Healing Assessment of Spinal Tuberculosis: A Systematic Review.

OBJECTIVE: Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB. METHODS: A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study. RESULTS: Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing. CONCLUSIONS: Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

Hypertrophic cardiomyopathy - phenotypic variations beyond wall thickness.

Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy (LVH) in the absence of another causal disease. Several morphologic and histologic changes have been described. Given the morbidity and mortality associated with HCM, understanding these anatomic variations is key to interpreting imaging. This is especially important since many patients exhibit these associated findings in the absence of LVH and prompt early detection of these variations may lead to early diagnosis and treatment. This article describes the appearance of morphologic variations seen in HCM beyond myocardial thickening including: papillary muscle and mitral valve variants, myocardial crypts, left ventricular myocardial bands, and dystrophic calcification related to increased wall tension.

Deformity Correction with Interbody Fusion Using Lateral versus Posterior Approach in Adult Degenerative Scoliosis: A Systematic Review and Observational Meta-analysis.

This study was designed to systematically review and meta-analyze the functional and radiological outcomes between lateral and posterior approaches in adult degenerative scoliosis (ADS). Both lateral (lumbar, extreme, and oblique) and posterior interbody fusion (posterior lumbar and transforaminal) are used for deformity correction in patients with ADS with unclear comparison in this cohort of patients in the existing literature. A literature search using three electronic databases was performed to identify studies that reported outcomes of lateral (group L) and posterior interbody fusion (group P) in patients with ADS with curves of 10°-40°. Group P was further subdivided into minimally invasive surgery (MIS-P) and open posterior (Op-P) subgroups. Data on functional, radiological, and operative outcomes, length of hospital stay (LOHS), fusion rates, and complications were extracted and meta-analyzed using the random-effects model. A total of 18 studies (732 patients) met the inclusion criteria. No significant difference was found in functional and radiological outcomes between the two groups on data pooling. Total operative time in the MIS-P subgroup was less than that of group L (233.86 minutes vs. 401 minutes, p <0.05). The total blood loss in group L was less than that in the Op-P subgroup(477 mL vs. 1,325.6 mL, p <0.05). Group L had significantly less LOHS than the Op-P subgroup (4.15 days vs. 13.5 days, p <0.05). No significant difference was seen in fusion rates, but complications were seen except for transient sensorimotor weakness (group L: 24.3%, group P: 5.6%; p <0.05). Complications, such as postoperative thigh pain (7.7%), visceral injuries (2%), and retrograde ejaculation (3.7%), were seen only in group L while adjacent segment degeneration was seen only in group P (8.6%). Lateral approach has an advantage in blood loss and LOHS over the Op-P subgroup. The MIS-P subgroup has less operative time than group L, but with comparable blood loss and LOHS. No significant difference was found in functional, radiological, fusion rates, pseudoarthrosis, and complications, except for transient sensorimotor deficits. Few complications were approach-specific in each group.

A Practical Review of the Presentation, Diagnosis, and Management of Cutaneous B-Cell Lymphomas.

This review of cutaneous B-cell lymphoma (CBCL) is focused on the clinical presentation, treatment, and workup of each type of lymphoma. Part 1 is an overview of each of the CBCLs, including clinical presentation, recent advances in the pathobiology, and evidence regarding treatment strategies. Part 2 is a detailed guide to the steps in diagnosis and workup of a newly diagnosed CBCL according to the International Society for Cutaneous Lymphoma/European Organization for Research and Treatment of Cancer and NCCN guidelines.

Differential survival of systemic B-cell lymphomas initially diagnosed in the skin: a population-based study of 883 patients.

