Endoscopic decompression of L3 nerve root in a case of adult spinal deformity correction with post-operative neurological deficit: a case report.

Adult spinal deformities (ASD) have a very high incidence of postoperative neurological decline. Spine surgeons all over the world are broadening the indications of endoscopic spine surgery (ESS) with similar/better outcomes to other conventional spine surgeries. In this report we present a case of L3-radiculopathy post ASD correction and its management with ESS. A 78-year-old female operated for ASD presented with backache, and right-side-dominant radiating leg pain. Imaging showed distal junctional failure with left rod fracture between L5-S1 and screw loosening with gross sagittal imbalance. She was treated with L4 pedicle subtraction osteotomy (PSO) with T10-iliac posterior fixation with use of satellite rods at PSO site. Post-operatively she developed left-sided L3 motor deficit. Imaging revealed left L3 root compression by bone fragment near the left L3 pedicle screw-head. We presume that, since the L3 pedicular screw had to be inserted deeper than the other screws to accommodate the satellite-rod, the bone in the area near the screw head (part of either the pedicle or facet) caused compression of the left L3 nerve root. The patient was treated with interlaminar ESS under awake anaesthesia and the compressing bone was drilled out. Post-operatively, patient had rapid relief of the radicular pain and improvement in the left quadriceps (L3) power with no recurrence at 1-year follow-up. Thus, post-operative iatrogenic neurological deficits can be treated successfully using ESS when the exact cause of the deficit is identified and is amenable to endoscopic removal. We could successfully treat a case of left-sided L3-radiculopathy, caused due to protruding bony spur after ASD correction surgery with ESS.

Are we neglecting long-term effects of vertebral shortening on pulmonary function in spinal tuberculosis?

PURPOSE: In developing part of the world, it is common to see complete destruction of vertebral bodies in tuberculosis. Our study aims to assess the effect of spinal tuberculosis with vertebral shortening on pulmonary function. METHODS: Fifty cases of spinal TB (14 males, 36 females) managed both operatively and non-operatively, who presented to tertiary care institute between years 2011 and 2016 were assessed. Vertebral height loss was assessed by spinal deformity index (SDI). All patients underwent pulmonary function testing using same equipment sitting in upright position. RESULTS: Mean age was 27.9 years (27.9 ± 11.9). 11 patients with mean SDI of 2.7 ± 1.1 showed normal lung function. 36 patients showed restrictive pattern of which 12 were mild, 14 were moderate and 10 showed severe pattern with a mean SDI of 3.8 ± 1.2, 5.6 ± 1.3 and 6.1 ± 1.4, respectively. 3 cases showed obstructive pattern. As the apex of curve shifted proximally, FVC% reduced. Increase in SDI value was associated with a fall in the vital capacity and FEV1. Increase in the kyphotic angle was associated with a deleterious effect on PFT results. CONCLUSIONS: Risk stratification of pulmonary dysfunction resulting from vertebral body height loss due to kyphosis will emphasize the need for early detection of spinal tuberculosis before deformity occurs.

Drivers of fatal bird collisions in an urban center.

Millions of nocturnally migrating birds die each year from collisions with built structures, especially brightly illuminated buildings and communication towers. Reducing this source of mortality requires knowledge of important behavioral, meteorological, and anthropogenic factors, yet we lack an understanding of the interacting roles of migration, artificial lighting, and weather conditions in causing fatal bird collisions. Using two decades of collision surveys and concurrent weather and migration measures, we model numbers of collisions occurring at a large urban building in Chicago. We find that the magnitude of nocturnal bird migration, building light output, and wind conditions are the most important predictors of fatal collisions. The greatest mortality occurred when the building was brightly lit during large nocturnal migration events and when winds concentrated birds along the Chicago lakeshore. We estimate that halving lighted window area decreases collision counts by 11× in spring and 6× in fall. Bird mortality could be reduced by ∼60% at this site by decreasing lighted window area to minimum levels historically recorded. Our study provides strong support for a relationship between nocturnal migration magnitude and urban bird mortality, mediated by light pollution and local atmospheric conditions. Although our research focuses on a single site, our findings have global implications for reducing or eliminating a critically important cause of bird mortality.

