Incidence of spine surgery in the South African private healthcare sector: ten-year trends within a large open medical scheme.

PURPOSE: Studies from developed countries suggest a dramatic increase in the utilization of spine surgery in recent decades, however less is known about spine surgery rates in the developing world. The aim of this study was to investigate ten-year trends in the incidence of spine surgery within South Africa's largest open medical scheme. METHODS: This retrospective review included adult inpatient spine surgeries funded by the scheme between 2008 and 2017. The incidence of spine surgery was investigated by age group-overall and for degenerative pathologies, fusion and instrumentation. Surgeons per 100,000 members were determined. Trends were evaluated by linear regression and by crude 10-year change in incidence. RESULTS: A total of 49,575 spine surgeries were included. The incidence of surgery for lumbar degenerative pathology showed a significant upward trend among 60-79 year olds but declined among 40-59 year olds. The incidence of lumbar fusion and lumbar instrumentation declined significantly among 40-59 year olds with little change among 60-79 year olds. The ratio of orthopaedic spinal surgeons decreased from 10.2 to 6.3 per 100,000 members whereas the ratio of neurosurgeons decreased from 7.6 to 6.5 per 100,000. CONCLUSION: Spine surgery in the South African private healthcare sector bears some similarity to developed countries in that it is dominated by elective procedures for degenerative pathology. However, the findings did not reflect the marked increases in the utilization of spine surgery reported elsewhere. It is hypothesized that this may be partly related to differences in the supply of spinal surgery.

Loss to follow-up among patients diagnosed with spinal tuberculosis at a tertiary hospital in Western Cape Province, South Africa: A retrospective cohort study.

BACKGROUND: Patients diagnosed with spinal tuberculosis (TB) at a major tertiary hospital in Western Cape Province, South Africa, are required to attend regular follow-up at the hospital's outpatient spine clinic and to remain on TB treatment for at least 9 months. This follow-up and lengthy treatment is intended to allow for specialist monitoring of TB treatment response and early identification of secondary complications, and to reduce the risk of recurrence. However, little is known about adherence to these recommendations. OBJECTIVES: The main objectives were to describe (i) loss to spine clinic follow-up (LTFU), and (ii) TB treatment duration among patients diagnosed with spinal TB at the hospital. Secondary objectives were to investigate (i) the association between LTFU and treatment duration, and (ii) factors associated with LTFU. METHODS: This retrospective cohort study included 173 adults diagnosed with spinal TB between 2012 and 2015 and investigated follow-up within 2 years from diagnosis. Clinical, demographic and appointment data were obtained from hospital records and a dataset provided by the provincial Department of Health. LTFU was presented as frequency (%) and as a survival analysis. TB treatment duration was reported as frequency <9 months or ≥9 months, and the association between LTFU and <9 months of treatment was investigated using relative risk (RR) with 95% confidence intervals (CIs). Univariate associations between explanatory variables and LTFU were investigated using simple logistic regression analysis. RESULTS: Patients had a median (interquartile range) age of 36 (29 - 48) years and included 98 females (57%) and 151 individuals (87%) residing <50 km from the hospital. Primary outcomes were that 129 patients (75%) were LTFU within 2 years of diagnosis and 45 (30%) completed <9 months of treatment. The RR of <9 months of treatment was 1.62 (95% CI 1.39 - 1.88) among those LTFU compared with those retained in follow-up. LTFU was not associated with any of the clinical or demographic variables investigated. CONCLUSIONS: Three-quarters of the patients did not complete follow-up at the tertiary hospital spine clinic, and almost one in three received <9 months of TB treatment. Remaining in spine clinic follow-up was significantly associated with receiving at least the minimum duration of TB treatment. However, LTFU could not be predicted from routine clinical and demographic information and is likely to be related to factors not accounted for in the current analysis.

Child and adult spinal tuberculosis at tertiary hospitals in the Western Cape, South Africa: 4-year burden and trend.