Although the majority of lymphomas are diagnosed in lymph nodes, bone marrow, or other viscera, initial diagnosis of systemic lymphomas in the skin is a rare but important occurrence in dermatology. This study seeks to quantify the incidence of initial skin presentation in patients with systemic B-cell lymphomas (BCL) via examination of data in the Surveillance, Epidemiology, and End Results (SEER)-18 database; cases of primary cutaneous B-cell lymphoma were excluded. We found that an initial diagnosis of lymphoma in the skin is a very rare occurrence for systemic B-cell lymphomas, comprising < 0.3% of cases overall. Follicular lymphoma was the most likely to be diagnosed in the skin (1.47%), followed by marginal zone lymphoma (MZL, 0.5%), mantle cell lymphoma (0.4%), diffuse large B-cell lymphoma (DLBCL, 0.23%), Burkitt lymphoma (0.23%), Hodgkin lymphoma (0.04%), and chronic lymphocytic leukemia (0.006%). While indolent systemic lymphomas (MZL and FL) presenting initially in the skin have a better prognosis than those presenting at other sites, the more aggressive systemic DLBCL presenting in the skin does not demonstrate improved prognosis.

Is Final Fusion Necessary for Growing-Rod Graduates: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: The need for definitive fusion for growing rod graduates is a controversial topic in the management of Early-onset scoliosis (EOS) patients. The authors performed a systematic review and meta-analysis on the available literature to evaluate the outcomes of growing rod graduates undergoing final fusion or observation with implants in-situ. METHODS: An extensive literature search was carried out aimed at identifying articles reporting outcomes in growing rod graduates. Apart from the study characteristics and demographic details, the extracted data included Cobb's correction, trunk height parameters, and revision rate. The extracted data was analyzed and forest plots were generated to draw comparisons between the observation and fusion groups. RESULTS: Of the 11 included studies, 6 were case-control and 5 were case series. The authors did not find any significant difference between the 2 groups with respect to the pre-index and final Cobb's correction, T1-T12 or T1-S1 height gain in either over-all, or sub-analysis with case-control studies. The meta-analysis showed a significantly higher revision rate in patients undergoing a definitive fusion procedure. CONCLUSION: The current analysis revealed comparable outcomes in terms of correction rate and gain in the trunk height but a lesser need of revisions in observation sub-group. The lack of good quality evidence and the need for prospective and randomized trials was also propounded by this review.

Is it Safe to Save Levels and Choose the Lowest Instrumented Vertebra as Touched Vertebra While Selectively Fusing Lenke 1/2 Curves? A Proportional Meta-Analysis of Existing Evidence.

STUDY DESIGN: Meta-analysis. OBJECTIVE: To compare the clinical and radiological outcomes in patients with Adolescent Idiopathic scoliosis (AIS) treated by selective thoracic fusion (STF) with lowest instrumented vertebra (LIV) at touched vertebra (TV) vs stable vertebra (SV). METHODS: The databases PubMed, Embase and Google Scholar were searched until November 2020.Studies which had Lenke type 1 curves and Lenke type 2 curves in adolescent population treated by STF and which reported pre- and post-operative curve characteristics including correction percentage and complications were included. Studies which did not report the LIV selection, curve correction percentages and whose full text could not be acquired were excluded. RESULTS: Eight studies were included for analysis of which seven were found to be retrospective studies (level III evidence) and one was prospective study (level II evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, total srs-22 scores, and complication rates. CONCLUSION: The evaluation of SV group and TV group as LIV for selective thoracic fusions in AIS reveals a comparable outcome in terms of curve correction, patient satisfaction scores and complication rates. The TV can be chosen safely as the LIV especially in type A and B Lenke 1&2 curves, as it saves more motion segments when compared to SV.

Patient perspectives of the climate of diversity, equity, and inclusion in the emergency department.

