Publications by authors named "Vikas Tandon"

49 Publications

Hydatid Cyst of the Spine: A Rare Case Report and Review of Literature.

J Orthop Case Rep 2020 May-Jun;10(3):57-59

Department of Spine Services, Indian Spinal Injuries Centre, Delhi, India.

Introduction: Hydatid disease is caused by the parasite Echinococcus granulosus which is also known as the dog tapeworm. This disease is a relatively uncommon cause of spinal cord and dural compression.

Case Report: We came across a peculiar case in a 41-year-old male patient who presented to us with pus discharge from a surgical wound over lower back for 10 days. The patient was a diagnosed as a case of lumbar canal stenosis with recurrent hydatid cyst. The patient had neurological involvement in the form of left-sided foot drop. The patient gave a history of lumbar canal stenosis secondary to hydatid cyst, for which decompression and cyst excision were done 3 years prior. The patient was re-operated in the form of wound debridement with removal of hydatid cyst.

Conclusion: Meticulous surgery avoiding spillage of cyst material, appropriate medication as advised by the infectious disease specialist, will avoid recurrence of the disease.
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http://dx.doi.org/10.13107/jocr.2020.v10.i03.1748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051559PMC
May 2021

Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM): protocol for a randomized controlled trial.

CMAJ Open 2021 Jan-Mar;9(1):E142-E148. Epub 2021 Mar 2.

School of Nursing (McGillion, Levesque, Lounsbury, Bird, Ouellette), McMaster University, Hamilton, Ont.; Population Health Research Institute (McGillion, Whitlock, Devereaux, Belley-Cote, Borges, Vincent, Lamy, Bangdiwala, Le Manach, Harvey, Conen), Hamilton, Ont.; Department of Anesthesiology and Perioperative Medicine (Parlow, Arellano), Queen's University, Kingston, Ont.; Department of Anesthesiology and Perioperative Medicine (Parlow, Shelley, DuMerton, Arellano), Kingston Health Sciences Centre, Kingston, Ont.; Department of Medicine (Belley-Cote, Yousef, Borges, Marcucci, Chaudhry, Haider, Guyatt, Patel, Conen, Tandon), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (Whitlock, Devereaux, Marcucci, Bangdiwala, Guyatt), McMaster University, Hamilton, Ont.; Departments of Critical Care and Anesthesiology (Jacka), University of Alberta, Edmonton, Alta.; Department of Surgery (Adili, Harlock, Simunovic, Nenshi), McMaster University, Hamilton, Ont.; St. Joseph's Healthcare Hamilton (Adili, LeBlanc, Nenshi, Tandon), Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (Lalu, McCartney, Hamilton), University of Ottawa and The Ottawa Hospital, Ottawa, Ont.; Ottawa Hospital Research Institute (Moloo, Lalu, Halman, Forster, Hamilton), Ottawa, Ont.; Department of Anesthesia and Perioperative Medicine (Sehmbi, Nagappa, Yang), Schulich School of Medicine, University of Western Ontario, London, Ont.; Department of Anesthesia and Perioperative Medicine (Sehmbi, Nagappa, Yang), London Health Sciences Centre, London, Ont.; Hamilton Health Sciences (Meyer, Paulin, Pettit, Lamy, Lounsbury, Scott, Patel, Ouellette, O'Leary), Hamilton, Ont.; Department of Anesthesia (Shanthanna, Paul, Le Manach, O'Leary), McMaster University, Hamilton, Ont.; Department of Medicine (Roshanov, Mrkobrada), Schulich School of Medicine, University of Western Ontario, London, Ont.; Department of Internal Medicine (Ofori), University of Port Harcourt, Port Harcourt, Nigeria, West Africa; Department of Medicine (Graham, Taylor), University of Alberta, Edmonton, Alta.; Department of Medicine (Halman, Forster), University of Ottawa and The Ottawa Hospital, Ottawa, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Peter), University of Toronto, Toronto, Ont.; Department of Medicine (Marosi), Queen's University, Kingston, Ont.; Alberta Health Services (Deuchar), Alberta, Canada; Department of Surgery (Parry, Schlachta, Schemitsch), University of Western Ontario and London Health Sciences Centre, London, Ont.; Department of Surgery (Williams), University of Alberta, Edmonton, Alta.; Department of Oncology (Meyer), McMaster University, Hamilton, Ont.; Department of Surgery (Pichora), Queen's University and Kingston Health Sciences Centre, Kingston, Ont.; Department of Surgery (Moloo), University of Ottawa and The Ottawa Hospital, Ottawa, Ont.; The Ottawa Hospital (Waggott), Ottawa, Ont.

Background: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery.

Methods: We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study's tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem-enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization.

Interpretation: This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement.

Trial Registration: ClinicalTrials.gov, no. NCT04344665.
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http://dx.doi.org/10.9778/cmajo.20200176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034369PMC
March 2021

Functional Outcomes of Nerve Root Sparing Posterior Corpectomy in Lumbar Vertebral Burst Fractures.

Global Spine J 2021 Jan 25:2192568220984128. Epub 2021 Jan 25.

Department of Spine Services, 76434Indian Spinal Injuries Centre, Vasant kunj, Sector C, New Delhi, India.

Study Design: Retrospective observational.

