Need For Early Surgical Intervention Research Articles

The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention

The aim of this narrative review is to describe the various surgical management strategies employed in fracture-related infection (FRI), to explore how they are selected and discuss the rationale for early surgical intervention. Surgical treatment options in patients with FRI include debridement, antibiotics and implant retention (DAIR), revision (exchange) or removal. In selecting a treatment strategy, a variety of factors need to be considered, including the condition of the bone, soft tissues, host and causative microorganism. Irrespective of the selected treatment strategy, prompt surgical intervention should be considered in order to confirm the diagnosis of an FRI, to identify the causative organism, remove necrotic or non-viable tissue that can serve as a nidus for ongoing infection, ensure a healthy soft tissue envelope and to prevent the vicious cycle of infection associated with skeletal and/or implant instability. Ultimately, the objective is to prevent the establishment of a persistent infection. Urgent surgery may be indicated in case of active, progressive disease with systemic deterioration, local progression of infection, deterioration of soft tissues, or progressive fracture instability. In case of static disease, the patient should be monitored closely and surgery can be performed on an elective basis, allowing adequate time for optimisation of the host through risk factor modification, optimisation of the soft tissues and careful planning of the surgery.

Large aplasia cutis congenita of the vertex conservative management.

Aplasia cutis congenita (ACC) of the vertex with bone defect is a rare and begnin anomaly that can involve the epidermis, dermis, and subcutaneous tissues of the scalp with significant bone defect Bajpai and Pal (J Pediatr Surg 38(2):e4, 2003). When associated with skull defect, this rare malformation carries the risk of severe complications such as rupture of the superior sagittal sinus or infections. We report a case of aplasia cutis congenita of the scalp with skull defect measuring 9 × 10cm and an exposed sagittal sinus in a newborn. Both conservative and surgical methods have been proposed to treat this condition. In our case, conservative treatment was planned led to complete epithelization and the patient was healing well at 5years of follow-up. ACC of the vertex with a large scalp defects present a management dilemma Rocha et al. (Clin Case Rep 3(10):841-4, 2015). Based on a review of the literature, we report this case to demonstrate that even for the largest skin and bone defects, an initial conservative approach may allow for complete wound closure without the need for early surgical intervention.

Spinal epidural abscess as predicting factor for the necessity of early surgical intervention in patients with pyogenic spondylitis

BackgroundPyogenic spondylitis is a condition with low incidence that can lead to neurological sequelae and even life-threatening conditions. While conservative methods, including antibiotics and bracing, are considered the first-line treatment option for pyogenic spondylitis, it is important to identify patients who require early surgical intervention to prevent progressive neurologic deficits or deterioration of the systemic condition. Surgical treatment should be considered in patients with progressive neurologic deficits or deteriorating systemic condition. However, currently, there is a lack of treatment guidelines, particularly with respect to whether surgical treatment is necessary for pyogenic spondylitis. This study aims to analyze the radiological epidural abscess on MRI and clinical factors to predict the need for early surgical intervention in patients with pyogenic spondylitis and provide comprehensive insight into the necessity of early surgical intervention in these patients.MethodsThis study retrospectively reviewed 47 patients with pyogenic spondylitis including spondylodiscitis, vertebral osteomyelitis, epidural abscess, and/or psoas abscess. All patients received plain radiographs, and a gadolinium-enhanced magnetic resonance imaging (MRI) scan. All patients have either tissue biopsies and/or blood cultures for the diagnosis of a pathogen. Demographic data, laboratory tests, and clinical predisposing factors including comorbidities and concurrent other infections were analyzed.ResultsWe analyzed 47 patients, 25 of whom were female, with a mean age of 70,7 years. MRI revealed that 26 of 47 patients had epidural abscesses. The surgical group had a significantly higher incidence of epidural abscess than the non-surgical group (p = 0.001). In addition, both CRP and initial body temperature (BT) were substantially higher in the surgical group compared to the non-surgical group. There was no significant difference between the surgical group and the non-surgical group in terms of age, gender, comorbidities, and concurrent infectious disorders, as well as the number of affected segments and affected spine levels. However, the surgical group had lengthier hospital stays and received more antibiotics.ConclusionThe presence of an epidural abscess on MRI should be regarded crucial in the decision-making process for early surgical treatment in patients with pyogenic spondylitis in order to improve clinical outcomes.

