily of bottled ELO water or drinking water. RESULTS: ELO water raised arterial oxygen tension pO2 significantly (335 ± 26 vs. 188 ± 18 mmHg, p = 0.006) compared with tap water. In cells cultured in control water, mitochondrial mass and membrane potential were both significantly lower at 25 mM glucose compared with 5.5 mM glucose; in contrast, mitochondrial mass and membrane potential did not differ significantly at normal or high glucose concentrations in cells cultured in ELO water. The high-glucose environment induced a greater mitochondrial proton leak in cells cultured in ELO water compared to cells cultured in control medium at similar glucose concentration. In type 2 diabetic adults, HbA1c decreased significantly (p = 0.002) by 0.3 ± 0.7% (4 ± 8 mmol/mol), with ELO water after 12 weeks of treatment but was unchanged with placebo. CONCLUSIONS: ELO water raises arterial blood oxygen levels, appears to have a protective effect on hyperglycaemia-induced reduction in mitochondrial mass and mitochondrial dysfunction, and may be effective adjuvant therapy for type 2 diabetes.

Prognostic impact of stress echocardiography with discordant stress electrocardiography in patients with suspected coronary artery disease.

INTRODUCTION: During stress echocardiography, the echocardiologist routinely collects both echocardiographic images and stress electrocardiogram (ECG) concurrently. The managing physician faces a dilemma when the stress ECG and stress echocardiography results are discordant; for example, when a patient has negative stress echocardiography but positive stress ECG. We therefore sought to evaluate the prognostic value of stress echocardiography in relation to concordant or discordant stress ECG findings in our local Singapore setting, which has a well-defined Southeast Asian population. METHODS: This was a retrospective observational study of all patients who underwent stress echocardiography in 2012 at Changi General Hospital, Singapore. All study patients were followed up for 18 months via electronic medical records. RESULTS: There was no difference in the major adverse cardiovascular events (MACE) outcome of patients with normal stress echocardiography and normal stress ECG (reference group) as compared with patients with normal stress echocardiography but positive (discordant) stress ECG (odds ratio 2.02, 95% confidence interval 0.82‒4.98; p = 0.125). CONCLUSION: This study will help to reassure cardiologists that discordant results (negative stress echocardiography but positive stress ECG) do not portend a higher risk of MACE when compared to concordant results (i.e. both stress echocardiography and stress ECG are negative).

Endoscopic plantar fasciotomy for plantar fasciitis: A systematic review and network meta-analysis of the English literature.

BACKGROUND: Currently, there is limited evidence on outcomes for endoscopic plantar fasciotomy. OBJECTIVES: An evidence-based literature review for outcomes of endoscopic plantar fasciotomy for the treatment of plantar fasciitis is provided. METHODS: A comprehensive evidence-based literature review of PubMed and Cochrane databases was conducted on 9th March 2019, which identified 12 relevant articles assessing the efficacy of endoscopic plantar fasciotomy. The studies were then assigned to a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against endoscopic plantar fascia release. RESULTS: Based on the results of this evidence-based review, there is poor evidence (grade C) to support endoscopic plantar fascia release. Release of the medial 2/3 of the plantar fascia in endoscopic plantar fasciotomy was associated with higher AOFAS score. CONCLUSION: Although the majority of the level of evidence was low (level IV) and grade of recommendation was poor (grade C), there seemed to be good outcomes for endoscopic plantar fasciotomy. There is a need for more high quality level I randomized controlled trials with validated outcome measures to allow for stronger recommendations to be made.

Primary breast lymphoma: A single-centre experience.

BACKGROUND: Primary non-Hodgkin lymphoma is an extremely rare entity, and this condition represents less than 0.5% of all malignant lesions involving the mammary gland. As such, there has been a paucity of relevant clinical data arising from Southeast Asia. AIMS: Our study aims to review the clinical presentation, diagnostic methods, treatment, and survival outcomes of all patients diagnosed with primary breast lymphoma in our institution between 2011 and 2017. METHODS AND RESULTS: Patients who had histologically proven lymphoma involving the breast were identified from a prospectively collected database in a single institution between 2011 and 2017. All seven patients were female, with a median age of 65 years old, and had presented with unilateral large breast or axillary masses. All the histological diagnosis was achieved with adequate tissue diagnosis either through core, incisional, or excisional biopsy. Five patients had diffuse large B cell lymphoma, one had marginal zone lymphoma, and the other had follicular lymphoma. Based on Ann Arbor classification, one patient had stage 1, three had stage 2, one with stage 3, and two patients with stage 4 disease. Five patients had received standard CHOP regimen with rituximab. At the time of analysis, patients who had nondisseminated disease had a median survival of 57 months. The overall mean survival time for all seven patients was 47 months. With the standard systemic chemotherapy treatment regimen, the estimated 3-year overall survival was found to be 64%. CONCLUSION: Primary breast lymphoma, though uncommon, may present in a similar manner as breast carcinomas, but the main treatment modality remains nonsurgical with systemic chemotherapy. Hence, it is prudent to obtain accurate histological diagnosis of primary breast lymphoma. In this study, our patients with nondisseminated breast lymphoma have demonstrated a fairly good survival outcome following chemotherapy.

Accuracy and clinical outcomes of coronary CT angiography for patients with suspected coronary artery disease: a single-centre study in Singapore.

INTRODUCTION: This study aimed to assess the accuracy and outcomes of coronary computed tomography angiography (CCTA) performed in a regional hospital in Singapore. METHODS: The Changi General Hospital CCTA database was retrospectively analysed over a 24-month period. Electronic hospital records, catheter coronary angiography (CCA) and CCTA electronic databases were used to gather data on major adverse cardiovascular events (MACE) and CCA results. CCTA findings were deemed positive if coronary artery stenosis ≥ 50% was reported or if the stenosis was classified as moderate or severe. CCA findings were considered positive if coronary artery stenosis ≥ 50% was reported. RESULTS: The database query returned 679 patients who had undergone CCTA for the evaluation of suspected coronary artery disease. Of the 101 patients in the per-patient accuracy analysis group, there were six true negatives, one false negative, 81 true positives and 13 false positives, resulting in a negative predictive value of 85.7% and positive predictive value of 86.2%. The mean age of the study sample was 53 ± 13 years and 255 (37.6%) patients were female. Mean duration of patient follow-up was 360 days. Of the 513 negative CCTA patients, none developed MACE during the follow-up period, and of the 164 positive CCTA patients, 19 (11.6%) developed MACE (p < 0.001). CONCLUSION: Analysis of CCTA studies suggested accuracy and outcomes that were consistent with published clinical data. There was a one-year MACE-free warranty period following negative CCTA findings.