Objectives: This study aimed to document the safety and efficacy of lumbar corpectomy with reconstruction of anterior column through posterior-only approach in complete burst fractures.

Methods: In this retrospective study, we analyzed complete lumbar burst fractures treated with corpectomy through posterior only approach between 2014 and 2018. Clinical and intraoperative data including pre and post-operative neurology as per the ISNCSCI grade, VAS score, operative time, blood loss and radiological parameters, including pre and post-surgery kyphosis, height loss and canal compromise was assessed.

Results: A total of 45 patients, with a mean age of 38.89 and a TLICS score 5 or more were analyzed. Preoperative VAS was 7-10. Mean operating time was 219.56 ± 30.15 minutes. Mean blood loss was 1280 ± 224.21 ml. 23 patients underwent short segment fixation and 22 underwent long segment fixation. There was no deterioration in post-operative neurological status in any patient. At follow-up, the VAS score was in the range of 1-3. The difference in preoperative kyphosis and immediate post-operative deformity correction, preoperative loss of height in vertebra and immediate post-operative correction in height were significant (p < 0.05).

Conclusion: The posterior-only approach is safe, efficient, and provides rigid posterior stabilization, 360° neural decompression, and anterior reconstruction without the need for the anterior approach and its possible approach-related morbidity. We achieved good results with an all posterior approach in 45 patients of lumbar burst fracture (LBF) which is the largest series of this nature.
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http://dx.doi.org/10.1177/2192568220984128DOI Listing
January 2021

Missing Disc Fragment: A Rare Surgical Experience.

Asian J Neurosurg 2020 Jul-Sep;15(3):674-677. Epub 2020 Aug 28.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

About 35%-72% of lumbar disc herniations are associated with fragment migration. However, the posterior epidural migration is rare. We present a strange situation encountered during surgical decompression of the posterior migrated fragment. A 72-year-old male presented with a history of pain radiating to the left lower limb and Grade 3 power of the extensor hallucis longus. Magnetic resonance imaging revealed a prolapsed intervertebral disc and a possible posterior epidural migration of disc fragment. Routine surgical steps for microdiscectomy were followed after confirmation of level using fluoroscopy. However, the extruded disc fragment was not seen, and both exiting and traversing roots were free with adequate mobility. After extensively searching for a disc in the spinal canal, suction fluid was filtered through a surgical mop used as a sieve. Material collected was sent for histopathological study. Biopsy report confirmed material filtered was indeed the intervertebral disc. Thus, accidental suction of disc material in case of the posterior epidural migrated disc is a possibility, and we should be vigilant about this scenario to avoid disaster.
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http://dx.doi.org/10.4103/ajns.AJNS_79_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591192PMC
August 2020

Mini-open thoracoscopic-assisted spinal thoracotomy for traumatic injuries: A technical note.

Surg Neurol Int 2020 29;11:265. Epub 2020 Aug 29.

Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Background: Mini-open thoracoscopic-assisted thoracotomy (MOTA) has been introduced to mitigate disadvantages of conventional open anterior or conventional posterior only thoracoscopic procedures. Here, we evaluated the results of utilizing the MOTA technique to perform anterior decompression/fusion for 22 traumatic thoracic fractures.

Methods: There were 22 patients with unstable thoracic burst fractures (TBF) who underwent surgery utilizing the MOTA thoracotomy technique. Multiple variables were studied including; the neurological status of the patient preoperatively/postoperatively, the level and type of fracture, associated injuries, operative time, estimated blood loss, chest tube drainage (intercostal drainage), length of hospital stay (LOS), and complication rate.

Results: In 22 patients (averaging 35.5 years of age), T9 and T12 vertebral fractures were most frequently encountered. There were 20 patients who had single level and 2 patients who had two-level fractures warranting corpectomies. Average operating time and blood loss for single-level corpectomy were 91.5 ± 14.5 min and 311 ml and 150 ± 18.6 min and 550 ml for two levels, respectively. Mean hospital stay was 5 days. About 95.45% of cases showed fusion at latest follow-up. Average preoperative kyphotic angle corrected from 34.2 ± 3.5° to 20.5 ± 1.0° postoperatively with an average correction of 41.1% and correction loss of 2.4%.

Conclusion: We concluded that utilization of the MOTA technique was safe and effective for providing decompression/fusion of traumatic TBF.
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http://dx.doi.org/10.25259/SNI_435_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533086PMC
August 2020

Advancements in osteoporotic spine fixation.

J Clin Orthop Trauma 2020 Sep-Oct;11(5):778-785. Epub 2020 Jul 6.

Department of Spine Service, Indian Spinal Injuries Center, Sector-C, Vasant Kunj, New Delhi, 110070, India.

