Feasibility of telemedicine program using a hand-held nonmydriatic retinal camera in Panama

AimTo evaluate the image quality of a telemedicine screening program for retinal disease using a nonmydriatic camera among rural island communities in Bocas del Toro, Panama.MethodsIn June 2018, a group of three medical students volunteered at clinics operated by the Floating Doctors in the province of Bocas del Toro, Panama. Non-mydriatic images of the retina were obtained using the Pictor Plus (Volk Optical, Mentor OH), randomized, and sent to two board-certified ophthalmologists at the University of California, Irvine for analysis using a modified version of the FOTO-ED scale. Inter-rater reliability was calculated using the kappa statistic.ResultsSeventy patients provided a total of 127 images. Average image quality was 3.31, and most frequent image quality was 4/5 on the FOTO-ED scale. Thirty patients had at least one eye image with ideal quality (42.86%), while only one patient had no adequate photos taken (1.43%). However, high quality images were obtained in both eyes in only 12 patients (17.14%). The inter-rater reliability between the two ophthalmologists was 0.614.ConclusionFurther improvements are necessary to acquire higher quality images more reliably. This may include further training and experience or mydriasis

Abstract Number ‐ 137: Delayed aneurysmal rupture of a giant fusiform vertebrobasilar aneurysm after flow‐diversion embolization with adjunctive coiling

Introduction Vertebrobasilar aneurysms carry a high risk of operative morbidity and high mortality risk with rupture. Treatment with flow diversion embolization has gained popularity. While adjunctive coiling may lower the risk of delayed aneurysm rupture (DAR), DAR can occur during stent endothelialization. describe a case of DAR following flow diversion with adjunctive coil embolization of a giant vertebrobasilar aneurysm and review the literature to further characterize this phenomenon. Methods PubMed was queried using search terms: “delayed,” “aneurysm,” “rupture,” “flow diverter,” “flow diversion,” and “flow diverting stent” yielding 220 results. There were 47 studies describing 89 patients with DAR after flow diversion. Results A forty‐five‐year‐old male presented with posterior fossa compression symptoms secondary to a 30‐mm fusiform basilar artery aneurysm, which grew during short‐interval follow‐up to 35 mm. The patient consented to endovascular embolization. Tri‐axial catheter access system was used to deploy seven telescoping flow diverters from the basilar tip to the intradural left vertebral artery, and nine coils were subsequently deployed in the aneurysm dome. The right vertebral artery was coil embolized. The procedure was uncomplicated and the patient was continued on dual‐antiplatelet therapy. Four weeks later, the patient became unresponsive with absent brainstem reflexes, workup revealed diffuse subarachnoid hemorrhage with intraventricular hemorrhage. Digital subtraction angiography demonstrated contrast extravasation at the aneurysm neck. He succumbed to his neurological injury two days later. Out of 89 patients with DAR after flow diversion, only 3 occurred in fusiform basilar aneurysms treated with adjunctive coil embolization. Only one case, a 37.1‐mm aneurysm treated with 3 flow diverters with adjunctive embolization, occurred at greater than 30 days post‐intervention. Conclusions This case highlights the need to better characterize the role of adjunctive coiling with flow diversion for large or giant aneurysms, and to better understand risk factors related to delayed aneurysm rupture

Trends in Diagnosis and Treatment of Sacroiliac Joint Pathology Over the Past 10 Years: Review of Scientific Evidence for New Devices for Sacroiliac Joint Fusion

Sacroiliac (SI) joint pathology is a newly appreciated contributor to lower back pain. Sacroiliac joint fusion (SIJF) has grown rapidly in popularity in association with the advent of minimally-invasive surgical techniques. This has led to an explosion of new medical devices used for SIJF. The objective of this article is to outline clinical trends, summarize the current data, and categorize novel devices for SIJF. Trends in SI joint pathology and fusion were obtained via the Healthcare Cost and Utilization Project's (HCUP) National Inpatient Sample (NIS) database and Web of Science. To review literature on devices for SIJF, PubMed was searched using the Boolean phrase "sacroiliac joint AND (fusion OR arthrodesis)" since 2010. To establish a list of SIJF devices not represented in the literature, searches were performed on the FDA 510(k), premarket approval, and de novo databases, as well as Google and LinkedIn. Literature review yielded 11 FDA-approved devices for minimally invasive SIJF. Database query yielded an additional 22 devices for a total of 33 devices. Twenty-one devices used the lateral transiliac approach, six posterior allograft approach, three posterolateral approach, and three combined the lateral transiliac and posterolateral approaches. The evidence for the lateral transiliac approach is the most robust. Many novel devices have been developed for minimally invasive SIJF over the past 10 years. Further randomized comparative trials are warranted to evaluate different surgical approaches and novel devices at this time

Surgical management of a rare myxopapillary ependymoma of the gluteal region: A case report.

