BERTOLOTTI SYNDROME: AN UNDER RECOGNIZED CAUSE OF INFLAMMATORY BACK PAIN?

BackgroundBertolotti syndrome describes a lumbosacral transitional vertebra (LSTV) which causes symptoms, usually low back pain. LATV is a congenital anomaly where the L5 vertebra has an unusual morphology. Bertolotti syndrome is an under-recognised condition by clinicians.ObjectivesTo clarify the presentation of Bertolotti syndrome, whether there are features of inflammatory back pain (IBP) and the effect on quality of life.MethodsIn this pilot study, 62 patients with LSTV were identified on imaging (plain x-ray). Imaging was performed for a variety of indications, predominently for back pain. In total, 34 patients agreed to take part, with 18 returning questionnaires. Questionnaires were selected for face vailidity and included: Calin IBP Questionnaire, EQ-5D Questionnaire, Visual analogue pain scale (VAS-P). In view of Covid restrictions all contact was by phone and questionnaires were completed online or returned via post.Plain X-rays visualising the lumbar spine were assessed for radiological features of LSTV.ResultsSeventeen (94%) of the participants (n=18) recorded a VAS-P score >3, indicating a clinically significant level of pain. The mean VAS-P score was 6 (range of 2-9). 89% of respondents scored at least 3/5 in the Calin questionnaire. Of the 5 features of inflammatory back pain in the Calin questionnaire, 4 out of the 5 were reported by most respondents. The exception was ‘improvement on exercise', which was only reported by 18% of respondents. Quality of life was impaired-EQ-5D (mean: 0.503, range -0.074 to 0.796).The commonest radiological abnormality was enlarged transverse process (100%) followed by pseudoarticulation with the sacrum (83%) and scoliosis (33%). Presence of sclerosis and/or osteoarthritis at the pseudoarticulation was associated with worse pain scores. Female respondents reported worse pain.ConclusionThese results suggest Bertolotti syndrome is associated with pain in the majority of patients and affects quality of life,. The character and site of the pain suggests that Bertollotti syndrome should be considered in the differential diagnosis of spondyloarthritis.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsSimon Stebbings Consultant of: Abbvie.Janssen, Ciara White: None declared, Terence Doyle: None declared.

A New Clinical Tool for Scoliosis Risk Analysis: Scoliosis Tele-Screening Test.

Study Design: Methodological, observational clinical study. Purpose: This study aimed to develop a virtual screening test to detect scoliosis risk initially by parents without the need for medical visit during the coronavirus disease 2019 pandemic. Overview of Literature: The scoliosis screening program has been implemented to early detect scoliosis. Unfortunately, access to health professionals was limited during the pandemic. However, during this time, interest in telemedicine has increased remarkably. Recently, mobile applications related to postural analysis were developed, but none permits evaluation by parents. Methods: Researchers developed the Scoliosis Tele-Screening Test (STS-Test), which included drawing-based images of body asymmetries, to assess the scoliosis-associated risk factors. The STS-Test was shared on social networks, allowing the parents to evaluate their children. After test completion, the risk score was generated automatically, and children with medium and high risks were then advised for medical consultation for further evaluation. The test accuracy and consistency between the clinician and parents were also analyzed. Results: Of the 865 tested children, 358 (41.4%) consulted clinicians to confirm their STS-Test results. Scoliosis was then confirmed in 91 children (25.4%). The parents were able to detect asymmetry in 50% of the lumbar/thoracolumbar curvatures and 82% of the thoracic curvatures. In addition, the forward bend test revealed favorable agreement between parents and clinicians (r =0.809, p<0.0005). Internal consistency of the esthetic deformities domain in the STS-Test was also excellent (α=0.901). This tool was 94.97% accurate, 83.51% sensitive, and 98.87% specific. Conclusions: The STS-Test is a new parent-friendly, virtual, cost-effective, result-oriented, and reliable tool for scoliosis screening. It allows parents to actively participate in the early detection of scoliosis by screening their children for the risk of scoliosis periodically without the need to visit the health institution.

Scoliosis Management through Apps and Software Tools.

