Dr. Dharmesh Chandra Sharma
Associate Blood Transfusion Officer ( ABTO), Incharge Blood Component & Aphaeresis Unit Blood Bank, Department of Pathology, J. A. Groups of Hospital  and G. R. Medical College, India.

ISBN 978-93-90888-78-8 (Print)
ISBN 978-93-90888-86-3 (eBook)
DOI: 10.9734/bpi/hmmr/v11

This book covers key areas of medicine and medical research. The contributions by the authors include pre-auricular sinus, extra-pulmonary region, tuberculosis, lymphadenitis, breast carcinoma, core needle biopsy, sentinel lymph node dissection, thoracoabdominal flap, thyroiditis, fishbone, caesarean section, Robson’s classification, anemia, iron deficiency, physical activity, overweight, obesity, ovarian masses disorder, benign neoplastic lesions, neoplastic malignant lesions, gynaecological problem, abnormal vaginal discharge, bacterial vaginosis, meningitis, prone position, COVID-19, acute respiratory distress syndrome, severe acute respiratory syndrome coronavirus, Vaping, respiratory distress, lysozyme, thermal stabilization, scoliosis, deformity, brace treatment, radiography, idiopathic scoliosis, functional tethering, extracorporeal shock wave therapy, Chêneau brace, soft brace treatment, physiotherapy, velocity bracing, cerebral toxoplasmosis, diagnosis, toxoplasma infection, western blot technique, autoimmunity, common variable immunodeficiency disorder, systemic lupus erythematosus, primary immunodeficiency. This book contains various materials suitable for students, researchers and academicians in the field of medicine and medical research.


Media Promotion:


A Dicey Diagnosis: Pre-auricular Swelling of Tubercular Origin

Sphoorthi Basavannaiah

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 1-6

Pre-auricular sinuses are congenital malformations that typically develop at the anterior margin of the ascending limb of the external ear's helix. They are not uncommon ear anomalies, and since they are typically asymptomatic, they are not frequently diagnosed. Tuberculosis is a major infection that affects both children and adults around the world, resulting in substantial morbidity and mortality.

They are most common in the extra pulmonary area, where lymphadenitis is the most common clinical manifestation. Lymph nodes, mostly cervical, mediastinal, and axillary and inguinal nodes, are often involved. Extrapulmonary tuberculosis is difficult to diagnose since there are no constitutional signs and a high degree of clinical suspicion is needed. Here, is a rare case presented by an adult male with infected pre-auricular sinus coexisting with lymphadenitis in right pre-auricular region.

Surgical Management of Breast Lesions

Amrit Pal Singh Rana, Manjit Kaur Rana

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 7-11

Surgery is the mainstay of the treatment of breast lesions. Diagnostic modalities and clinical examination are being used to identify the type of lesion and plan their surgical management. Management and treatment of patients if done according to guidelines and application of new techniques can provide excellent results. Patients attending surgical out patient door with breast lesions were diagnosed definitely before operative management with fine needle aspiration cytology, core needle biopsy/Excision biopsy. In our experience modified radical mastectomy with axillary lymph node dissection and thoracoabdominal skin flaps wherever needed were applied. Sentinallymphnode dissection was done followed by axillary dissection or breast conservative surgery where indicated. In clinically node negative cases of carcinoma breast, accuracy of ultrasonography guided fine needle aspiration cytology was found to be accurate in more than 80% cases. Preoperatively diagnosed benign cases underwent surgical excision. Incision and drainage were also performed as indicated. In our experience with breast lesions, surgical management that followed the recommendations resulted in a positive outcome. The use of new methods yielded excellent results with high precision.

