Patients' Perception and Satisfaction on Neck and Shoulder Imbalance in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To evaluate the perception and satisfaction among adolescent idiopathic scoliosis (AIS) patients on Neck Tilt with Medial Shoulder Imbalance and Lateral Shoulder Imbalance. METHODS: Lenke 1 and 2 AIS patients were stratified into 6 groups of preoperative/ postoperative Balanced (B), Lateral Shoulder Imbalance (LSI) (>2 cm), and Neck Tilt with Medial Shoulder Imbalance (NT) (Grade 3). Patients were interviewed using Modified Neck and Shoulder Appearance and SRS-22r questionnaires. T1 tilt, Cervical Axis (CA), Clavicle Angle (Cla-A) and Radiographic Shoulder Height (RSH) were measured. RESULTS: A total of 120 Lenke 1 and 2 AIS patients were recruited. NT patients were aware and unhappy with their abnormal neck with medial shoulder appearances (P < .001). Similarly, LSI patients were aware and unhappy with their abnormal lateral shoulder appearances (P < .001). NT group had larger preoperative/ postoperative T1 tilt (9.2 ± 5.0°; 9.5 ± 5.3°) and CA (4.6 ± 3.1°; 7.0 ± 2.0°) (P < .01). LSI group had larger preoperative/ postoperative Cla-A (4.8 ± 2.8°; 4.0 ± 1.3°) and RSH (20.1 ± 9.4 mm; 17.0 ± 6.6 mm) (P < .001). Postoperative B group scored higher in overall SRS-22r scores, self-image and satisfaction domains (4.2 ± 0.3; 4.0 ± 0.5; 4.4 ± 0.5) while preoperative LSI scored the lowest comparatively (3.5 ± 0.4; 2.4 ± 0.5; 3.3 ± 0.5) (P < .001). CONCLUSION: NT and LSI were major concerns among AIS patients. Both NT and LSI groups were unhappy with their appearances. NT group had larger T1 tilt/ CA whereas LSI group had larger Cla-A/ RSH. Postoperative B group scored higher in overall SRS-22r scores, self-image and satisfaction domains.

Aberrant left brachiocephalic vein is a contraindication for anterior cervicothoracic approach.

Aberrant left brachiocephalic vein is a rare condition. Its occurrence in patients requiring anterior cervicothoracic approach for severe kyphoscoliosis has not been described. A 16-year-old male with neurofibromatosis and severe upper thoracic kyphoscoliosis presented to us with curve progression. Halo gravity traction was attempted but failed to achieve significant correction. Subsequently, he underwent halo-pelvic traction and later Posterior Spinal Fusion (PSF) from C2 to T10. Second-stage anterior cervicothoracic approach with anterior fibula strut grafting was planned; however, preoperative computed tomography angiography revealed an aberrant left brachiocephalic vein with an anomalous retrotracheal and retroesophageal course, directly anterior to the T5/T6 vertebrae (planned anchor site for fibula strut graft) before draining into superior vena cava. Therefore, surgery was abandoned due to the risks associated with this anomaly. Aberrant left brachiocephalic vein is rare, the presence of which could be a contraindication for anterior cervicothoracic approach. Assessment of the anterior neurovascular structures is crucial in preoperative planning.

C1-C2 fusion with absence of C1 posterior arch and presence of C2 high-riding vertebral artery: Is it possible?

The presence of anatomical anomalies such as absence of C1 posterior arch and presence of C2 high-riding vertebral artery may not allow a conventional C1-C2 fusion, and this patient will require occipitocervical fusion. A 62-year-old lady presented with cervical myelopathy. CT scan demonstrated an os odontoideum with C1-C2 dislocation. The posterior arch of atlas on right C1 vertebra was absent, and there was high-riding vertebral artery on left C2. MRI revealed severe cord compression with cord oedema. The chronic atlantoaxial dislocation was reduced successfully with skeletal traction. Hybrid C1-C2 fusion augmented with autogenous local bone graft with corticocancellous iliac crest bone graft was performed to avoid an unnecessary occipitocervical fusion. She was stable throughout surgery and discharged 6 days later. CT scan 6 months post-operation showed a solid posterior fusion mass. Hybrid C1-C2 fusion can be performed to avoid occipitocervical fusion despite presence of abnormal anatomy at C1 and C2 vertebrae.

