Comprehensive Spinal Tuberculosis Score: A Clinical Guide for the Management of Thoracolumbar Spinal Tuberculosis.

STUDY DESIGN: A newly proposed scoring tool was designed to assist in the clinical management of adult thoracolumbar spinal tuberculosis (TB). PURPOSE: To formulate a comprehensive yet simple scoring tool to guide decision-making in the management of adult thoracolumbar spinal TB. OVERVIEW OF LITERATURE: Spine surgeons have differing consensus in defining the threshold grade for clinico-radiological parameters when deciding between operative or conservative treatment for adult thoracolumbar spinal TB. Currently, the void in decision-making from the lack of well-defined guidelines is compensated by the surgeon's experience in treating these patients. To the best of our knowledge, no scoring system holistically integrates multiple facets of spinal TB to guide clinical decision-making. METHODS: The RAND/University of California, Los Angeles appropriateness method was employed among an expert panel of 10 spine surgeons from four apex tertiary care centers. Vital characteristics that independently influenced treatment decisions in spinal TB were identified, and a scoring tool was formulated. Points were assigned for each component based on their severity. The cutoff scores to guide clinical management were determined from the receiver operating characteristic curve based on the retrospective records of 151 patients treated operatively or non-operatively with improved functional outcomes at the 1-year follow-up. RESULTS: The components of the comprehensive spinal TB score (CSTS) are pain, kyphosis angle, vertebral destruction, and neurological status. A score classification of <5.5, 5.5-6.5, and >6.5 was established to guide the patient toward conservative, conservative/ operative, and operative management, respectively. CONCLUSIONS: The CSTS was designed to reflect the essential indicators of mechanical stability, neurological stability, and disease process stabilization in spinal TB. The scoring tool is devised to be practical and serve as a common language in the spine community to facilitate discussions and decision-making in thoracolumbar spinal TB. The validity, reliability, and reproducibility of this tool must be assessed through multicenter long-term studies.

A novel technique of managing an irreducible posteriorly displaced type 2 odontoid fracture: A case report.

Background: Type 2 odontoid fractures with posterior displacement are rare. Most acute cases reported in the literature are readily reduced with traction alone. Here, we reviewed the management of a chronic, posteriorly displaced odontoid fracture that was managed with a unique posterior reduction maneuver. Case Description: A 58-year-old male with a chronic type 2 retro-odontoid displaced fracture was managed with traction and an anterior force applied to the displaced odontoid fragment using rods attached to bilateral C1 lateral mass screws. Notably, this included a simultaneous cantilever maneuver using a lever placed between the C1 and C2 facet joints. Following reduction, an atlantoaxial fusion was performed. The postoperative course of the patient was uneventful and the bone union was achieved in 1 year. Conclusion: Closed reduction is rarely successful in chronic posteriorly displaced type 2 odontoid fractures. These cases require meticulous open reduction and fixation.

Giant Cell Tumor of the Proximal Fibula With Common Peroneal Nerve Neuropraxia.

Giant cell tumor (GCT) is among the commonest benign tumors and represents 5% of bone neoplasms. It is more common in young adults aged between 20 and 40 years. The distal femur is one of the most common sites, with the proximal tibia and distal radius the next frequently involved site, respectively. Previous research indicates that the tumor is an uncommon occurrence at this given age and location. Surgical management is the primary treatment for GCT universally. Extended curettage with the use of an argon beam cauterizer, a power burr, bone cement, hydrogen peroxide, phenol, liquid nitrogen, and zinc chloride are some of the treatment modalities for GCT. Opting for appropriate surgical treatments plays a crucial role to reduce the rate of recurrence and improve functional and oncological outcomes. In this case study, a 55-year-old male was diagnosed with GCT of the head of the right fibula with foot drop. The patient was managed with wide excision of the tumor and anchoring of lateral collateral ligament and biceps femoris to medial tibia condyle followed by postoperative galvanic stimulation for common peroneal nerve neuropraxia and guarded weight-bearing mobilization with bracing for knee joint. After 12 months of follow-up, there is no evidence of recurrence with a stable knee joint and dorsiflexion of the right ankle up to the neutral position.