A Case Report on Acute Suppurative Thyroiditis

I. O. Oluwayemi, F. O. Abduraheem, O. T. Agaja, O. J. Oke, E. O. Ogundare, A. B. Ajite, O. S. Olatunya

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 12-18

Acute suppurative thyroiditis is a rare but potentially life-threatening endocrine emergency. It represents 0.1 to 0.7% of surgically-treated thyroid pathologies. We report a case of 3 years 11 month old girl who was brought to the hospital by her parents with a history of painful anterior neck swelling of one week duration which was initially the size of the distal phalanx of the child’s middle finger and progressively increased to occupying most of the anterior neck. There was a preceding history of fish bone impaction while eating 2 weeks earlier. Within 24 h of admission child was noticed to be febrile (temperature 38.5°C), she had dysphagia, hoarseness and limitation in movement of the head. No history or clinical features suggestive of hyper- or hypothyroidism. Anterior cervical lymph nodes were enlarged and tender. She had a normal weight of 13 kg. Local examination showed a mass at the anterior neck more on the left half, measured 4 cm × 4 cm, no skin changes, no discharge. There was differential warmth and tenderness. It was fluctuant and moves with swallowing. Thyroid ultrasound scan showed normal right lobe; left thyroid gland is enlarged to 4.52 cm × 3.37 cm with a heterogenous echo texture. Thyroid function test was in keeping with euthyroid sick syndrome: TSH 0.3 (0.5-3.7 mIU/L); fT3 0.3 (1.4-4.2 pg/ml); fT4 1.4 (0.8-2.0 pg/ml). An assessment of acute suppurative thyroiditis was made and patient was treated with I.V. Cefuroxime and metronidazole, and by the 5th day on antibiotics, a portion of the swelling had become overtly hyperemic and begun to exude pus. The abscess was incised and 4 ml of frank pus was drained. Microscopy, culture and sensitivity of the aspirate revealed klebsiella sensitive to ciprofloxacin, ofloxacin and amoxyl-clavulanic acid. Child’s condition improved significantly thereafter and she has since been discharged home and doing well. Thus prompt diagnosis and treatment is vital.  Pyriform sinus fistula should be suspected in all paediatric cases.

Introduction: Caesarean section rates have been slowly rising all over the world as the safety of operative deliveries has improved. An examination of a center's caesarean section incidence will reveal preventable causes of the growing issue. Caesarean section is usually performed to ensure safety of the mother and child under obstetric risks.

Objective: This retrospective study used Robson's Ten Group Classification System to examine the indications for caesarean deliveries over a one-year period from June 18, 2017 to June 17, 2018, and to determine the preventable causes of caesarean section.

Methods: The labour room delivery registry was used to track down all patients who gave birth during this time period. Age, parity, risk factors, mode of delivery, intrapartum incidents, and indication of caesarean section were all taken into consideration while reviewing their records.

The information was entered into an Excel spreadsheet and categorised using Robson's Ten Group Classification System.

Results: Caesarean section rate was 52.7% during the study period. Caesarean section was lowest in Group 3(10.31%) and highest in Group 6(92.68%).Group 2 made the highest contribution to overall Caesarean section rate(23.93%). Analysis of indications in Group 2 showed that Oligohydramnious and Post ART pregnancies were the two modifiable indications where decision towards Caesarean section was much liberal.

Conclusion: Primigravida who are admitted to the hospital for safe containment, i.e. not in labour, should be the focus of strategies to reduce the caesarean section rate. The hospital's policy on interference in oligohydramniosis and post-ART pregnancies needs to be reviewed. Strict policy recommendations on labour induction procedures and labour trials in prior caesarean cases would strengthen the situation.

Background: Anemia is a worldwide health issue that affects children, especially those under the age of five, resulting in morbidity and mortality. The most common type of nutritional deficiency anemia in India is iron deficiency anemia. The aim of this study was to determine the prevalence of anaemia in children under the age of five, as well as the severity of anaemia in each age group.

Methods: This was a prospective study that conducted from January to December 2015 and included all children with clinical Anemia and haemoglobin levels less than 11 gm/dl.

With a complete blood count and a peripheral smear test, data on age, sex, dietary habits, socioeconomic status and haemoglobin level were analysed.

Results: There were 109 children in total, with females outnumbering males. Anemia was most common (60.55%) in children aged 6 to 24 months, followed by children aged 37 to 60 months (21.10%). Anemia was found in a high number of children who ate a vegetarian diet, were from a low socioeconomic background, and had not been breastfed for the first 4-6 months. Regarding pattern of severity of anemia maximum number (47.705%) belonged to moderate type of anemia followed by mild (35.77%) 0 and severe (16.50%).

Conclusion: In our research, the most vulnerable age group for Anemia in children was 6 months to 24 months, especially for those who came from a low socioeconomic background, ate a vegetarian diet, and were not breastfed for the first 4-6 months of their lives. The majority of the children had mild Anemia. These vulnerable children should be tested as soon as possible to avoid the short and long-term effects of anaemia.

Introduction: One of the most significant lifestyle-related health determinants is physical activity. Daily moderate-intensity physical activity, such as walking, cycling, or participating in sports, has many health benefits. Physical activity, which is one of the most important health-protective behaviours in today's world, appears to be declining among teenagers. Regular physical activity is proven to help prevent and manage non-communicable diseases such as heart disease, stroke, hypertension, diabetes and several cancers. It also helps maintain healthy body weight and can improve mental health, quality of life and well-being.