Focused assessment with sonography for trauma in predicting early surgical intervention in hemodynamically unstable children with blunt abdominal trauma.

ObjectivesThe predictive accuracy and clinical role of the focused assessment with sonography for trauma (FAST) exam in pediatric blunt abdominal trauma are uncertain. This study investigates the performance of the emergency department (ED) FAST exam to predict early surgical intervention and subsequent free fluid (FF) in pediatric trauma patients.MethodsPediatric level 1 trauma patients ages 0 to 15 years with blunt torso trauma at a single trauma center were retrospectively reviewed. After stratification by initial hemodynamic (HD) instability, the association of a positive FAST with (1) early surgical intervention, defined as operative management (laparotomy or open pericardial window) or angiography within 4 hours of ED arrival and (2) presence of FF during early surgical intervention was determined.ResultsAmong 508 salvageable pediatric trauma patients with an interpreted FAST exam, 35 (6.9%) had HD instability and 98 (19.3%) were FAST positive. A total of 42 of 508 (8.3%) patients required early surgical intervention, and the sensitivity and specificity of FAST predicting early surgical intervention were 59.5% and 84.3%, respectively. The specificity and positive predictive value of FF during early surgical intervention in FAST‐positive HD unstable patients increased from 50% and 90.9% at 4 hours after ED arrival to 100% and 100% at 2 hours after ED arrival, respectively.ConclusionsIn this large series of injured children, a positive FAST exam improves the ability to predict the need for early surgical intervention, and accuracy is greater for FF in HD unstable patients 2 hours after arrival to the ED.

Craniosynostosis: Neonatal Perspectives.

Craniosynostosis is the premature fusion of 1 or more sutures that normally separate the bony plates of an infant's skull and occurs in about 1 in 2,000 to 2,500 live births. Primary or congenital craniosynostoses represent the majority of cases and consist of single-suture and multisuture synostoses. Multisuture synostoses are typically associated with distinct craniofacial syndromes, including Muenke syndrome, Apert syndrome, Crouzon syndrome, and Pfeiffer syndrome, and are thus categorized under syndromic craniosynostoses. Secondary causes of craniosynostoses include metabolic or hematologic disorders that affect bone metabolism and typically present much later than primary synostoses. The severity of the deformity and the presence of increased intracranial pressure dictate the need for early surgical intervention, prompting the importance of early recognition and timely referral. Infants with craniosynostosis are also at increased risk for neurodevelopmental impairment and thus require close follow-up and monitoring. The early recognition and referral of craniosynostosis is imperative for the optimization of management and minimization of potential neurologic impairments that may develop.

The prediction of surgical intervention in patients with tubo-ovarian abscess

The aim of this study was to compare the clinical characteristics of patients with tubo-ovarian abscess (TOA) who responded to medical treatment and those who underwent surgical intervention due to medical treatment failure. Electronic medical records were evaluated retrospectively to identify patients who were diagnosed with TOA. Demographic, clinical, and laboratory data including white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared between the medical treatment group and the surgical intervention group. Patient age, TOA diameter, WBC count, CRP, and ESR were significantly different between the groups. On multiple regression analysis, significant correlations were identified between age (p = .001), ESR (p = .045), and failure of medical treatment. TOA diameter (p = .065) showed a borderline association with surgical intervention. The risk of needing surgical intervention in TOA patients can be predicted using ESR in addition to age and TOA size as risk factors. IMPACT STATEMENT What is already known on this subject? For patients diagnosed with a tubo-ovarian abscess (TOA), the size of TOA and the patient’s age are helpful for early identification of patients who are likely to need surgical treatment. Inflammatory markers such as C-reactive protein and white blood cell are also associated with the risk of surgical intervention. What do the results of this study add? Erythrocyte sedimentation rate (ESR) in addition to the size of TOA and the patient’s age is a useful marker in determining whether to undergo surgery in patients with TOA. What are the implications of these findings for clinical practice and/or further research? ESR combined with the patient’s age and the size of TOA is clinically useful in predicting the need for early surgical intervention in patients with TOA. Large prospective controlled studies are required to establish relationship between inflammatory markers and the risk of surgical intervention.

