Xpert HIV-1 qual point-of-care testing for HIV early infant diagnosis in Tanzania: experiences and perceptions of health care workers in a 2016 study.

BACKGROUND: HIV early infant diagnosis (HEID) at the centralized laboratory faces many challenges that impact the cascade of timely HEID. Point of Care (PoC) HEID has shown to reduce test turnaround times, allow for task shifting and has the potential to reduce infant mortality. We aimed at assessing the feasibility of nurse based PoC-HEID in five facilities of Mbeya region. METHODS: We analysed data from healthcare workers at five obstetric health facilities that participated in the BABY study which enrolled mothers living with HIV and their HIV exposed infants who were followed up until 6 weeks post-delivery. Nurses and laboratory personnel were trained and performed HEID procedures using the Xpert HIV-1 Qual PoC systems. Involved personnel were interviewed on feasibility, knowledge and competency of procedures and overall impression of the use of HIV-1 Qual PoC system in clinical settings. RESULTS: A total of 28 health care workers (HCWs) who participated in the study between 2014 and 2016 were interviewed, 23 being nurses, 1 clinical officer, 1 lab scientist and 3 lab technicians The median age was 39.5 years. Majority of the nurses (22/24) and all lab staff were confident using Gene Xpert PoC test after being trained. None of them rated Gene Xpert handling as too complicated despite minor challenges. Five HCWs (5/24) reported power cut as the most often occurring problem. As an overall impression, all interviewees agreed on PoC HEID to be used in clinical settings however, about half of them (11/24) indicated that the PoC-HEID procedures add a burden onto their routine workload. CONCLUSION: Overall, health care workers in our study demonstrated very good perceptions and experiences of using PoC HEID. Efforts should be invested on quality training, targeted task distribution at the clinics, continual supportive supervision and power back up mechanisms to make the wide-scale adoption of nurse based PoC HEID testing a possibility.

Prospective Measurement of Skin Conductance Response during Trauma Interview Predicts Future PTSD Severity in Trauma Exposed Children.

Previous cross-sectional studies have shown that sympathetic nervous system (SNS) arousal is positively associated with posttraumatic stress disorder (PTSD) symptoms in children with trauma exposure. One of the ways that SNS activity is measured is through skin conductance response (SCR), which has been shown to predict future PTSD severity in adults. In this study, we explored the utility of a novel, low-cost mobile SCR device, eSense, to predict future PTSD symptom severity in trauma exposed children. We recruited children (N=43, age 9 years at initial visit) for a longitudinal study in which SCR was recorded at baseline visit, and PTSD symptoms were assessed two years later. Results indicated an interaction between SCR and trauma exposure, such that children with lower trauma exposure who demonstrated greater SCR reported higher PTSD severity two years later. This association remained significant even after controlling for baseline PTSD symptoms. Children with higher levels of trauma exposure did not show this association, potentially due to ceiling effects of PTSD symptoms. Together these findings suggest the utility of SCR as a biomarker for predicting trauma related disorders in children, and that it may be a valuable tool in clinical interventions targeting sympathetic arousal.

Resting heart rate associations with violence exposure and posttraumatic stress symptoms: sex differences in children.

BACKGROUND: Traumatic events experienced in childhood can lead to increased risk of cardiovascular disorders in adulthood. Black Americans are disproportionately affected, as they are at increased risk for experiencing childhood trauma and cardiovascular diseases in adulthood. One of the hypothesized mechanisms of this association is through long-lasting dysregulation of the autonomic nervous system, a hallmark physiological biomarker of posttraumatic stress disorder (PTSD), which is twice as prevalent in women compared to men. METHODS: Ninety-one, majority Black American children, aged 9 were recruited to be a part of our longitudinal study of child development at research centers in Atlanta, GA and Detroit, MI. Resting HR was measured through a electrocardiogram (ECG) recording using the Biopac MP150. Self-report measures of violence exposure and PTSD symptoms were administered by research staff. RESULTS: Children with more violence exposure reported increased PTSS as well as lower resting HR. Regression analysis showed evidence of sex modifying this relationship, (B = -0.64, p < 0.05), such that the association between resting HR and PTSS was stronger in girls than in boys. In our exploratory analysis with standard clinical cutoffs of resting HR, the normative HR group was found to significantly moderate the relationship between violence exposure and PTSS in boys, (B = -2.14, p < 0.01), but not girls (B = -0.94, p = 0.27). CONCLUSION: In our sample of primarily Black urban children, we found that violence exposure was associated with slower, more adult-like HR, that girls showed greater PTSS associated with slower HR while boys did not, and that girls with lower than normative HR showed significantly higher PTSS compared to girls with normative HR. Our sample's demonstration of psychological consequences in addition to the physiological implications could provide new information about a psychobiological sequelae of violence exposure.