Aim and Objectives: To investigate the pattern of physical activity and its relationship to overweight and obesity in rural school-aged adolescents.

Materials and Methods: A one-year cross-sectional study was carried out in Rohtak district's Lakhanmajra block (rural block) from July 2016 to June 2017. The study included 750 students from six co-educational government senior secondary schools. The data was collected using a pre-planned, pre-tested semi-structured interview schedule and analysed using SPSS version 20.0.

Results:  Overweight and obesity were prevalent in 6.7% and 1.1 % of the population, respectively.

Obesity/overweight was found in 10.3 percent of the study subjects who were not in the habit of doing any exercise after getting up in the morning. Approximately one-fourth (25.6%) of the study subjects who slept in the afternoon or evening were obese/overweight. Overweight/obesity was significantly associated with the habit of playing daily, its duration, and sleeping in the afternoon/evening. Conclusion: Obesity is caused by a lack of physical activity, which contributes to cardiovascular disease and diabetes. As a result, it is critical to resolve this issue and develop initiatives and strategies to prevent adolescent overweight and obesity. Physical activity should be promoted in children not only for weight loss but also for overall health.

A Retrospective Study on Ovarian Tumours in a Tertiary Care Hospital

Alla Satyanarayana Reddy, G. Ambujam

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 42-47

A popular gynaecological issue is ovarian masses.The majority are non-neoplasic or functional cysts, while the rest are neoplastic cysts, whether benign or malignant. This is a retrospective study conducted in the Department of Obstetrics and Gynaecology, Vinayaka Missions Medical College and Hospital, Karaikal, Union Territory of Puducherry, in 2017. The research included all patients who went to the gynaecology OPD and were diagnosed with Ovarian masses.297 of the 8564 patients who visited the Gynecological OPD had ovarian masses, with 96 of them undergoing surgery. According to the histopathology survey, of the women with neoplastic tumours, 83.3% were benign and 16.7% were malignant.CA 125 is increased (>35 U/mL) in 38% of patients who were operated. The average CA-125 in benign Neoplastic lesions is 17U/mL and the average CA 125 in Neoplastic malignant lesions is 112 U/mL. Commonest malignancy was Serous Cyst adenocarcinoma (81.8%) followed by Mucinous Cyst adenocarcinoma (18%). Functional ovarian masses is more in the women with infertility or in women who are on infertility treatments. Cysts in the ovaries are not uncommon in the first trimester of pregnancy or in the postnatal or postabortal period.

Prevalence of Bacterial Vaginosis and Associated Factors among Non Pregnant Women: A Recent Study

Alla Satyanarayana Reddy, Manjula Sivaramakrishnan

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 48-54

Among sexually active women, bacterial vaginosis is a common cause of vaginal infection and irregular vaginal discharge.From January to December 2018, the research was carried out in the department of Obstetrics and Gynecology at Vinayaka Missions Medical College and Hospital in Karaikal, Puducherry. The Main objective of this study is to determine the prevalence and the association of risk factors for bacterial vaginosis. All patients who came to the gynaecology OPD with vaginal discharge were tested for bacterial vaginosis.The features of women with bacterial vaginosis and those who do not are compared. Out of 5130 patients who attended the gynaecological OPD, 1534 came with complaints of vaginal discharge and 422 among them were positive for bacterial vaginosis by Amsel's criteria. 1112 women didn’t have. Among symptomatic patients with irregular vaginal discharge, the average prevalence of bacterial vaginosis was 27.5% Bacterial vaginosis is more common in women aged 30-40, who are illiterate, and who work as farmers. Contraceptive users on anatomical sites (IUCD and Barrier method) were more likely to contract bacterial vaginosis than those who did not. The higher prevalence of bacterial vaginosis indicates that periodic screening and prompt intervention to prevent adverse outcomes should be done. All women with irregular vaginal discharge should have their vaginal discharge checked for bacterial vaginosis on a regular basis to avoid long-term complications.

The Role of CSF LDH Estimation to Differentiate Different Types of Meningitis: A Cross Sectional Study

S. P. Anita, R. Legha, P. S. Manu

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 55-71

Introduction: Meningitis is a medical condition in which the meninges become inflamed.

