Approaches to minimize the risk of epidural fibrosis after lumbar disc surgery: [clinical - and MRI-based outcome evaluation]

Epidural fibrosis [EF] after lumbar disc surgery is a consequence of normal wound healing. Previous clinical studies have demonstrated a significant association between the presence of extensive post-lumbar discectomy EF formation and the recurrence of low-back and radicular pain with poor surgical outcomes in 5% up to 60%; in the nearly absent curable surgical solutions. Moreover, the presence of fibrosis may lead to nerve root tethering and renders reoperations risky. Theoretical approaches to minimizing the risk of developing EF include decreasing the chance of its development by decreasing the amount of postoperative hematoma by suction drainage [SD] and hence its invasion of by dense fibrous tissue; providing a barrier like autogenous fat between the exposed dura and the healing connective tissues; or applying a drug locally which is supposed to decrease scar tissue formation as steroids. In the present study, we aimed to evaluate the results of these theoretical approaches in the clinical and imaging outcomes of patients after lumbar disc surgery. The present study is a prospective, pragmatic, cohort study conducted and designed to evaluate the clinical outcome and efficacy of SD alone and combined with local application of fat grafts and/or steroids in prevention of post-lumbar discectomy EF. These outcomes were compared with outcomes in patients in whom neither the drain nor the barrier or steroids was implanted. A total of 58 patients [25 women, 33 men] indicated for surgery for a symptomatic, unilateral or bilateral, single-level lumbar disc herniation was included in this study. All patients underwent randomization and surgery. Patients were divided into 2 major groups with 33 patients in Group I [intervention group] and 25 patients in Group II [control group]. Group II served as the control, with decompressive surgery of their symptomatic nerve root alone without SD, local fat or steroid application. Group I was subdivided into 4 subgroups [Ia, Ib. Ic, and Id] according to the procedure done, whether decompressive surgery followed by SD alone or SD combined with local fat and/or steroid application. The barrier tested was autogenous fat graft. Thirty one patients underwent surgery at L4-5, and twenty-seven at L5-S1. Clinical outcome was assessed pre-and postoperatively by evaluating pain intensity, and patients' functional outcome. Pain intensity was evaluated in our study by numeric verbal rating [NVR] scale; and the patients' functional clinical outcome was measured by the range of motion and straight leg raising [SLR] tests. Imaging outcome was assessed on the basis of follow-up magnetic resonance imaging [MRI] findings. We proposed an MRI-based grading system for the extent of EF. No operative or early post operative complications were reported, and no new neurological deficits occurred. A significant proportion of patients in group I showed pain relief compared to the control group, as well as compared to the baseline findings. Analysis of functional outcome showed significant improvements in the intervention group compared to the baseline, as well as the control group at intervals of 3 months, 6 months, and 12 months. The results of pain relief and recovery of the functional status at the end of the study [12m] was best in group Id [SD + fat graft + steroids], followed by group Ib [SD + fat graft], group Ic [SD + steroids], and group Ia [SD alone] respectively. The worst results were obtained in the control group II. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain and functional status. At 1-year follow-up MRI examination, there was a trend toward better outcome in the intervention group. Both suction drainage and fatlsteroid combinations consistently reduced the frequency and the extent of epidural fibrosis on MRI. We conclude that, in patients operated on for unilateral, single-level lumbar disc herniations, implantation of suction drainage into the operation site results in less formation of EF radiologically and yields better clinical outcome. Fat grafts further reduced epidural fibrosis and did not impair normal healing. Local steroid is an effective adjuvant in a significant number of patients without adverse effects. Thus, the use of SD with addition of peridural fat barrier and steroids may improve outcome in these patients

Residues of some organochlorine pesticides in human blood in the Fadasi Area, Sudan

For many years, organochlorine pesticides [OCPs] have been of interest, because of their toxicity and high persistence .In developing countries, [OCPs] were used in large quantities to control agricultural pests and vectors of endemic diseases. In Sudan [OCPs] were restricted to public health purposes in 1981. This study was conducted to asses the residue levels in the human blood. A randomized population sample from Fadasi Village, which is located in a rural area where pesticides have been used for over 35 years were examined. Analysis of human blood revealed the presence of gamma HCH, aldrin, heptachlor epoxide and DDE in varying concentrations. Statistical correlation was found to exist between the pesticide concentration and age, weight and duration of exposure. DDE was present in high concentrations, ranging between 0.38 - 6.88 ppm

impact of immune response to schistosoma hematobium infection on the outcome of HCV in patients with concomitant HCV and Schistosoma hematobium infection in El-Minya governorate in Egypt