Background: Scoliosis is curvature of the spine, often found in adolescents, which can impact on quality of life. Generally, scoliosis is diagnosed by measuring the Cobb angle, which represents the gold standard for scoliosis grade quantification. Commonly, scoliosis evaluation is conducted in person by medical professionals using traditional methods (i.e., involving a scoliometer and/or X-ray radiographs). In recent years, as has happened in various medicine disciplines, it is possible also in orthopedics to observe the spread of Information and Communications Technology (ICT) solutions (i.e., software-based approaches). As an example, smartphone applications (apps) and web-based applications may help the doctors in screening and monitoring scoliosis, thereby reducing the number of in-person visits. Objectives: This paper aims to provide an overview of the main features of the most popular scoliosis ICT tools, i.e., apps and web-based applications for scoliosis diagnosis, screening, and monitoring. Several apps are assessed and compared with the aim of providing a valid starting point for doctors and patients in their choice of software-based tools. Benefits for the patients may be: reducing the number of visits to the doctor, self-monitoring of scoliosis. Benefits for the doctors may be: monitoring the scoliosis progression over time, managing several patients in a remote way, mining the data of several patients for evaluating different therapeutic or exercise prescriptions. Materials and Methods: We first propose a methodology for the evaluation of scoliosis apps in which five macro-categories are considered: (i) technological aspects (e.g., available sensors, how angles are measured); (ii) the type of measurements (e.g., Cobb angle, angle of trunk rotation, axial vertebral rotation); (iii) availability (e.g., app store and eventual fee to pay); (iv) the functions offered to the user (e.g., posture monitoring, exercise prescription); (v) overall evaluation (e.g., pros and cons, usability). Then, six apps and one web-based application are described and evaluated using this methodology. Results: The results for assessment of scoliosis apps are shown in a tabular format for ease of understanding and intuitive comparison, which can help the doctors, specialists, and families in their choice of scoliosis apps. Conclusions: The use of ICT solutions for spinal curvature assessment and monitoring brings several advantages to both patients and orthopedics specialists. Six scoliosis apps and one web-based application are evaluated, and a guideline for their selection is provided.

Segmental lung anatomy for ultrasound assessment for post-COVID conditions

Introduction: Ultrasound (US) has become a more reliable method for lung parenchyma assessment. Precise detecting localization and effective monitoring treatment is crucial in respiratory medicine patients. The aim was to evaluate the accuracy of the US to detect and monitor lung lesions in compliance with lung segmental anatomy in post-COVID patients with associated comorbid respiratory conditions. Materials: We did an evaluation of 30 consecutive patients (25-74?years), who suffered from various chronic respiratory conditions and underwent COVID-19 during the last 3 months. All patients underwent first line lung ultrasound followed by CT and bronchoscopy where needed. Result(s): US can detect correctly in 28/30 cases to verify lesion and segmental localization as confirmed on CT and/or endoscopy. The US was effective to monitor treatment in 24/30 cases without need for follow up CT, including 5 patients after bronchoscopic lavage. Various specific conditions were detected and monitored on US: segmental atelectasis, pneumonia (22 cases);right middle lobe atelectasis (3);bronchiectatic disease (3);lung cirrhosis, post tuberculosis changes (2). Lung compression / atelectasis due to severe scoliosis and thoracic deformities detected in 2 patients. In some cases US was more effective vs CT due to possibility of real time ventilation observation, detecting tissue movement;dorsal areas ventilation was underdetected on CT due to patients'position. Conclusion(s): US can be used for detecting peripheral lung lesions, precise determination of segmental localization, is important for early diagnosis and monitoring.

Impact of the COVID-19 Pandemic on Middle-Aged and Older Patients With Adolescent Idiopathic Scoliosis Who Underwent Spinal Fusion: A Questionnaire-Based Survey.

Purpose To investigate the impact of the COVID-19 pandemic on middle-aged and older patients with adolescent idiopathic scoliosis (AIS) who underwent spinal fusion. Methods The subjects were 252 AIS patients who underwent spinal fusion between 1968 and 1988. The surveys were performed before the COVID-19 pandemic (a primary survey in 2014) and during the pandemic (a secondary survey in 2022). The self-administered questionnaires were mailed to the patients. We analyzed 35 patients (33 females and two males) who replied to both surveys. Results The pandemic had low impacts on 11 patients (31.4%). Two patients reported refraining from seeing a doctor because they were concerned about going to the clinic or hospital, eight reported that the pandemic impacted their work, and five reported fewer opportunities to go out (based on multiple-choice answers). Twenty-four patients reported that their lives were unaffected by the pandemic. No significant differences were detected between both surveys for Scoliosis Research Society-22 (SRS-22) in any domains (function, pain, self-image, mental, or satisfaction). The Oswestry Disability Index (ODI) questionnaires revealed a significant worsening of the survey during the pandemic compared with the survey before the pandemic. There was no significant difference in the impact of the pandemic between the ODI deterioration group (27.8%) and the ODI stable group (35.3%). Conclusion The COVID-19 pandemic had a low impact on 31.4% of middle-aged and older patients with AIS who underwent spinal fusion. The impact of the pandemic did not significantly differ between the groups with ODI deteriorations and the groups with stable ODI. The pandemic had a smaller impact on AIS patients at a minimum of 33 years after surgery.

Idiopathic Scoliosis Trends One Year After COVID-19: A Retrospective Study.

Introduction The reorganization of healthcare services during the COVID-19 pandemic was associated with compromised management of conditions not related to the pandemic. Methods A retrospective descriptive case series study was carried out that included patients followed up at the Spine Deformities (SD) consultation at Centro Hospitalar e Universitário Lisboa Central from January 2019 through December 2021 regarding diagnosis, treatment, referral, and the number of consultations performed. Results Referrals significantly dropped in 2020 (p<0.001). The average number of consultations per patient was found to not vary significantly in 2020 despite the reorganization of our healthcare unit due to the pandemic. 22% of the consultations were performed online. Idiopathic scoliosis (IS) was the primary diagnosis in 50% of the patients observed for the first time during the three-year time period. An increase of 18% was found in the number of IS patients that required bracing in 2021. However, late referrals, defined as the patient meeting surgical criteria at the time of initial presentation, did not increase. Conclusion Despite the significant decrease in primary care referrals during 2020, an overcompensation increase in referrals was not observed in 2021. However, the increase in the percentage of patients needing bracing might reflect a delayed initial presentation to the SD consultation.