Meningitis is a medical, neurologic, and sometimes neurosurgical emergency that necessitates a multidisciplinary treatment plan. Anatomically, meningitis is classified into two types: pachymeningitis (inflammation of the dura), which is less common, and leptomeningitis (inflammation of the arachnoid and subarchanoid space), which is more common.The key to a good outcome is early and accurate diagnosis. The cerebrospinal fluid examination is the cornerstone of diagnosis. Total count, differential count, protein, sugar, gramme staining culture and sensitivity, AFB staining, and in some cases, CSF ADA and Tuberculous RNA PCR are all part of the cerebrospinal fluid study. Other tests, such as CSF lactate, C-Reactive Protein, SGOT, glutamate level, and Lactate Dehydrogenase, may be performed (LDH). Though CSF abnormalities in meningitis is well documented, only few studies have been conducted in our part of the world. This study is conducted to know the role of CSF LDH to differentiate different types of meningitis.

Materials and Methods:  This was a cross-sectional analysis conducted in a hospital.During the months of April 2012 and March 2013, all patients admitted to a tertiary care centre in South Kerala with recorded clinical and biochemical evidence of meningitis (viral, bacterial, or tuberculous) were included. After getting informed consent from Patients after applying inclusion and exclusion criteria, those fulfilling all the inclusion criteria were subjected to detailed evaluation, Lumbar puncture (for CSF collection and analysis of CSF) was done.

Patients were classified into four classes based on the criteria: viral, bacterial, tuberculous, and partially treated meningitis. The amount of LDH in the CSF was tested to see whether there was a connection to the diagnosis. The mean LDH level in different forms of meningitis was compared using the unpaired T test. The Chi square test was used to verify the association.

Observations: This study involved 180 patients, 111 of whom were males and 69 of whom were females. In bacterial and viral meningitis, the majority of patients were younger, ranging in age from 31 to 40 years, while in tuberculous meningitis, the majority of patients were older, ranging in age from 61 to 70 years. Among the total 180 patients,33% were categorized as bacterial, 33% as viral, 4.44% as tuberculous and 28.88% as partially treated meningitis according to the study definitions. The average white blood cell count of the CSF among patients with bacterial meningitis was 613,tuberculous meningitis was 656,and in viral meningitis was 101cells /mm3 .In the bacterial community, the differential count was mostly polymorphs, while in the other groups, it was mostly lymphocytic. The average CSF protein in the bacterial meningitis group was 102.4 mg/dl, 33.6 mg/dl in the viral meningitis group, 89.4 mg/dl in the tuberculous meningitis group, and 75.47 mg/dl in the partially treated group. The average CSF sugar value in bacterial meningitis was 29.5 mg/dl, 68.4 mg/dl in viral meningitis, 23.3 mg/dl in Tuberculous meningitis, and 43.03 mg/dl in the partially treated community. The average ADA value in the bacterial meningitis group was 6.4, 4.8 in the viral meningitis group, and 20 in the tuberculous meningitis group. We noticed that the tuberculous category had the highest average ADA value.  Among the 18 tuberculous patients, 17 had an ADA of more than 15. The average CSF LDH value was 94.1 IU/L in bacterial meningitis group, 30.2 IU/L in viral meningitis group &119.9 IU/L in tuberculous meningitis group. Out of the 72 patients who had viral meningitis in our study,18 (25%) had JE/WEST NILE virus positivity. This high frequency of encephalitis was not observed in other studies, which indicates a high frequency of JE in our part of the world. In those tested positive for JE, the CSF LDH was significantly high. We had 52 (28.88%) patients in the partially treated meningitis group. Among this 34 had features of bacterial &6 had features of tuberculous meningitis. The CSF LDH value was significantly elevated in these two catogories. Rest of the12 patients with features suggestive of viral meningitis only had a mild elevation of LDH. The mean CSF LDH in viral meningitis & tuberculous meningitis group were 77.2 & 22.5 % respectively.

Conclusion: CSF LDH was significantly elevated in Tuberculous meningitis and bacterial  meningitis. In viral meningitis, CSF LDH showed only a mild elevation. Viral meningitis with increased CSF LDH were positive for JE. Hence in Viral meningitis with high LDH should raise suspicion of encephalitis.

A Literature Review of Prone Position in Non-intubated Patients with COVID-19 as a Useful Maneuver to Avoid Mechanical Ventilation

Juárez-Villa Daniel, Mora-Ruiz Pablo, Sáenz-Luna Carlos, Zavala-Jonguitud Luis, Olascoaga-Lugo Arturo, Flores Guillermo, Zepeda-Quiroz Iván

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 72-85

The spectrum of coronavirus disease 2019 (COVID-19) ranges from asymptomatic to acute respiratory distress syndrome (ARDS). Prone position has been widely used in ARDS patients with mechanical ventilation and its benefits have been proven. The prone position in the awake patient is a different procedure than in the patient under invasive mechanical ventilation. This maneuver can be extrapolated to non-intubated patients with COVID-19, avoiding mechanical ventilation in some patients. Previous reports have demonstrated the benefits of this intervention.