Clinical phenotypes of COPD and health-related quality of life: a cross-sectional study.

INTRODUCTION: The Spanish COPD guideline (GesEPOC) classifies COPD into four clinical phenotypes based on the exacerbation frequency and dominant clinical manifestations. In this study, we compared the disease-specific health-related quality of life (HRQoL) of patients with different clinical phenotypes. METHODS: This was a cross-sectional study of patients with COPD attending the respiratory medicine clinic of University of Malaya Medical Centre from 1 June 2017 to 31 May 2018. Disease-specific HRQoL was assessed by using the COPD Assessment Test (CAT) and St George's Respiratory Questionnaire for COPD (SGRQ-c). RESULTS: Of 189 patients, 28.6% were of non-exacerbator phenotype (NON-AE), 18.5% were of exacerbator with emphysema phenotype (AE NON-CB), 39.7% were of exacerbator with chronic bronchitis phenotype (AE CB), and 13.2% had asthma-COPD overlap syndrome phenotype (ACOS). The total CAT and SGRQ-c scores were significantly different between the clinical phenotypes (P<0.001). Patients who were AE CB had significantly higher total CAT score than those with ACOS (P=0.033), AE NON-CB (P=0.001), and NON-AE (P<0.001). Concerning SGRQ-c, patients who were AE CB also had a significantly higher total score than those with AE NON-CB (P=0.001) and NON-AE (P<0.001). However, the total SGRQ-c score of AE CB patients was only marginally higher than those who had ACOS (P=0.187). There was a significant difference in the score of each CAT item (except CAT 7) and SGRQ-c components between clinical phenotypes, with AE CB patients recording the highest score in each of them. CONCLUSION: Patients who were AE CB had significantly poorer HRQoL than other clinical phenotypes and recorded the worst score in each of the CAT items and SGRQ-c components. Therefore, AE CB patients may warrant a different treatment approach that focuses on the exacerbation and chronic bronchitis components.

The Effect of 20-Minute Mindful Breathing on the Rapid Reduction of Dyspnea at Rest in Patients With Lung Diseases: A Randomized Controlled Trial.

CONTEXT: Dyspnea is a common and distressing symptom in respiratory diseases. Despite advances in the treatment of various lung diseases, the treatment modalities for dyspnea remain limited. OBJECTIVES: This study aims to examine the effect of 20-minute mindful breathing on the rapid reduction of dyspnea at rest in patients with lung cancer, chronic obstructive pulmonary disease, and asthma. METHODS: We conducted a parallel-group, nonblinded, randomized controlled trial of standard care plus 20-minute mindful breathing vs. standard care alone for patients with moderate to severe dyspnea due to lung disease, named previously, at the respiratory unit of University Malaya Medical Centre in Malaysia, from August 1, 2017, to March 31, 2018. RESULTS: Sixty-three participants were randomly assigned to standard care plus a 20-minute mindful breathing session (n = 32) or standard care alone (n = 31), with no difference in their demographic and clinical characteristics. There was statistically significant reduction in dyspnea in the mindful breathing group compared with the control group at minute 5 (U = 233.5, n1 = 32, n2 = 31, mean rank1 = 23.28, mean rank2 = 37.72, z = -3.574, P < 0.001) and minute 20 (U = 232.0, n1 = 32, n2 = 31, mean rank1 = 23.00, mean rank2 = 36.77, z = -3.285, P = 0.001). CONCLUSION: Our results provide evidence that a single session of 20-minute mindful breathing is effective in reducing dyspnea rapidly for patients with lung cancer, chronic obstructive pulmonary disease, and asthma.