The aim of this retrospective review was to assess the overall burden and trend in spinal tuberculosis (TB) at tertiary hospitals in the Western Cape Province of South Africa. All spinal TB cases seen at the province's three tertiary hospitals between 2012 and 2015 were identified and clinical records of each case assessed. Cases were subsequently classified as bacteriologically confirmed or clinically diagnosed and reported with accompanying clinical and demographic information. Odds ratios (OR) for severe spinal disease and corrective surgery in child vs. adult cases were calculated. A total of 393 cases were identified (319 adults, 74 children), of which 283 (72%) were bacteriologically confirmed. Adult cases decreased year-on-year (P = 0.04), however there was no clear trend in child cases. Kyphosis was present in 60/74 (81%) children and 243/315 (77%) adults with available imaging. Corrective spinal surgery was performed in 35/74 (47%) children and 80/319 (25%) adults (OR 2.7, 95% confidence interval 1.6-4.5, P = 0.0003). These findings suggest that Western Cape tertiary hospitals have experienced a substantial burden of spinal TB cases in recent years with a high proportion of severe presentation, particularly among children. Spinal TB remains a public health concern with increased vigilance required for earlier diagnosis, especially of child cases.

Raloxifene and selective cell cycle specific agents: a case for the inclusion of raloxifene in current breast cancer treatment therapies.

BACKGROUND: Breast cancer patients are at increased risk of osteoporosis. Contributing factors include age and/or chemotherapy. The selective estrogen modulator, raloxifene (RAL), effective in the prevention of breast cancer and approved for the treatment and prevention of osteoporosis, may prove beneficial in current breast cancer treatment modules. The purpose of this study was to evaluate RAL in combination with 5-fluorouracil (5-FU) and trimetrexate (TMX) to determine the most effective sequence in which to administer these cell cycle specific agents while taking into consideration the cellular mechanism of action. The goal was to maintain cytotoxicity to breast cancer cells and capitalize on the selective estrogen receptor modulatory effects of RAL. MATERIALS AND METHODS: MCF-7 cells were exposed to (i) TMX, 5-FU or RAL alone, or (ii) RAL 24 h prior to 5-FU followed 2 h later by TMX, or (iii) 5-FU 2 h prior to TMX followed 24 h later by RAL. The cell viability was determined using the Quick Cell Proliferation Assay. RESULTS: The growth rate of MCF- 7 cells exposed to early RAL was 68.25 +/- 4.11% that of the control, however, late RAL exposure produced a growth of 34.75 +/- 4.79% that of the control. Late RAL maintained the cytotoxicity of the regimen. The findings were further supported by cell flow cytometry and Western blot analysis data. CONCLUSION: RAL given prior to 5-FU/TMX significantly compromised cytotoxicity to breast cancer cells.

Sequential combination chemotherapy in human breast cancer: a basis for increased antineoplastic activity and bone marrow protection.

These studies were designed to develop procedures that would capitalize on the growth inhibitory effects of tamoxifen (Tam) and methotrexate (MTX) in breast cancer, while protecting bone marrow with a priming dose of 5-fluorouracil (5-FU). High-dose MTX (10 microM) cytotoxicity is maintained in MCF-7 breast cancer cells but reduced in human bone marrow by a priming and nontoxic dose of 5-FU (10 microM). MTX cytotoxicity is decreased in MCF-7 breast cancer cells when the selective estrogen receptor modulator (SERM) Tam (10 microM) is administered 24 hours prior to 5-FU (10 microM) followed two hours later by MTX (early Tam) resulting in a growth rate of 57.42 +/- 4.38% of the control rate. However, when breast cancer cells are exposed to Tam 24 hours after 5-FU + MTX (late Tam), the interaction between MTX and Tam is not antagonistic, the percentage of the control is 29.47 +/- 4.54%. Bone marrow exposure to these drug combinations exhibits a protective effect to the MTX cytotoxicity, with the early Tam combination yielding 59.45 +/- 16.38% of the control for MTX alone. These studies suggest that a) Tam in combination with a priming dose of 5-FU protects bone marrow from MTX cytotoxicity, b) the interactions between Tam and MTX are sequence-dependent, c) Tam decreases the effect of MTX when Tam administration precedes MTX.

Torticollis as a sign of cervico-thoracic epidural haematoma in an infant with severe haemophilia A.

We describe the case of a spinal epidural haematoma in an infant with severe haemophilia A. Initial signs and symptoms were non-specific resulting in delay of the diagnosis and more definitive therapy. The patient eventually developed torticollis, acute flaccid paralysis of the upper extremities, and respiratory distress, prompting radiological examination of the spinal cord. The patient was treated with recombinant FactorVIII and laminectomy. Neurological recovery was complete 3 months following the event. We hypothesize that infants with haemophilia may be at higher risk for this rare complication because of their increasing mobility, frequent falls while cruising furniture, and lack of prophylactic factor replacement. Non-specific signs such as irritability without a focus should alert the clinician to this diagnostic possibility. Torticollis should prompt rapid radiological evaluation of the cervical spine with magnetic resonance imaging to avoid delay in diagnosis.

