Safety of tranexamic acid in surgically treated isolated spine trauma.

BACKGROUND: Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma. AIM: To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively. METHODS: This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom. RESULTS: We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA. CONCLUSION: Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.

A Case of Inflammatory Pseudotumour Masquerading as Hepatocellular Carcinoma.

Inflammatory pseudotumors (IPTs) of the liver can mimic malignant lesions. As the name implies, they are usually associated with an inflammatory process and usually regress with the treatment of the underlying pathology. We report a case of a 67-year-old female who presented with right upper quadrant pain, deranged liver enzymes, elevated tumor markers [alpha-fetoprotein (AFP) and CA 19-9], and a large liver mass on imaging, suspected to be hepatocellular carcinoma (HCC). She was eventually diagnosed with IPT complicating the liver inflammation due to autoimmune hepatitis (AIH). She responded well to treatment with steroids and immunosuppressive therapy.

Viruses and autism: A Bi-mutual cause and effect.

Autism spectrum disorder (ASD) is a group of heterogeneous, multi-factorial, neurodevelopmental disorders resulting from genetic and environmental factors interplay. Infection is a significant trigger of autism, especially during the critical developmental period. There is a strong interplay between the viral infection as a trigger and a result of ASD. We aim to highlight the mutual relationship between autism and viruses. We performed a thorough literature review and included 158 research in this review. Most of the literature agreed on the possible effects of the viral infection during the critical period of development on the risk of developing autism, especially for specific viral infections such as Rubella, Cytomegalovirus, Herpes Simplex virus, Varicella Zoster Virus, Influenza virus, Zika virus, and severe acute respiratory syndrome coronavirus 2. Viral infection directly infects the brain, triggers immune activation, induces epigenetic changes, and raises the risks of having a child with autism. At the same time, there is some evidence of increased risk of infection, including viral infections in children with autism, due to lots of factors. There is an increased risk of developing autism with a specific viral infection during the early developmental period and an increased risk of viral infections in children with autism. In addition, children with autism are at increased risk of infection, including viruses. Every effort should be made to prevent maternal and early-life infections and reduce the risk of autism. Immune modulation of children with autism should be considered to reduce the risk of infection.

Albumin-based solution is the ideal post-thawing suspension medium for cord blood hematopoietic stem cells: A stability and proliferative evaluation.

BACKGROUND: Cryopreservation and thawing protocols represent key factors for the efficacy of cellular therapy products, such as hematopoietic stem cells (HSCs). While the HSC cryopreservation has already been standardized, the thawing procedures have been poorly studied. This study aimed to evaluate the thawing and washing protocol of cord blood (CB) derived HSCs or the HPC(CB), by selecting the optimal thawing solution and determining CD34+ cells' stability over time. STUDY DESIGN AND METHODS: Seven cryopreserved CB products were thawed, washed, and resuspended in three different solutions (10% Dextran40 in NaCl equally prepared with 5% human albumin; 5% human albumin in PBS/EDTA; and normal saline) and stored at 4°C (±2°C). Mononuclear cell (MNC) count, CD45+/CD34+ cell enumeration, and cell viability were tested at 0, 1, 2, 4, 6, 8, 12, 24, 36, and 48 h. The protocol with the selected solution was further validated on additional 10 CB samples. The above parameters and the colony-forming unit (CFU) assay were analyzed at time points 0, 2, 4, 6, and 8 h. RESULTS AND DISCUSSION: The results showed that the 5% human albumin was the most suitable thawing solution. MNCs were stable up to 4 h (p = 0.009), viable CD45+ cells were unstable even at 2 h (p = 0.013), and viable CD34+ cells were stable until 6 h (p = 0.019). The CFU assay proved the proliferative potential up to 8 h, although significantly decreased after 4 h (p = 0.013), and correlated with the viable CD34+ cell counts. We demonstrated that the post-thawed and washed HPC(CB) using 5% human albumin is stable for up to 4 h.

An Unusual Cause of Abdominal Pain in a Middle-Aged Female: The Nutcracker Syndrome.

A middle-aged female presented with lower abdominal pain associated with nausea and vomiting and was admitted to the acute hospital. She was thoroughly investigated and treated presumably as having a urinary tract infection. However, she was admitted again shortly after discharge with persistent symptoms. A careful evaluation and review were done, and she was diagnosed with nutcracker syndrome based on the clinical assessment, computed tomography (CT), and ultrasound (US) findings.