With the global rise in the population of elderly along with other risk factors, spine surgeons have to encounter osteoporotic spine more often. Osteoporotic spine, however, causes problems in management, particularly where instrumentation is involved, resulting in screw loosening, pull out, pseudoarthroses or adjacent segment kyphosis. Osteoporosis alters the bio mechanics at the bone implant interface resulting in various degrees of fixation failure. Various advancements have been made in this field to deal with such issues in addition to modification of basic surgical techniques such as increasing the diameter and length of the screw, smaller pilot hole, under tapping, longer constructs, supplemental anterior fixation, sublaminar wires or laminar hooks, use of transverse connectors and triangulation techniques, among others. They include novel surgical techniques such as cortical bone trajectory, superior cortical trajectory, double screw technique, cross trajectory technique, bicortical screw technique or prophylactic vertebroplasty. Advances in the screw design include expandable screws, fenestrated screws, conical screws and coated screws. In addition to PMMA cement augmentation, other biodegradable cements have been introduced to mitigate the side effects of PMMA such as calcium phosphate, calcium apatite and hydroxyapatite. Pharmacotherapy with teriparatide can aid fusion and lower the rate of pedicle screw loosening. Many of these strategies have only bio mechanical evidence and require well designed clinical trials to establish their clinical efficacy. Though no single technique is fool proof, little modifications in the existing techniques or utilizing a combination of techniques without adding to the cost of the surgery may help to achieve a near-ideal result. Surgeons have to equip their armamentarium with all the recent advances, and should be open to novel thoughts and techniques.
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http://dx.doi.org/10.1016/j.jcot.2020.06.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452352PMC
July 2020

Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance.

Br J Anaesth 2021 01 5;126(1):163-171. Epub 2020 Aug 5.

Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Canada.

Background: We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS.

Methods: This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery.

Results: Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%.

Conclusions: Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery.

Clinical Trial Registration: NCT00512109.
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http://dx.doi.org/10.1016/j.bja.2020.06.051DOI Listing
January 2021

Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study.

Br J Anaesth 2021 01 24;126(1):172-180. Epub 2020 Jul 24.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.

Background: Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin <70 g L, leads to blood transfusion, or is judged to be the direct cause of death. Preoperative prediction guides for BIMS can facilitate informed consent and planning of perioperative care.

Methods: In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin <120 g L.

Results: With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837-0.852). A simplified index based on preoperative haemoglobin <120 g L, open surgery, and high-risk surgery also predicted BIMS, but less accurately (C-statistic, 0.787; 95% confidence interval, 0.779-0.796). Both prediction guides could improve decision making compared with knowledge of haemoglobin <120 g L alone.

Conclusions: BIMS, defined as bleeding that leads to a postoperative haemoglobin <70 g L, leads to blood transfusion, or that is judged to be the direct cause of death, can be predicted by a simple risk index before surgery.

Clinical Trial Registration: NCT00512109.
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http://dx.doi.org/10.1016/j.bja.2020.02.028DOI Listing
January 2021

Sympathetic Outflow Disturbance After Posterior Deformity Correction: A Rare Complication.

World Neurosurg 2020 08 11;140:89-95. Epub 2020 May 11.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Introduction: Sympathetic system injury is a known but rare complication in scoliosis deformity correction. It is not common following posterior correction. We report a case of diastematomyelia with neuromuscular scoliosis with unusual complication of sympathetic outflow disturbance, after posterior instrumented correction.

Case Description: A 13-year-old girl presented with complaints of deformity in the back first noticed 4 years ago. Roentgenogram revealed a right thoracolumbar kyphoscoliotic deformity of 105° with apex at T8 with non-structural lumbar and cervicothoracic curves with positive sagittal alignment. Magnetic resonance imaging showed split-cord malformation with bony crest near the apex of the curve. Detethering followed by removal of the bony crest and restoration of the dual dural sleeves of the split cord into single neural tube was done in the first stage. In the second stage, pedicle screw fixation with was done from D3 to L3. Deformity correction was achieved using multilevel Smith Peterson osteotomy and concave rib osteotomy. On the second postoperative day, intensive care unit staff noticed persistent sinus tachycardia and profuse sweating in both upper limbs, chest, and upper-back. Twenty-four-hour Holter monitoring did not reveal any abnormality. Patient improved gradually and was discharged on postoperative day 9 when both sinus tachycardia and hyperhidrosis resolved.

Conclusions: Sympathetic chain disturbances after surgery recover with time. The exact time duration needed for recovery is not yet defined, however. Spine surgeons should be aware of this postsurgical complication and identify it so that management can be initiated. The symptoms may be long and drawn out, thus the roles of communication with and counseling of the patient as cannot be underemphasized.
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http://dx.doi.org/10.1016/j.wneu.2020.05.039DOI Listing
August 2020

Dysphagia in a Young Adult: Rare Case of Giant Cervical Osteophyte.

Asian J Neurosurg 2020 Jan-Mar;15(1):218-221. Epub 2020 Feb 25.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Cervical osteophytes may be seen in diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, posttraumatic, postoperative, degenerative causes, cervical spondylosis, and infectious spondylitis. A cervical osteophyte is very rarely considered among the differentials for symptoms of dysphagia. C5-C6 as well as C6-C7 being a site of greater load-bearing and mobility, the propensity to form osteophytes is high, with a small osteophyte leading to local mass effect. A 42-year-old male patient presented with mild dyspnea and significant dysphagia since 8 months, accompanied by dysphonia, weight loss, and intermittent aspiration. Clinical examination including neurological examination was normal. A barium swallow showed that osteophytes were severely protruding and displacing the lower pharynx and the proximal esophagus anterosuperiorly. The patient underwent surgical removal of the osteophyte through Smith-Robinson approach. Complaints of dysphagia were significantly decreased in postoperative period. A thorough evaluation is necessary to rule out other causes of dysphagia. Surgical management of this uncommon condition might be considered after confirmation of the osteophyte to be the offending lesion as it has favorable clinical outcomes.
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http://dx.doi.org/10.4103/ajns.AJNS_181_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057907PMC
February 2020

A Prospective Study on the Feasibility, Safety, and Efficacy of a Modified Technique to Augment the Strength of Pedicle Screw in Osteoporotic Spine Fixation.

