Gaisbock's Syndrome: A Case Study.

A 73-year-old hypertensive was found to have new-onset polycythemia during his routine health check up. A workup revealed no evidence of polycythemia rubra vera or a secondary cause of his polycythemia (his erythropoietin level was normal, he had no splenomegaly, and a test for JAK2 v617F mutation was negative). Over the next year of follow up, his hematological profile returned to normal levels. We conclude that this patient had Gaisbock's syndrome, a relative polycythemia that occurs when there is clinically evident contraction of the intravascular fluid space (plasma volume) in smokers and people who received diuretics.

Prevalence and severity of secondary traumatic stress and optimism in Indian health care professionals during COVID-19 lockdown.

BACKGROUND: The COVID-19 pandemic has brought to light the lacunae in the preparedness of healthcare systems across the globe. This preparedness also includes the safety of healthcare providers (HCPs) at various levels. Sudden spread of COVID-19 infection has created threatening and vulnerable conditions for the HCPs. The current pandemic situation has not only affected physical health of HCPs but also their mental health. OBJECTIVE: This study aims to understand the prevalence and severity of secondary traumatic stress, optimism parameters, along with states of mood experienced by the HCPs, viz., doctors, nurses and allied healthcare professionals (including Physiotherapist, Lab technicians, Phlebotomist, dieticians, administrative staff and clinical pharmacist), during the COVID-19 lockdown in India. METHODOLOGY: The assessment of level of secondary traumatic stress (STS), optimism/pessimism (via Life Orientation Test-Revised) and current mood states experienced by Indian HCPs in the present COVID-19 pandemic situation was done using a primary data of 2,008 HCPs from India during the first lockdown during April-May 2020. Data was collected through snow-ball sampling technique, reaching out to various medical health care professionals through social media platforms. RESULT: Amongst the study sample 88.2% of doctors, 79.2 of nurses and 58.6% of allied HCPs were found to have STS in varying severity. There was a female preponderance in the category of Severe STS. Higher optimism on the LOTR scale was observed among doctors at 39.3% followed by nurses at 26.7% and allied health care professionals 22.8%. The mood visual analogue scale which measures the "mood" during the survey indicated moderate mood states without any gender bias in the study sample. CONCLUSION: The current investigation sheds light on the magnitude of the STSS experienced by the HCPs in the Indian Subcontinent during the pandemic. This hitherto undiagnosed and unaddressed issue, calls for a dire need of creating better and accessible mental health programmes and facilities for the health care providers in India.

Bilateral serous choroidal detachment in brucellosis and its management and outcome: Literature review and case report.

To report an unusual case of a 71-year-old livestock farmer with systemic brucellosis and ocular involvement. Examination showed vitreous haze with bilateral serous choroidal detachment. He was treated with topical antibiotics and corticosteroids, Tab rifampicin 600 mg and doxycycline 100 mg for 6 weeks with visual recovery and complete resolution of serous choroidal detachment in 2 weeks. This is the first case of bilateral serous choroidal detachment in a case of systemic brucellosis. Immune-mediated complex and direct microbial invasion of uveal tissue leading to serous choroidal detachment is the proposed pathogenesis that responds well to topical corticosteroids.

Fluoroscopically guided caudal epidural steroid injections in degenerative lumbar spine stenosis.

BACKGROUND: Caudal epidural steroid injections are commonly utilized to help reduce radicular pain in lumbar spinal stenosis. There have been studies done to evaluate the effectiveness of this procedure non-fluoroscopically guided. Search revealed no prospective studies evaluating the effectiveness of fluoroscopically guided caudal epidural injections on patients with bilateral radicular pain from degenerative lumbar spinal stenosis. OBJECTIVE: To evaluate the therapeutic benefit of fluoroscopically guided caudal epidural steroid injections in the treatment of bilateral radicular pain from symptomatic Degenerative Lumbar Spinal Stenosis (DLSS). DESIGN: This prospective cohort study was performed on 34 patients with bilateral radicular pain from lumbar spinal stenosis who received fluoroscopically guided caudal epidural injections at a multidisciplinary spine center as they did not improve with conservative care. The patients' degenerative lumbar spinal stenosis was confirmed by magnetic resonance imaging and classified as mild, moderate, or severe. The patients were evaluated by an independent observer and completed questionnaires, prior to initial injection, at 6 weeks, 6 months and 12 months after the injections. OUTCOME MEASURES: Visual analog scale, patient satisfaction scale, standing/walking tolerance scale and Oswestry low back pain disability questionnaire. RESULTS: A total of 34 patients met our inclusion criteria and were followed at 6 weeks, 6 months, and 12 months. Sixty-five percent of patients at 6 weeks, 62% at 6 months, and 54% at 12 months had a successful outcome, reporting at least a >50% reduction between pre-injection and post injection visual analog pain scores. Fifty nine percent of patients had an improved walking tolerance at 6 weeks (p <0.0001), 56% at 6 months (p <0.0001), and 51% at 12 months (p=0.0005). Fifty percent of patients had an improved standing tolerance at 6 weeks (p= 0.0002), 54% at 6 months (p < 0.0001), and 51% at 12 months (p=0.0005). The patient satisfaction scale revealed 64% of patients felt completely or somewhat better at 6 weeks, 59% at 6 months and 52% at 12 months. Owestry low back pain disability questionnaire scores showed statistically significant improvement from initial scores to 6 weeks (p < 0.0001), initial to 6 months (p= 0.0095), and initial to 12 months (p=0.00015). The outcome was statistically significant even in severe stenotic patients when comparing initial mean scores to 12 month mean scores in standing tolerance (p =0.2956), walking tolerance (p=0.0250), and VAS (p= 0.0199). CONCLUSION: Fluoroscopically guided caudal epidural steroid injections may help reduce bilateral radicular pain and improve standing and walking tolerance in patients with DLSS.