Experiencing traumatic events in childhood can lead to increased risk of heart disease in adulthood. One of the ways this might happen is through long-lasting changes of the autonomic nervous system. This system is dysregulated in posttraumatic stress disorder (PTSD), which is twice as common in women compared to men. We explored whether resting heart rate (HR), a measure of autonomic functioning was associated with violence exposure in children, and whether this relationship was different in boys and girls. We also explored whether categorizing our sample into resting HR groups based off standardized norms for HR predicted differing relationships between violence exposure and posttraumatic stress symptoms (PTSS). Because childhood trauma and heart disease impact Black Americans at greater rates, we recruited our sample of 92 nine-year-old children from research centers in Atlanta, GA and Detroit, MI. We measured their resting HR, exposure to violence, and PTSS. We found that violence exposure was associated with lower HR overall, that girls showed greater PTSS associated with lower HR when compared to boys, and that boys with lower than normative HR showed a stronger association between violence exposure and PTSS compared to boys with normative HR. Future studies should examine potential mechanisms underlying this sex difference to best understand the long-term cardiovascular consequences for sex-related health disparities. Specifically, longitudinal studies may be able to help researchers understand how reduced HR during adolescents might lead to future cardiovascular disease and psychopathology.

Complete Spinal Cord Injury Secondary to Serratia marcescens Spinal Epidural Abscess: A Report of Significant Neurological Improvement After a Delayed Presentation.

The exact time at which neurological deficits secondary to a spinal cord injury (SCI) become permanent is unknown. However, urgent decompression within 24 hours of insult is advocated to maximize the return of function. Despite previous literature showing poor neurological recovery with intervention after 24-72 hours, multiple cases have since shown noteworthy clinical improvement following significant delays in presentation. We report the case of a 55-year-old incarcerated male who presented to our hospital with a four-week history of a complete (American Spinal Injury Association (ASIA) A) SCI after a prison altercation. The patient exhibited profound deficits of over one-month duration, and magnetic resonance imaging (MRI) revealed an epidural abscess at T7-T8 with severe cord compression and another epidural abscess at L4-L5. This prompted immediate IV antibiotic therapy. A full neurological examination at hospital admission showed a complete absence of sensation, motor, rectal tone, and rectal function below T8, indicating a grade ASIA A SCI. Blood cultures grew Serratia marcescens. After thorough deliberation, considering over a month of complete neurological deficits, it was decided that surgical intervention would be unlikely to improve the patient's clinical status. Nonetheless, after only 24 hours of IV antibiotic administration, the patient progressed from an ASIA A to B, with a return of 100% accurate, although dull, sensation below T8. Within one week, his abscesses diminished on follow-up MRI, yet T7-T8 remained under significant pressure with no further clinical improvements. Due to his unexpected improvement to an ASIA B, which then plateaued at this level, surgery was again discussed in an attempt to maximize recovery. The patient wished to proceed, even given low chances of a meaningful recovery. He subsequently underwent evacuation and decompression. Two weeks postoperatively, the patient advanced from an ASIA B to C; he remained so until discharge 46 days after presentation and 30 days after surgical decompression. This case is noteworthy within the literature due to two compelling features. Firstly, it represents a significantly delayed presentation of a complete SCI with unexpected, meaningful, and swift improvement after medication and surgical intervention. Secondly, it is one of the few documented cases of Serratia marcescens spinal epidural abscess (SEA).