Impact of the Suspension of Elective Surgeries for Adolescent Idiopathic Scoliosis during the COVID-19 Pandemic.

Objectives This study evaluated the radiographic progressions of scoliotic curves higher than 40° in patients with adolescent idiopathic scoliosis (AIS). These subjects waited for the surgical procedure while elective surgeries were on hold during the COVID-19 pandemic. In addition to radiographic progressions, this study described the quality of life of these patients. Methods This study is a retrospective cohort assessing 29 AIS patients with surgical indications registered in the Brazilian public healthcare service. We compared the scoliotic radiographic measurements in two moments: at the beginning of the interruption of elective surgeries due to the COVID-19 pandemic and when these procedures resumed. Results When comparing the radiographic measurements before and after the suspension of assessments for elective surgeries, we observed a significant increase in main curve angles ( p < 0.001), with variations ranging from 0 to 68° and a median value of 10°. In secondary curves, we observed an increase in angles from the proximal thoracic ( p < 0.001) and lumbar ( p = 0.001) regions. However, the increase in the main thoracic region was not significant ( p = 0.317). Conclusion The suspension of elective surgeries for AIS resulted in a significant increase in the radiographic values of patients' spine deformities. This increase harmed the quality of life of these subjects and their families.

Safety and feasibility of distraction procedure in growing rods for Early Onset Scoliosis as day care procedure - A retrospective observational study of 653 procedures

Purpose: To investigate the safety and feasibility of growth rod distraction procedure as 'daycare surgery' in early-onset scoliosis (EOS). EOS is an 'enigma' in spine surgery as early fusion and deformity correction will negatively affect truncal growth and pulmonary development. Likewise, delaying the treatment would lead to grotesque deformity with severe systemic implications. Therefore, worldwide we use 'Growth rods' for EOS and periodically distract it to allow for spinal growth in a 'controlled' manner. However, regular distraction every 6 months until definitive fusion would incur huge financial challenges and resource utilization . Our hypothesis is that the growth rod distraction procedure can be routinely used as a daycare procedure, thereby, cutting down the cost and resource utilization, especially in these pandemic times. Method(s): Hospital records and operation notes were retrospectively reviewed of 119 patients with a focus on details of neurological events/ complications during their index surgeries/lengthening procedures. Multimodality IONM was used as a mandatory protocol in all our index cases . However, for growth rod lengthening procedures we had well-defined indications-i) patients in whom intraoperative drop in signals were present during index case ii)patients who had intraspinal abnormality and had synchronous neurosurgical procedure iii) patients who underwent rod exchange/revision surgery concurrent with lengthening procedure. Except for these indications, none of our patients had IONM during the routine lengthening procedure.An amplitude drop of greater than 50% in trans cranial MEP or somatosensory evoked potentials (SSEP) was considered a neuromonitoring 'alert'. Result(s): 653 procedures involving primary growing rod surgeries (119 / 653) and lengthening procedures (534/653) were performed in 119 patients with EOS with a mean age of 7.3+/-2.3 years. Traditional growing rods (TGR-454/534) or magnetically controlled growing rods (MCGR-80/534) were implanted and subsequent lengthening procedures (Average -4.7 (range 2-9)) were done at stipulated intervals (TGR- 6.5 months, MCGR -3.8 mo). The mean anesthesia to surgical time for TGR (96.6+/-23 min vs 41.3 +/- 12 min) and MCGR was done as an outpatient procedure with mean average time of 26.2+/-9 minutes, respectively. The mean average blood loss in TGR vs MCGR was reported as 108+/-38 mL vs 0 mL.None of the patients with rod lengthening procedures required blood transfusion or experienced a neuromonitoring alert. On the morning of surgery these patients were admitted on short admission to Operating theatres and were not administered any pre-medication drugs. Induction was done using propofol (calm patients) or sevoflurane (restless patients) and BIS monitoring was done throughout the procedure. Intraoperative pain management was done using a fentanyl bolus. Furthermore, In the immediate post-operative period these patients were managed on fentanyl single bolus dose (0.5 microgram/kg) and later administered paracetamol injection (15 mg/kg - <30 kg) or ketorolac injection (0.1 mg/kg). At discharge, patients were managed on non-steroidal anti-inflammatory oral medications. Average reporting pain control (VAS-1.3+/-0.78) was satisfactory and mobilization was initiated within 4 hours, postoperatively. All our patients were discharged on the same evening with oral analgesics. Our 30-day readmission was noted in 2/119 secondary to superficial wound infection, which was managed on oral antibiotics. Conclusion(s): Growth rods (TGR, MCGR ) lengthening procedures can be safely undertaken as 'daycare surgery' under standardized anaesthesia and pain protocol. Secondly, intraoperative neuromonitoring can also be avoided in distraction procedures, thereby, helping in cost-cutting. This is especially relevant in changing paradigms of resource limitation in the COVID pandemic situation worldwide.