A Case Report on Vaping Related Interstitial Airspace Disease in a Teenager

Amee A. Amin, Erica Haught, Youmna Mousattat

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 86-91

In this case, we present a unique case presentation of vaping associated lung injury and treatment approaches. A 17-year-old previously healthy male was admitted to the hospital for intractable & persistent vomiting, fever, cough, abdominal pain, and intermittent diarrhea and dehydration. He presented with severe chest pain and O2 desaturations up to 80% on room air. An infectious (including a Nasopharyngeal swab), GI, and cardiac workup was completed and was negative except for elevated inflammatory markers with a C-reactive protein (CRP) of 261 mg/L, erythrocyte sedimentation rate (ESR) of 53 mm/hr and a d-dimer of 0.93 mcg/ml. Chest X-ray showed diffuse multifocal infiltrates. The patient was treated with ceftriaxone, and azithromycin initially for a suspected pneumonia. He was also started on 4L of nasal cannula O2 supplementation. Due to persistent hypoxic respiratory failure, worsening respiratory distress clinically, with tachypnea and retractions, and lab findings of elevated d-dimer, a chest CT was performed to rule out a pulmonary embolism (PE). Computed Tomography (CT) findings were negative for PE but notable for diffuse airspace opacities, primarily within the lower lobes, with a ground-glass appearance concerning for ARDS. Upon further investigation of the social history, the patient admitted to vaping nicotine products for the past 4 years and tetrahydrocannabinol (THC) products within the last several months. He was immediately started on Prednisone 30mg BID for a diagnosis of E-cigarette or Vaping Product Use Associated Lung Injury (EVALI) and started showing clinical improvement. The patient was able to be weaned off of supplemental oxygen to room air and clinical symptoms of respiratory distress began to improve over the next 24 hours.

The heat stress tolerance of hen egg white lysozyme (HEWL) was markedly enhanced by the addition of water-miscible aprotic ionic liquids consisting of 1-ethyl-3-methylimidazolium cation and several kinds of anions to the aqueous solution of HEWL. Inorganic salts and glycerol inhibited the formation of enzyme aggregation to some extent, and enhanced the thermal stability of HEWL, while ?-cyclodextrin, Triton-X, and pectin had no effect on the thermal stability of HEWL. On the other hand, ionic liquids could more effectively increase the thermal stability of HEWL, compared to conventional stabilizing agents. Addition of ionic liquids to the aqueous solution of HEWL prevented partially unfolded enzymes from aggregating irreversibly at high temperatures. The thermal denaturation curve of HEWL with ionic liquids was remarkably shifted to higher temperature, compared with that without ionic liquids. Moreover, the remaining activity of HEWL after the heat treatment was strongly dependent upon the kind and concentration of ionic liquids. The remaining activities of HEWL with 1.5 M 1-ethyl-3-methylimidazolium tetrafluoroborate ([emim][BF4]) and 0.1 M 1-ethyl-3-methylimidazolium trifluoromethanesulfonate ([emim][Tf]) exhibited 88 and 68% after the heat treatment at 90°C for 30 min, respectively, although that without ionic liquids was perfectly lost.

In literature, there are papers on scoliosis reporting improvements of spinal curvatures under brace treatment, but this predominately relates to results revealed on x-ray, not clinically. Therefore, it is worthwhile (1) to review the literature showing improvements after brace treatment and (2) to show what can be done conservatively via bracing in curvatures exceeding 45° Cobb.

Materials and Methods: (1) A Pub Med review of the literature with a keyword search for (a) ‘scoliosis’, ’brace treatment’ and ‘improvement’ and alternatively for (b) ‘scoliosis’, ‘orthosis’ and ‘improvement’. (2) Additionally, a case series of patients is demonstrated with curvatures exceeding 45° clinically and radiologically.

Results: 92 papers displayed in the keyword search for (a) ‘scoliosis’, ’brace treatment’ and ‘improvement’ and 79 papers displayed with the keyword search for (b) ‘scoliosis’, ‘orthosis’ and ‘improvement’.

A case series of three patients with curvatures exceeding 45° is demonstrated within this paper revealing radiological and clinical improvement when using the recent Chêneau standard of bracing with a reliable CAD library of braces and an experienced team.