Getting Better with Age? A Review of Psychophysiological Studies of Fear Extinction Learning Across Development.

A critical developmental task is learning what constitutes reliable threat and safety signals in the environment. In humans, atypical fear learning processes are implicated in many mental health conditions, particularly fear and anxiety disorders, pointing to the potential for laboratory measures of fear learning to facilitate early identification of at-risk individuals. This chapter reviews studies of fear learning and extinction learning that incorporate peripheral measures of psychophysiological response and include a developmental sample. Broadly, these studies indicate substantial consistency in differential learning and extinction across development, as assessed with multiple paradigms, across physiological indices. Importantly, though, response coherence across measures (e.g., physiological, neural, and behavioral) was inconsistent across studies. There was also less consistency in results from studies that probed associations between anxiety and fear learning processes. These mixed findings highlight the need for additional examination of when and why there is variability, both across development and in relation to individual differences factors, including mental health, childhood adversity, and sex. In addition, there remains a need for studies that test for developmental change in extinction recall learning and whether stimulus type impacts learning across development. Longitudinal studies designed to address these questions could provide novel insight into the developmental trajectory of fear learning and extinction.

Human fear neurobiology reimagined: Can brain-derived biotypes predict fear-based disorders after trauma?

Human studies of fear neurobiology have established neural circuits that are activated to threatening stimuli, whether it be during Pavlovian fear conditioning or in response to naturally occurring threats. This circuitry involves the central and basolateral amygdala, as well as the bed nucleus of the stria terminalis, insula, hippocampus, and regulatory regions such as the anterior cingulate cortex and ventromedial prefrontal cortex. While research has found that fear-based disorders, such as anxiety and post-traumatic stress disorder, as associated with dysfunction in these circuits, there is substantial individual heterogeneity in the clinical presentation of symptoms. Recent work has used data-driven methods to derive brain biotypes that capitalize on the activity of the fear circuit and its interaction with other regions of the brain. These biotypes have great utility in both describing individual variation in psychopathology and in identifying individuals at greater risk for fear-based disorders after an environmental stressor, such as a traumatic event. The review discusses recent examples of how fear neurobiology studies can be leveraged to derive biotypes that may ultimately lead to improved treatment.

Long-term follow-up on HIV infected and non-infected women with cervical cancer from Tanzania: staging, access to cancer-directed therapies and associated survival in a real-life remote setting.

BACKGROUND: Worldwide 85% of cervical cancer (CC) related deaths occur in low- and middle-income countries. Sub-Saharan Africa is burdend by an overlapping high incidence of CC as well as HIV infection, a risk factor for HPV associated disease progression. Recent upscaling of CC screening activities increased the number of CC diagnoses in a previous unscreened population. The aim of the 2H study was to follow up on women with CC in the context of available health care services in Tanzania in relation to their HIV infection status. METHODS: This longitudinal observational cohort study included women with histological confirmed CC from Mbeya, Tanzania, between 2013-2019. All women were referred for CC staging and cancer-directed therapies (CDT), including surgery and/or radio-chemotherapy, or palliative care. Annual follow-up focused on successful linkage to CDT, interventions and survival. We assessed factors on compliance, used Kaplan-Meier-Survivor functions to evaluate survival time and poisson regression models to calculate incidence rate ratios on mortality (IRR) two years after diagnosis. RESULTS: Overall, 270 women with CC (123 HIV infected) were included. Staging information, available in 185 cases, showed 84.9% presented with advanced stage disease (FIGO ≥ IIB), no difference was seen in respect to HIV status. HIV-infected women were 12 years younger at the time of cancer diagnosis (median age 44.8 versus 56.4 years, p < 0.001). Median follow up period was 11.9 months (range 0.2-67.2). Survival information, available in 231 cases, demonstrated for women diagnosed in early-stage disease a median survival time of 38.3 months, in advanced-stage 16.0 months and late-stage disease 6.5 months after diagnosis. Of all women, 42% received CDT or palliative support. HIV co-infection and education were associated with higher health care compliance. CDT was significantly associated with lower 2-year mortality rates (IRR 0.62, p = 0.004). HIV coinfection did not impact mortality rates after diagnosis. CONCLUSION: High numbers of advanced and late staged CC were diagnosed, compliance to CDT was low. A beneficial impact of CDT on CC mortality could be demonstrated for local health care services. This study indicates challenges for successful linkage and supports an effective scale up of cancer care and treatment facilities.