Patients with schistosoma haematobium display immune response may alter the outcome of HCV in-patients with concomitant HCV and schistosoma haematobium. This study was aimed at evaluation of the effect of immune response to schistosoma haematobium on the outcome of HCV in-patients with concomitant infection [HCV and schistosoma haematobium]. This study was conducted on 70 subjects 59 of them were infected with HCV and/or schistosomiasis selected form the outpatient clinic of El-Minya University Hospital while the remaining eleven subjects were healthy control volunteers with no history and negative serology to both HCV and schistosomiasis. The patients were grouped into three groups. Group [I] it included 24 patients with concomitant HCV and schistosomal infections. Group [II] it included 19 patients with schistosoma haematobium infection. Group [III] it included 16 patients with HCV infection alone and control group. It included 11 healthy subjects. All groups were subjected to history taking, clinical examination, abdominal ultrasonography and rectal snip were done for all groups and liver biopsy was done for HCV +ve patients. Routine laboratory investigations and ELISA assessed hepatitis markers [A, B, C] antibodies and Special investigations, CD3, CD4, CD8, and estimation of CD[4]/CD[8] ratio and detection of ant-bilharzial antibody titer. Absolute CD4 was highly significant higher in group 3 when compared to control group [p- value < 0.001] and was highly significant lower in group 1 when compared to control group [p- value < 0.001]. As regard to absolute CD4 between different groups of patient it was high in group 3 then less in group 2 and much lower in group 1 and these differences were highly significant [p- value <0.001]. Absolute CD8 was highly significant higher in group 3 when compared to control group [p- value < 0.001] and was highly significant lower in group 1 when compared to control group [p- value < 0.001]. As regard to absolute CD8 between different groups of patient it was high in group 3 then less in group 2 and much lower in group 1 and these differences were highly significant [p- value <0.001]. Absolute CD4 / CD8 ratio was highly significant lower in group 1, 2 and 3 when compared to control group [p-value < 0.001] and was highly significant lower in group 1 when compared to group 3 [p- value < 0.001]. As regard to absolute CD3, CD4, CD8 and CD4/ CD8 ratio absolute CD4 and CD4/CD8 ratio were higher in-patients treated with praziquantel versus those not receiving this medication. While CD8 was higher in-patients not received this medications versus those received the medications. This study has documented that schistosoma haematobium display a suppressive effect on the immune system so that a concomitant infection with HCV will present with a more protracted disease with severe sequel and adverse complications. Also this study has documented that CD4, CD8, and CD4/CD8 ratio may be good indicators of the disease activity. It is recommended that strict control and treatment of schistosomiasis may ameliorate the problem of HCV induced chronic liver disease in Egypt

correlation between the serum testosterone level and insulin sensitivity in patients with pre-eclampsia-eclampsia syndrome

To study serum testosterone level, insulin sensitivity and their correlation in mild, severe pre-eclasmpsia and eclampsia compared to normal pregnant women. The study included sixty patients. All were primigravidae, in 3[rd] trimester, they were divided into two groups, the first was normal control group [15 cases] and the second group [45 cases] was subdivided equally into three subgroups mild, severe pre-eclampsia and eclamptic cases. All cases were subjected to fasting venous blood sampling to measure glucose, insulin, total and free testosterone. The mean fasting serum testosterone [total and free] increased in pre-eclamptic toxemia cases significantly compared to the control group and in between subgroups, P was = 0.027 and 0.000 respectively. The mean fasting insulin level increased in pre-eclamptic toxemia significantly compared to control group and in subgroups p= 0.013. Mean fasting levels of testosterone, [total and free] were significantly higher in primigravidae with pre-eclampsia-eclampsia syndrome than in normotensive women with similar gestational ages. Levels of mean fasting insulin also were significantly higher than normotensive women. So there is positive correlation between hyperandrogenism and hyperinsulinemia or insulin resistance in preeclampsia-eclampsia syndrome

Skull vault defects reconstruction: comparison of different techniques and results and effect on cerebral hemodynamics: evaluation with transcranial Doppler sonography