Objective: Assessing the diversity, equity, and inclusion (DEI) climate of emergency departments (EDs) can inform organizational change to provide equitable, inclusive, and high-quality care to their diverse patient populations. The purpose of this project was to investigate patient perspectives on the climate of DEI in an urban ED. Methods: This was a cross-sectional survey study conducted in a large-volume, urban ED in Detroit, MI, from November 2018 to January 2019. The survey was developed by an experienced ED DEI committee via an iterative process and broad consensus. Results: During their care in the ED, 849 patients completed an anonymous survey about their perspectives and experiences of DEI in that ED. Overall, the responses were favorable as most respondents reported that the ED staff treated patients from all races equally (75.8%) and made patients feel accepted (86%). However, some respondents felt that the ED staff's treatment of populations with greater complexity, such as patients who are mentally ill (16.8%) or lower income (14.3%), needs the most improvement. Conclusions: This DEI climate assessment survey of ED patients' perspectives revealed important insights that could guide strategic initiatives to advance DEI in the ED. This assessment may serve as a model for continuous evaluation of DEI over time and in multiple healthcare settings to help guide organizational change efforts.

The positive-negative mode link between brain connectivity, demographics and behaviour: a pre-registered replication of Smith et al. (2015).

In mental health research, it has proven difficult to find measures of brain function that provide reliable indicators of mental health and well-being, including susceptibility to mental health disorders. Recently, a family of data-driven analyses have provided such reliable measures when applied to large, population-level datasets. In the current pre-registered replication study, we show that the canonical correlation analysis (CCA) methods previously developed using resting-state magnetic resonance imaging functional connectivity and subject measures (SMs) of cognition and behaviour from healthy adults are also effective in measuring well-being (a 'positive-negative axis') in an independent developmental dataset. Our replication was successful in two out of three of our pre-registered criteria, such that a primary CCA mode's weights displayed a significant positive relationship and explained a significant amount of variance in both functional connectivity and SMs. The only criterion that was not successful was that compared to other modes the magnitude of variance explained by the primary CCA mode was smaller than predicted, a result that could indicate a developmental trajectory of a primary mode. This replication establishes a signature neurotypical relationship between connectivity and phenotype, opening new avenues of research in neuroscience with clear clinical applications.

Neglected floating cervical spine fracture with myelopathy and Anderson lesion of D2 D3: report of an unusual case.

INTRODUCTION: The cervical spine is the most commonly affected region in traumatic spine injuries of patients with Ankylosing Spondylitis (AS), accounting for 75% of cases, followed by the thoracic and lumbar spine. The fracture may not be detectable in plain radiographs alone due to pre-existing kyphotic deformity with distorted anatomy and high-riding shoulders. CASE PRESENTATION: We present a case with a floating cervical spine following a trivial trauma injury and with cervical myelopathy symptoms. After posterior fixation of the cervico-thoracic spine, the patient improved with Nurick score and mJOA score improvement. After 6 months follow up the patient was walking without support, and myelopathy symptoms were negligible. DISCUSSION: In this patient, a posterior approach was performed. We obtained a rigid construct so that we were able to mobilize a patient on the very next day and his myelopathy symptoms improved with minimal postoperative complications.

Acute spine care services during covid-19 pandemic and 'lockdown': case series and our perspective from a level 1 trauma centre.

STUDY DESIGN: Case Series. OBJECTIVE: Sudden 'lockdown' to contain spread of SarsCoV-2 infection had far-reaching consequences on the Spine Unit of our tertiary care hospital, situated in a hilly-region of Northern India. We intend to share our experience of providing care for acute spinal disorders from 23rd March, 2020, when nationwide lockdown and closure of elective services started in our country, to till 12th May, 2020, and to formulate few recommendations at the end. SETTING: Northern India. METHODS: Between 23rd March, 2020 and 12th May, 2020, data of all patients with spinal conditions presenting to Emergency Department for acute care services were collected prospectively. Existing protocols were modified in line with changing national and institute policies for functionality of the spine unit, challenges faced and steps taken were noted. RESULTS: All elective cases were postponed for an indefinite period at the starting of 'Lockdown'. A total of 24 patients were received in ED during study period and 14 (58%) were managed operatively. The majority (79%) were with traumatic spine injury, and fall from height was most common mechanism of injury in traumatic spine patients (84%). There was higher incidence of surgical site infections (14%) among operated patients, compared to our previous average. We had modified routine policies to tackle challenges faced and till date of writing this article, none of the members of spine team or patients treated by us tested positive for SARSCoV-2. CONCLUSION: To continue providing care for acute spinal conditions and maintaining academic activities of spine unit during 'lockdown' needs innovative policies in line with national protocols.