Posterior Spinal Fusion in a Scoliotic Patient With Congenital Heart Block Treated With Pacemaker: An Intraoperative Technical Difficulty.

STUDY DESIGN: Case report. OBJECTIVE: To describe the technical difficulties on performing posterior spinal fusion (PSF) on a pacemaker-dependent patient with complete congenital heart block and right thoracic scoliosis. SUMMARY OF BACKGROUND DATA: Congenital complete heart block requires pacemaker implantation at birth through thoracotomy, which can result in scoliosis. Corrective surgery in this patient was challenging. Height gain after corrective surgery may potentially cause lead dislodgement. The usage of monopolar electrocautery may interfere with the function of the implanted cardiac device. METHODS: A 17-year-old boy was referred to our institution for the treatment of right thoracic scoliosis of 70°. He had underlying complete congenital heart block secondary to maternal systemic lupus erythematosus. Pacemaker was implanted through thoracotomy since birth and later changed for four times. PSF was performed by two attending surgeons with a temporary pacing inserted before the surgery. The monopolar electrocautery device was used throughout the surgery. RESULTS: The PSF was successfully performed without any technical issues and complications. Postoperatively, his permanent pacemaker was functioning normally. Three days later, he was recovering well and was discharged home from hospital. CONCLUSION: This case indicates that PSF can be performed successfully with thoughtful anticipation of technical difficulties on a pacemaker-dependent patient with underlying congenital heart block. LEVEL OF EVIDENCE: 5.

Quality indicators in pediatric colonoscopy in a low-volume center: Implications for training.

AIM: To study implications of measuring quality indicators on training and trainees' performance in pediatric colonoscopy in a low-volume training center. METHODS: We reviewed retrospectively the performance of pediatric colonoscopies in a training center in Malaysia over 5 years (January 2010-December 2015), benchmarked against five quality indicators: appropriateness of indications, bowel preparations, cecum and ileal examination rates, and complications. The European Society of Gastrointestinal Endoscopy guideline for pediatric endoscopy and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition training guidelines were used as benchmarks. RESULTS: Median (± SD) age of 121 children [males = 74 (61.2%)] who had 177 colonoscopies was 7.0 (± 4.6) years. On average, 30 colonoscopies were performed each year (range: 19-58). Except for investigations of abdominal pain (21/177, 17%), indications for colonoscopies were appropriate in the remaining 83%. Bowel preparation was good in 87%. One patient (0.6%) with severe Crohn's disease had bowel perforation. Cecum examination and ileal intubation rate was 95% and 68.1%. Ileal intubation rate was significantly higher in diagnosing or assessing inflammatory bowel disease (IBD) than non-IBD (72.9% vs 50.0% P = 0.016). Performance of four trainees was consistent throughout the study period. Average cecum and ileal examination rate among trainees were 97% and 77%. CONCLUSION: Benchmarking against established guidelines helps units with a low-volume of colonoscopies to identify area for further improvement.

Exploring Electronic Medical Record and Self-Administered Medication Risk Screening Tools in a Primary Care Clinic.