The present study is a single-institution prospective clinical and radiological study conducted to evaluate the techniques and results of skull vault defects reconstruction and to investigate changes of cerebral hemodynamics after cranioplasty using transcranial Doppler sonography [TCDS]. All patients underwent clinical and radiological evaluation of their skull defects before and immediately after surgery and at least one year later. The cerebral hemodynamics was examined with TCDS pre-operatively and during the first month postoperatively. The average preoperative defect surface area measured 34 cm2 [range 6-110 cm2]. Skull defects were reconstructed using different methods of cranioplasty. Fifteen patients were repaired with fixed autogenous bone grafts [five cases with rib grafts, five cases with iliac grafts and five cases with split-thickness cranial bone grafts], five cases with acrylic, five cases with titanium mesh and five cases with high-density polyethylene implants [medpor implants]. Regarding follow-up, all patients were monitored a minimum of 12 months with a mean of 21 months. The results and complications were evaluated in relation to each technique. Changes in cerebral blood flow [CBF] were recorded. Before cranioplasty, all the velocities ipsilateral to the cranial defect were significantly low, while in the contralateral side they were near normal. Ipsilateral low cerebral blood flow increased and reached normal levels after cranioplasty. During the follow-up, neurological improvements was observed

Renal ultrasonography in neonates

Ultrasound [US] is a safe and accurate imaging method in the evaluation of urinary tract and its anomalies in neonates. It is helpful in establishing correct diagnosis in the majority of cases and facilitates precise measurement of kidney length. We conducted this work to study the prevalence and types of renal anomalies in Egyptian neonates and to identify their normal renal length. Our study was conducted on 500 Egyptian neonates, at Alexandria University Maternity and Children's Hospitals. Ultrasonographic examination and measurement of both kidneys were done in all neonates. Abnormal renal ultrasonographic findings were found in 15 neonates, with a prevalence of 3%. The abnormalities encountered were severe bilateral hydronephrosis in 8 cases [1.6%], moderate bilateral hydronephrosis in 3 cases [0.6%]. Horseshoe kidney, bilateral hyperechoic renal medulla, polycystic kidney disease [ARPKD], and unilateral renal tumor were detected in equal frequencies of 0.2% each. Further evaluation of the cases with severe hydronephrosis revealed: posterior urethral valve [PUV] in 5 cases, bilateral primary vesicouretral reflux [VUR] in 2 cases, bilateral pelviureteric junction obstruction [PUJO] in one case. Cases with moderate hydronephrosis resolved on follow-up. Sonographic renal appearance in normal neonates was different from that seen in older children. They showed a pattern of increased corticomedullary differentiation with markedly sonolucent medullary pyramids. The mean renal length in normal newborns was 4.7 +/- 0.7cm. There was a positive correlation between renal length and each of body length and weight than with age and head circumference. The high prevalence of renal anomalies in Egyptian neonates justifies early postnatal renal US examination of all neonates; especially those who had abnormal antenatal ultrasonographic findings. Early diagnosis of such anomalies will lead to proper early management and prevention of chronic renal failure

Effect of ethanol administration on energy metabolism of skeletal muscle

Ethanol administration causes a lot of complications in different organs in the body. The main object of this work was to study the effect of ethanol administration on energy metabolism in the skeletal muscles. In this study, ouabain and oligomycin were used as Na- K ATPase inhibitor and mitochondrial ATPase inhibitor, respectively, to determine the total and specific ATPase activity in the quadriceps muscle. It was found that alcohol causes a significant increase in catabolic pathway evidenced by increase in ATP, adenosine and inosine. It was noticed that ATPase activity was not too much affected and this may be due to the fact that ATPase is a multienzyme complex which can catabolize both ATP formation and hydrolysis. Ethanol has a dual action on ATPase activity. It may increase ATP synthesis by increasing reducing equivalents. On the contrary, it increases ATP hydrolysis by increasing lactic acid accumulation

Transient tachypnea in neonates of mothers receiving glucose 5% and oxytocin during labour