Discussion: The solution for the high variability of bracing outcomes is standardization. Braces can be standardized when applying well-tested, standardized brace models from CAD libraries. In comparison, braces made manually cannot be standardized, resulting in unpredictable outcomes. In addition, there is future advancement potential of baseline quality in braces produced using CAD/CAM technologies.

Conclusions: Trunk and backshape can be improved conservatively even in patients with curvatures exceeding 45°. Modern concepts of bracing may improve even scoliotic deformities exceeding 45° Cobb, radiologically. Clinical improvements, with modern bracing concepts, are comparable to clinical improvements via surgery. For the majority of scoliosis patients with curvatures exceeding 45°, surgery is not indicated considering the long-term detrimental effects as shown in literature.

How to Reduce Radiation Exposure in the Follow-up of Patients with Scoliosis

Hans-Rudolf Weiss, Sarah Seibel

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 115-121

Scoliosis patients are subjected to multiple x-ray investigations during growth. The need for x-rays during regular check-ups when clinical measurements are taken can be reduced (ATR, Surface Topography), however as indications and check-ups still rely on the measurement of the Cobb angle on a full standing x-ray, the exposure of children and adolescents with scoliosis cannot be avoided. Therefore, it would make sense to reduce the exposition of this patient group to radiation drastically.

One way to reduce radiation is the reduction of the exposure. The other way is the reduction of the diagnostic field. This study was undertaken to investigate the possibility to use one single 45 x 45 cm detector of a DR system for diagnosing and follow-up of adolescent girls with scoliosis.

Materials and Methods: 32 consecutive standing x-rays of girls, aged 10 to 14, made with a single 45 x 45 cm detector of a DR system were analyzed as to whether sufficient information has been provided for diagnosis and follow-up of the patients.

Results: Ground plate of Th1 was clearly visible in 31%, ground plate Th2 in 56% and ground plate Th3 in 88% of the rest. Major curvatures (thoracic and lumbar) were fully visible in 100% of those tested. Risser 3 or 4 would have been (or has been) detected in 100% of cases.

Conclusion: Adolescent girls with scoliosis can be followed and diagnosed with a drastic reduction of the diagnostic field using a 45 x 45 cm detector of a DR system for direct radiography. A drastic reduction of the exposure to radiation of children and adolescents with scoliosis is easily possible by reducing the diagnostic field (window) and by reducing the exposure time. For proper diagnosis and follow-up, it is rarely necessary to expand the field size to higher than Th3 level.

Adolescent Idiopathic Scoliosis – Pilot Study on the Application of Extra-corporal Shockwave Therapy (ECSWT)

Hans-Rudolf Weiss, Sarah Seibel, Marc Moramarco

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 122-130

Idiopathic scoliosis is a lateral deviation of the spine of unknown origin. Initiation and progression of AIS may result from vertebral column overgrowth through a lordo-scoliotic maladaptation of the spine to the subclinical (functional) tether of a relatively short spinal cord.

Implications for treatment, however have not yet been derived from the findings as published so far with the exception of spinal manipulation described by Tomaschewski or neurosurgical release of the filum terminale as described by Royo-Salvador.

Following the rationale of Tomaschewski external manipulation might influence the ‘flatback’ contracture as found in the lower thoracic area in patients with beginning AIS and have a beneficial effect on the 3D deformity of the spine and trunk. The hypothesis for this pilot investigation was that with the application of ECSWT, the ‘flatback’ contracture as commonly found in the lower thoracic area of patients with AIS can be reduced.

Materials and Methods: Inclusion criteria for the study were: Girls with a Cobb angle between 20 and 50° (average 35.3°, SD 9.6), age 12 to 15 years (average 14.1years SD 1.1).

The methodology included (1) Surface Topography (FormetricÔ Diers) before, (2) after 5 min in the treatment position without application of ECSWT and (3) after the application of ECSWT.

Results: Lateral deviation (RMS = Root Mean Square) and Surface Rotation (RMS) both were consistently reduced after the intervention. The sagittal parameters kyphosis angle and lordosis angle both were consistently increased after the intervention. The results were consistent but not significant.

Conclusions: The concept of a functional tethering of the spinal cord in patients with AIS is supported by the results from this investigation. The application of ECSWT in patients with AIS seems to have a beneficial influence on 3D deformity and the subjective feeling of a tensed back. Manipulation of the ‘flatback’ contracture as commonly found in the lower thoracic area may be beneficial as pointed out by Tomaschewski.