Utility of the Interferon-Gamma Release Assay for Latent Tuberculosis Infection Screening among Indian Health-Care Workers.

BACKGROUND: The utility of interferon-gamma release assays (IGRAs) for latent tuberculosis infection (LTBI) screening among health-care workers (HCWs) in low- and middle-income countries (LMICs) remains unclear. METHODS: This was a prospective cohort study among HCW trainees undergoing annual LTBI screening via tuberculin skin test (TST) and QuantiFERON® TB Gold Test-in-tube (QFT-GIT) in Pune, India. TST induration ≥ 10 mm and QFT-GIT ≥ 0.35 IU/ml were considered positive. Test concordance was evaluated at entry among the entire cohort and at 1 year among baseline TST-negative participants with follow-up testing. Overall test agreement was evaluated at both timepoints using the kappa statistic: fair (k < 0.40), good (0.41 ≥ k ≤0.60), or strong (k > 0.60). RESULTS: Of 200 participants, prevalent LTBI was detected in 42 (21%) via TST and 45 (23%) via QFT-GIT; QFT-GIT was positive in 27/42 (64%) TST-positive and 18/158 (11%) TST-negative trainees. Annual TST conversion was 28% (40/142) and included 11 trainees with baseline TST-/IGRA+; QFT-GIT was positive in 17/40 (43%) TST-positive and 5/102 (5%) TST-negative trainees. Overall test concordance was 84% (k = 0.52; 95% confidence interval [CI]: 0.38-0.66) and 80% (k = 0.44; 95% CI: 0.29-0.59) at baseline and 12 months, respectively. CONCLUSIONS: We observed good overall agreement between TST and QFT-GIT, and QFT-GIT detected additional LTBI cases among TST-negative trainees with possible early detection of LTBI conversion. Overall, our results support the use of IGRA for annual LTBI screening among HCWs in a high burden LMIC setting.

Primary Total Hip Replacement in a Case of Unilateral Hypo Plastic Proximal Femur - A Case Report.

INTRODUCTION: Primary total hip replacement in hypo plastic proximal femur is difficult due to the presence of a small canal, soft- tissue contracture, fragility of bone, and poor femoral cement mantle when used. Intraoperatively, there could be occurrence of fracture of the femur, inadequate fit, and fill with cement less femoral component.It is found unilaterally in cases of osteonecrosis of femoral head, post- traumatic, and in sequelae of childhood septic arthritis. CASE REPORT: A 45-year- old male patient presented to the OPD with complaints of pain in the left hip and difficulty in walking since for 4 years. The patient had a history of fever and swelling over the left hip in childhood with no treatment taken for the same. X-ray of pelvis with both hips showed deformed femoral head, short neck, narrow femoral canal (Grade 1 Dorr), and arthritic changes in acetabulum. We managed with total hip replacement using Wagner cone stem. Postoperatively, the patient is having good range of motion and having no difficulty in walking and weight- bearing. Functional outcome is good as per Harris hip score. CONCLUSION: Total hip replacement in hypo plastic femur with arthritis is always a challenging problem. It requires surgical expertise and proper implant selection and pre-operative planning, which prevents intraoperative and post-operative complications. Wagner cone stem is a very good option in managing this type of patients.

Diabetes Mellitus and Tuberculosis Treatment Outcomes in Pune, India.

BACKGROUND: Diabetes mellitus (DM) increases the risk of tuberculosis (TB) disease. Knowledge of the impact of DM on TB treatment outcomes is primarily based on retrospective studies. METHODS: We conducted a prospective cohort study of new pulmonary TB patients with and without DM (TB-DM and TB only) in India. The association of DM with a composite unfavorable TB treatment outcome (failure, recurrence, mortality) over 18 months was determined, and the effect of DM on all-cause mortality and early mortality (death during TB treatment) was assessed. RESULTS: Of 799 participants, 574 (72%) had TB only and 225 (28%) had TB-DM. The proportion of patients with DM who experienced the composite outcome was 20%, as compared with 21% for TB-only participants (adjusted hazard ratio [aHR], 1.13; 95% CI, 0.75-1.70). Mortality was higher in participants with DM (10% vs 7%), and early mortality was substantially higher among patients with DM (aHR, 4.36; 95% CI, 1.62-11.76). CONCLUSIONS: DM was associated with early mortality in this prospective cohort study, but overall unfavorable outcomes were similar to participants without DM. Interventions to reduce mortality during TB treatment among people with TB-DM are needed.