Asian Spine J 2020 Apr 8;14(3):357-363. Epub 2020 Jan 8.

Department of Spine Service, Indian Spinal Injuries Center, New Delhi, India.

Study Design: Prospective case study.

Purpose: Osteoporotic spine fixation by pedicle screw instrumentation is complicated by screw loosening, migration, or pullout with rates of up to 62% documented in the literature. Contemporary solutions have not adequately addressed these complications. We propose a modified surgical technique of cement augmentation with bicortical pedicle screw fixation to address the issue related to implant failure in osteoporotic spine.

Overview Of Literature: Zindrick and his colleagues described a "windshield wiper" effect owing to the shift of center of rotation to the distal tip of the screw in the bicortical purchase of screws. An increase in pullout strength from 119% to 250% with polymethyl methacrylate augmentation has been documented in the literature. This technique has not been described in the literature.

Methods: A prospective study was conducted with 40 patients who underwent surgery by the modified technique. Intraoperative and postoperative complications directly related to the procedure were assessed. Improvement in pain and functional status were assessed. Follow-up radiographs were assessed to check for appreciable screw migration, loosening, or pullout.

Results: This technique was used in inserting 364 screws in 40 patients. We did not encounter any difficulty in inserting the screws. A total of 19 screws failed to breach the anterior cortex owing to an error in measurement. There were no complications during the procedure in any of the patients, and the postoperative period was uneventful. The mean follow-up period was 18 months. There were two patients in whom proximal junctional failure with kyphosis was noted during follow-up, who were surgically managed by extension of the fixation levels.

Conclusions: Bicortical fixation with cement augmentation is a technically feasible, safe, and effective technique to augment the strength of pedicle screws in osteoporotic spine fixation. It has the potential to be established as a standard of care in osteoporotic spine fixation.
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http://dx.doi.org/10.31616/asj.2019.0211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280929PMC
April 2020

Adjacent Level Tuberculous Spondylodiscitis Leading to Proximal Junctional Kyphosis: Rare and Unusual Presentation.

World Neurosurg 2020 Feb 9;134:e808-e814. Epub 2019 Nov 9.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Background: Vertebral osteomyelitis manifesting as a compression fracture misdiagnosed in the setting of steroid-induced or senile osteoporosis is very rare, although such patients are prone to infection or reactivation, as their immune system is exhausted. Spondylodiscitis occurring at adjacent levels following instrumented spinal fusion leading to pathologic fracture and proximal junctional failure, especially caused by tuberculosis, to our knowledge, has not been discussed in the literature.

Methods: In case 1, a 61-year-old woman with osteoporotic T12 collapse was treated with corpectomy, anterior reconstruction, and posterior fixation from T9-L2. Initial biopsy and culture were normal. She presented 4 months later with compression fracture of T8; T8 corpectomy with anterior reconstruction and proximal extension of the construct was performed. In case 2, a 65-year-old woman with multiple comorbidities and osteoporotic L1 compression fracture was treated with L1 corpectomy, anterior reconstruction, and posterior instrumentation from T11-L3. She presented 4 months later with T10 vertebral body acute collapse; 2-stage anterior corpectomy and reconstruction was performed. In both cases, probing the affected vertebral body yielded pus. Pus and bone tissue samples sent for culture and histopathologic examination were positive for tuberculosis suggesting tuberculous spondylitis in both cases.

Results: In both patients, tuberculous spondylodiscitis at the proximal adjacent level was diagnosed <1 year after the initial spinal surgery. Neither patient had a previous history of pulmonary or extrapulmonary tuberculosis. They were successfully treated with antituberculous therapy and proximal extension of the construct with anterior reconstruction.

Conclusions: Adjacent segment spondylodiscitis should be suspected and intraoperative biopsy must be considered for histopathologic and microbiologic examination to rule out subclinical infection in immunosuppressed patients with multiple comorbidities. Management should be individualized, considering the context of infection, causative organism, extent of bone destruction, and neurologic involvement.
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http://dx.doi.org/10.1016/j.wneu.2019.11.007DOI Listing
February 2020

Effects of accelerated versus standard care surgery on the risk of acute kidney injury in patients with a hip fracture: a substudy protocol of the hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) international randomised controlled trial.

BMJ Open 2019 09 24;9(9):e033150. Epub 2019 Sep 24.

Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.

Introduction: Inflammation, dehydration, hypotension and bleeding may all contribute to the development of acute kidney injury (AKI). Accelerated surgery after a hip fracture can decrease the exposure time to such contributors and may reduce the risk of AKI.

Methods And Analysis: Hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) is a multicentre, international, parallel-group randomised controlled trial (RCT). Patients who suffer a hip fracture are randomly allocated to either accelerated medical assessment and surgical repair with a goal of surgery within 6 hours of diagnosis or standard care where a repair typically occurs 24 to 48 hours after diagnosis. The primary outcome of this substudy is the development of AKI within 7 days of randomisation. We anticipate at least 1998 patients will participate in this substudy.