Spinal deformity surgery is accompanied by serious complications: report from the Morbidity and Mortality Database of the Scoliosis Research Society from 2013 to 2020.

PURPOSE: The Morbidity and Mortality (M&M) report of the Scoliosis Research Society (SRS) has been collected since 1965 and since 1968 submission of complications has been required of all members. Since 2009, the SRS has collected information on death, blindness, and neurological deficit, with acute infection being added in 2012 and unintentional return to the operating room (OR) being added in 2017. In this report, we use the most recent data submitted to the SRS M&M database to determine the rate of neurological deficit, blindness, acute infection, unintentional return to the OR, and death, while also comparing this information to previous reports. METHODS: The SRS M&M database was queried for all cases from 2013 to 2020. The rates of death, vision loss, neurological deficit, acute infection, and unintentional return to the OR were then calculated and analyzed. The rates were compared to previously published data if available. Differences in complication rates between years were analyzed with Poisson regression with significance set at α = 0.05. RESULTS: The total number of cases submitted per year varied with a maximum of 49,615 in 2018 and a minimum of 40,464 in 2020. The overall reported complication rate from 2013 to 2020 was 2.86%. The overall mortality rate ranged from 0.09% in 2018 to 0.14% in 2015. The number of patients with visual impairment ranged from 4 to 13 between 2013 and 2015 (no data on visual impairment were collected after 2015). The overall infection rate varied from 0.95 in 2020 to 1.30% in 2015. When the infection rate was analyzed based on spinal deformity group, the neuromuscular scoliosis group consistently had the highest infection rate ranging from 3.24 to 3.94%. The overall neurological deficit rate ranged from 0.74 to 0.94%, with the congenital kyphosis and dysplastic spondylolisthesis groups having the highest rates. The rates of unintentional return to the OR ranged from 1.60 to 1.79%. Multiple groups showed a statistically significant decreasing trend for infection, return to the operating room, neurologic deficit, and death. CONCLUSIONS: Neuromuscular scoliosis had the highest infection rate among all spinal deformity groups. Congenital kyphosis and dysplastic spondylolisthesis had the highest rate of neurological deficit postoperatively. This is similar to previously published data. Contrary to previous reports, neuromuscular scoliosis did not have the highest annual death rate. Multiple groups showed a statistically significant decreasing trend in complication rates during the reporting period, with only mortality in degenerative spondylolisthesis significantly trending upwards. LEVEL OF EVIDENCE: Level III.

Evaluation of Blended Online Learning in Three Spinal Surgery Educational Courses.

COVID-19 pandemic created a need to improvise and redefine blended learning to be executed fully online. Background information on the effectiveness of fully online blended learning activities, especially for surgical disciplines is limited. This study describes a fully online blended learning course format on spinal surgery and aims to provide data regarding it effectiveness. Fully online blended courses on three topics of spinal surgery designed as six-week asynchronous and followed by 3-day live parts. Learning gaps (LGs) were identified with a survey at the beginning of asynchronous part, at its end, and at the end of the live part. The effectiveness of the asynchronous and live parts was assessed by LGs and a quiz, login statistics of learners and faculty and a post-course survey. Participants' LGs decreased in all courses, statistically significant in two. Faculty and learner login rates significantly correlated with each other. Faculty and learner satisfaction was very high. A fully online blended learning course can be delivered effectively on spine surgery with a high participant and faculty satisfaction rate. The asynchronous part contributes to learning significantly.