Detection of genital tuberculosis among women with infertility using best clinical practices in India: An implementation study.

BACKGROUND: Diagnosis of genital tuberculosis (TB) as a cause of infertility still remains a diagnostic dilemma for clinicians, as no standard guidelines exist. The recently proposed best practices for genital TB diagnosis have not been evaluated yet in India. OBJECTIVES: To implement best practices to diagnose and treat likely genital TB as a cause of infertility. METHODS: Between April 2016 and June 2018, consenting women seen at a tertiary hospital infertility clinic were assessed by thorough TB related clinical history, ultrasonography, tuberculin skin test (TST), and ESR. Those with suspected genital TB underwent laparohysteroscopy. Clinical and laboratory characteristics were compared between likely (microbiologically confirmed or probable TB) and unlikely (possible and no genital TB) genital TB. Fertility outcome was assessed among women initiated on anti-TB treatment (ATT). RESULTS: Of 185 women seeking infertility care, likely genital TB was identified among 29 (15.7%) women, with 6 (21%) confirmed and 23 (79%) probable genital TB. Compared to unlikely genital TB cases, the likely genital TB group were found to have past history of TB (p < 0.001); positive TST (p = 0.002) and elevated ESR (p = 0.001). Among the likely genital TB group, all 6 confirmed genital TB were started on ATT and 2 (33.3%) conceived. Of 5 probable genital TB started on ATT, 3 (60%) conceived. CONCLUSION: Approximately 1/6th of women seeking infertility care met the criteria for likely genital TB. Conception among over-half of treated probable genital TB cases provides preliminary evidence that best clinical practices can be utilized, but needs further confirmatory studies.

Cervical corpectomy in delayed presentation of irreducible cervical dislocation: experience with eight cases.

OBJECTIVE: To describe a single-staged procedure for the management of neglected subaxial cervical spine injuries. METHODS: Between January 2012 and December 2014, 12 patients presented to us with healed cervical sub axial dislocations. The deformities could not be reduced using skull traction. Eight were operated with anterior cervical corpectomy. American spinal injury Association (ASIA) grade, Neck Disability index (NDI), and Visual analog scale (VAS) score were recorded throughout the patient course and CT was done at 12 months for assessment of fusion. RESULTS: Four patients improved from ASIA C to ASIA D, two patients improved from ASIA B to ASIA E, one patient improved from ASIA D to ASIA E and one patient remained static at ASIA B. All patients except one showed evidence of fusion on CT scan at 12 months. NDI improved from preoperative range (18-32, mean 25) to postoperative range (8-16 mean, 11.25), VAS from preoperative range (3-6, mean 4.25) to postoperative range (1-3, mean 1.75). CONCLUSIONS: Single-stage in situ fixation does not disrupt ongoing natural healing and has good clinical and radiological outcomes.

The Neck of Femur Fracture in an Elderly Patient with Schizophrenia and Parkinsonism Managed with Dual Mobility Total Hip Replacement- A Rare Case Report.