Intracranial "white" epidermoid tumours - An imaging approach and systematic review.

INTRODUCTION: Intracranial epidermoid cysts are rare congenital inclusion cysts that can be divided into the classical "black epidermoid" and the exceedingly rare "white epidermoid". White epidermoids are often misdiagnosed because they have different imaging features compared to black epidermoids. There is a paucity of imaging review on white epidermoids. We hereby derive an explanation for the variable imaging features of white epidermoids and propose an imaging approach to distinguish white epidermoids from black epidermoids. METHODS: We conducted a review of white epidermoids in PubMed and Cochrane databases based on PRISMA principles. Qualitative analysis was carried out on the selected cases of white epidermoids, focusing on pathogenesis, imaging features, treatment and prognosis. RESULTS: Out of 1281 studies, we identified 26 full-text articles, comprising 68 patients with white epidermoid cysts, including an illustrative case example from our institution. White epidermoids have completely different MRI signals compared to the classical black epidermoids. Owing to tumour adhesions to the surrounding structures, there is a higher risk of leakage of white epidermoid content during surgery, causing severe aseptic meningitis. We demonstrate an approach to explain the variable imaging features of white epidermoids based on their cyst content - white epidermoids with low T2 signals content often contain high protein levels and viscosity, while those with high T2 signals contain blood products. CONCLUSION: During preoperative planning, it is important to identify white epidermoids. Extensive neurovascular damage should be avoided during surgery given the favourable prognosis of the epidermoids regardless of the extent of tumour resection.

Cervical Spine Pedicle Screw Accuracy in Fluoroscopic, Navigated and Template Guided Systems-A Systematic Review.

Background: Pedicle screws provide excellent fixation for a wide range of indications. However, their adoption in the cervical spine has been slower than in the thoracic and lumbar spine, which is largely due to the smaller pedicle sizes and the proximity to the neurovascular structures in the neck. In recent years, technology has been developed to improve the accuracy and thereby the safety of cervical pedicle screw placement over traditional fluoroscopic techniques, including intraoperative 3D navigation, computer-assisted Systems and 3D template moulds. We have performed a systematic review into the accuracy rates of the various systems. Methods: The PubMed and Cochrane Library databases were searched for eligible papers; 9 valid papers involving 1427 screws were found. Results: fluoroscopic methods achieved an 80.6% accuracy and navigation methods produced 91.4% and 96.7% accuracy for templates. Conclusion: Navigation methods are significantly more accurate than fluoroscopy, they reduce radiation exposure to the surgical team, and improvements in technology are speeding up operating times. Significantly superior results for templates over fluoroscopy and navigation are complemented by reduced radiation exposure to patient and surgeon; however, the technology requires a more invasive approach, prolonged pre-operative planning and the development of an infrastructure to allow for their rapid production and delivery. We affirm the superiority of navigation over other methods for providing the most accurate and the safest cervical pedicle screw instrumentation, as it is more accurate than fluoroscopy and lacks the limitations of templates.

Does Coronavirus Disease 2019 (COVID-19) Affect Perioperative Morbidity and Mortality for Patients Requiring Emergency Instrumented Spinal Surgery? A Single-Center Cohort Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic sent shockwaves through health services worldwide. Resources were reallocated. Patients with COVID-19 still required instrumented spinal surgery for emergencies. Clinical outcomes for these patients are not known. The objective of this study was to evaluate the effects of COVID-19 on perioperative morbidity and mortality for patients undergoing emergency instrumented spinal surgery and to determine risk factors for increased morbidity/mortality. METHODS: This retrospective cohort study included 11 patients who were negative for COVID-19 and 8 patients who were positive for COVID-19 who underwent emergency instrumented spinal surgery in 1 hospital in the United Kingdom during the pandemic peak. Data collection was performed through case note review. Patients in both treatment groups were comparable for age, sex, body mass index (BMI), comorbidities, surgical indication, and preoperative neurologic status. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariable analysis was used to identify risk factors for increased morbidity. RESULTS: There were no mortalities in either treatment group. Four patients positive for COVID-19 (50%) developed a complication compared with 6 (55%) in the COVID-19-negative group (P > 0.05). The commonest complication in both groups was respiratory infection. Three patients positive for COVID-19 (37.5%) required intensive care unit admission, compared with 4 (36%) in the COVID-19-negative group (P > 0.05). The average time between surgery and discharge was 19 and 10 days in COVID-19-positive and -negative groups, respectively (P = 0.02). In the COVID-19 positive group, smoking, abnormal BMI, preoperative oxygen requirement, presence of fever, and oxygen saturations <95% correlated with increased risk of complications. CONCLUSIONS: Emergency instrumented spinal surgery in patients positive for COVID-19 was associated with increased length of hospital stay. There was no difference in occurrence of complications or intensive care unit admission. Risk factors for increased morbidity in patients with COVID-19 included smoking, abnormal BMI, preoperative oxygen requirement, fever and saturations <95%.