Associations between children's trauma-related sequelae and skin conductance captured through mobile technology.

Although many children experience trauma, few receive diagnoses and subsequent care despite experiencing trauma-related sequelae. At age nine (M = 9.11), children (N = 62; female = 46.4%) who predominantly identified as Black (78.7%) were enrolled in this first study examining how skin conductance as captured by mobile technology, eSense, related to children's traumatic experiences and trauma-related symptoms. Skin conductance measures were associated with degree of trauma exposure and PTSD hyperarousal symptoms. These findings suggest that physiological responses in addition to self-report measures may be easily used to assess children's trauma exposure and symptoms. Given eSense's ease-of-use, this technology could assist clinics and research institutions assess children's trauma-related needs.

Complications of Spine Surgery in "Super Obese" Patients.

STUDY DESIGN: Retrospective chart review with matched control. OBJECTIVE: To evaluate the indications and complications of spine surgery on super obese patients. METHODS: A retrospective review assessed super obese patients undergoing spine surgery at a level-1 trauma and spine referral center from 2012 to 2016. Outcomes were compared to age-matched controls with body mass index (BMI) <50 kg/m2. The control group was further subdivided into patients with BMI <30 kg/m2 (normal) and BMI between 30 and 50 kg/m2 (obese). RESULTS: Sixty-three super obese patients undergoing 86 surgeries were identified. Sixty patients (78 surgeries) were in the control group. Age and number of elective versus nonelective cases were not significantly different. Mean BMI of the super obese group was 55 kg/m2 (range 50-77 kg/m2) versus 29 kg/m2 in the controls (range 20-49 kg/m2). Fifty-two percent of surgeries were elective, and the most common indication was degenerative disease (39%). Compared with controls, super obese patients had a higher complication rate (30% [n = 19] vs 10% [N = 6], P = .0055) but similar 30-day mortality rate (5% vs 5%), a finding that was upheld when comparing super obese with each of the control group stratifications (BMI 30-50 and BMI <30 kg/m2). The most common complication among super obese patients was wound dehiscence/infection (n = 8, 13%); 2 patients' surgeries were aborted. Complication rates for elective surgery were 21% (n = 7) for super obese patients and 4% (n = 1) for controls (P = .121); complication rates for nonelective procedures were 40% (n = 12) and 14% (n = 5), respectively (P = .023). CONCLUSION: The complication rate of spine surgery in super obese patients (BMI ≥ 50 kg/m2) is significantly higher than other patients, particularly for nonelective cases.

Thecal Transection and Canal Fusion With Structural Allograft for Refractory Charcot Spinal Arthropathy: Technical Note.

Charcot spinal arthropathy presents significant surgical challenges, with large bony defects and limitations in fixation and reconstruction which are exacerbated in often numerous revision surgeries. These challenges make the development of additional salvage techniques useful. We report on a technique of thecal transection and canal fusion with structural allograft as a salvage technique for refractory cases of Charcot spinal arthropathy. We illustrate the technique with 4 procedures done in 3 patients, over a period of 10 years.

Unaffected ex vivo clotting cascade by experimental hemostatic nanoparticles when introduced in the presence of recombinant tissue plasminogen activator.