Long-term outcomes for children with an incidentally discovered Chiari malformation type 1: what is the clinical significance?

Chiari malformation type 1 (CM1) is an increasingly common incidental finding on magnetic resonance imaging (MRI). The proportion of children with an incidentally discovered CM1 who upon further evaluation require operative intervention for previously unrecognized signs and symptoms of neurological compromise or significant radiographic findings (syringomyelia) is unclear. An extensive long-term single-institution patient series was evaluated to better clarify the likelihood of surgery in patients who present with an incidentally discovered CM1. This study was conducted using prospective data for patients up to 18years old that were evaluated for a CM1 at a large tertiary pediatric neurosurgery clinic between February 2009 and June 2019. Patients were excluded if they did not have an incidentally discovered CM1 and at least 12months of clinical follow-up. A total of 218 consecutive patients were included in this study. The mean age at the initial neurosurgical evaluation was 6.5years (range 5months to 18.4years), and the mean duration of clinical follow-up was 40.6months (range 12 to 114months). Initial MR imaging was most commonly obtained for the evaluation of seizures (15.1%), nonspecific headaches (not occipital or tussive) (14.7%), trauma (9.6%), and developmental delay (7.8%). Of the patients studied that eventually required surgery, we identified two groups: those operated before 6months since presentation and those operated after 6months. A total of 36 patients (16.5%) underwent a decompression with 22 patients (61.1%) receiving surgery within 6months and the remaining 14 patients (38.9%) beyond 6months. Patients undergoing early surgery (10.1%) initially presented with a significant syrinx or were noted to have an occult neurological dysfunction, whereas a smaller subset of patients (6.4%) eventually required surgery over time due to the development of new symptoms or a de novo syrinx. Only the presence of syringomyelia was statistically significant for the need of a surgical intervention, while age, sex and degree of tonsillar herniation were not. Evaluation of a large group of patients with an incidentally discovered Chiari malformation demonstrated that most patients may be managed conservatively, especially in the absence of syringomyelia. However, there is a subset of patients who will go on to develop a de novo syrinx or neurological symptoms that are new or progressive during follow-up, which should be evaluated by imaging of the brain and spinal cord. The presence of syringomyelia was associated with need for early surgical intervention. However, for patients without syringomyelia, surgical intervention is uncommon but may be delayed up to several years after presentation; therefore, long-term clinical follow-up is recommended.

Factors Predicting the Need for Early Surgical Intervention for Small Bowel Obstruction.

Purpose Small bowel obstruction (SBO) is a common disease that requires hospitalization. The most common cause of SBO is postoperative adhesion. Delayed timing of operations in patients who need surgical intervention results in mortality or morbidity. A number of studies on SBO have established criteria for emergency surgery. However, few objective clinical parameters are available for screening patients who need a delayed operation. Therefore, we analyzed factors that affect the clinical course of SBO to select appropriate therapeutic plans for reducing the risk of complications in these patients.Methods We investigated the clinical characteristics of patients admitted to the surgery department of our hospital between January 1, 2015, and December 31, 2016, who were diagnosed with SBO. Patients were divided into an operative treatment group (n = 12) and a conservative treatment group (n = 96). We compared clinical characteristics between the 2 groups.Results The operative treatment group underwent more operations before SBO than the conservative treatment group (P = 0.007). Initial leukocyte counts (P = 0.004) and C-reactive protein (CRP) levels (P = 0.028) were elevated in the operative group. Body mass index (BMI) was lower in the operative group (P = 0.013).Conclusion The number of operations before SBO, leukocyte counts, CRP levels, and BMI were useful parameters for selecting patients who needed an urgent operation for SBO.