Ethics And Dissemination: We obtained ethics approval for additional serum creatinine recordings in consecutive patients enrolled at 70 participating centres. All patients provide consent before randomisation. We anticipate reporting substudy results by 2021.

Trial Registration Number: NCT02027896; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2019-033150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773307PMC
September 2019

An Unusual Case of Transdural Herniation of a Lumbar Intervertebral Disc: Diagnostic and Surgical Challenges.

World Neurosurg 2019 Aug 20;128:385-389. Epub 2019 May 20.

Spine Unit, Indian Spinal Injuries Centre, New Delhi, India.

Background: Intradural lumbar disc herniation is rare, with an incidence of 0.3%-1%, but has been well reported in the literature. Transdural migration of the disc penetrating both ventral and dorsal dura is extremely rare, and there is a dearth of literature in the pathophysiology and surgical management of transdural herniation. Lack of knowledge on this type of presentation can cause intraoperative surprises and inadvertent cauda equina root injuries and lead to prolonged operative time. We report 1 such case, describe our surgical experience, and discuss the pathological mechanisms and signs.

Case Description: A 30-year-old woman presented to outpatient clinic with chronic cauda equina syndrome due to massive L4-L5 disc herniation. L4-L5 decompression and transforaminal lumbar interbody fusion were planned. Unexpectedly, however, surgery revealed a transdural herniation, which was effectively managed with laminectomy, extension of durotomy, discectomy, repair of both dorsal and ventral dura, and interbody fusion, but at the expense of prolonged surgical time.

Conclusions: Transdural herniation of a lumbar disc is very rare presentation. It can be effectively managed with laminectomy, extension of durotomy, discectomy and repair of both dorsal and ventral dura. It can be diagnosed by magnetic resonance imaging preoperatively only if read with suspicion of such presentation.
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http://dx.doi.org/10.1016/j.wneu.2019.05.103DOI Listing
August 2019

Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients.

BMJ Open 2019 05 1;9(4):e028537. Epub 2019 May 1.

Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

Introduction: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications.

Methods And Analysis: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients.

Ethics And Dissemination: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources.

Trial Registration Number: NCT02027896; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2018-028537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501985PMC
May 2019

Relationship between Perioperative Hypotension and Perioperative Cardiovascular Events in Patients with Coronary Artery Disease Undergoing Major Noncardiac Surgery.

Anesthesiology 2019 05;130(5):756-766

From the Lilibeth Caberto London Kidney Clinical Research Unit, London Health Sciences Centre, London, Canada (P.S.R.) the Department of Medicine (P.S.R., T.S., E.D., V.T., P.J.D.) Department of Health Research Methods, Evidence and Impact (P.S.R., E.D., P.J.D.), McMaster University, Hamilton, Canada the Population Health Research Institute, Hamilton, Canada (E.D., P.J.D.) the Division of General Internal Medicine, McGill University Health Center, Montreal, Canada (A.B.) the Department of Anesthesia and Intensive Care, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China (M.T.V.C.) the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (C.B.) the Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada (B.J.W.C.) the Department of Radiology, University of Ottawa, Ottawa, Canada (B.J.W.C.) the Department of Anesthesia, University of Toronto, Toronto, Canada (J.S.K).

Background: Perioperative hypotension is associated with cardiovascular events in patients having noncardiac surgery. It is unknown if the severity of preexisting coronary artery disease determines susceptibility to the cardiovascular risks of perioperative hypotension.

Methods: In this retrospective exploratory analysis of a substudy of an international prospective blinded cohort study, 955 patients 45 yr of age or older with history or risk factors for coronary artery disease underwent coronary computed tomographic angiography before elective inpatient noncardiac surgery. The authors evaluated the potential interaction between angiographic findings and perioperative hypotension (defined as systolic blood pressure less than 90 mmHg for a total of 10 min or more during surgery or for any duration after surgery and for which intervention was initiated) on the composite outcome of time to myocardial infarction or cardiovascular death up to 30 days after surgery. Angiography assessors were blinded to study outcomes; patients, treating clinicians, and outcome assessors were blinded to angiography findings.

Results: Cardiovascular events (myocardial infarction or cardiovascular death within 30 days after surgery) occurred in 7.7% of patients (74/955), including in 2.7% (8/293) without obstructive coronary disease or hypotension compared to 6.7% (21/314) with obstructive coronary disease but no hypotension (hazard ratio, 2.51; 95% CI, 1.11 to 5.66; P = 0.027), 8.8% (14/159) in patients with hypotension but without obstructive coronary disease (hazard ratio, 3.85; 95% CI, 1.62 to 9.19; P = 0.002), and 16.4% (31/189) with obstructive coronary disease and hypotension (hazard ratio, 7.34; 95% CI, 3.37 to 15.96; P < 0.001). Hypotension was independently associated with cardiovascular events (hazard ratio, 3.17; 95% CI, 1.99 to 5.06; P < 0.001). This association remained in patients without obstructive disease and did not differ significantly across degrees of coronary disease (P value for interaction, 0.599).

Conclusions: In patients having noncardiac surgery, perioperative hypotension was associated with cardiovascular events regardless of the degree of coronary artery disease on preoperative coronary computed tomographic angiography.
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http://dx.doi.org/10.1097/ALN.0000000000002654DOI Listing
May 2019

Acute traumatic cervical spinal cord injury in a third-trimester pregnant female with good maternal and fetal outcome: a case report and literature review.