Massive lower gastrointestinal tract bleeding due to splenic artery aneurysm: a case report.

True aneurysm of the splenic artery is the third most common intraabdominal aneurysm and constitutes 60% of all visceral aneurysms. The incidence of splenic artery aneurysms ranges from 0.01% to as high as 10.4% in the elderly. In approximately 30% of cases, the aneurysm may rupture into a viscus. Aneurysmal rupture into the colon is a potentially fatal but extremely uncommon complication. We report a case of splenic artery aneurysm communicating with the descending colon, presenting as massive lower gastrointestinal tract bleeding. The patient was treated and survived the episode. In English literature, fewer than 15 cases have been described with only two patients surviving.

Adverse effects of fluoroscopically guided interlaminar thoracic epidural steroid injections.

OBJECTIVES: To assess the prevalence of adverse effects or complications from fluoroscopically guided thoracic interlaminar epidural steroid injections. DESIGN: A retrospective study with independent observer review. Patients presenting with thoracic radicular pain, caused by either herniated nucleus pulposus or thoracic spondylosis as confirmed by magnetic resonance imaging, received an interlaminar thoracic epidural steroid injection as part of a conservative-care treatment plan. The study was performed in a multidisciplinary spine care center. All injections were performed over a 5-yr period. An independent observer reviewed medical charts, which included a 24-hr postprocedure standardized questionnaire completed by telephone by an ambulatory surgical center nurse. Ambulatory surgical center operative reports and physician follow up office notes up to 3 mos after the procedures, along with epidurograms, were also reviewed. RESULTS: A total of 21 patients who received 39 injections were reviewed. Adverse effects or complications per injection observed included three with increased pain at injection site (7.7%), two with facial flushing (5.1%), one transient nonpositional headache (2.6%), one episode of insomnia the night of the injection (2.6%), and one episode of fever the night of the procedure (2.6%). Statistical analysis revealed no significant difference based on diagnosis (herniated nucleus pulposus vs. spondylosis, P = 0.9156), and age was not linked to higher prevalence of adverse/effects complications (P = 0.3137). CONCLUSIONS: No major complication arose. Adverse effects did occur with a rate of 20.5%. All adverse effects resolved without morbidity. No statistical difference was observed in the rate of adverse effects in patients with herniated nucleus pulposus or spondylosis.

Complications of fluoroscopically guided interlaminar cervical epidural injections.

OBJECTIVES: To assess the incidence of complications of fluoroscopically guided interlaminar cervical epidural injections. DESIGN: A retrospective cohort design study. SETTING: A multidisciplinary spine care center. PARTICIPANTS: One hundred fifty-seven consecutive patients with cervical radicular pain caused by cervical spondylosis or herniated nucleus pulposus confirmed by magnetic resonance imaging or computed tomography scanning. INTERVENTIONS: Fluoroscopically guided interlaminar cervical epidural injections were performed at the C7-T1 or C6-7 level using an 18-gauge, 9-mm Tuohy needle with 2mL of 1% lidocaine (Xylocaine) and 80-mg of triamcinolone acetonide (Kenalog). All injections were performed consecutively over a 12-month period by 1 of 5 physicians. MAIN OUTCOME MEASURES: An independent observer reviewed medical charts, which included a 24-hour postprocedure telephone call by an ambulatory surgery center nurse who asked a standardized questionnaire about complications after the injections. Also reviewed were physician notes regarding office follow-up consultations 3 weeks or less after the injections and epidurograms. RESULTS: The charts of 157 patients, who received 345 injections, were reviewed. Complications per injection included 23 increased neck pain (6.7%), 16 transient nonpositional headaches that resolved within 24 hours (4.6%), 6 episodes of insomnia the night of the injection (1.7%), 6 vasovagal reactions (1.7%), 5 facial flushing (1.5%), 1 fever the night of the procedure (0.3%), and 1 dural puncture (0.3%). The incidence of all complications per injection was 16.8%. CONCLUSIONS: Because all complications resolved without morbidity and no patient required hospitalization, fluoroscopically guided interlaminar cervical epidural injections may be a safe procedure for use in patients with cervical radicular pain.