Validation of a Virtual Reality Simulator for Percutaneous Pedicle Screw Insertion.

INTRODUCTION: Working-hour restrictions, rota gaps and an increasing drive for theatre efficiency have resulted in challenges to surgical training. As a result, Virtual Reality (VR) has emerged as a popular tool to augment this training. Our aim was to evaluate the validity of a VR simulator for performing percutaneous pedicle screw guidewire insertion. MATERIALS AND METHODS: Twenty-four participants were divided into three equal groups depending on prior surgical experience: a novice group (<10 procedures), an intermediate group (10-50 procedures) and an expert group (>50 procedures). All subjects performed four guidewire insertions on a TraumaVision® simulator (Swemac Innovation AB, Linköping, Sweden) in a set order. Six outcome measures were recorded; total score, time, fluoroscopy exposure, wire depth, zone of placement and wall violations. RESULTS: There were statistically significant differences between the groups for time taken (p<0.001) and fluoroscopy exposure (p<0.001). The novice group performed the worst, and the expert group outperformed both intermediates and novices in both categories. Other outcome results were good and less variable. There was an observed learning effect in the novice and intermediate groups between each of the attempts for both time taken and fluoroscopy exposure. CONCLUSIONS: The study contributes constructive evidence to support the validity of the TraumaVision® simulator as a training tool for pedicle screw guidewire insertion. The simulator is less suitable as an assessment tool. The learning effect was evident in the less experienced groups, suggesting that VR may offer a greater benefit in the early stages of training. Further work is required to assess transferability to the clinical setting.

Spectrum of lung perfusion changes on dual-energy CT in COVID-19: incremental benefit to conventional CT.

The purpose of this case report is to demonstrate lung perfusion changes on dual-energy CT (DECT) in patients with Coronavirus disease 2019 (COVID-19). Since the first case of COVID-19 was reported in Wuhan, Hubei province in China, the spectrum of lung parenchymal findings has been well described but the underlying pathophysiology is less well understood. DECT imaging contributes to the growing evidence that vascular dysregulation has an important role in the underlying pathophysiology of the disease. Three patients with reverse transcriptase polymerase chain reaction (RT-PCR)-confirmed COVID-19 underwent DECT scans. One patient had a DECT for persistent spikes in temperature while the other two patients underwent dual-energy CT pulmonary angiograms (CTPA) for worsening shortness of breath, elevated D dimers and suspected pulmonary embolism. The perfusion abnormalities include focal areas of both hyperperfusion, hypoperfusion, and areas of hypoperfusion surrounded by hyperemia. In addition, dilatation of segmental and subsegmental pulmonary arteries was seen in relation to the lung parenchymal change. DECT has proven useful in supporting the hypothesis that vascular dysregulation plays a significant role in the pulmonary pathophysiology of COVID-19. Early identification and a high index of suspicion  is required in the emergency department setting to identify and isolate cases even prior to the results of RT-PCR test being available. Vascular changes on DECT may be an additional radiological feature in detecting the presence of and predicting the severity of disease in the emergency department or acute care setting.

Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach.

STUDY DESIGN: Narrative review. OBJECTIVE: The high rate of complications associated with the surgical management of neuromuscular spinal deformities is well documented in the literature. This is attributed to attenuated protective physiological responses in multiple organ systems. METHODS: Review and synthesis of the literature pertaining to optimization of patients with neuromuscular scoliosis undergoing surgery. Our institutional practice in the perioperative assessment and management of neuromuscular scoliosis is also described along with a clinical vignette. RESULTS: Respiratory complications are the most common to occur following surgery for neuromuscular disorders. Other categories include gastrointestinal, cardiac, genitourinary, blood loss, and wound complications. A multidisciplinary approach is required for perioperative optimization of these patients and numerous strategies are described, including respiratory management. CONCLUSION: Perioperative optimization for patients with neuromuscular disorders undergoing corrective surgery for spinal deformity is multifaceted and complex. It requires a multidisciplinary evidence-based approach. Preadmission of patients in advance of surgery for assessment and optimization may be required in certain instances to identify key concerns and formulate a tailored treatment plan.