Spinal Cord Ser Cases 2018 23;4:93. Epub 2018 Oct 23.

3Department of Obstetrics and Gynaecology, Indian Spinal Injuries Centre, Vasant Kunj Sector C, New Delhi, India.

Background: The management of acute traumatic cervical spine injury in a third-trimester pregnancy is challenging with risks involved for both the mother and the fetus. We report one such case that was managed successfully with good maternal and fetal outcomes.

Case Presentation: A 30 years female, gravida 2, para 1, living 1 at 31 weeks 5 days of pregnancy, met with a RTA and was diagnosed with AIS B C4-C5 extension compression spinal cord injury (SCI) with a viable fetus. Closed reduction of C4-C5 dislocation was achieved through controlled cervical traction. Having involved the patient in informed decision-making, anterior cervical discectomy and fusion (ACDF) was performed under general anesthesia (GA), with obstetrician, as well as neonatologist available in the operation theater. The pregnancy was uneventful in the post-operative stage. A healthy baby was delivered at 36 weeks of gestation through cesarean section. At final follow-up review of 12 months the patient was ambulatory without support and was able to perform most of the regular activities independently.

Discussion: The significant risk of a spontaneous delivery with GA posed the dilemma of either managing the injury conservatively through bed rest, continuing the pregnancy till its term and then opting for surgical stabilization after delivery or opting for surgical stabilization of the spine immediately, with a view for early mobilization and rehabilitation. A successful outcome of traumatic cervical SCI in third-trimester pregnancy can be achieved by multi-disciplinary (anesthetist, obstetrician, neonatologist, spine surgeon, and physiatrist) team, and timely surgical spinal stabilization, followed by early comprehensive rehabilitation.
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http://dx.doi.org/10.1038/s41394-018-0127-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6199320PMC
October 2018

Reliability of Allen Ferguson classification versus subaxial injury classification and severity scale for subaxial cervical spine injuries: a psychometrics study.

Spinal Cord 2019 Jan 8;57(1):26-32. Epub 2018 Aug 8.

Indian Spinal Injuries Centre, Sector C, Vasant Kunj, New Delhi, India.

Study Design: A psychometrics study.

Objectives: To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems.

Setting: Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC.

Results: Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement.

Conclusion: This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.
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http://dx.doi.org/10.1038/s41393-018-0182-zDOI Listing
January 2019

Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial.

Lancet 2018 06;391(10137):2325-2334

Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.

Background: Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients.

Methods: In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101.

Findings: Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55-0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55-1·53; p=0·76).

Interpretation: Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication [corrected].

Funding: Boehringer Ingelheim and Canadian Institutes of Health Research.
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http://dx.doi.org/10.1016/S0140-6736(18)30832-8DOI Listing
June 2018

Aortic Rupture During Surgical Management of Tubercular Spondylodiscitis.

Cureus 2018 Mar 1;10(3):e2255. Epub 2018 Mar 1.

Spine Surgery, Indian Spinal Injuries Center, New Delhi.

Aortic rupture is a rare but possible complication during spine surgery. It may manifest as severe intraoperative hemorrhage or present in a delayed manner after the formation of an aneurysm or an arteriovenous fistula. Though it is commonly encountered during anterior surgeries involving the surgical field close to the thoracic or abdominal aorta, it can also occur during a posterior surgery. Aortic injury could be associated with surgeries ranging from the commonly performed pedicle screw instrumentation to a complex three-column osteotomy. It can also occur, as in the reported case, while performing complex procedures in the presence of a pre-existing aneurysm or aortic adhesions due to coexisting infectious or inflammatory pathologies. The treatment options for such aortic ruptures range from open repair to endovascular stenting techniques. We discuss a case of an aortic rupture that occurred during a posterior vertebral column resection (PVCR) procedure performed on a 58-year-old female with spastic paraparesis secondary to tuberculous spondylodiscitis and the lessons learnt.
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http://dx.doi.org/10.7759/cureus.2255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930971PMC
March 2018

Design of a Randomized Placebo-Controlled Trial to Assess Dabigatran and Omeprazole in Patients with Myocardial Injury after Noncardiac Surgery (MANAGE).

Can J Cardiol 2018 03 2;34(3):295-302. Epub 2018 Feb 2.

McMaster University, Department of Health Research Methods, Evidence, and Impact, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.

Background: Worldwide approximately 200 million adults undergo major surgery annually, of whom 8 million are estimated to suffer a myocardial injury after noncardiac surgery (MINS). There is currently no trial data informing the management of MINS. Antithrombotic agents such as direct oral anticoagulants might prevent major vascular complications in patients with MINS.

Methods: The Management of Myocardial Injury After Noncardiac Surgery (MANAGE) trial is a large international blinded randomized controlled trial of dabigatran vs placebo in patients who suffered MINS. We used a partial factorial design to also determine the effect of omeprazole vs placebo in reducing upper gastrointestinal bleeding and complications. Both study drugs were initiated in eligible patients within 35 days of suffering MINS and continued for a maximum of 2 years. The primary outcome is a composite of major vascular complications for the dabigatran trial and a composite of upper gastrointestinal complications for the omeprazole trial. We present the rationale and design of the trial and baseline characteristics of enrolled patients.