INTRAMEDULLARY GAS: A NEW FEATURE THAT PORTENDS A POOR PROGNOSIS IN COVID-19?

SESSION TITLE: Lessons Learned from Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Air outside the lungs, bowel, or paranasal cavities suggests critical pathology. Pneumoperitoneum is a classic example in which free abdominal air may signify hollow viscus injury and the need for emergent surgical management. Ectopic gas can also be secondary to barotrauma secondary to mechanical ventilation and concurrent lung injury;the latter being findings often observed in COVID pneumonia (1,2,3). Our case of extensive intramedullary gas in the setting of COVID pneumonia is an example of extensive dissecting air related to barotrauma, but also illustrates how it mimics dire cases of pneumoperitoneum. Therefore, it is an imaging finding that intensivists caring for COVID pneumonia patients should be aware of. CASE PRESENTATION: A 52-year-old male with mild restrictive lung disease from congenital scoliosis developed COVID pneumonia and hypoxic respiratory failure requiring intubation. Clinical course was complicated by renal failure, deep venous thromboses, and radial artery occlusion. CT evaluation revealed large volume upper abdominal pre-peritoneal gas, pneumoperitoneum, soft tissue and intramedullary gas within bilateral ribs and multiple vertebral bodies. Despite reassuring abdominal exams, the patient deteriorated. The patient was placed on comfort care and expired. DISCUSSION: Intramedullary gas refers to the presence of air within the cortical or trabecular bone, bone marrow, or medullary cavity. It is an exceedingly rare imaging finding which was first described in ischemic vertebral collapse and osteomyelitis (4,5). Differential diagnosis includes infection, trauma, degenerative and iatrogenic causes (5,6). Embryologically, fascial layers of the thorax and periosteal coverings of the thoracic osseous structures are derived from the mesoderm, thus creating a continuum between the lungs, surrounding soft tissues, peritoneum, and surrounding osseous structures, and therefore allowing gas to travel between the lung and intramedullary space (7). As cases of COVID pneumonia with ARDS increase, we are becoming aware of the increasing incidence of ectopic air, and the poor prognosis and increased mortality that results (1). Therefore, the finding of intramedullary gas is an important prognostic indicator that the clinician should be aware of. CONCLUSIONS: Several recent studies demonstrate increased mortality in COVID patients who develop ectopic gas as a result of barotrauma and/or acute lung injury (1,2,3). As such the clinician should be aware of these findings, which include pneumomediastinum, subcutaneous emphysema, pneumoperitoneum, pre-peritoneal air, and intramedullary gas for early recognition. Reference #1: 1. Lemmers DHL, Abu Hilal M, Bnà C, Prezioso C, Cavallo E, Nencini N, Crisci S, Fusina F, Natalini G. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty? ERJ Open Res. 2020 Nov 16;6(4):00385-2020. doi: 10.1183/23120541.00385-2020. PMID: 33257914;PMCID: PMC7537408. Reference #2: 2. Guven BB, Erturk T, Kompe Ö, Ersoy A. Serious complications in COVID-19 ARDS cases: pneumothorax, pneumomediastinum, subcutaneous emphysema and haemothorax. Epidemiol Infect. 2021 Jun 8;149:e137. doi: 10.1017/S0950268821001291. PMID: 34099076;PMCID: PMC8207553. Reference #3: 3. Tetaj N, Garotto G, Albarello F, Mastrobattista A, Maritti M, Stazi GV, Marini MC, Caravella I, Macchione M, De Angelis G, Busso D, Di Lorenzo R, Scarcia S, Farina A, Centanni D, Vargas J, Savino M, Carucci A, Antinori A, Palmieri F, D'Offizi G, Ianniello S, Taglietti F, Campioni P, Vaia F, Nicastri E, Girardi E, Marchioni L, Icu Covid-Study Group. Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate-Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital. J Clin Med. 2021 Nov 29;10(23):5608. doi: 10.3390/jcm10235608. PMID: 34884310;PMCID: PMC8658701. DISCLOSURES: Researc support relationship with 4D Medical Please note: March 2021 Added 04/04/2022 by Anu Brixey, value=Grant/Research Support No relevant relationships by raluca mccallum

Intra-oral kinking of a micro-cuff endotracheal tube: an unusual cause of difficult ventilation