BACKGROUND: Electronic medical record (EMR) screening for indicators of medication risk could improve efficiency in identifying primary care clinic patients in need of clinical pharmacist care compared with patient self-reporting. OBJECTIVES: To (a) compare the performance of an EMR medication risk assessment questionnaire (MRAQ) with a self-administered (SA) MRAQ and (b) explore each tool's ability to predict indicators of health behavior, health status, and health care utilization. METHODS: A prospective cohort study was conducted with 143 adults who attended an academic family medicine center and were taking ≥ 2 medications. All participants completed the 10-item SA-MRAQ, Morisky Medication Adherence Scale, Chew's health literacy screener, Stanford Health Distress Scale, and SF-36 overall rating of health. A blinded investigator completed the EMR-MRAQ and a chart review to ascertain 6 months of health care utilization. Outcome measures included the following: (a) scores from the 5- and 10-item SA-MRAQs and 5-item EMR-MRAQ; (b) sensitivity and specificity to determine the accuracy of the 5-item EMR versus the 5-item SA risk scores; (c) correlations between risk assessments and health behavior/status scales; and (d) area under the receiver operator curve to determine how well a high-risk score predicted health care utilization. RESULTS: The 5-item SA-MRAQ, the 5-item EMR-MRAQ, and the 10-item SA-MRAQ categorized 52.9% (55/104), 69.2% (99/143), and 17.6% (18/102) of participants as high risk, respectively. For the 104 participants who completed both 5-item MRAQ tools, the EMR-MRAQ had a sensitivity of 81.8% and specificity of 49.0% in detecting a high-risk SA-MRAQ score. Both 5-item risk assessments showed weak correlations with health distress and overall health, while the 10-item SA-MRAQ additionally showed weak correlations with medication adherence. The EMR-MRAQ was most effective in predicting all-cause emergency room visits/hospitalization (c-statistic = 0.69; 95% CI=0.57-0.81) and high clinic utilization (≥ 4 visits per 6 months; c-statistic = 0.77; 95% CI = 0.69-0.85). The EMR-MRAQ had high sensitivities but low specificities for these health care utilization outcomes, respectively (82.6% and 33.3%; 88.9% and 42.7%). CONCLUSIONS: This pilot study suggests that EMR-MRAQ screening has high sensitivity but low specificity in comparison with self-reporting and was able to discriminate between those who would and would not experience health care utilization outcomes. These results justify further development and validation of an automated EMR-based tool to predict patient-important consequences of medication-related problems. DISCLOSURES: This work was funded by the Canadian Society of Hospital Pharmacists Research and Education Foundation, which had no role in the analysis or interpretation of data or the decision to submit the manuscript for publication. The authors have no conflict of interests, potential or otherwise, to report. Makowsky had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Makowsky and Cor. Makowsky and Wong collected the data, and data interpretation was performed by Makowsky, Cor, and Wong. The manuscript was written by Makowsky and was critically reviewed for intellectual content by Makowsky, Cor, and Wong.

Reliability of scoring arousals in normal children and children with obstructive sleep apnea syndrome.

STUDY OBJECTIVES: Scoring of arousals in children is based on an extension of adult criteria, as defined by the American Sleep Disorders Association (ASDA). By this, a minimum duration of 3 seconds is required. A few recent studies utilized modified criteria for the study of children, with durations as short as 1 second. However, the validity and reliability of scoring these shorter arousals have never been verified. Based on studies in adults, we hypothesized that interscorer agreement for scoring arousals shorter than 3 seconds was poor. DESIGN: Retrospective review of polysomnograms by 2 experienced sleep practitioners who independently scored arousals according to the ASDA 3-second criteria and modified duration criteria of 1 and 2 seconds. SETTING: Academic hospital. PATIENTS OR PARTICIPANTS: 20 polysomnographic studies from children aged 3 to 8 years with mild to severe obstructive sleep apnea syndrome, and 16 polysomnographic studies from normal children. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The intraclass correlation coefficient for scoring ASDA arousals was 0.90 (95% confidence interval: 0.81-0.95), indicating excellent interscorer agreement. The intraclass correlation coefficient for scoring modified 1-second and 2-second arousals were 0.35 (95% confidence interval: 0.02-0.61) and 0.42 (95% confidence interval: 0.12-0.65) respectively, indicating poor to fair interscorer agreement. Furthermore, modified 1-second and 2-second arousals accounted for less than 15% of all arousals scored. CONCLUSIONS: We conclude that there is much poorer interscorer agreement for scoring arousals shorter than 3 seconds, when compared to the standard ASDA criteria. We propose that scoring of arousals in children should follow the standard ASDA criteria.