A weather surveillance radar view of Alaskan avian migration.

Monitoring avian migration within subarctic regions of the globe poses logistical challenges. Populations in these regions often encounter the most rapid effects of changing climates, and these seasonally productive areas are especially important in supporting bird populations-emphasizing the need for monitoring tools and strategies. To this end, we leverage the untapped potential of weather surveillance radar data to quantify active migration through the airspaces of Alaska. We use over 400 000 NEXRAD radar scans from seven stations across the state between 1995 and 2018 (86% of samples derived from 2013 to 2018) to measure spring and autumn migration intensity, phenology and directionality. A large bow-shaped terrestrial migratory system spanning the southern two-thirds of the state was identified, with birds generally moving along a northwest-southeast diagonal axis east of the 150th meridian, and along a northeast-southwest axis west of this meridian. Spring peak migration ranged from 3 May to 30 May and between, 18 August and 12 September during the autumn, with timing across stations predicted by longitude, rather than latitude. Across all stations, the intensity of migration was greatest during the autumn as compared to spring, highlighting the opportunity to measure seasonal indices of net breeding productivity for this important system as additional years of radar measurements are amassed.

Anterior Distraction and Reduction with Posterior Stabilization for Basilar Invagination: A Novel Technique.

BACKGROUND: Introduction of a posterior spacer for atlantoaxial joint distraction followed by posterior stabilization is a commonly performed procedure for irreducible atlantoaxial dislocation. We present a unique case in which posterior distraction was associated with increased risk of injury to the vertebral artery (VA) owing to its anomalous course, and hence a novel anterior distraction technique was used. CASE DESCRIPTION: A 45-year-old woman presented with severe neck pain for 1 month with gait imbalance and history of occipital headache for 1 year. Clinical examination revealed upper motor neuron-type findings. Hoffmann sign was positive bilaterally. Clinically, the patient had Nurick grade 4 cervical myelopathy. Magnetic resonance imaging showed basilar invagination along with Arnold-Chiari malformation and syrinx formation at C3-C4 vertebral levels. CT angiography revealed anomalous VAs directly overlying the atlanto-occipital joint. Owing to the anomalous route of the VA and unfavorable slope of facet joints, a 2-step anterior reduction followed by posterior stabilization surgery was planned. We achieved complete reduction using a 10-mm titanium cage inserted via a retropharyngeal approach. Following anterior reduction, instrumented in situ occipitocervical fusion was performed using a plate and screw construct. At 2-year follow-up, the patient is ambulating independently without gait imbalance and with successful radiologic fusion. CONCLUSIONS: The craniovertebral junction has a unique pathoanatomy, and the course of the vertebral artery is variable. Appropriate investigations, including computed tomography angiography, with adequate surgical planning will provide a desirable long-term outcome. Our novel technique has the potential to add a new dimension to the management of irreducible atlantoaxial dislocation.

An audit of admissions and mortality of orthopedic indoor patients in a tertiary care hospital of India.

INTRODUCTION: Mortality in orthopaedics is different in underdeveloped, developing and developed countries depending on the health, orthopaedic and trauma care services, education status and social awareness. Analysis of mortality and causes of death is an important step to identify the risk factor. Such study is invaluable for epidemiological monitoring and health care planning. METHODS: Between September 2015 to August 2018 demographic data, timing and primary diagnosis of both mortality and admission were collected retrospectively in a leading tertiary care hospital in the city of Mumbai, India. RESULTS: Total admissions of 10,937 in the 3-year period with increased average monthly admission in the month of June, July and August. Trauma to be most common cause of admission and death and Road traffic accident to be the most common cause of trauma followed by slip and fall. The death rate was 0.55 per 100 admissions per year. In males most common age group was 18-60 years and in females above 60 years of age. CONCLUSION: There is a link of increased admission rate in the monsoon months (rainy season) in India and road traffic accident and slip and fall. So accident prevention and health care planning and management of trauma victim, improvement of quality of life of general population will reduce trauma and related complications.

Efficacy of alternative fidaxomicin dosing regimens for treatment of simulated Clostridium difficile infection in an in vitro human gut model.