Introduction: Neck of femur fractures is the most common fractures in elderly people as they present with osteoporosis. There is a higher chance of proximal femur fracture in a schizophrenic patient as there is a loss of bone mineral density due to a drug-induced increase in the level of prolactin and immobility. Patients with Parkinson's disease were at higher risk for the development of hip fractures due to gait disturbances and instability. Case Report: A 63-year-old male patient presented with complaints of the right arm pain, swelling, deformity of the right arm, and difficulty in extending the wrist for 3 days. The patient had a history of falls and trauma to the left arm at home. X-ray right arm showed distal one-third spiral humerus fracture for which intramedullary nailing was done. X-ray of the pelvis with both hips showed right neck of femur fracture with associated greater trochanter (GT) fracture. We managed with total hip replacement using a dual mobility cup and tension band wiring for GT fracture. Postoperatively, the patient has a good range of motion at the hip. The functional outcome is good as per Harris's hip score. Conclusion: Neck femur fractures in elderly patients with associated comorbidities such as schizophrenia and parkinsonism are best managed with total hip replacement using a dual mobility cup. It avoids the risk of dislocation in high-risk patients and prevents secondary procedures. Careful clinical and radiological examination of the pelvis is very essential even in asymptomatic patients with a history of trauma to prevent delayed diagnosis of these types of fractures in patients with schizophrenia and parkinsonism.

Primary Total Knee Replacement in a Case of Lateral Tibial Condyle Delayed Union with Severe Grade 4 Osteoarthritis Knee - A Case Report.

INTRODUCTION: Tibial plateau fractures are not uncommon. These fractures occur in bimodal age distribution consisting of 8% of all geriatric fractures. They usually occur as a result of low-energy trauma in the elderly. The management options include closed/open reduction and internal fixation (ORIF) using screws and plates. The osteosynthetic treatment options cause malreduction, non-union, implant failure in elderly patients due to osteoporosis and this may lead to post-traumatic arthritis, requiring total knee replacement (TKR) as a secondary procedure later. CASE REPORT: A 76-year-old male patient presented with pain and swelling in the left knee with a history of trauma to the left knee. X-ray of the left knee showed the split fracture of the left lateral tibial condyle with severe Grade 4 osteoarthritis. On examination, tenderness was present over the lateral tibial condyle. We managed with cemented primary TKR using stemmed tibial component. Postoperatively, the patient is having good knee range of motion and having no difficulty in walking and weight-bearing. Functional outcome is good as per Oxford knee score. CONCLUSION: Primary TKR is a viable alternative treatment option compared to ORIF in elderly patients with preexisting osteoarthritis with tibial condyle fractures. It helps in early mobilization, weight-bearing and avoids secondary surgical procedures.

Impact of the Fogarty Training Program on Trainee and Institutional Research Capacity Building at a Government Medical College in India.

Background: Strengthening health research is essential to inform public health policies. However, few research training programs have systematically measured their impact on capacity building and most evaluations have been limited to reporting of individual trainee metrics. Hence, we conducted an evaluation of the impact of a five-year training program focused on building both trainee and institutional research capacity at a public medical college in India. Methods: Quantitative and qualitative methods were used to assess the individual and institutional research capacity building of a five-year HIV-TB research training program at Byramjee Jeejeebhoy Government Medical College in Pune, India, supported by the US National Institutes of Health, Fogarty International Center. In addition to documentation of the number of trainee research projects initiated, the number of research papers produced by the Fogarty Scholars (FSs) available on PubMed was calculated. The institutional impact of this program was assessed by documentation of research training activities conducted by the FSs, as well as by surveys and in-depth interviews conducted at the beginning and end of the program. Results: Twenty-one mid-level BJGMC faculty were provided training in HIV-TB research competencies. Between 1 April 2014 and 1 April 2019, 13 of these FSs designed and implemented new IRB-approved research studies and contributed to 49 PubMed listed research papers, including 11 first-authored manuscripts. FSs also conducted 36 journal club discussions, mentored 58 student research projects and conducted 5 institutional research method workshops. Pre- and-post-program surveys and in-depth interviews documented a perceived increase in institutional research capacity, particularly in TB research (epidemiology, clinical research, laboratory research). The impact of the Fogarty Training Program on institutional scientific output was perceived to be marginally improved. Conclusion: The Fogarty Training Program had a significant impact on building individual research capacity. To sustain this impact beyond the five years of Fogarty support, additional governmental and institutional resources, the establishment of dedicated space for faculty research and protected faculty time for research are needed. These findings can inform the design and implementation of future health research capacity building initiatives.

Intensified Short Symptom Screening Program for Dengue Infection during Pregnancy, India.