BackgroundEpendymomas are rare tumors originating from neuroepithelial cells lining the wall of the ventricles or central canal of the spinal cord. While these tumors mainly occur within the central nervous system (CNS), there are occasional reports in children and young adult patients with a primary tumor occurrence outside of the CNS. Ependymomas of the sacrococcygeal region have been infrequently described in the literature with no standard of care established. We present a case report and review of the literature regarding this rare entity.Case descriptionA 24-year-old woman presented with right gluteal pain worsened by sitting and a palpable soft tissue mass of the sacrococcygeal region. Magnetic resonance imaging revealed a 3.7 cm cystic mass centered in the right gluteal region. She underwent a biopsy at an outside institution, with histology revealing myxopapillary ependymoma. The patient was referred to our hospital and underwent an interdisciplinary neurosurgical and orthopedic oncology en bloc resection of the ependymoma, which intraoperatively appeared to originate from the coccygeal nerve.ConclusionIn the present report, the authors demonstrate that a myxopapillary ependymoma may present as an isolated gluteal mass attached to the coccygeal nerve, without frank CNS involvement. Furthermore, an interdisciplinary approach to surgical resection of this lesion appears to represent an effective treatment modality

Cost analysis comparison between anterior and posterior cervical spine approaches.

BackgroundThe costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution.MethodsWe performed propensity score matching on financial data from 276 patients undergoing 1-3 level anterior versus posterior cervical fusions for degenerative disease (2015-2019).ResultsWe found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs.$45,110.52), net revenue ($40,877.25 vs.$34,036.01), or contribution margins ($14,230.19 vs.$6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (β = -392.3) and length of stay (LOS; β = -1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs.$6,312.54, P = 0.01).ConclusionAnterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS

Pacific Spine and Pain Society (PSPS) Evidence Review of Surgical Treatments for Lumbar Degenerative Spinal Disease: A Narrative Review

Abstract Introduction Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments. Methods The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria. Results The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis. Conclusions There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes

The NUTRIENT Trial (NUTRitional Intervention among myEloproliferative Neoplasms): Results from a Randomized Phase I Pilot Study for Feasibility and Adherence

PurposeChronic inflammation is integral to myeloproliferative neoplasm (MPN) pathogenesis. JAK inhibitors reduce cytokine levels, but not without significant side effects. Nutrition is a low-risk approach to reduce inflammation and ameliorate symptoms in MPN. We performed a randomized, parallel-arm study to determine the feasibility of an education-focused Mediterranean diet intervention among patients with MPN.Experimental designWe randomly assigned patients with MPN to either a Mediterranean diet or standard U.S. Dietary Guidelines for Americans (USDA). Groups received equal but separate education with registered dietician counseling and written dietary resources. Patients were prospectively followed for feasibility, adherence, and symptom burden assessments. Biological samples were collected at four timepoints during the 15-week study to explore changes in inflammatory biomarkers and gut microbiome.ResultsThe Mediterranean diet was as easy to follow for patients with MPN as the standard USDA diet. Approximately 80% of the patients in the Mediterranean diet group achieved a Mediterranean Diet Adherence Score of ≥8 throughout the entire active intervention period, whereas less than 50% of the USDA group achieved a score of ≥8 at any timepoint. Improvement in symptom burden was observed in both diet groups. No significant changes were observed in inflammatory cytokines. The diversity and composition of the gut microbiome remained stable throughout the duration of the intervention.ConclusionsWith dietician counseling and written education, patients with MPN can adhere to a Mediterranean eating pattern. Diet interventions may be further developed as a component of MPN care, and potentially incorporated into the management of other hematologic conditions.SignificanceDiet is a central tenant of management of chronic conditions characterized by subclinical inflammation, such as cardiovascular disease, but has not entered the treatment algorithm for clonal hematologic disorders. Here, we establish that a Mediterranean diet intervention is feasible in the MPN patient population and can improve symptom burden. These findings warrant large dietary interventions in patients with hematologic disorders to test the impact of diet on clinical outcomes