Sacroiliac Joint Fusion – Impact of a New Image-Guidance Protocol on Safety and Complications

INTRODUCTION Low back pain is a common affliction impacting patients worldwide. The burden of low back pain on modern society in terms of direct costs associated with diagnosis and treatment, as well as indirect costs such as time missed from work for both patients and caregivers, is estimated to be as high as $100 billion annually in the United States alone.1,2 Up to 2-3% of physician visits are thought to be related to chronic low back pain.1,3 While the traditional focus of healthcare providers has been on lumbosacral pathology, sacroiliac joint dysfunction is an underappreciated and underdiagnosed cause of low back pain. Previous studies3-8 have suggested that 15-30% of chronic low back pain is due to pathology located in the sacroiliac joint. Historically, recognition of this pathology was difficult, limited by lack of standardized diagnostic criteria and disease-specific outcome measures. Traditional treatment focused on conservative therapy, such as physical therapy with focus on core and pelvic stability, orthoses, pain and anti-inflammatory medication, weight loss, intra- or peri-articular injections, and radiofrequency ablation.4,5,9-12 Early surgical intervention came in the form of morbid open approaches often utilizing iliac crest autografting. More recently, minimally invasive techniques for sacroiliac fusion have been developed that allow for significant sparing of muscle dissection, shorter operating room times and blood loss, reduced length of stay, and fewer complications.13-17 Such techniques are often performed with fluoroscopic guidance. However, three-dimensional sacral anatomy can be challenging to conceptualize on fluoroscopic imaging and several centers are now beginning to perform the procedure utilizing image-guidance with intraoperative CT data. This is particularly helpful in patients with transitional lumbosacral anatomy or those undergoing revision procedures. Complications such as pseudarthrosis and neural injuries, while rare, are often associated with need for revision surgery and poorer outcome.18,19 The transition to CT-based image-guidance aims to reduce such complications. The purpose of this study is to review our series of minimally invasive sacroiliac fusion with a focus on safety and complications, and to review differences in these parameters between patients undergoing fluoroscopic technique versus CT-based image-guidance

Association between air pollution and ventricular arrhythmias in high-risk patients (ARIA study): a multicentre longitudinal study

Summary Background Although the effects of air pollution on mortality have been clearly shown in many epidemiological and observational studies, the pro-arrhythmic effects remain unknown. We aimed to assess the short-term effects of air pollution on ventricular arrhythmias in a population of high-risk patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation therapy defibrillators (ICD-CRT). Methods In this prospective multicentre study, we assessed 281 patients (median age 71 years) across nine centres in the Veneto region of Italy. Episodes of ventricular tachycardia and ventricular fibrillation that were recorded by the diagnostic device were considered in this analysis. Concentrations of particulate matter of less than 10 μm (PM 10 ) and less than 2·5 μm (PM 2·5 ) in aerodynamic diameter, carbon monoxide, nitrogen dioxide, sulphur dioxide, and ozone were obtained daily from monitoring stations, and the 24 h median value was considered. Each patient was associated with exposure data from the monitoring station that was closest to their residence. Patients were followed up for 1 year and then scheduled to have a closing visit, within 1 more year. This study is registered with ClinicalTrials.gov, number NCT01723761. Findings Participants were enrolled from April 1, 2011, to Sept 30, 2012, and follow-ups (completed on April 5, 2014) ranged from 637 to 1177 days (median 652 days). The incidence of episodes of ventricular tachycardia and ventricular fibrillation correlated significantly with PM 2·5 (p 10 . An analysis of ventricular fibrillation episodes alone showed a significant increase in risk of higher PM 2·5 (p=0·002) and PM 10 values (p=0·0057). None of the gaseous pollutants were significantly linked to the occurrence of ventricular tachycardia or ventricular fibrillation. In a subgroup analysis of patients with or without a previous myocardial infarction, only the first showed a significant association between particulate matter and episodes of ventricular tachycardia or ventricular fibrillation. Interpretation Particulate matter has acute pro-arrhythmic effects in a population of high-risk patients, which increase on exposure to fine particles and in patients who have experienced a previous myocardial infarction. The time sequence of the arrhythmic events suggests there is an underlying neurally mediated mechanism. From a clinical point of view, the results of our study should encourage physicians to also consider environmental risk when addressing the prevention of arrhythmic events, particularly in patients with coronary heart disease, advising them to avoid exposure to high levels of fine particulate matter. Funding There was no funding source for this study