Background: Intra-oral kinking of endotracheal tube is a rare but not unheard of complication. It could be lifethreatening if left unrecognised. Case presentation: A ten-year-old boy with developmental delay, scoliosis and recurrent chest infections was transferred to our paediatric intensive care (PIC) with SARS-CoV-2 pneumonia. The child was intubated with a size 5.5 micro-cuff endotracheal tube for critical hypoxic respiratory failure at his local hospital. The intubation was reported to be straightforward, with a grade 1 laryngoscopy view, but he was notably difficult to ventilate and oxygenate on the ventilator. He was transferred by road and was requiring a fraction of inspired oxygen of 0.8 and inhaled nitric oxide at 20 parts per million to maintain oxygen saturations of greater than 94%. The retrieval team also reported that he required a peak inspiratory pressure of as high as 49 cmH2O and positive end-expiratory pressure of 8 cmH2O with a 1:1 I: E ratio to maintain tidal volume of 6 ml/kg for his weight of 30kg. He was fully sedated and paralysed. The child was examined on arrival to PIC. His trachea was central and there was no wheeze or abdominal distension. The capnography waveforms were of normal appearance. A chest X-ray was also done to exclude endobronchial intubation and obvious pneumothorax. He was noted to be unusually difficult to bag ventilate, and the delivery of tidal volumes were hugely variable with any change in head positioning. He was best ventilated with head-tilt and chin-lift. Our concerns were escalated when the 'red-flag' of inability to pass the suction catheter was highlighted by the nursing team. The course of his tracheal tube was immediately palpated, and a twist was felt in the oropharynx. This finding was confirmed on laryngoscopy, which revealed a significant kink at letter C of this micro-cuff tube (Figure 1). The airway was swiftly exchanged, and immediate improvements of both ventilation and gas exchanged were observed. Conclusion: The polyvinyl polymers of endotracheal tubes are known to soften at body temperature and have a higher tendency to bent at acute angles,1 where the pilot tubing exists2;and when bending forces are applied away from the anatomical curvature, also known as the Magill curve (radius of approximately 140 millimetres), of most conventional tracheal tubes.2-5 Kinking of endotracheal tube at blind spots such as within the pharynx may happen more frequently in paediatrics than in adult critical care practice due to the use of straighter tracheal tubes with smaller wall thickness. We would like to raise awareness of this unusual case of difficult bag ventilation and high airway pressure ventilation. If a well-secured tracheal tube suddenly becomes problematic following, or in relation to positional changes, tube malfunction should be suspected. The integrity of the endotracheal tube must also be interrogated.

Bedside echocardiographic diagnosis of Pericardial effusion in the critically ill patient and prevention of catastrophic hemodynamic compromise

Introduction: In recent years, the use of ultrasound in critical care has revolutionized the bedside assessment of ICU patients. Though operator dependent, the advantage of repeatability and being relatively inexpensive makes it imperative for critical care physicians to stay updatedwith thismodality. The purpose of this report is to describe an incidental finding of pericardial effusion in a patent admitted with respiratory distress. Main body: A 26 years old female was admitted with shortness of breath and increase in oxygen requirements. She had a background of cerebral palsy, tracheostomized since 2009 after being operated for scoliosis and had a vagal nerve stimulator in situ. On admission, her 1st covid swab was negative. She normally required home ventilation only at night, however 2 days prior to admission, she required 24 hours of ventilator support. A large leak was noted on the ventilator and had a non-cuffed tracheostomy tube in situ, which was later changed to a cuffed one. A quick bedside FICE (Focused Intensive Care Echocardiography) revealed a large circumferential pericardial effusion with fibrin strands. There was no haemodynamic compromise on admission, however the large pericardial effusion could have been an attributing factor to her severe respiratory distress. She progressively started deteriorating hemodynamically, requiring intravenous fluids and vasopressor support. A definitive ECHO done by the cardiologist confirmed the findings of FICE. There was a rapid change in her condition post-pericardiocentesis. As per the institute protocol, a second covid swab was sent for her, which reported positive. Covid-19 RTPCR testing was not validated on pericardial fluid, hence was not undertaken. The culture of pericardial fluid revealed staphylococcus aureus, but there was a high index of suspicion of COVID and bacterial pericarditis was unlikely. Conclusion: Echocardiographic evaluation of Pericardial effusion is of paramount importance for timely and appropriate diagnosis. In view of quick bed side diagnosis with ultrasound, our patient was able to survive this life-threatening condition and treatment was initiated promptly. If left undiagnosed based on clinical presentation, it could have been catastrophic for a completely treatable cause. Brief description of ultrasound video: Pericardial effusion appears as an echo-free space between the 2 layers of pericardium. This video shows a 4-chamber echocardiographic view suggestive of a globular pericardial effusion with fibrin strands. An element of hemodynamic compromise was visible on 4-chambered view as well as para-sternal long axis view.

Genetic variants associated with the occurrence and progression of adolescent idiopathic scoliosis: a systematic review protocol.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a structural lateral spinal curvature of ≥ 10° with rotation. Approximately 2-3% of children in most populations are affected with AIS, and this condition is responsible for approximately $1.1 billion in surgical costs to the US healthcare system. Although a genetic factor for AIS has been demonstrated for decades, with multiple potentially contributory loci identified across populations, treatment options have remained limited to bracing and surgery. METHODS: The databases MEDLINE (via PubMed), Embase, Google Scholar, and Ovid MEDLINE will be searched and limited to articles in English. We will conduct title and abstract, full-text, and data extraction screening through Covidence, followed by data transfer to a custom REDCap database. Quality assessment will be confirmed by multiple reviewers. Studies containing variant-level data (i.e., GWAS, exome sequencing) for AIS subjects and controls will be considered. Outcomes of interest will include presence/absence of AIS, scoliosis curve severity, scoliosis curve progression, and presence/absence of nucleotide-level variants. Analyses will include odds ratios and relative risk assessments, and subgroup analysis (i.e., males vs. females, age groups) may be applied. Quality assessment tools will include GRADE and Q-Genie for genetic studies. DISCUSSION: In this systematic review, we seek to evaluate the quality of genetic evidence for AIS to better inform research efforts, to ultimately improve the quality of patient care and diagnosis. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration #CRD42021243253.