Results: The trial randomized 1754 patients between January 2013 and July 2017. Patients' mean age was 69.9 years, 51.1% were male, 14.3% had a history of peripheral artery disease, 6.6% had a history of stroke or transient ischemic attack, 12.9% had a previous myocardial infarction, and 26.0% had diabetes. The diagnosis of MINS was on the basis of an isolated ischemic troponin elevation in 80.4% of participants.

Conclusion: MANAGE is the first randomized controlled trial to evaluate a potential treatment of patients who suffered MINS.
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http://dx.doi.org/10.1016/j.cjca.2018.01.020DOI Listing
March 2018

Colchicine for Prevention of Perioperative Atrial Fibrillation in patients undergoing lung resection surgery: a pilot randomized controlled study.

Eur J Cardiothorac Surg 2018 05;53(5):945-951

Department of Medicine, Hamilton General Hospital, Population Health Research Institute, Hamilton, ON, Canada.

Objectives: We carried out a pilot randomized controlled study to determine the feasibility of a large trial evaluating the impact of colchicine versus placebo on postoperative atrial fibrillation or atrial flutter (POAF) among patients undergoing lung resection surgery.

Methods: Patients ≥55 years of age undergoing lung resection surgery were randomly assigned to receive colchicine 0.6 mg or placebo starting a few hours before surgery. Postoperatively, patients received colchicine 0.6 mg or placebo twice daily for an additional 9 days. Our feasibility outcomes included the period of time required to recruit 100 patients, the completeness of follow-up and compliance with the study drug. The primary efficacy outcome was POAF within 30 days of randomization.

Results: One hundred patients were randomized (49 to colchicine and 51 to placebo) over a period of 12 months at 2 centres in Canada. All patients completed the 30-day follow-up. The mean staff time required to recruit and to follow-up each patient was 165 min. In all, 71% of patients completed the study drug course without interruption. Patient refusal to continuing taking the study drug was the main reason for permanent drug discontinuation. New POAF occurred in 5 (10.2%) patients in the colchicine group and 7 (13.7%) patients in the placebo group (adjusted hazard ratio 0.69, 95% confidence interval 0.20-2.34).

Conclusions: These results show the feasibility of a trial evaluating Colchicine for the prevention of perioperative Atrial Fibrillation in patients undergoing lung resection surgery. This pilot study will serve as the foundation for the large multicentre COP-AF trial.
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http://dx.doi.org/10.1093/ejcts/ezx422DOI Listing
May 2018

Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery.

Ann Intern Med 2018 02 14;168(4):237-244. Epub 2017 Nov 14.

Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (G.R.M.).

Background: Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery.

Objective: To evaluate benefits and harms of perioperative aspirin in patients with prior PCI.

Design: Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet randomization was done between 2010 and 2013. Patients, clinicians, data collectors, and outcome adjudicators were blinded to treatment assignment. (ClinicalTrials.gov: NCT01082874).

Setting: 135 centers in 23 countries.

Patients: Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery.

Intervention: Aspirin therapy (overall trial, n = 4998; subgroup, n = 234) or placebo (overall trial, n = 5012; subgroup, n = 236) initiated within 4 hours before surgery and continued throughout the perioperative period. Of the 470 subgroup patients, 99.9% completed follow-up.

Measurements: The 30-day primary outcome was death or nonfatal myocardial infarction; bleeding was a secondary outcome.

Results: In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% [95% CI, 0.4% to 10.5%]; hazard ratio [HR], 0.50 [CI, 0.26 to 0.95]; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% [CI, 1.0% to 10.8%]; HR, 0.44 [CI, 0.22 to 0.87]; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% [CI, -2.6% to 5.2%]). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% [CI, 0.1% to 1.6%]; HR, 1.22 [CI, 1.01 to 1.48]; P for interaction = 0.50).

Limitation: Nonprespecified subgroup analysis with small sample.

Conclusion: Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI.

Primary Funding Source: Canadian Institutes of Health Research.
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http://dx.doi.org/10.7326/M17-2341DOI Listing
February 2018

Bleeding impacting mortality after noncardiac surgery: a protocol to establish diagnostic criteria, estimate prognostic importance, and develop and validate a prediction guide in an international prospective cohort study.

CMAJ Open 2017 Aug;5(3):E594-E603

Affiliations: Lilibeth Caberto Kidney Clinical Research Unit (Roshanov, Garg), London Health Sciences Centre, London, Ont.; Department of Medicine (Eikelboom, Tandon, Borges, Kearon, Panju, Sheth, Mizera, Ribas, Devereaux), Department of Surgery (Lamy, Whitlock, de Beer, Winemaker, Pinthus, Simunovic), Department of Health Research Methods, Evidence, and Impact (Lamy, Guyatt, Le Manach, Thabane, Simunovic, Devereaux), Department of Pathology and Molecular Medicine (Crowther, Kavsak), Department of Anesthesia (Spence, VanHelder, Le Manach), Thrombosis and Atherosclerosis Research Institute (Kearon) and School of Nursing (McGillion), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Population Health Research Institute (Eikelboom, Borges, Lamy, Whitlock, Spence, McGillion, Le Manach, Devereaux), Hamilton, Ont.; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital, Observatory, South Africa, and University of Cape Town, South Africa; Department of Intensive Care and Perioperative Medicine (Szczeklik), Jagiellonian University Medical College, Krakow, Poland; Institute for Clinical Evaluative Sciences at Western (Garg), London, Ont.; Faculty of Health and Life Sciences (McGillion), Coventry University, Coventry, United Kingdom; Department of Outcomes Research (Sessler), Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont.