CONTEXT: Hemostatic nanoparticles (hNPs) have shown efficacy in decreasing intracerebral hemorrhage (ICH) in animal models and are suggested to be of use to counter tissue plasminogen activator (tPA)-induced acute ICH. AIMS: The objective of this study was to test the ability of an hNP preparation to alter the clotting properties of blood exposed to tPA ex vivo. MATERIALS AND METHODS: Fresh blood samples were obtained from normal male Sprague-Dawley rats (~300 g; n = 6) and prepared for coagulation assays by thromboelastography (TEG) methods. Samples were untreated, exposed to tPA, or exposed to tPA and then to hNP. TEG parameters included reaction time (R, time in minutes elapsed from test initiation to initial fibrin formation), coagulation time (K, time in minutes from R until initial clot formation), angle (α, a measure in degrees of the rate of clot formation), maximum amplitude (MA, the point when the clot reaches its MA in mm), lysis at 30 min after MA (LY30, %), and clot strength (G, dynes/cm2), an index of clot strength. STATISTICAL ANALYSIS USED: Kruskal-Wallis test was employed to compare TEG parameters measured for untreated control samples versus those exposed to tPA and to compare tPA-exposed samples to samples treated with tPA + hNPs. Significances were inferred at P ≤ 0.05. RESULTS: Compared to untreated samples, tPA-treated samples showed a trend toward decreased angle and G suggesting potentially clot formation rate and clot strength. The addition of hNP did not affect any of these or other measured indices. CONCLUSIONS: The data demonstrated no hemostatic effects when the hNP was used in the presence of tPA. The lack of change in any of the TEG parameters measured in the present study may indicate limitations of the hNPs to reverse the thrombolytic cascade initiated by tPA.

HPV Type Distribution in HIV Positive and Negative Women With or Without Cervical Dysplasia or Cancer in East Africa.

BACKGROUND: Women living with HIV in sub-Saharan Africa are at increased risk to develop cervical cancer (CC), which is caused by persistent infection with 13 oncogenic human papilloma viruses (HR-HPVs). It is important to accurately identify and target HIV-positive women at highest risk to develop CC for early therapeutic intervention. METHODS: A total of 2,134 HIV+ and HIV- women from South-West Tanzania were prospectively screened for cervical cancer and precancerous lesions. Women with cervical cancer (n=236), high- and low-grade squamous intraepithelial lesions (HSIL: n=68, LSIL: n=74), and without lesion (n=426) underwent high-resolution HPV genotyping. RESULTS: Eighty percent of women who were diagnosed with HSIL or LSIL were living with HIV. Any lesion, young age, HIV status, and depleted CD4 T cell counts were independent risk factors for HPV infections, which were predominantly caused by HR-HPV types. While multiple HR-HPV type infections were predominant in HIV+ women with HSIL, single-type infections predominated in HIV+ CC cases (p=0.0006). HPV16, 18, and 45 accounted for 85% (68/80) and 75% (82/110) of HIV+ and HIV- CC cases, respectively. Of note, HPV35, the most frequent HPV type in HSIL-positive women living with HIV, was rarely detected as a single-type infection in HSIL and cancer cases. CONCLUSION: HPV16, 18, and 45 should receive special attention for molecular diagnostic algorithms during CC prevention programs for HIV+ women from sub-Saharan Africa. HPV35 may have a high potential to induce HSIL in women living with HIV, but less potential to cause cervical cancer in single-type infections.

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group.

BACKGROUND: Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA. METHODS: We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis. RESULTS: From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p < 0.001). CONCLUSION: In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.

Robotic-Navigated Percutaneous Pedicle Screw Placement Has Less Facet Joint Violation Than Fluoroscopy-Guided Percutaneous Screws.

OBJECTIVE: To directly compare robotic-versus fluoroscopy-guided percutaneous pedicle screw (PPS) placement in thoracolumbar spine trauma with a focus on clinically acceptable pedicle screw accuracy and facet joint violation (FJV). METHODS: A retrospective chart review assessed 37 trauma patients undergoing percutaneous thoracic and/or lumbar fixation. Postoperative computed tomography images were reviewed by authors blinded to surgical technique who assessed pedicle screw trajectory accuracy and FJV frequency. RESULTS: Seventeen patients underwent placement of 143 PPS with robotic assistance (robot group), compared with 20 patients receiving 149 PPS using fluoroscopy assistance (control group). Overall, the robot cohort demonstrated decreased FJV frequency of 2.8% versus 14.8% in controls (P = 0.0003). When further stratified by level of surgery (i.e., upper thoracic, lower thoracic, lumbar spine), the robot group had FJV frequencies of 0%, 3.2%, and 3.7%, respectively, compared with 17.7% (P = 0.0209), 14.3% (P = 0.0455), and 11.9% (P = 0.2340) in controls. The robot group had 84.6% clinically acceptable screw trajectories compared with 81.9% in controls (P = 0.6388). Within the upper thoracic, lower thoracic, and lumbar regions, the robot group had acceptable screw trajectories of 66.7%, 87.1%, and 90.7%, respectively, compared with 58.8% (P = 0.6261), 91.1% (P = 0.5655), and 97.6% (P = 0.2263) in controls. CONCLUSIONS: There was no significant difference in clinically acceptable screw trajectory accuracy between robotic versus fluoroscopy-guided PPS placement. However, the robot cohort demonstrated a statistically significantly decreased FJV overall and specifically within the thoracic spine region. Use of robotic technology may improve radiographic outcomes for a subset of patients or spine surgeries.