Self-reported physical activities in patients with adolescent idiopathic scoliosis-A cross-sectional observational study

Introduction: The impact of idiopathic scoliosis on exercise and activities of affected adolescents are not well-documented. The aim of this study was to assess the self-reported physical activity (PA) of patients with Adolescent Idiopathic Scoliosis (AIS) in Hong Kong. Materials and Methods: This was an observational, cross-sectional study conducted at a scoliosis clinic in a tertiary referral centre in Hong Kong. Patients referred from the Hong Kong Scoliosis School Screening Programme were consecutively recruited and asked to fill in the Chinese-translated version of the Paffenbarger Physical Activity Questionnaire (PPAQ) online. Details included flights of stairs climbed, city blocks walked, and frequency, duration and intensity of sporting activities were recorded, from which a Physical Activity Index (PAI) in kilocalories/week (kcal/week) was calculated. The PAI provides an estimate of the total energy expenditure of the subject. Radiographic data including Cobb angles and region of major curve, and anthropometric data was collected from routine clinical examinations. Results: 33 male (mean age = 14.6 ± 1.84) and 102 female (mean age = 13.2 ± 1.46) were included in the study. The mean BMI of male patients was 17.3 ± 2.2 kg/m2, and that of females was 18.0 ± 3.06 kg/m2, both of which are classified as underweight. 64 patients had a mild Cobb angle (10°-24.9°), 52 had a moderate Cobb angle (25°-39.9°) and 17 had a severe Cobb angle (>40°). In terms of PA, 72 patients (53%) reported participation in yearly PA activity excluding physiotherapy and mandatory physical education classes, and 55 (40.7%) in weekly PA that caused sweating, increased heart rate and shortness of breath. The 80 patients that did not participate in any PA were asked to provide reasons for their lack of physical activity. 30% of patients reported "lack of time" and 16.3% reported "laziness". Other reasons include lack of interest (6.3%), the COVID pandemic (2.5%) and being unfit (5%). A Physical Activity Index (PAI) in kcal/week was calculated based on subjects' answers to flights of stairs climbed, city blocks walked and sporting activities. Patients that were unable to provide a numerical answer to such questions were excluded from the PAI calculations. 113 PAIs were calculated, with a mean of 2611.2 ± 5009.4 kcal/week, and a median of 1128.4 kcal/week. 48 patients (42.5%) expended under 1000 kcal/week, 30 patients (26.5%) expended 1000-2000 kcal/week, 21 patients (18.6%) expended 2000-4000 kcal/week, and 14 patients (12.4%) expended over 4000kcal/week. According to the WHO guidelines on Physical Activity and Sedentary Behavior, PA recommendations for children and adolescents include 60 minutes of moderate-to-vigorous-intensity PA per day, which totals to 365 hours per week. Only 2 patients fulfilled this criterion. Conclusion: Adolescents with AIS in Hong Kong exhibited a wide range of PA levels. However, the majority of AIS patients in this study did not participate adequate physical activity according to WHO guidelines. Further studies are required to correlate if AIS negatively impacted on their motivation to participate in physical activities and exercises.

Metastatic Pulmonary Epithelioid Hemangioendothelioma: A Case Report

Introduction: Pulmonary Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor;with approximately 248 cases of reported in the literature, making diagnosis and management challenging. Case: A 57-year-old female with past history of hypertension, hyperthyroidism and scoliosis was admitted with worsening chronic right flank pain. Initial lab workup was unremarkable. revealed COVID-19 PCR test was negative. CT chest revealed bilateral pleural effusions and CT abdomen showed 2.8 x2.0cm vague hypo-attenuating lesion in the right hepatic lobe. A repeat CT scan following thoracentesis demonstrated multiple bilateral pulmonary nodules, with the largest located in the right lower lobe (RLL) measuring 2.1cm (Image). Flowcytometry on bronchoalveolar lavage fluid was significant for a CD4/CD8 ratio of 5;however, the transbronchial biopsy was unremarkable. Differential diagnosis included sarcoidosis and hence patient was discharged on prednisone with Bactrim prophylaxis. She underwent VATS lung biopsy. RLL and pleural biopsies revealed EHE. Following the prednisone taper, patient was placed on pazopanib 800mg. The dose of medication subsequently reduced to 300-600mg due to adverse events. Repeat CT scans at 3 months demonstrated minimal change in size of the nodules. Patient continues to be followed on regular basis with a stable clinical status. Discussion: EHE is a low-intermediate grade malignancy which affects mostly liver, lungs and bones;although it can be found in any bodily tissue. Up to 50- 76% of patients are asymptomatic at diagnosis, with the most common symptomatic being local pain. Radiologically, Pulmonary EHE consists of bilateral perivascular nodularity. Our case describes the clinical course of a rare and poorly understood disease. Clinicians must be aware of the characteristics of unusual diseases and pursue robust diagnostic approach. In our case, biopsy led to the definitive diagnosis of EHE. Because of its rarity, there is no standard therapy for metastatic disease. Pazopanib has demonstrated prolonged long-term disease control in observational studies. Some other reports have shown response to cytotoxic chemotherapy such as doxorubicin-containing regimens, however, long-term survival is compromised. Lenalidomide, sorafenib and sunitinib have also been used, but the experience is limited. Our patient is currently on her 4th month of treatment with pazopanib, with 3-month follow-up showing no progression of disease. (Figure Presented).