Improving the Virtual Neurosurgery Residency Interview Experience

The residency selection process has proven a challenge in the face of the Covid-19 pandemic. In the neurosurgery match, residents are chosen based on objective metrics as well as their ability to effectively work as part of a team tasked with caring for medically complex patients faced with neurosurgical conditions. As there remain limitations on the number of externships students could participate in and the Step 1 examination is expected to be reported as either pass or fail in years to come, we will have fewer objective metrics to review in the student application. We conducted a study to best select neurosurgery resident applicants who could effectively work with our team to ultimately provide effective patientcentered care. Through a post-interview survey among applicants, we identified points of improvements for the neurosurgery residency application interview

Success and complication rates of trabeculectomies augmented with MMC in the management of glaucoma

Abstract Glaucoma unresponsive to medical treatment is managed by surgery. Augmentation with mitomycin C (MMC) is considered in patients at high risk of surgery failure. Aim: In this paper we assess and compare the success and complications of this procedure performed in the local state hospital with those of larger international centres. Methods: A retrospective study, of the surgery performed between 2003 and 2007 at St. Luke's Hospital by one surgeon (FM), was conducted. The total number of eyes considered in this analysis was 32. Intraocular pressures and complications up to one year post-operatively were recorded. Results: The mean intraocular pressure decreased from 30mmHg pre-operatively to 18mmHg post-operatively. The mean IOP drop registered was 42%. Of the 32 eyes that underwent trabeculectomy augmented with MMC, 23 were classified as a complete success with IOP remaining below 21mmHg at 1year post-surgery. Six eyes were considered as a partial success since they had an IOP under 21mmHg but this had to be kept under control with the administration of medications. Failure of surgery was classified as uncontrollable IOP, although also on medications. This was seen in 3 eyes. Using the central limit theorem, the significance of the difference in means and difference in percentages of IOP drop and complication rates, between the local state hospital procedures and international centres, were calculated. Conclusion: Incidences obtained from this analysis compare very favourably with results from international studies, showing no significant differences

Domestication influences morphological and physiological responses to salinity in Brassica oleracea seedlings

Brassica oleracea cultivars include important vegetable and forage crops grown worldwide, whereas the wild counterpart occurs naturally on European sea cliffs. Domestication and selection processes have led to phenotypic and genetic divergence between domesticated plants and their wild ancestors that inhabit coastal areas and are exposed to saline conditions. Salinity is one of the most limiting factors for crop production. However, little is known about how salinity affects plants in relation to domestication of B. oleracea. The objective of this study was to determine the influence of domestication status (wild, landrace or cultivar) on the response of different B. oleracea crops to salinity, as measured by seed germination, plant growth, water content and mineral concentration parameters at the seedling stage. For this purpose, two independent pot experiments were conducted with six accessions of B. oleracea, including cabbage (group capitata) and kale (group acephala), in a growth chamber under controlled environmental conditions. In both taxonomic groups, differences in domestication status and salt stress significantly affected all major process such as germination, changes in dry matter, water relations and mineral uptake. In the acephala experiment, the domestication × salinity interaction significantly affected water content parameters and shoot Na+ allocation. At early stages of development, wild plants are more succulent than cultivated plants and have a higher capacity to maintain lower Na+ concentrations in their shoots in response to increasing levels of salinity. Different responses of domesticated and cultivated accessions in relation to these traits indicated a high level of natural variation in wild B. oleracea. Exclusion of Na+ from shoots and increasing succulence may enhance salt tolerance in B. oleracea exposed to extreme salinity in the long term. The wild germplasm can potentially be used to improve the salt tolerance of crops by the identification of useful genes and incorporation of these into salinity-sensitive cultivars.M.L. recognizes an Isidro Parga Pondal-I2C Program fellowship from the Xunta de Galicia. Md.Y.A. was supported by the EXPERTS_II (Erasmus Mundus) Interchange ProgramS