Effects of telemedicine triage on efficiency and cost-effectiveness in spinal care.

BACKGROUND CONTEXT: Ambulatory spine referral triage must be optimized to improve both quality of care and access to specialists. PURPOSE: To evaluate cost savings in an existing model of telemedicine/electronic-triage for ambulatory spine referrals. STUDY DESIGN/SETTING: Retrospective review. Institutional spine center. PATIENT SAMPLE: All patients/referrals made to the institutional spine center of a tertiary medical center from 2011 to 2014 were included in the data analysis. OUTCOME MEASURES: Cost savings and efficiency was evaluated based upon intake to appointment time, rate of referral to surgeons versus nonoperative providers, additional testing required, and extrapolated cost savings based on estimated avoidance of unnecessary office visits and travel. METHODS: All ambulatory spine referrals electronically triaged (E-triaged) from 2011 to 2014 were analyzed. The E-triage database was mined for data from intake until triage completion. Hospital electronic medical record system was mined for data on initial clinic visit, tests ordered, follow-up appointments, and presence of surgical encounters. Financial savings from avoiding unnecessary visits were estimated. RESULTS: There were 16,174 records created from 2011 to 2014, of which 10,832 were E-triaged by spine surgeons. E-triage generated 3,718 nonoperative provider visits within our healthcare system. The "saved" surgical consult that was avoided resulted in total estimated savings of $793,835 to the patient population; 4,446 patients were deemed surgical and were offered appointments with a spine surgeon. CONCLUSIONS: Appropriate triage of ambulatory spine referrals improves access and quality of care. E-triage resulted in $800,000 cost savings. Further studies are required to fully evaluate the effects of an E-triage system on ambulatory spinal care.

Impact of immediate postpartum insertion of TCu380A on the quantity and duration of lochia discharges in Tanzania.

BACKGROUND: The insertion of Intrauterine Contraceptive Device (PPIUD) for the purpose of contraception immediately after delivery is becoming popular in countries where the use of IUD for contraception has been extremely low. Since 2015, Tanzania implemented the initiative by the International Federation of Gynecology and Obstetrics (FIGO) to institutionalize PPIUD. As a result of capacity building and information delivery under the initiative, there have been increased uptake of the method. Working in this context, the focus of the study was to generate evidence on the effect of TCu380A IUD on amount and duration of lochia and equip service providers with evidence-based knowledge which can help them in counselling their PPIUD clients. OBJECTIVE: Establish impact of postpartum TCu380A on amount and duration of lochia. METHODS: A prospective cohort study of delivered women in two teaching hospitals in Tanzania with immediate insertion of TCu380A or without use of postpartum contraception in 2018. TCu380A models; Optima (Injeflex Co. Brazil) and Pregna (Pregna International, Chakan, India) were used. Follow-up was done by weekly calls and examination at 6th week. Lochia was estimated by Likert Scale 0-4 relative to the amount of lochia on the delivery day. An estimated 250 women sample (125 each group) would give 80% power to detect a desired 20% difference in the proportion of women with prolonged lochia discharges among the Exposed and Unexposed groups. Data analysis was by SPSS. RESULTS: Two hundred sixty women were analysed, 127 Exposed and 133 Unexposed. Medical complaints were reported by 41 (28.9%) Exposed and 37 Unexposed (27.8%), p = 0.655. Lack of dryness by end of 6th week was to 31 (23.3%) Exposed and 9 (7.1%) Unexposed, p < 0.001. Exposed had higher weekly mean lochia scores throughout with the difference most marked in 5th week (3.556 Versus 2.039, p < 0.001) and 6th week (1.44 Versus 0.449, p<0.001). CONCLUSION: PPIUD is associated with increased amount of lochia and slows progression to dryness within 6 weeks of delivery. The implications of PPIUD clients' needs to be informed about the possibility of delayed dryness of lochia at time of counseling are discussed.