Mosquitoborne diseases (e.g., malaria, dengue, and chikungunya) are endemic to India and pose diagnostic challenges during pregnancy. We evaluated an intensified short symptom screening program in India to diagnose dengue during pregnancy. During October 2017-January 2018, we screened pregnant women during antenatal surveillance for symptoms of mosquitoborne diseases (fever only, fever with conjunctivitis, fever with rash, or all 3 symptoms) within the previous 15 days. Of 5,843 pregnant women screened, 52 were enrolled and tested for dengue, chikungunya, and Zika viruses by using a Trioplex real-time reverse transcription PCR. Of 49 who had complete results, 7 (14%) were dengue positive. Of these ocular pain was seen in 4 (57%) and conjunctivitis in 7 (100%). Intensified symptom screening using conjunctivitis, in addition to rash, in pregnant women with fever might improve dengue case detection and can be included in routine symptom screening during pregnancy.

Cervical Myelopathy and Lumbar Spondylolisthesis in Elderly Patients with Diffuse Idiopathic Skeletal Hyperostosis (DISH) - A Case Series.

INTRODUCTION: Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory disease, which causes the ossification of spinal longitudinal ligaments and enthesis leads to stiffness in the affected segment of the spine and neurological deficit due to compression of spinal cord or nerve roots by osteophytes. CASE PRESENTATION: We present three cases of DISH, presented with cervical myelopathy, lumbar spondylolisthesis, and dysphagia. All three patients had neurodeficit and radiological examination showed cord compression, canal stenosis, listhesis, and contiguous ossification in the spine with normal sacroiliac joints. The first patient had cervical myelopathy because of compression of cord by ossified posterior longitudinal ligament, which was managed with posterior laminectomy, decompression, and stabilization. The second patient had L4-L5 listhesis with canal stenosis, which was managed with decompression, instrumentation and fusion (TLIF). The third patient had cervical myelopathy due to C6-C7 listhesis and also had dysphagia because of compression of esophagus by anterior osteophytes, which was managed with removal of anterior osteophytes and anterior discectomy and fusion (ACDF). Postoperatively, all three patients recovered completely with no residual neurodeficit. CONCLUSION: DISH can present in various ways, which depends on the site of involvement in the spine. Early surgical intervention helps in getting a better outcome in patients with neurodeficit and prevents further complications.

High risk for latent tuberculosis infection among medical residents and nursing students in India.

Defining occupational latent tuberculosis infection (LTBI) risk among healthcare workers is needed to support implementation of prevention guidelines. Prospective cohort study of 200 medical residents and nursing students in India was conducted May 2016-December 2017. Tuberculin skin test (TST) and QuantiFERON TB Gold Test-in-tube (QFT-GIT) were performed at study entry and 12 months. Primary outcome was incident LTBI (≥10mm TST induration and/or ≥0.35IU/mL QFT-GIT) at 12 months; secondary outcomes included baseline LTBI prevalence and risk factors for incident and prevalent LTBI using Poisson regression. Among 200, [90 nursing students and 110 medical residents], LTBI prevalence was 30% (95% CI, 24-37); LTBI incidence was 26.8 (95% CI, 18.6-37.2) cases per 100 person-years and differed by testing method (28.7 [95% CI, 20.6-38.9] vs 17.4 [95% CI, 11.5-25.4] cases per 100 person-years using TST and QFT-GIT, respectively). Medical residents had two-fold greater risk of incident LTBI than nursing students (Relative Risk, 2.16; 95% CI, 1.05-4.42). During study period 6 (3%) HCWs were diagnosed with active TB disease. Overall, median number of self-reported TB exposures was 5 (Interquartile Range, 1-15). Of 60 participants with prevalent and incident LTBI who were offered free isoniazid preventive therapy (IPT), only 2 participants initiated and completed IPT. High risk for LTBI was noted among medical residents compared to nursing students. Self-reported TB exposure is underreported, and uptake of LTBI prevention therapy remains low. New approaches are needed to identify HCWs at highest risk for LTBI.

Methanol Poisoning.