Introduction: Brace treatment during the growth spurt is the primary treatment for patients with scoliosis. Scoliosis is regarded as a three-dimensional deformity of the spine and trunk. The standard of bracing worldwide varies. Patients cannot rely on a certain standard of application among practitioners. From evidence available in literature it has been determined that braces effectively stop curvature progression and some even improve trunk deformity. However, questions still remain about stabilization in the long term. The aim of this case report is to show a case with lasting clinical and radiological correction over time, after weaning.

Case Report: A girl with AIS was treated with a Chêneau light brace starting in 2005. At the start of treatment, she was 11 years old, Tanner stage was 2 and the Cobb angle of the single thoracic curvature was 38°. After two years of treatment the brace had to be renewed. In the x-ray taken prior to the adjustment of the new brace Cobb angle measurement was 19°. Weaning began at the age of 15 as there was no residual growth expected. Cobb angle at weaning was 14°. Recently, the patient presented at the age of nearly 21 years, five and a half years after brace weaning. There was no change with respect to trunk deformity when compared to the intermediate result achieved 2007. Final Cobb angle was 19°, half of the Cobb angle at the start of treatment. The patient has full functionality and is highly satisfied with the end result.

Conclusion: Bracing scoliosis may be highly efficient and is supported by scientific evidence. Bracing according to the cutting-edge developments can improve the angle of curvature as well as the trunk deformity. Bracing according to cutting-edge developments are able to lead to relevant and lasting improvements of Cobb angle as well as trunk deformity in the long-term.

A Critical Appraisal on Soft Brace Treatment in Patients with Scoliosis

Hans-Rudolf Weiss

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 138-145

Introduction: Soft/dynamic braces today are used all over the world under the name of SpineCor. The marketing concept is very effective in promoting the soft brace as the first and only ‘dynamic’ brace. A short review has been undertaken, investigating the history of dynamic braces and devices available today.

Short Communication: The use of soft braces to treat scoliosis has been documented by Schanz as early as 1904. In his book, various soft and hard braces with soft add-ons are described as state of the art in the nineteenth century. Many of these soft braces were developed by Fischer.

Today, shortcomings of the dynamic brace have been revealed in literature in comparison with hard braces; however, the concept of improving the quality of life while under brace treatment should be considered further. The purpose of this review is to highlight the history of soft braces and to present recent developments.

Conclusion: There is more than one soft brace used today, and the history of soft bracing is long (over 120 years). Claims made by a company to distribute the first and only soft/dynamic brace is misleading.

There is a great variety of exercises for scoliosis offered worldwide many of them with little benefit for the patient. We distinguish between unspecific and specific exercises. Specific physiotherapy may have a significant influence on many signs and symptoms of a scoliosis. This, however has up to now only been proven for the Schroth method and in part for the Schroth Best PracticeÔ program as well. Purpose of this study was to investigate the amount of corrections possible with respect to the spinal curvature and trunk deformity.

Materials and methods. This is a prospective short-term cohort study. 60 patients with idiopathic scoliosis regularly treated at our department with the Schroth Best PracticeÔ program have been followed up prospectively for at least two months. Average age was 16 years (11 – 19 years), average Cobb angle thoracic was 23.5° (6 – 56°), lumbar 21.2° (6 - 52°). Average ATR (Angle of trunk rotation) thoracic was 8° (3 – 18°) and lumbar 7.9° (2 – 17°).

Results. The follow-up period was 2,9 months. During this time the average thoracic Cobb angle decreased from 23.5° to 18.2° (-5.3°; p < 0,05). Lumbar Cobb angle decreased from 21.2° to 15.7° (- 5.5°; p < 0.01). Thoracic ATR decreased from 8° to 5.6° (- 2.4°; p < 0.01) while lumbar ATR decreased from 7.9° to 5.7°(- 2.2°; p < 0.01). The subset of patients with Cobb angles exceeding 30° experienced a correction of more than 9° (p < 0.01).

Conclusions: The Schroth Best PracticeÔ program is highly effective with respect to improvements of spinal curves and trunk deformity. Curvatures exceeding 30° show better results than smaller curvatures. The out-patient Schroth Best PracticeÔ program seems to provide better results than intensive in-patient rehabilitation using the old Schroth standard still in use today. In phases of little growth or in the outgrown patient this program can be used as the sole form of treatment. In phases of high growth velocity bracing is indicated primarily. Here this program is used as an adjunct to bracing regularly.