A one-year cohort study of complications, continuation, and failure rates of postpartum TCu380A in Tanzania.

BACKGROUND: Less than 1% of married women in Tanzania use an Intrauterine Contraceptive Device (IUD) for contraception. An initiative by the International Federation of Gynecology and Obstetrics (FIGO) has been in progress since 2015 resulting in escalated method uptake in implementing hospitals. This study investigates failure rate, complications, and risk factors for one-year continuation of TCu380A IUD when used for immediate postpartum contraception under the initiative in Tanzania. METHODOLOGY: A prospective cohort study of women who had TCu380A insertion within 48 h of delivery in 6 hospitals in Tanzania between 1st December 2017 and 18th April 2018 was conducted. Face to face post insertion interviews were made with 1114 clients before discharge and later through phone calls up to the beginning of 13th month postpartum. Postpartum Intrauterine Device (PPIUD) continuation status, complications, duration of time they stayed with the IUD and the currently used method if PPIUD was discontinued were enquired. The outcome variable was PPIUD continuation at one year of IUD insertion. Data were analyzed using Statistical Product and Service Solutions software (SPSS) for Windows version 20 (IBM SPSS Statistics, Chicago, IL, USA). RESULTS: In total 511(45.8%)clients had consented and availed to complete the one-year follow-up. Out of these, 440 still had IUD, giving a one-year continuation rate of 86.1%. Most (63%) IUD discontinuations occurred in the period between 7th week and 6 months of insertion. One-year method expulsion rate was 2.1%. There was one reported pregnancy that gives a method failure rate of about 2 per 1000. The independent risk factors in favor of method continuation at one year were absence of medical or social problem, being a youth (16-24 years), and delivery by Cesarean section. CONCLUSIONS: The continuation rate when CuT380A is used for immediate postpartum contraception is high, with low complication and failure rates. Some medical and social factors are important for method continuation, hence the need to consider in training, counselling and advocacy.

Hangman's Fracture.

STUDY DESIGN: Review article. OBJECTIVE: A review and update of the treatment of Hangman's fractures including the indications for both nonoperative and operative treatment of typical and atypical fractures. SUMMARY OF BACKGROUND DATA: Hangman's fractures are the second most common fracture pattern of the C2 vertebrae following odontoid fractures. Many of the stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIa and III fractures require surgical stabilization. METHODS: A review of the literature. RESULTS: The clinical and radiographic outcomes of the treatment of Hangman's fractures lend a good overall prognosis when the correct diagnosis is made. The nonoperative treatment of stable type I and II fractures with external immobilization leads to excellent long-term outcomes as does the operative treatment of the unstable type IIa and III fractures. CONCLUSIONS: Hangman's fractures can be classified as stable (type I and most II) or unstable (type IIa and III) and the optimal treatment depends upon this distinction. Stable injuries do well with rigid immobilization and rarely require operative intervention. In contrast, unstable injuries do poorly if treated nonoperatively but do well with surgical intervention. When treating atypical Hangman's variants, great vigilance and close clinical observation is paramount if nonoperative treatment is indicated given the potential for neurological compression in this fracture pattern. Properly identifying and treating these injuries represents an opportunity for the spine surgeon to optimize patient outcomes.