BACKGROUND: Fidaxomicin treatment reduces the risk of recurrent Clostridium difficile infection (CDI) compared with vancomycin. Extending duration of fidaxomicin therapy may further reduce recurrence. We compared the efficacy of four extended fidaxomicin regimens in an in vitro model of CDI. METHODS: Four gut models were primed with human faeces, spiked with C. difficile spores (PCR ribotype 027) and clindamycin instilled (33.9 mg/L, four-times daily, 7 days) to induce simulated CDI. Four extended fidaxomicin treatment regimens were evaluated: model 1, 20 days, 200 mg/L twice daily; model 2, 5 days 200 mg/L twice daily, 5 days rest, 5 days 200 mg/L twice daily; model 3, 5 days 200 mg/L twice daily, 5 days rest, 10 days 200 mg/L once daily; and model 4, 5 days 200 mg/L twice daily, 20 days 200 mg/L once every other day. C. difficile populations, toxin, gut microbiota and antimicrobial levels were monitored daily. RESULTS: All fidaxomicin regimens successfully resolved simulated CDI without recurrence. Five days of fidaxomicin instillation was barely sufficient to resolve CDI (models 2-4). A second pulse or tapered dosing further reduced C. difficile and toxin detection. All regimens were sparing of microbiota, affecting only enterococci and bifidobacteria. Pulsed or tapered regimens allowed greater bifidobacteria recovery than the extended (20 day) regimen. Bioactive fidaxomicin persisted throughout the experiment in all models at concentrations inhibitory to C. difficile. CONCLUSIONS: Pulsed or tapered fidaxomicin regimens may enhance suppression of C. difficile whilst allowing microbiota recovery; clinical studies are required to ascertain the potential of this approach in further reducing recurrent CDI.

Cyclophosphamide in pulmonary alveolar hemorrhage due to leptospirosis.

BACKGROUND AND AIMS: Severe pulmonary involvement in leptospirosis carries high mortality rates. It is the most common cause of death due to leptospirosis in many parts of India and the world. Exacerbated immune response of the host plays an important role in its pathogenesis. Hence, immunosuppressive drugs could be useful in its treatment. Glucocorticosteroids have been found to be useful in several studies. Cyclophosphamide, an immunosuppressive agent, has been found to be useful in a majority of pulmonary alveolar hemorrhages due to non leptospiral causes. This study was carried out to study the effects of cyclophosphamide in patients with leptospiral pulmonary alveolar hemorrhage. METHOD: A total of 65 patients with confirmed leptospirosis with severe pulmonary involvement admitted to a tertiary care center in south Gujarat were included in the study. All of the patients were treated with injection crystalline penicillin, methyl prednisolone pulse therapy, and non invasive mechanical ventilation. A total of 33 patients were given parenteral cyclophosphamide 60 mg/kg body weight stat on diagnosis. Their outcomes were compared with the remaining 32 patients who had not been given this drug. Survival was considered the main outcome indicator. RESULTS: Out of the 33 patients treated with cyclophosphamide, 22 (66.7%) survived, while in the control group out of 32 patients, three (9.4%) survived. On statistical analysis, the odds ratio was 19.33 (4.22-102.13) and the P-value was < 0.001. Leucopenia (78.78%) and alopecia (18.75%) were the main side effects noted. No mortality was noted due to these side effects. CONCLUSION: Cyclophosphamide improves survival in cases of severe pulmonary alveolar hemorrhage due to leptospirosis. Statistically, the improvement is highly significant.

New method for the rapid identification of tetracycline residues in foods of animal origin - using the PremiTest in combination with a metal ion chelation assay.

A post-screening classification assay for tetracycline compounds has been developed and integrated into the previously reported optimized PremiTest methodology. The new post-antimicrobial screening assay is based on a metal ion chelation using calcium and sodium chloride and has been shown to be specific towards the tetracycline class. The assay is both cost-effective and complementary to the post-screening procedures that have previously been developed for the beta-lactam and sulfonamide compounds. A validation study was conducted in accordance with 2002/657/EC (Commission Decision). The method is rugged and applicable to a range of tetracyclines of differing antimicrobial potencies over a wide concentration range. A blind trial was undertaken in which all antimicrobial residues in the unknown samples were successfully identified by the analyst following the integrated PremiTest procedure for the classification of antimicrobial compounds.