Characterization of Primary and Secondary Cutaneous B-Cell Lymphomas: A Population-Based Study of 4758 Patients.

INTRODUCTION/BACKGROUND: Cutaneous B-cell lymphomas are a heterogeneous group of rare malignancies whose specific site tropisms and site-specific survival have not been well documented. In this study, we seek to investigate the frequency and survival for primary and secondary cutaneous MZL (pcMZL and scMZL), primary and secondary cutaneous FCL (pcFCL and scFCL), and primary and secondary cutaneous DLBCL (pcDLBCL and scDLBCL) to better understanding their prognosis and natural history. MATERIALS AND METHODS: A total of 4758 cases of CBCL diagnosed between 1975 and 2016 were identified in the SEER-18 database. Statistical analysis was performed to identify the frequency of location and survival. RESULTS: pcMZL was disproportionately likely to present on the face and upper limb while those of scMZL approximated the expected ratios based on body surface area. pcFCL and scFCL were more likely to present on the face and scalp/neck. pcDLBCL and scDLBCL were more likely to present on the face, scalp/neck, and lower limb. Patients with systemic MZL or FCL, but not DLBCL, had significantly better survival than those diagnosed in the skin than at other sites. CONCLUSIONS: All of these lymphomas demonstrate site-specific tropisms and survival. Molecular characterization of cutaneous lymphomas with analyses of tumor microenvironment are the next steps in understanding disease biology.

Conundrum in surgical management of three-column injuries in sub-axial cervical spine: a systematic review and meta-analysis.

STUDY DESIGN: Systematic Review and Meta-analysis. PURPOSE: Three-column injuries making the spine unstable require adequate fixation which can be achieved by anterior alone, posterior alone or combined anterior-posterior approach. There is no general consensus till date on a single best approach in sub-axial cervical spine trauma. This study comparing the three approaches is an attempt to establish a firmer guideline in this disputed topic. MATERIAL AND METHODS: The protocol was registered with PROSPERO. PubMed, Embase and Google Scholar were searched for relevant literature. For each study, pre-defined data were extracted which included correction of kyphosis, loss of correction, hospital stay, operative time, blood loss during surgery as the outcome variables. Studies were also screened for the complications. RESULTS: Eleven studies were evaluated for qualitative analysis and quantitative synthesis of the data in our review. The result demonstrated significant difference with most correction achieved in combined approach subgroup. Though no significant difference was found, the anterior group was having maximum loss of correction. Combined approach showed significantly more operative time and blood loss followed by posterior approach and then anterior approach alone. The improvement in VAS was significantly more in anterior subgroup when compared to combined approach. CONCLUSION: Cervical alignment is best restored by combined approach compared to the other two. Anterior only approach showed more correction than posterior approach. However, there is no significant difference between all three approaches in loss of correction at long-term follow-up. Anterior only approach is superior to posterior and combined approach on basis of intraoperative and perioperative parameters. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

PEEK vs Titanium Cage for Anterior Column Reconstruction in Active Spinal Tuberculosis: A Comparative Study.

BACKGROUND: Posterolateral decompression and debridement in patients with TB spine led to defect in the anterior column which makes the spinal column unstable, thus making anterior column reconstruction an important step in surgical management. OBJECTIVE: Through the study, authors sought to answer the following questions: 1) What are the differences in clinical outcomes between patients with TB spine undergoing anterior column reconstruction using titanium mesh cage versus PEEK cage? 2) What are the differences in radiological outcomes between these two groups of patients? METHODS: This is a retrospective comparative study including patients with TB spine undergoing surgical management. The included subjects were divided into groups A and B depending on the implantation of PEEK or titanium mesh cage respectively for anterior column reconstruction. Outcome criteria analyzed included clinical criteria like VAS and ODI scores, radiological criteria like kyphosis correction, loss of kyphosis at follow-up, cage subsidence, and bony fusion on a 2D CT scan. RESULTS: The study population included 14 patients in Group A and 15 patients in Group B. Improvement in VAS and ODI scores was comparable between groups. There was no significant difference in radiological outcome measures between the two groups, however, two patients from group B showed implant-related complications needing revision. All patients showed good bony fusion at the final follow-up. CONCLUSION: PEEK and titanium cages have comparable clinico-radiological outcomes for anterior column reconstruction in patients with active TB spine. Its advantages for being radiolucent and its ease of use may make it a choice of implant.