Guidance on noncorticosteroid systemic immunomodulatory therapy in noninfectious uveitis: fundamentals of care for uveitis (focus) initiative

Topic: An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. Clinical Relevance: The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. Methods: An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic reviewof the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE,CINAHL,SCOPUS,BIOSIS, andWeb of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review.Atotal of 44 globally representativegroupmembersmet in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence. Results: In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed. Conclusions: Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents

Synthesis of titanate nanostructures using amorphous precursor material and their adsorption/photocatalytic properties

This paper reports on a new and swift hydrothermal chemical route to prepare titanate nanostructures (TNS) avoiding the use of crystalline TiO2 as starting material. The synthesis approach uses a commercial solution of TiCl3 as titanium source to prepare an amorphous precursor, circumventing the use of hazardous chemical compounds. The influence of the reaction temperature and dwell autoclave time on the structure and morphology of the synthesised materials was studied. Homogeneous titanate nanotubes with a high length/diameter aspect ratio were synthesised at 160^{\circ}C and 24 h. A band gap of 3.06\pm0.03 eV was determined for the TNS samples prepared in these experimental conditions. This value is red shifted by 0.14 eV compared to the band gap value usually reported for the TiO2 anatase. Moreover, such samples show better adsorption capacity and photocatalytic performance on the dye rhodamine 6G (R6G) photodegradation process than TiO2 nanoparticles. A 98% reduction of the R6G concentration was achieved after 45 minutes of irradiation of a 10 ppm dye aqueous solution and 1 g/L of TNS catalyst.Comment: 29 pages, 10 figures, accepted for publication in Journal of Materials Scienc

Associations Between Methylation of Paternally Expressed Gene 3 (PEG3), Cervical Intraepithelial Neoplasia and Invasive Cervical Cancer.

Cytology-based screening for invasive cervical cancer (ICC) lacks sensitivity and specificity to discriminate between cervical intraepithelial neoplasia (CIN) likely to persist or progress from cases likely to resolve. Genome-wide approaches have been used to identify DNA methylation marks associated with CIN persistence or progression. However, associations between DNA methylation marks and CIN or ICC remain weak and inconsistent. Between 2008-2009, we conducted a hospital-based, case-control study among 213 Tanzania women with CIN 1/2/3 or ICC. We collected questionnaire data, biopsies, peripheral blood, cervical scrapes, Human papillomavirus (HPV) and HIV-1 infection status. We assessed PEG3 methylation status by bisulfite pyrosequencing. Multinomial logistic regression was used to estimate odds ratios (OR) and confidence intervals (CI 95%) for associations between PEG3 methylation status and CIN or ICC. After adjusting for age, gravidity, hormonal contraceptive use and HPV infection, a 5% increase in PEG3 DNA methylation was associated with increased risk for ICC (OR = 1.6; 95% CI 1.2-2.1). HPV infection was associated with a higher risk of CIN1-3 (OR = 15.7; 95% CI 5.7-48.6) and ICC (OR = 29.5, 95% CI 6.3-38.4). Infection with high risk HPV was correlated with mean PEG3 differentially methylated regions (DMRs) methylation (r = 0.34 p<0.0001), while the correlation with low risk HPV infection was weaker (r = 0.16 p = 0.047). Although small sample size limits inference, these data support that PEG3 methylation status has potential as a molecular target for inclusion in CIN screening to improve prediction of progression. Impact statement: We present the first evidence that aberrant methylation of the PEG3 DMR is an important co-factor in the development of Invasive cervical carcinoma (ICC), especially among women infected with high risk HPV. Our results show that a five percent increase in DNA methylation of PEG3 is associated with a 1.6-fold increase ICC risk. Suggesting PEG3 methylation status may be useful as a molecular marker for CIN screening to improve prediction of cases likely to progress