Two cases of medication‐related osteonecrosis of the jaw with extension to the cranial base

AbstractThere is no established treatment for medication‐related osteonecrosis of the jaw (MRONJ). Advanced MRONJ of the maxilla dose not cure with conservative treatment, and progression may cause neurological symptoms. We herein report two cases in which MRONJ of the maxilla spread to the skull base despite conservative treatment, causing abducens paralysis in one case and hydrocephalus in the second. Case 1: A 50‐year‐old woman who received denosumab for 2 years for multiple bone metastases of breast cancer developed MRONJ in the left maxilla after tooth extraction. MRONJ of the maxillae can progress to the skull and may cause neurological symptoms. Abducens paralysis developed for MRONJ. Magnetic resonance images revealed narrowing of the internal carotid artery and necrosis of the sphenoid bone and clivus. Sequestrectomy was performed. Two weeks after surgery, abducens paralysis resolved. Magnetic resonance imaging 3 months after surgery showed improvement of internal carotid artery narrowing. Case 2: A 73‐year‐old woman who received zoledronic acid for 2 years for multiple bone metastases of breast cancer developed MRONJ in the left maxilla that spread broadly despite conservative treatment. Sequestrectomy was planned, but the patient developed altered consciousness and a stiff neck; ventricular enlargement was observed on magnetic resonance images of the brain. We diagnosed hydrocephalus resulting from bacterial meningitis caused by MRONJ; ventricular drainage was performed. After drainage followed by 2 weeks of antibiotics, the sequestrum was removed. These cases suggest that some patients with maxillary MRONJ might not respond to conservative therapy and the need for early surgical intervention should be considered in order to reduce the risk of necrosis progressing and the associated infection spreading to the base of skull.

Cerebrovascular blood flow in patients with tetralogy of fallot: prediction for early surgical intervention.

Children with tetralogy of Fallot (TOF) require initial intervention at varying times reflecting a spectrum of obstruction to pulmonary blood flow. In utero, fetal patients with right sided obstructive lesions demonstrate increased middle cerebral artery (MCA) pulsatility index (PI). We sought to determine whether MCA flow patterns are associated with the degree of pulmonary obstruction and the consequential need for early surgical intervention (ESI). We performed a multi-center retrospective study evaluating patients with a prenatal diagnosis of TOF. All echocardiographic fetal studies performed from 16 weeks' gestational age through delivery were reviewed between 2001 and 2015 with subsequent postnatal medical chart review. 82 patients met inclusion criteria. Patients who ultimately required ESI (n=30) demonstrated an increased MCA PI z-score (-0.68 vs -1.32, p=0.02) compared to those who did not (n=52). An elevated MCA PI in patients with TOF was associated with ESI after 24 weeks' gestational age (-0.36 vs -1.22, p=0.02). Fetal patients with TOF demonstrate altered MCA flow that correlates with need for ESI. This effect is blunted earlier in gestation which may reflect cerebral autoregulation. MCA PI may be a beneficial tool in helping determine perinatal management and counseling for patients with TOF.

Foot drop: an iatrogenic complication of spinal anesthesia

Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention.

The cytopathology of Actinomyces, Nocardia, and their mimickers.

Nocardia species and Actinomyces species are 2 of the most commonly diagnosed filamentous bacteria in routine cytopathology practice. These genera share many overlapping cytomorphologic features, including their thin, beaded, branching, Gram-positive, GMS-positive filamentous structures that fragment at their peripheries into bacillary- and coccoid-appearing forms. Features that help distinguish between these 2 microorganisms include the width of their filamentous structures, the angles at which they branch, and their ability or lack thereof to retain a modified acid-fast stain. In addition to cytomorphologic overlap, overlap in clinical presentation is frequent with pulmonary and mucocutaneous presentations seen in both. Differentiating between Nocardia and Actinomyces is essential because patients with these infections require different approaches to medical management. Both antibiotic susceptibilities and the need for early surgical intervention as part of the treatment plan vary greatly among these 2 groups. This review focuses on the clinical presentation, cytomorphology and staining characteristics that can be useful in identifying and distinguishing between Nocardia and Actinomyces infections, as well as their mimickers.