Symptom Interval in Cases of Benign Cystic Lesions of Bone and its correlation with Surgical Intervention.

INTRODUCTION: Benign lesions in bone are less studied in terms of progression and prognosis. There is presently no literature studying symptom interval (SI) in neoplastic bone lesions or determinants of delay in Indian setting. The literature is also sparse on SI in benign lesions of bone, since benign bone lesions have seemingly less menacing symptoms and slow progression as compared to their malignant counterparts. Social and cultural issues peculiar to the region of study have an impact on the symptom interval of benign bony lesions. METHOD: A prospective, observational study was conducted at a tertiary level University teaching hospital from December 2017 to August 2019. The study included 55 patients presenting with benign cystic lesions of bone. Appropriate radiological investigations along with tissue biopsy were done. All the patients were enquired as per a preformed questionnaire to determine the delay and its determinants. RESULT: Out of the 55 patients included in the study, wide variety of cystic lesions was observed with varied presentation and delay. Median SI of 175 days (range 27-3705 days) was observed in the present study. However, it was found that longer SI did not have a statistically significant effect on the type of procedure done (p = 0.206) though diagnostic delay was significantly related to the intervention required (p = 0.004). It was observed that tumor behavior at the time of presentation such as histopathological diagnosis (p = 0.000), presence of cortical breach (p = 0.001), stage of tumor (0.001), and articular involvement (p = 0.000) remained as some of the most important factors in determining the prognosis and outcome in case of benign cystic lesions of bone.

Comparison of diagnostic ability of standard automated perimetry, short wavelength automated perimetry, retinal nerve fiber layer thickness analysis and ganglion cell layer thickness analysis in early detection of glaucoma.

Purpose: The aim of this study was to compare the diagnostic ability of macular ganglion cell layer (GCL) analysis using spectral domain optical coherence tomography against retinal nerve fiber layer analysis (RNFL), short-wavelength automated perimetry (SWAP), and standard automated perimetry (SAP) in early detection of glaucoma. Methods: Participants fulfilling the inclusion criteria were consecutively enrolled from the glaucoma clinic of tertiary care eye hospital in Western India from November 2015 to October 2016. The subjects underwent a detailed evaluation by trained glaucoma specialists. On suspicion of glaucoma, the patients underwent SAP, SWAP, and SD-OCT for GCL and RNFL analysis. Results: There were 91 patients in total of which experts classified 54 eyes into GON and 37 eyes into nonglaucomatous group. Sensitivity of SAP (42.59%) was significantly lower (P < 0.05) than that of average GCL thickness (79.63%) and average RNFL thickness (72.22%). Specificity and positive LR of SWAP (97.3% and 19.19, respectively) and SAP (94.6% and 7.88, respectively) were greater than those of GCL (81.08% and 4.21) and RNFL (67.57% and 2.23) parameters. Negative LR of average GCL thickness (0.25) was superior to that of average RNFL thickness (0.411), SWAP (0.495), and SAP (0.607). Conclusion: Macular GCL parameters perform better than RNFL parameters in patients with early glaucomatous damage. There is superior ability of SWAP over SAP in detecting glaucomatous changes in glaucoma suspect group. GCL thickness analysis has higher sensitivity and negative likelihood ratio, whereas SWAP had higher specificity and positive likelihood ratio. Thus, combining both tests can lead to better diagnostic ability for early glaucomatous damage.