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Sacral slanting—defined as the oblique tilt of the upper sacral endplate measurable on standing anteroposterior whole-spine radiographs—is a distinctive and clinically underappreciated finding in adolescent idiopathic scoliosis (AIS). Its etiology is multifactorial and incidence among AIS patients reaches 40%. The direction and degree of sacral slanting interact with the distal lumbar curve type (L4-left vs. L4-right) to influence the pattern of postoperative radiographic changes at the distal spine and shoulder. In patients with L4-left curves and left-sided slanting, stopping fusion at L3 generally prevents coronal decompensation. Furthermore, 5-year data show that the disc wedge angle below the lowermost instrumented vertebra (LIV) does not progress when LIV is L3, and patient-reported outcomes are preserved without revision surgery. When fusion extends to L4 in patients with high sacral slanting, coronal decompensation is more frequent, yet functional outcomes remain comparable and no revision has been required in published series to date, indicating that the decompensation observed is radiographically significant but clinically tolerable within the medium term. In Lenke 1A patients with right-sided sacral slanting (L4-right type), the slanting lowers the last touching vertebra and may facilitate distal adding-on. In Lenke 2A patients with right-sided slanting, distal adding-on serves as a natural shoulder-rebalancing mechanism and may be reasonably monitored conservatively rather than reflexively treated, pending further validation in independent cohorts, unless progressive or symptomatic. Across all scenarios, the optimal distal fusion level remains an unresolved dilemma requiring further long-term prospective study. This review synthesizes the available literature to characterize sacral slanting as a promising radiographic parameter that may serve as a potentially useful adjunct in distal fusion level planning, while highlighting the need for prospective multicenter validation before its routine incorporation into surgical decision-making in AIS.
BACKGROUND:Epistaxis is a common ear, nose, throat (ENT) presentation in the emergency department (ED), with the majority of the population having experienced an episode during their lifetime and required hospitalization. Like many district general hospitals (DGHs) in the country, St Peter's Hospital does not offer adult inpatient or out-of-hours emergency cover for ENT, necessitating patients who require intranasal packing with a Rapid Rhino® (Smith & Nephew, Hull, UK) to be transferred to another hospital for assessment and admission, with most transfers being via ambulance. Apart from being resource-heavy, both the procedure itself and the prolonged stay in ED awaiting transport are a distressing experience for the patient. Therefore, the present quality improvement analysis was performed for the assessment of the effectiveness of Floseal® (Baxter Healthcare, Deerfield, IL, USA) and NasoPore® (Stryker, Kalamazoo, MI, USA), a bioresorbable material for epistaxis. METHODS:We introduced the revised Royal College of Surgeons (RCS) ENT UK guidelines for epistaxis management in our department. Two Plan-Do-Study-Act (PDSA) cycles were conducted in parallel. To assess the patient experience, a feedback form was designed with particular focus on pain score using the Visual Analog Scale (VAS). IBM SPSS Statistics for Windows, Version 16 (Released 2007; IBM Corp., Armonk, New York, United States) was used for descriptive analysis, and cost-effectiveness analysis was also performed to compare the outcomes with rapid rhino nasal packing. A telephonic follow-up on days 2 and 5 was organized to document any adverse features. RESULTS:The use of bioresorbable nasal packing among 60 patients demonstrated a clear benefit over the conventional practice of a non-absorbable packing, like Rapid Rhino. It reduced the length of stay (LOS) in ED and allowed the patients to go home with self-care instructions. In addition to much better patient comfort and tolerability (drop in pain score from 7 to 2 on VAS), this intervention also had a significant cost-saving impact with more than 65% cost reduction. CONCLUSION:Floseal bioresorbable material can be used as a replacement for traditional nasal packing, as it was found to be more effective and cost-effective.
Diabetic cardiovascular dysfunction arises from a progressive metabolic-vascular-myocardial injury pathway rather than from hyperglycemia alone. In this review, the "gluco-vascular injury axis" is used as a proposed conceptual framework describing how diabetes-related metabolic stress promotes endothelial dysfunction, vascular injury, microvascular impairment, myocardial remodeling, and heart failure. Chronic hyperglycemia, insulin resistance, dyslipidemia, oxidative stress, inflammation, AGE-RAGE (advanced glycation end products-receptor for advanced glycation end products) signaling, mitochondrial impairment, arterial stiffness, and coronary microvascular dysfunction contribute to fibrosis, diastolic dysfunction, and heart failure. Because these mechanisms are often discussed separately, the primary clinical message can become obscured. This narrative review synthesizes mechanistic, experimental, and clinical evidence to organize these processes into a clinically interpretable continuum. The novelty of this review lies in integrating diabetic cardiomyopathy, atherosclerosis, endothelial dysfunction, and coronary microvascular disease into one metabolic-vascular-myocardial framework, with endothelial dysfunction positioned as the transition point between glucose-lipid stress and cardiovascular injury. It was not designed as a systematic review and did not use formal search, screening, or meta-analytic methods. The review highlights metabolic triggers, endothelial injury, inflammatory amplification, macrovascular disease, microvascular dysfunction, mitochondrial redox imbalance, and diabetic cardiomyopathy. The key takeaway is that cardiovascular protection in diabetes may need to address the entire gluco-vascular injury process through a combination of metabolic, endothelial, inflammatory, mitochondrial, microvascular, and myocardial protective strategies.