HALO-TRACTION INDUCED OBSTRUCTIVE SLEEP APNEA

Introduction: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. It is a multi-factorial disease with a variety of identified causes including age, male gender, obesity, craniofacial and upper airway abnormalities. We would like to describe a patient who had severe OSA following application of Halo traction, which significantly improved following the removal of the device. Report of Cases: 14-year-old male with medical history of spina bifida, chiari malformation s/p decompression, shunted hydrocephalus and severe scoliosis, was admitted to the hospital for anterior spinal discectomy L2-S1 and Halo application with traction for scoliosis. He previously had nocturnal polysomnogram (NPSG) in 2017 that demonstrated very mild mixed apnea with an apnea hypopnea index (AHI) of 5.5. Because central apneas were very brief and clustered in REM, family elected to repeat a study rather than treat. In 2019, he had a follow up study with complaints of snoring and thirst, and this demonstrated an AHI of 21 with 29 brief central apneas and 72 hypopneas, 1 obstructive apnea. He had a T&A and turbinate ablation and due to the global pandemic did not undergo repeat sleep study. During admission for his anterior spinal discectomy and Halo, he demonstrated persistent night time hypoxia. A split night sleep study showed evidence of severe OSA with pretreatment AHI of 94.4, oxygen nadir 86%. Continuous positive airway pressure (CPAP) was initiated at 5 cm of water and titrated to 11 cm of water. On CPAP of +11 severe obstructive events continued with an AHI of 40.6, oxygen nadir 92%. A bilevel positive airway pressure (BIPAP) titration study the subsequent night started at pressures of 12/6 and titrated to 21/9 with respiratory rate of 12 yet demonstrated AHI of 51, oxygen nadir 89%. Study transitioned to average volume assisted pressure support (AVAPS) with IPAP max of 26, IPAP minimum of 12 EPAP of 9, tidal volume of 175ml, rate of 12 with inadequate control of his obstructive events with an AHI of 24.8, minimum oxygen saturations of 91. While hospitalized, he remained on AVAPS with normal capillary blood gases. Halo traction was removed 2 weeks following his surgery with plan was to send him home on AVAPS and repeat NPSG in 6 weeks. However, as a result of COVID pandemic/Philips recall, CPAP was the only device available for home use, so CPAP therapy at +8 cm was trialed overnight, demonstrating oxygen nadir of 92% and a normal capillary blood gas in the morning. Patient was then discharged home on CPAP of +8 cm of water. He returned back to sleep center for a BIPAP titration study to re-establish BIPAP/AVAPS settings, as his inpatient sleep study had shown severe OSA. During the sleep study, he was started on BIPAP 12/6 and he remained on it throughout the night with 0 central and 0 obstructive events. As he did well, he was advised to continue CPAP +8 with plans to repeat the sleep study off CPAP. In clinic follow up, he reported mild skin breakdown and occasionally waking unrefreshed. Conclusion: As our patient did significantly better following the removal of Halo traction device, it is likely that Halo traction device caused fixed over flexion of the cervical spine that resulted in decrease in his airway diameter, which further worsened during his sleep, and caused severe OSA.

A Dangerous Curve: Impact of the COVID-19 Pandemic on Brace Treatment in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Observational Cohort study. OBJECTIVES: We aim to document the abandon and irregular compliance rate towards brace treatment during the COVID-19 pandemic and its impact on AIS progression. METHODS: We reviewed a database of AIS patients recruited between March and September 2020. We included AIS patients under brace treatment according to SRS criteria. The patients were divided in 2 cohorts: those with self-reported Good-Compliance (GC) to treatment and those who had a Bad-Compliance (BC). Data analysis included biometric and radiographic data at first visit and last follow-up and percentage of progression. Unpaired student-t tests and Chi2 were used for comparison. RESULTS: 152 patients met inclusion criteria. 89 patients (age:12.1y.o.±1.4) reported good adherence to treatment, while 63 patients (age:12.7y.o.±1.8) were not compliant. Within the BC group, 18 patients reported irregular brace wear, while 45 had completely abandoned treatment (abandon rate of 29%). The GC cohort started treatment with a mean main thoracic (MT) curve of 26° and finished with 27°. The mean difference between measurements was +.65°±7.5; mean progression rate was -4.6%. However, the BC cohort started with a mean MT curve of 27° and finished with 32°, with a mean increase of +5°±8 and a mean progression rate of -13%. The differences between the 2 cohorts were statistically significant (P = .0002). Six patients from the BC group progressed and were offered surgery. CONCLUSION: The abandon rate of brace treatment in AIS significantly increased during the first wave of COVID-19 pandemic. Patients who voluntarily discontinued treatment had significant increases in curve progression and surgical indication rates. LEVEL OF EVIDENCE: III.