Cerebral Toxoplasmosis in an HIV Patient with Fatal Outcome

Marcela Espinoza-Oliva, Erik Severiano Avila, Maribel Barquera Artega, Laura Rocío Rodríguez-Pérez, Laura Verónica Sánchez Orozco, María de la Luz Galván-Ramírez

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 154-159

Background: Latent toxoplasmosis is present in a third of the world population, however, 80% of cases are asymptomatic. In HIV patients, encephalitis caused by Toxoplasma is the most common opportunistic infection and cause of focal brain lesions with a fatal outcome. In these patients, a clinical deterioration occurs despite increased CD4 counts and decreased plasma HIV viral load; this phenomenon has been described as Immune Restoration Disease (IRD) or the Immune Reconstitution Inflammatory Syndrome (IRIS). During this syndrome it is possible the reactivation of opportunistic infections as Toxoplasma, because the immune system has an abnormal inflammatory reaction.

Aims: The aims in this case was to diagnose the existence of cerebral toxoplasmosis in a pediatric patient with HIV.

Methods: Mycobacterium tuberculosis culture and polymerase chain reaction. To Diagnostic of Brain Toxoplasmosis; Computerized Tomography of brain Enzyme Liked Absorbent assay (ELISA) IgG e IgM, PCR and Western-Blot were performed.

Results: Anti-Toxoplasma antibodies IgM negative and IgG test was positive >300 IU/mL, Western-blot was positive to IgG antibodies. Toxoplasma DNA was negative through Polymerase Change Reaction.

Conclusion: High level of IgG antibodies confirmed by Western blot, and the image studies of Computerized Tomography of brain confirmed a Neurotoxoplasmosis.

Common variable immunodeficiency disorder (CVID) is a primary immunodeficiency (PID) with heterogeneous clinical features. It is linked to different autoimmune diseases from autoimmune cytopenias to rheumatologic diseases such as systemic lupus erythematosus (SLE). Patients with the co-occurrence of SLE and CVID are infrequent in the literature and represent less than 1% from the overall. The objective of this review is to determine the clinical and demographic characteristics presented for this group of patients. In addition, it has been explored the similarities and differences that both pathologies have, because they represent opposite poles. SLE is characterized by a polyclonal activation of B-cells with hyperproduction of autoantibodies (hypergammaglobulinemia), by contrary CVID is a PID defined by a hypogammaglobulinemia with deficiencies of IgG and/or IgM and IgA immunoglobulins. Thus, the therapeutic approach of both pathologies is totally the opposite.

Long-Term Complications and Risks of Surgery for Adolescent Idiopathic Scoliosis

Hans-Rudolf Weiss, Marc Moramarco, Kathryn Moramarco

Highlights on Medicine and Medical Research Vol. 11, 4 May 2021, Page 169-179

Background: Recently, a paper was published containing the long-term results of the first ‘modern’ double rod instrumentation, the Cotrel-Debousset (CD) instrumentation. Results showed an unexpected high rate of reoperation of nearly 50% due to late infections or chronic back pain occurring after surgery. Further research into the long-term complications of spinal fusion surgery in Adolescent Idiopathic Scoliosis ‘AIS’ patients is necessary with special attention to more recent instrumentations.

Materials and Methods: The previous systematic review on long-term complications, as they might develop over a lifetime, was published in 2008. The first author conducted a Pub Med search to locate additional studies related to long term outcomes of AIS surgical complications published after August 2008. Target publications were (1) prospective or retrospective papers on complications in spinal fusion surgery for AIS with a minimum follow-up of 10 years and (2) prospective or retrospective papers on reoperation rates in spinal fusion surgery for AIS with a minimum follow-up of 10 years.

Results: No paper with the topic on complications and a long-term follow-up of at least 10 years was found. Two papers were found with the topic of reoperation rates and a long-term follow-up of at least 10 years. Reoperation rates were reported between 12.9% and 47.5%.

Discussion: Since there is no evidence indicating surgical correction in patients with AIS and post-surgical complications are estimated around 50% over a lifetime, claims for a medical indication of AIS surgery should not be made except in very extreme curvatures. In the relatively benign population of AIS patients, according to the findings within this review, it may be concluded that the long-term outcome of surgery for AIS is worse than the long-term consequences of the condition itself.

Conclusions: A medical indication for AIS spinal fusion surgery does not exist, except in extreme cases. The rate of complications of spinal fusion surgery appears to increase with time. The risk/reward relationship of spinal fusion surgery is unfavorable for the AIS patient, except in rare cases. There is no evidence that spinal fusion surgery improves quality of life for AIS patients vs. natural history. The risks and long-term costs, in terms of pain and suffering, after spinal fusion surgery exceeds what is reasonable for AIS patients, putting the common practice of surgery in question, except in extreme cases.