Introduction: Various definitions of bleeding have been used in perioperative studies without systematic assessment of the diagnostic criteria for their independent association with outcomes important to patients. Our proposed definition of bleeding impacting mortality after noncardiac surgery (BIMS) is bleeding that is independently associated with death during or within 30 days after noncardiac surgery. We describe our analysis plan to sequentially 1) establish the diagnostic criteria for BIMS, 2) estimate the independent contribution of BIMS to 30-day mortality and 3) develop and internally validate a clinical prediction guide to estimate patient-specific risk of BIMS.

Methods: In the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) study, we prospectively collected bleeding data for 16 079 patients aged 45 years or more who had noncardiac inpatient surgery between 2007 and 2011 at 12 centres in 8 countries across 5 continents. We will include bleeding features independently associated with 30-day mortality in the diagnostic criteria for BIMS. Candidate features will include the need for reoperation due to bleeding, the number of units of erythrocytes transfused, the lowest postoperative hemoglobin concentration, and the absolute and relative decrements in hemoglobin concentration from the preoperative value. We will then estimate the incidence of BIMS and its independent association with 30-day mortality. Last, we will construct and internally validate a clinical prediction guide for BIMS.

Interpretation: This study will address an important gap in our knowledge about perioperative bleeding, with implications for the 200 million patients who undergo noncardiac surgery globally every year. ClinicalTrials.gov, no NCT00512109.
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http://dx.doi.org/10.9778/cmajo.20160106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963363PMC
August 2017

Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery.

JAMA 2017 Apr;317(16):1642-1651

McMaster University, Hamilton, Ontario, Canada.

Importance: Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS).

Objective: To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality).

Design, Setting, And Participants: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013.

Exposures: Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement.

Main Outcomes And Measures: A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality.

Results: Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.

Conclusions And Relevance: Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.
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http://dx.doi.org/10.1001/jama.2017.4360DOI Listing
April 2017

Cardiovascular risk management in rheumatoid arthritis: A large gap to close.

Musculoskeletal Care 2018 03 18;16(1):152-157. Epub 2017 Apr 18.

Department of Medicine, McMaster University, Hamilton, ON, Canada.

Objective: Rheumatoid arthritis (RA) portends significant cardiovascular morbidity and mortality. We therefore determined how often rheumatologists screened for and managed cardiovascular risk factors in RA patients, and the barriers to doing so.

Methods: We examined 300 patient charts from 10 university-affiliated rheumatology practices, to ascertain if they had been screened, treated and/or referred over a 3-year period. We subsequently distributed a national survey to Canadian rheumatologists to elucidate challenges in performing optimal cardiovascular risk modification.

Results: Most patients were screened for hypertension. Forty-one per cent were found to be hypertensive; however, the majority of these patients were neither treated nor referred to another provider for management. A small minority of patients were screened for diabetes and/or hyperlipidaemia, and these were usually not addressed if abnormal. Men were referred more frequently than women. Consistent with these findings, the majority of rheumatologists from the national survey felt that they did not manage cardiovascular risk adequately; 79.4% cited a lack of time as a major barrier, and 82.5% felt that it should be managed by the primary care provider.

Conclusion: There is marked underdiagnosis and undertreatment of cardiac risk in RA. Several major barriers exist, including lack of time. Most rheumatologists feel that this aspect of care is the responsibility of primary care physicians.
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http://dx.doi.org/10.1002/msc.1196DOI Listing
March 2018

Dysplastic L5-S1 Spondyloptosis in a 3-Year-Old Child: A Case Report and Review of the Literature.

Case Rep Orthop 2017 5;2017:1892502. Epub 2017 Mar 5.

Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India.

A three-year-old girl presented with primary complaint of severe low back pain with radiation to both lower limbs below the knees since 2 months following history of fall and marked restriction of her daily routine activities. After clinicoradiological evaluation she was diagnosed of having dysplastic L5-S1 spondyloptosis. A staged procedure was planned after thorough discussion with her parents. During initial stage she underwent posterior decompression along L5-S1 segment including exposure of bilateral L5 and S1 nerve roots followed by instrumented reduction (L3-S2 5.5 mm pedicle screws) utilizing a rotational-translational technique. No interbody fusion was done at L5-S1 level and inner nuts of bilateral L3, L4, and S2 screws were intentionally kept loose. Subsequently after about symptom-free three-year follow up, she presented with recurrence of symptoms and underwent revision surgery as per initial plan discussed with her parents. Removals of posterior implants were done followed by stabilization with larger diameter pedicle screws (6.5 mm) at L5 and S1 level. During the same stage through anterior transperitoneal approach L5-S1 interbody fusion was done. At one-year follow-up after second-stage definitive surgery, patient remains symptom-free and fully active without any radiological evidence of reduction loss or implant failure.
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http://dx.doi.org/10.1155/2017/1892502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357515PMC
March 2017