Radiation exposure to the spinal interventionalist performing lumbar discography.

To evaluate radiation exposure to the spinal interventionalist performing lumbar discography. A prospective study on four spinal interventionalists who performed 106 consecutive lumbar discograms (levels) on 37 patients with low back pain. Radiation exposure was monitored with the assistance of a radiological technologist (RT) who allocated four (4) dosimetry badges to all spinal interventionalists performing Discograms on consecutive patients being referred for evaluation of possible discogenic pain. The badges were placed on the ring finger, glasses and both the inside and outside of the lead apron worn by the interventionalist. The mean fluoroscopy time per procedure was 57.24 seconds. The mean/cumulative exposure per procedure was 3.66(-/+0.915)/390(-/+9.750) mREM at the "ring" badge, 2.35(-/+0.635)/251(-/+6.275) mREM at the "outside apron" badge, 1.49(-/+0.373)/159(-/+3.975) mREM at the "glasses" badge. A statistically significant higher radiation exposure was found on discograms at the L5/S1 level compared to the L4/5 and L3/4 levels. Our study illustrates that radiation exposure to the spinal interventionalist performing lumbar discography is well within safety limits.

Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study.

OBJECTIVE: To identify the short- and long-term therapeutic benefit of fluoroscopically guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis. DESIGN: This prospective cohort study performed at a multidisciplinary spine center. There were a total of 34 patients who met our inclusion criteria for the treatment of unilateral radicular pain from degenerative lumbar spinal stenosis who underwent fluoroscopically guided lumbar transforaminal epidural injections. Patients with radiculopathy, who did not respond to physical therapy, antiinflammatories, or analgesics, caused by degenerative lumbar stenosis and confirmed by magnetic resonance imagining received fluoroscopically guided lumbar transforaminal epidural steroid injections at the presumed symptomatic nerve root. The injectant consisted of 12 mg of betamethasone acetate and 2 ml of 1% preservative-free lidocaine HCL. Patients were evaluated by an independent observer and received questionnaires before the initial injection, at 2 mo, and at 12 mo after the injections. Questionnaires included a visual analog scale, Roland 5-point pain scale, standing/walking tolerance, and patient satisfaction scale. RESULTS: A total of 34 patients met our inclusion criteria and were followed for 1 yr. Seventy-five percent of patients had successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, with an average of 1.9 injections per patient. Sixty-four percent of patients had improved walking tolerance, and 57% had improved standing tolerance at 12 mo. CONCLUSION: Fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with degenerative lumbar spinal stenosis.

Radiation exposure of the spinal interventionalist performing fluoroscopically guided lumbar transforaminal epidural steroid injections.

OBJECTIVE: To evaluate radiation exposure to spinal interventionalists while performing transforaminal epidural steroid injections (TFESIs). DESIGN: Prospective study. SETTING: Multidisciplinary spine center. PARTICIPANTS: One hundred consecutive patients with either herniated nucleus pulposus (HNP) or lumbar spinal stenosis (LSS). INTERVENTION: Fluroscopically guided lumbar TFESIs. MAIN OUTCOME MEASURE: Radiation exposure was monitored by radiography technologists who allocated 4 dosimetry badges to all spinal interventionalists performing fluroscopically guided lumbar TFESIs on patients being treated for radicular pain. Badges were placed on the ring finger, glasses, and the inside and outside of the lead apron worn by the interventionalists. The radiography technologists also wore marked badges outside their lead aprons. One control badge was placed 67in away from the fluoroscopy table and a second badge was placed in a desk more than 500ft away from the procedure to monitor ambient radiation. RESULTS: The average fluoroscopy time per procedure was 15.16 seconds. The average exposure per procedure was 0.7mrem at the ring badge, 0.4mrem at the glasses badge, and 0.3mrem at the outside apron badge. No radiation was detectable at the inside apron or at the outside room control badge. The cumulative exposure to the interventionalists from all 100 procedures was 70mrem at the ring badge, 40mrem at the glasses badge, and 30mrem at the outside apron badge. The radiography technologists' average exposure during these procedures was below the limit of detectablility. Radiation time under fluoroscopy ranged from 5 to 38 seconds. The interventionalist's exposure to radiation was significantly greater during procedures conducted on patients with LSS then during procedures on patients with HNP. CONCLUSION: Adhering to a radiation safety program that includes maximizing the distance the spinal interventionalist is from the radiation source, decreasing exposure time, and proper shielding is essential when performing fluoroscopically guided lumbar TFESIs. Our study shows that exposure to radiation of the spinal interventionalist performing fluoroscopically guided lumbar TFESIs was well within safety limits when proper techniques were followed.