The aim of this work was to study the frequency of transient tachypnea of the newborn [TTN] and the possible relation to the use of oxytocin and glucose 5% during labour Subjects investigated were enrolled into two groups: the first [study] group consisted of 100 newborn infants born to mothers who have received IV infusion of aqueous glucose solution 5% and oxytocin. The second [control] group consisted of 30 newborns whose mothers did not receive any IV infusion. In the study group, the amount and rate of infusion of oxytocin and glucose 5% were calculated. The blood samples [maternal and cord] were drawn just after delivery in the study and control groups. Newborns were diagnosed as having TTN if they fulfilled the following criteria: persistent tachypnea with onset within 1/2 hour after birth, minimal grunting and retractions, with or without cyanosis in room air, necessity for oxygen therapy, spontaneous improvement starting within 24 hours after birth, Fi02 not more than 0.4 and suggestive radiological findings. Our results showed that maternal and cord serum sodium levels of the study group were significantly lower than those of the control group with a significant negative correlation between the maternal and cord serum sodium and the amount of oxytocin and glucose 5%. No significant difference between maternal and related cord serum sodium in both groups. Hyponatremia developed in 25 out of 100 cases of the study group and in 2 out of 30 cases of the control group with a significant difference. TTN developed in 17% of the study group and in none of the control group. The difference was significant. Serum sodium in the newborns who developed TTN was lower than in those who did not develop TTN. Out of 25 cases with hyponatremia, 8 developed TTN [32%] while out of 75 cases without hyponatremia, only 9 [12%] developed TTN with a significant difference. The amount and rate of infusion of oxytocin were higher in the TTN group than the non-TTN group. TTN was more frequent when the amount of oxytocin exceeded 10 units and the rate of infusion exceeded 25 mu/min. The amount and rate of infusion of glucose 5% did not differ in the TTN group from the non-TTN group. We concluded that the amount of oxytocin and glucose 5% infusion are related to the development of maternal and neonatal hyponatremia and the amount and rate of infusion of oxytocin are related to the occurrence of TTN. To decrease the incidence of TTN, We recommend that the dose of oxytocin should not exceed 10 units at a rate of infusion of less than 25 mu/min

Pulse methylprednisolone therapy in children with resistant nephrotic syndrome

This study was conducted on 26 children with steroid-resistant idiopathic nephrotic syndrome [NS], 14 males and 12 females, ranging in age at the start of pulse methylprednisolone therapy from 14/12 to 9 10/12 years, admitted to Alexandria University Children's Hospital starting from 1-4-1996. All cases of idiopathic NS admitted during this period were treated by prednisone 2 mg/kg/day divided into 3-4 doses. If the child continues to have proteinuria [2+ or greater] after one month of this treatment, the nephrosis was considered steroid-resistant and renal biopsy was indicated to determine the precise etiology of the disease. All the 26 cases were still edematous with nephrotic proteinuria after one month of prednisone therapy. The diagnoses were: minimal-change disease [MCD], 8 cases, diffuse mesangial proliferation [DMP], 12 cases, and focal segmental glomerulosclerosis [FSGS], 6 cases. All cases received multiple infusions of high dose intravenous methylprednisolone as described by Mendoza and Tune. Many of the children also received cyclophosphamide according to the criteria of the previous authors. The period of follow up [from the start of therapy till 30-6-99] ranged from 4 to 38 months. At the last follow up, the results were as follows: In MCD, all cases responded with disappearance of edema and nephrotic-range proteinuria, 50% with complete remission and 50% with non-nephrotic proteinuria [partial response]. All maintained normal GFR. In DMP, normal GFR was maintained in 75% [9 cases]. Complete remission was found in 7 cases and partial response in 2 cases. End-stage renal failure [ESRF] occurred in one case and 2 cases died [one from septicemia and one from thromboembolic complications]. In FSGS, GFR was normal in 50% [3 cases], two cases with complete remission and one case with partial response. GFR was decreased in one case and ESRF developed in one case. One case died from septicemia. We concluded that pulse methyl prednisolone therapy with or without cyclophosphamide has better results than those reported for cyclophosphamide alone or cyclosporine. However, newer protocols are still needed to achieve better results

Calcium metabolism in aging: relation to senile osteoporosis

56 subjects of different age groups were included in this study. The age groups were; adolescents, adults, middle-aged and elderly [above 55 years old]. Colorimetric estimations of serum and urine calcium and phosphorus, and serum creatinine were performed, while serum parathyroid hormone [PTH] was estimated by radioimmunoassay [RIA]. Bone mineral density [BMD] of the lumbar vertebra [L2-L4] was estimated by dual photon absorptiometry. Progressive decrease in serum and urine calcium and in serum phosphoros and increase in serum creatinine and immunoreactive parathyroid hormone [iPTH] and urine phosphorus with age was obtained. These changes were statistically highly significant in group D vs. Each of group A and B. Corresponding bone loss that was progressive with age was also obtained. It was also statistically significant when group D was compared with either of A or B

comparison of isoflurane and halothane in anesthesia for cataract surgery

Isoflurane 0.75% was compared with halothane 0.5% as the volatile supplement in a normocapnic technique for intra-ocular surgery. Both agents gave satisfactory conditions for operation with a comparable reduction in intra-ocular pressure during the procedure. Systolic arterial pressure, however was significantly lower in the isoflurane group at the end of surgery and after tracheal extubation than in the halothane group. Isoflurane provides a useful alternative to halothane in anaesthesia for intra-ocular surgery