“As Little as Possible, As Much as Required”: Epilepsy Surgery in Children and Adults

Extensive, multilobar or hemispheric epileptogenic zones are usually associated with early epilepsy onset, a catastrophic course and, eventually, with the urgent need for early surgical intervention. The prevalent underlying etiologies of drug-resistant epilepsy in infants and young children are focal cortical dysplasia and glioneuronal tumors. The completeness of resection is the best predictor of postoperative seizure freedom, due to the intrinsic epileptogenicity of these lesions. Presurgical workup in the first years of life is challenging, due to the limitations of MRI diagnostics at an age of yet immature myelination. Infants and young children with a focal brain lesion may be favorable candidates for epilepsy surgery despite the prevalence of generalized EEG seizures and a diffuse pattern of hypsarrhythmia with multifocal bilateral interictal epileptiform discharges. Seizure semiology in focal epilepsies manifesting in the first years of life is rarely lateralizing and hardly ever localizing. Focal epileptogenic lesions in infancy may present with infantile spasms in the context of West syndrome. Young children undergo mostly multilobar and hemispheric procedures, in stark contrast to adults undergoing temporal lobe resections. Younger children require more extensive procedures, but have the potential to compensate neurological deficits due to increased brain plasticity in early life. Postoperative seizure freedom and anticonvulsant tapering are expected to have a positive effect on cognitive development, considering the devastating effects of seizures and anticonvulsants on the developing brain. This very young pediatric population differs to a great extent from adult cohorts with later epilepsy onset, due to a more limited epileptogenic zone, and later epilepsy surgery.

Subcutaneous pressure in cellulitis of the leg: can it be a predictor for early surgical intervention?

Background: Cellulitis, an infection of skin and subcutaneous tissue is usually managed conservatively and surgical intervention is required for local complications. The aim of this study was to correlate the subcutaneous pressure with the need for early surgical intervention in cases of lower limb cellulitis. Methods: We prospectively measured subcutaneous pressures in the normal leg and in the leg with cellulitis. Patients managed with parenteral antibiotics were compared to those managed with parenteral antibiotics and surgical intervention with standard statistical tests. Results: The median subcutaneous pressure was 3 mmHg and 9 mmHg in the normal leg and the other with cellulitis respectively. The mean of difference in subcutaneous pressure in legs with cellulitis compared to normal legs was 5.93 mmHg and 8.29 mmHg in the conservative group and surgical intervention group respectively. The difference in subcutaneous pressure between the normal leg and in the leg with cellulitis was statistically significant (p =7 with sensitivity of 85.7% and specificity of 57.1%. Area under the ROC curve (SE) was 0.71 (0.10) with 95% CI (0.51, 0.87). Conclusions: The subcutaneous pressure in leg with cellulitis is a predictor for the need for early surgical intervention. It can be used as an adjunct in management and clinical decision making for cases of cellulitis of lower limbs.

Surgical intervention strategy for postoperative chylothorax after lung resection.

The optimal surgical management of postoperative chylothorax has not been established. Thus, we evaluated the treatment strategy for postoperative chylothorax and identified associated predictors of surgical intervention. The subjects of this retrospective study were 50 patients who suffered postoperative chylothorax, representing 4% of 1235 patients who underwent pulmonary resection between 2008 and 2012. The chylothorax patients were classified into two groups based on their postoperative management: a conservative group and a surgical group. The following parameters were investigated to establish the predictors of surgical intervention for chylothorax: mode of surgery, preoperative complications, intraoperative management, and postoperative clinical status. Forty-one (82%) patients were treated conservatively and 9 (18%) underwent reoperation, as direct or concomitant ligation of the thoracic duct at the point of leakage. The frequency of postoperative chest tube drainage just after initial surgery was significantly greater in the surgical group than the conservative group before oral intake was restarted (448±189 vs. 296±117ml/12h, respectively; p=0.003). Furthermore, it was a significant predictor of reoperation based on a multivariate analysis (p=0.010). The amount of chest tube drainage just after surgery and before oral intake was a useful predictor to help us decide on the need for early surgical intervention for postoperative chylothorax.