Analysis of SARS-CoV-2 RNA-dependent RNA polymerase as a potential therapeutic drug target using a computational approach.

BACKGROUND: The Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) outbreak originating in Wuhan, China, has raised global health concerns and the pandemic has now been reported on all inhabited continents. Hitherto, no antiviral drug is available to combat this viral outbreak. METHODS: Keeping in mind the urgency of the situation, the current study was designed to devise new strategies for drug discovery and/or repositioning against SARS-CoV-2. In the current study, RNA-dependent RNA polymerase (RdRp), which regulates viral replication, is proposed as a potential therapeutic target to inhibit viral infection. RESULTS: Evolutionary studies of whole-genome sequences of SARS-CoV-2 represent high similarity (> 90%) with other SARS viruses. Targeting the RdRp active sites, ASP760 and ASP761, by antiviral drugs could be a potential therapeutic option for inhibition of coronavirus RdRp, and thus viral replication. Target-based virtual screening and molecular docking results show that the antiviral Galidesivir and its structurally similar compounds have shown promise against SARS-CoV-2. CONCLUSIONS: The anti-polymerase drugs predicted here-CID123624208 and CID11687749-may be considered for in vitro and in vivo clinical trials.

Appendicitis mimicking the CT appearance of an appendiceal mucinous neoplasm.

Occasionally, radiologically diagnosed acute appendicitis is found to harbour underlying appendiceal neoplasm on post-surgical histopathology. Conversely, a situation in which radiologically, the appendix demonstrates features consistent with an underlying tumour but post-operative pathology finds no evidence of neoplastic change is rare. We describe a case of a 50-year-old man who presented with a markedly dilated "mass-like" appendix with minimal inflammatory changes on a computed tomography scan. Radiological findings were suspicious for an appendiceal neoplasm/mucocele (i.e. low-grade mucinous neoplasm). However, the post-surgical histopathological diagnosis did not concur with the radiological diagnosis and instead demonstrated findings compatible with acute appendicitis without neoplastic change. In this case report we provide a histopathological correlation and an explanation as to how this may have happened with the hope of helping radiologists avoid this pitfall in the future.

The Diagnostic Value of Magnetic Resonance Imaging in Identifying Unsuspected Malignancy in Patients Undergoing Percutaneous Vertebral Augmentation for Vertebral Compression Fractures.

BACKGROUND: The aim of this study was to identify the rate of unsuspected malignancy in vertebral compression fractures (VCFs) treated with percutaneous vertebral augmentation procedures (PVAPs). METHODS: From 2004-2015, 410 patients with VCFs underwent PVAPs with biopsy in a single tertiary hospital. All patients had preoperative magnetic resonance imaging (MRI) read by consultant radiologists and reviewed by the performing surgeon prior to PVAPs. All procedures were performed by fellowship-trained spine surgeons. A patient was considered to have an unsuspected malignancy if preoperative MRI was negative for malignancy but histology from the operative biopsy was positive. RESULTS: A total of 44 of 45 patients (97.8%) were identified to have malignancy on preoperative MRI. One patient had a negative MRI but positive biopsy (myeloma). This patient also had a positive myeloma panel. A total of 41 of 44 patients with suspicious MRI preoperatively had a history of malignancy with histology consistent with metastatic spread from the known primary. Two patients had a new diagnosis of malignancy (1 breast carcinoma, 1 metastatic cancer likely of breast or gastrointestinal origin). Younger patients were more likely to have a VCF due to malignancy (odds ratio, 28.33 in age < 60 years). CONCLUSIONS: Almost 98% of patients with malignancy (44 of 45 patients) could be successfully identified with a preoperative MRI. The addition of a myeloma panel to MRI identified all patients with malignancies prior to PVAP in our study. We recommend MRI and myeloma panel for all patients with VCFs to be treated with PVAPs. For patients who undergo a PVAP, routine biopsy should be performed.

Mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection causing a diagnostic dilemma.