Comparing Autopsy Thoracic Injury Patterns between In-Hospital CPR Patients Receiving LUCAS Device vs Manual Chest Compressions

Background: Current research comparing CPR-associated injuries between those receiving LUCAS device and manual CPR has primarily focused on patients who suffered out-of-hospital cardiac arrest. During the SARS-CoV-2 pandemic, more hospitals leveraged mechanical CPR devices to provide distant yet high quality chest compressions for in-hospital cardiac arrest (IHCA) patients. We sought to investigate autopsy thoracic injury patterns in in-hospital non-traumatic cardiac arrests, comparing traditional manual compressions with the mechanical LUCAS device compressions. Design: Autopsies were screened for a history of in-hospital cardiopulmonary resuscitation in the absence of prior traumatic injuries at a single, large quaternary care center from 1/1/2018 to 06/30/2021. 20 received LUCAS compressions and 40 received manual compressions. Student's T-Tests were used to compare means for continuous variables, while chi-squared and Fischer's exact tests were used for categorical variables. An alpha of 0.05 was chosen as the threshold for statistical significance. Results: A statistically significant decrease in the rate of sternal fractures and rate of multiple sternal fractures during mechanical CPR was found. A statistically significant increase in other soft tissue injuries, such as pleural wall or lung injuries was seen in mechanical CPR cases, while an increased rate of bilateral rib fractures was noted in manual compression cases. Conversely, no difference in the number or laterality of rib fractures were noted. There was no significant difference in age, biological sex, or rate of scoliosis or kyphosis between cohorts. Results are listed in table 1. (Table Presented) Little research has looked at the injury patterns of mechanical CPR in the IHCA patient population. These results point to a potential difference in thoracic injury patterns from manual compressions when compared to LUCAS device compressions. The statistically significant decrease in sternal fractures with mechanical compressions is noteworthy. Conversely, the increase in other soft tissue injury demands further examination. The decrease in bilateral rib fractures with LUCAS use suggests that placement of the device may play a role in the epidemiology of rib injuries, but not in the number of ribs injured. Further research should examine rib injuries in more detail, and quantify additional comorbidities in both survivors and non-survivors of cardiac arrest.

The angle of trunk rotation and symmetry of a lower limb loading in musicians of a symphony orchestra in Poland: a pilot study concerning instrument-specific results.

BACKGROUND: The study aimed to evaluate the angle of trunk rotation (ATR) and symmetry of lower limb loading in professional musicians. MATERIAL AND METHODS: A total of 60 instrumentalists were examined: cellists, violinists and musicians playing wind instruments. The scoliometer examination was used to assess trunk asymmetry. The angle of trunk rotation was measured at segment: Th1-Th4, Th5-Th12, and Th12-L4. The maximum value (ATR max) and the sum of three rotations (STR) were calculated. Two scales were used to assess the symmetry of lower limb loading. Loading symmetry index (LSI) of the lower limb was calculated. RESULTS: Violinists have the highest mean values of ATR, ATR max, STR and LSI and musicians playing wind instruments have the lowest mean values. In the group of violinists and musicians playing wind instruments, a positive correlation was found between playing experience and ATR Th1-Th4. CONCLUSIONS: The body position during playing violin and cello may increase the angle of trunk rotation and the lower limb loading's asymmetry. Med Pr. 2022;73(2):85-93.

Anaesthetic management of severe dextroscoliosis in a post-covid patient undergoing lumbar fixation and laminectomy

Aim: Patients who have severe case of kyphoscoliosis face functional and physical difficulties, making anaesthetic treatment challenging. In this example, a severe case of scoliosis was successfully treated under general anaesthesia. The case report aims to highlight the meticulous perioperative management of a patient with severe scoliosis, even after the surgery has been completed. Case: A 69-year-old woman with severe dextroscoliosis, single-vessel disease, and a recent history of covid (1 month ago) was scheduled for L1 to S1 fixation with L2-L4 laminectomy. On post-covid chest x-ray, the patient showed lung fibrosis, making anaesthetic management more challenging. Discussion: Scoliosis can cause a sort of respiratory restriction. The angle of the malformation is connected to the severity of the pulmonary issue. Cardiovascular, respiratory, and neurological dysfunction caused by the abnormality should be assessed prior to surgery. Fluid shift needs to be monitored carefully and corrected if necessary. There were no issues associated to ocular changes or the biracial plexus. Conclusion: Thorough preanaesthetic evaluation and optimization of the respiratory and cardiovascular systems is critical. In severe kyphoscoliosis, precise planning of anaesthesia induction and meticulous approach will result in a satisfactory outcome.