An Unusual Case of “Late” Central Protrusion of the Helical Blade of Proximal Femoral Nail Antirotation

Central protrusion, or “cut-through” of the helical blade in proximal femoral nail antirotation (PFNA), is a unique and novel complication. Cases reported in the literature were presented early in the postoperative period and were associated with no bone healing, and managed with either revision or total hip replacement. We reported a case that presented late in the postoperative period that showed some bone healing and was erroneously treated with removal of the implant, resulting in varus malunion after implant removal. Possible causes for late presentation, preventive measures, and the need for early surgical intervention are discussed.

Features on MDCT That Predict Surgery in Patients with Adhesive-Related Small Bowel Obstruction

PurposeThe purpose of this study was to determine the contribution of multidetector-row computed tomography (MDCT) in the management of adhesion-related small bowel obstruction (SBO) and to identify its predictive value for surgery.MethodsWe conducted a retrospective review of 151 patients over a 5-year period with the diagnosis of SBO caused by adhesion. These patients were divided into two groups: surgery (n = 63) and observation group (n = 88). Two radiologists blinded to the outcome of the patients evaluated MDCT images retrospectively, recording the bowel diameter, bowel wall thickness, degree of obstruction, air-fluid level, mesenteric fatty stranding, transitional zone, intraperitoneal fluid, close loop, whirl sign, and faeces sign. Statistical analyses were performed using univariate and multivariable analyses.ResultsMultivariable analysis showed that MDCT demonstrated presence of intraperitoneal fluid (Odds ratio, OR, 4.38), high-grade or complete obstruction (OR, 3.19) and mesenteric fatty stranding (OR, 2.81), and absence of faeces sign (OR, 2.11) were the most significant predictors. When all of the four criteria were used in combination, high sensitivity of 98.4% and specificity of 90.9% were achieved for the prediction for surgery.ConclusionMDCT is useful to evaluate adhesion-related SBO and to predict accurately patients who require surgery. Use of the four MDCT features in combination is highly suggestive of the need for early surgical intervention.

Su1747 Combined Epigenetic and mRNA Expression Profiling Defines a Crohn's Disease (CD) Patient Population With Need for Early Surgical Intervention

Background: Studies have confirmed associations with TNFSF15 and CD in Caucasian and Asian populations, but these studies have been limited by the number of markers tested. Decoy Receptor 3 (DcR3), previously identified as a susceptibility gene from a Caucasian pediatric CD GWAS, is a decoy receptor that can neutralize pro-inflammatory ligands including, TL1A (TNFSF15). Aim: To perform transethnic fine mapping across TNFSF15 and DcR3 in Caucasian, Puerto Rican and Korean CD. Methods: Genotyping was performed in Non-Jewish Caucasians (NJ; 779 CD, 4182 controls), Ashkenazi-Jews (AJ; 492 CD, 395 controls), Puerto Ricans (PR; 300 CD, 235 controls), and South Koreans (SK; 729 CD, 469 controls) using the 200K SNP ImmunoChip genotyping array. Analysis of TNFSF15 (416 SNPs) and DcR3 (13 SNPs) was conducted. Principal components analysis controlled for population structure, and logistic regression models tested for association of each SNP with CD. Results: TNFSF15 analyses: 4 rare variants (MAF,1%) and 9 common variants (MAF= 27.7-34.9%) were significantly associated with NJ CD after correction for multiple-testing. Analyses in NJ CD confirmed that rare and common variants associations could each be tagged by a single SNP (rare: rs1322057, MAF=0.83%, p=3.02E-6, OR=6.97; common: rs7869487, MAF=22.6%, p=7.26E-5, OR=0.78). Further, the associations with CD of these SNPs were independent of each other. All 13 NJ CD SNP associations were replicated in SK CD (all P ,3.15E-10) but with higher MAF (0.13% vs 34.6% for rs1322057 and 32.4% vs 40.9% for rs7869487 in controls). The independence of the 2 SNPs seen in NJ was replicated in SK. The rare variants were also associated with PR CD but with higher MAF than in NJ (6.6% for rs1322057, p=3.19E-2, OR=1.62), but no association was seen at 9 common variants in PR. No significant SNP associations were observed with AJ CD. DcR3 analyses: rs6062496, located in intron 6 of DcR3, was significantly associated with NJ CD (p=5.83E-4, OR=1.22). This association was confirmed in SK CD (p=2.01E-2, OR=1.32) but not in AJ or PR CD. The associated SNP was also significantly associated with protection against stricturing CD (p=2.95E-2, OR=0.75). There were no significant gene-gene interactions between rs6062496 in DCR3 and the 2 independent SNPs from TNFSF15 in both NJ (p.0.18) and SK CD (p.0.61). Conclusion: We have identified novel associations of rare variants in TNFSF15 with NJ CD that are independent of previously reported common variants, and are also found in PR and SK. These variants are more common in SK and also associated with SK CD, perhaps explaining the ‘dominant' role of this locus in Asian IBD susceptibility. DcR3 is significantly associated with NJ CD, a finding replicated in SK and variation at this locus modifies a stricturing phenotype.