Mortality associated with methanol has been of great concern time and again. The concurrence of cases from a particular area raises doubts about methanol as the culprit. Knowledge of the patho-physiological changes that occur in the body after methanol consumption is essential for all practicing doctors. This article elucidates the clinical presentation and emergency management of these cases under the framework of basic physiological and biochemical phenomena after methanol exposure. Conversion of methanol to formaldehyde by hepatic enzyme alcohol dehydrogenase triggers the cascade of metabolic events. The manifestations begin as early as 30 minutes and progress to decompensated metabolic acidosis in about 12 hours, if left untreated. Seizures, hypoglycemia and blindness frequently complicate the picture. Acute kidney injury warrants urgent haemodialysis. Fundoscopic examination and arterial blood gas analysis are the key diagnostic elements. The management comprises of intravenous sodium bicarbonate, correction of dyselectrolytemia, ethanol, folic acid and haemodialysis, if necessary. The basic steps in approach must be carried out in the emergency department and followed-up with meticulous monitoring in the intensive care unit for salvage as well as prevention of long term sequelae.

Comparison of two radiological methods in the determination of skeletal maturity in the Indian pediatric population.

To determine a more precise and reliable method between Greulich-Pyle (GP) and MacKay's (MK) method for the determination of skeletal age in an Indian pediatric population. We carried out a cross sectional study for the assessment of skeletal age on the basis of examination of hand and wrist radiographs of 106 patients (1-15 years of age) who presented with soft tissue injury to hand by the GP and the MK method. These radiographs were evaluated by a radiologist and an orthopedic surgeon independently. In girls, the mean age difference between chronological and skeletal age was 8 months by the GP method, whereas it was 17 months by MK method. For boys, the mean age difference was 10 months by the GP method and by MKs method, it was 20 months. By the GP method, 44% of the boys showed a more reliable estimate of age whereas it was 10% by the MK method. However, the same for girls was 25% by the GP method and 16% by the MK method. The inter-rater reliability for the raters was found to be κ=0.68 and this was statistically significant (P<0.001), 95% confidence interval (0.504-0.848). We concluded that the GP method appeared to be more reliable in the determination of skeletal age in the Indian pediatric population.

Management of fracture dorso-lumbar spine in a pregnant female by surgery in prone position.

Surgical management of thoraco-lumbar spine fracture in pregnancy has specific concerns during surgery like positioning, approach, and radiation exposure to fetus. We report a case of burst fracture of 12th thoracic vertebrae with paraplegia in a young female with 26 weeks of gestation. Surgery was performed in prone position on a Toronto frame. This report also discusses the management of thoraco-lumbar spine fracture in pregnancy with review of literature.

The Anterior Interosseus Artery Perforator Flap: Anatomical Dissections and Clinical Study.

BACKGROUND: Reconstruction of upper extremity deformities continues to be a challenge to the reconstructive surgeon. Various loco regional, distant and free flaps are available for reconstruction. However, each has its own set of advantages and disadvantages. Of the commonly performed local flaps, radial artery forearm flap, and the posterior interosseus artery flap stand out prominently. Recently, perforator propeller flaps have been used for resurfacing the upper extremity. The anterior interosseus artery perforator flap is an uncommonly used and described flap. METHODS: This study was divided into anatomical study and clinical application in a IV level of evidence. In the anatomical study, five upper extremities were studied. Clinically, 12 patients underwent reconstruction using the anterior interosseus artery perforator flap. Flaps were performed by a single surgeon. A retrospective review of these cases from November 2008 to May 2014 is presented. RESULTS: The anterior interosseus artery perforator was identified in four out of five cadaver limbs. The septocutaneous perforator was in the fifth extensor compartment around 4 cm proximal to the wrist joint. Of the twelve flaps, there was complete necrosis in one flap, and partial necrosis in one flap. The patient with complete necrosis underwent skin grafting at a later date. The wound healed secondarily in case of partial flap necrosis. CONCLUSION: Anterior interosseus artery perforator flap must be considered as an important reconstructive option in the armamentarium of the plastic surgeon, while managing hand and wrist defects.