Mycotic pseudoaneurysms usually arise from an infectious arteritis or mycotic aneurysms secondary to weakening and destruction of the arterial wall resulting in a contained rupture. We report a case of a mycotic pseudoaneurysm affecting the aortic isthmus of the thoracic aorta which is an extremely rare infection. To our knowledge no case report of mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection has thus far been described. The specific case we present is also unique in that it posed a diagnostic imaging dilemma where the initial imaging revealed a periaortic mass which could not be accurately characterized and only on subsequent imaging reveal itself to be a thrombosed mycotic pseudoaneurysm. We hope that our case report highlights to the medical community the high degree of suspicion one should have regarding pseudoaneurysms when dealing with a complex mass intimately related to a vascular structure.

Fusion FDG-PET/MRI Evidence to Support Diagnosis of Frontotemporal Dementia-Related Primary Progressive Aphasia.

A 61-year-old right-handed man presented for cognitive neurological evaluation with word-finding difficulty, impaired word retrieval, impaired repetition of phrases, and stammering. Brain MRI and FDG-PET/CT were performed as initial imaging workup. Further FDG PET/MRI brain images were obtained through software fusion and revealed regional cortical atrophy with corresponding hypometabolic activity involving the posterior aspects of the left middle and inferior temporal gyri. These characteristic imaging findings are supportive of patient's diagnosis of frontotemporal dementia-related primary progressive aphasia.

Achondroplasia and limb lengthening: Results in a UK cohort and review of the literature.

AIMS: We aim to review the results, complications and outcomes of a single surgeon's series of lower limb lengthening in patients with achondroplasia. METHODS: Ten achondroplastic children underwent limb lengthening. The patients, medical records and radiographs were reviewed. RESULTS: The average age at the time of the index operation was 7.8 years. A single surgeon undertook all procedures. The average total length gain was 20.5 cm. The commonest complication was a fractured femur after removal of the frame. CONCLUSION: Although complication rates were high (70%), none were left with any long-term sequelae and all were pleased with the results.

Randomized clinical trial of cutting balloon angioplasty versus high-pressure balloon angioplasty in hemodialysis arteriovenous fistula stenoses resistant to conventional balloon angioplasty.

PURPOSE: To compare the efficacy and safety of cutting balloon angioplasty (CBA) versus high-pressure balloon angioplasty (HPBA) for the treatment of hemodialysis autogenous fistula stenoses resistant to conventional percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: In a prospective, randomized clinical trial involving patients with dysfunctional, stenotic hemodialysis arteriovenous fistulas (AVFs), patients were randomized to receive CBA or HPBA if conventional PTA had suboptimal results (ie, residual stenosis > 30%). A total of 516 patients consented to participate in the study from October 2008 to September 2011, 85% of whom (n = 439) had technically successful conventional PTA. The remaining 71 patients (mean age, 60 y; 49 men) with suboptimal PTA results were eventually randomized: 36 to the CBA arm and 35 to the HPBA arm. Primary and secondary target lesion patencies were determined by Kaplan-Meier analysis. RESULTS: Clinical success rates were 100% in both arms. Primary target lesion patency rates at 6 months were 66.4% and 39.9% for CBA and HPBA, respectively (P = .01). Secondary target lesion patency rates at 6 months were 96.5% for CBA and 80.0% for HPBA (P = .03). There was a single major complication of venous perforation following CBA. The 30-day mortality rate was 1.4%, with one non-procedure-related death in the HPBA group. CONCLUSIONS: Primary and secondary target lesion patency rates of CBA were statistically superior to those of HPBA following suboptimal conventional PTA. For AVF stenoses resistant to conventional PTA, CBA may be a better second-line treatment given its superior patency rates.

The use of stem cells for the treatment of spinal surgical conditions.

Spinal pathologies are a major burden on society and individuals. Recent years have seen a large number of studies dedicated to the use of stem cells in spinal surgery. This review focuses on recent advances and controversies regarding the applications of stem cells in spinal fusion surgery, spinal cord injury and intervertebral disc degeneration. There are significant concerns regarding the ethics and risks of stem cell use. Animal models do not always accurately depict the human condition. While a great deal has been achieved, successful translation into clinical practice is needed. However there is no doubt that stem cells have a major role to play in the future management of spinal conditions.

Perioperative management of chronic respiratory disease.

Respiratory disease contributes significantly to the perioperative challenges of surgery. Preexisting pulmonary co-morbidities and respiratory complications can have profound effects on patient outcomes. Knowledge of these conditions and the potentially deleterious effects of anaesthesia and surgery can enable clinicians to optimise lung function, reduce complications and improve results.