Posterior listhesis of a lumbar vertebra in spinal tuberculosis

The management of spinal tuberculosis, especially in children, is controversial. In children, vertebral destruction is more severe than adults because of the cartilaginous nature of their bone. Modern chemotherapy has significantly decreased mortality in spinal tuberculosis, but morbidity remains high. Without early surgery, patients can develop severe kyphosis leading to respiratory insufficiency, painful costopelvic impingement and paraplegia. Lumbar kyphosis results in early degenerative lumbar canal stenosis and is cosmetically unacceptable. We report a paediatric case of atypical spinal tuberculosis demonstrating the need for early surgical intervention to prevent significant spinal instability and neurologic deficit. A 12-year-old girl presented with increasing ambulatory difficulty and double incontinence 4months after initiating treatment for pulmonary tuberculosis. There was no history of traumatic injury. Examination revealed severe lower limb neurologic deficit, with hypotonia, areflexia, marked sensory loss, and grade 0/5 power in both lower limbs. Plain radiographs and magnetic resonance imaging (MRI) demonstrated grade IV posterior listhesis of the L2 vertebral body over L3, cauda equina compression and bilateral psoas abscesses. Erosion of both the body and pedicle of L2 was observed. Both serology and pus drained from the psoas abscesses were negative for microorganisms. The patient underwent an L2 vertebrectomy via a left retroperitoneal approach. A titanium cage packed with autologous bone graft was inserted, and the spine was stabilized by fixation with screw and rods. Histopathology confirmed a diagnosis of tuberculosis. Eighteen months following the procedure, the patient has regained some power in her right leg and has completed her course of anti-tuberculous chemotherapy, but remains wheelchair-bound. To our knowledge, this is the first reported case of posterior listhesis secondary to spinal tuberculosis. Here, we discuss the possible management options in such a case, and the indications for surgery. As the global HIV/AIDS epidemic causes a resurgence in tuberculosis, increased awareness among the medical community regarding the atypical presentations of spinal tuberculosis is necessitated; both in the developing world where advanced clinical presentations are common, and in the developed world where spinal tuberculosis is an often-neglected diagnosis.

Histological study of routine tonsillectomy specimen.

Palatine and nasopharyngeal tonsils are lymphatic flesh clusters of tissue of the respiratory and digestive tract's epithelium. There is not much literature pertaining to the histological assessment of resected tonsils though anecdotal case reports of choristoma, squamous cell cysts of the tonsil have been reported which mimicked chronic tonsillitis. Tonsils also are an important site for head and neck cancer in adults. AIM #ENTITYSTARTX00026; To study the histological features of routine tonsillectomy specimens and to study for the presence of choristomatic tissue or any other benign pathology as a cause of chronic tonsillitis. PATIENTS #ENTITYSTARTX00026; Fifty consecutive tonsillectomy specimens, which were received in the department of Pathology, Gandhi Medical College, were evaluated with regards to clinical information. Among 50 patients, a slight predominance of men (56 %) over women (44 %) was observed. The mesenchymal tissue consisted mainly of epithelium and lymphoid tissue with cartilage in a single case and fat in three cases. The role of imaging techniques, in assessing the need for early surgical intervention in cases with chronic tonsillitis, can be determined by assessing the micropathology of tonsillectomy specimens and is an arena for further research. We discussed the role of FDG-PET scan in the assessment of the same.