The interaction of the steroidal antagonist faslodex and methotrexate.

Faslodex (FAS, ICI 182, 780), a novel steroidal estrogen antagonist decreased high-dose methotrexate (MTX) cytotoxicity in MCF-7 breast cancer cells. When FAS is given at least 24 hr prior to MTX, the resultant interaction is antagonistic. However, when breast cancer cells are exposed to FAS 24 hr after MTX, the interaction between FAS and MTX is not antagonistic. The proliferation of cells exposed to 0.1 microM FAS and 10 microM MTX alone or in combination with FAS 24 hr prior to MTX was in the following order: FAS>FAS 24 hr prior to MTX>MTX. MTX administration 24 hr prior to FAS had the following inhibitory effects on the growth of cells: MTX 24 hr prior to FAS >MTX>FAS 24 hr prior to MTX>FAS>control (no drug exposure). To determine if the antagonistic interaction between FAS and MTX was a function of sequence and time, cells were exposed to FAS 24 hr and 36 hr prior to MTX exposure. The percentages of control rates were 42.70 +/- 4.60% and 57.89 +/- 0.55%, respectively, from a 24 hr and 36 hr exposure of FAS prior to MTX. The growth rates after 24 and 36 hr exposures to MTX alone were 30.30 +/- 0.61% and 33.11 +/- 2.57% of control rates, respectively. These studies suggest that: a) the interactions between FAS and MTX are sequence-dependent; b) FAS antagonizes the effect of MTX when FAS administration precedes MTX, and c) FAS antagonism to MTX is a function of time.

Second malignancy following high-dose therapy and autologous stem cell transplantation: incidence and risk factor analysis.

To establish incidence and risk factors for development of second malignant neoplasms after high-dose chemo/radiotherapy (HDT) and autologous hematopoietic stem cell transplantation (AHSCT), the case files of 800 consecutive patients who underwent AHSCT at our institution between June 1982 and December 2000 were reviewed. In all, 26 patients developed 29 second malignancies (nine myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML), 16 solid tumors and four lymphoproliferative disorders (LPDs)) for a 15-year cumulative incidence of 11% (95% confidence interval (CI), 5-18%). These second tumors occurred at a median of 68 (range 1.5-177) months following AHSCT. The relative risk (RR) compared to the general population of developing a second malignancy following AHSCT was 3.3 (CI 2.2-4.7) P<0.001. The RR of developing MDS/AML, LPD and a solid tumor was 47.2 (CI 21.5-89.5) P<0.001, 8.1 (2.2-20.7) P=0.002 and 1.98 (1.1-3.2) P=0.009, respectively. In multivariate analysis, age >or=35 years at the time of AHSCT (P=0.001) and an interval from diagnosis to AHSCT >or=36 months (P=0.03) were associated with a greater risk of developing a second malignancy. Patients who have undergone HDT and AHSCT are at significant risk for developing a second malignancy and should receive indefinite follow-up.

Nitrate removal effectiveness of a riparian buffer along a small agricultural stream in western Oregon.

The Willamette Valley of Oregon has extensive areas of poorly drained, commercial grass seed lands. Little is know about the ability of riparian areas in these settings to reduce nitrate in water draining from grass seed fields. We established two study sites with similar soils and hydrology but contrasting riparian vegetation along an intermittent stream that drains perennial ryegrass (Lolium perenne L.) fields in the Willamette Valley of western Oregon. We installed a series of nested piezometers along three transects at each site to examine NO3-N in shallow ground water in grass seed fields and riparian areas. Results showed that a noncultivated riparian zone comprised of grasses and herbaceous vegetation significantly reduced NO3-N concentrations of shallow ground water moving from grass seed fields. Darcy's law-based estimates of shallow ground water flow through riparian zone A/E horizons revealed that this water flowpath could account for only a very small percentage of the streamflow. Even though there is great potential for NO3-N to be reduced as water moves through the noncultivated riparian zone with grass-herbaceous vegetation, the potential was not fully realized because only a small proportion of the stream flow interacts with riparian zone soils. Consequently, effective NO3-N water quality management in poorly drained landscapes similar to the study watershed is primarily dependent on implementation of sound agricultural practices within grass seed fields and is less influenced by riparian zone vegetation. Wise fertilizer application rates and timing are key management tools to reduce export of NO3-N in stream waters.

High-dose melphalan, etoposide, total-body irradiation, and autologous stem-cell reconstitution as consolidation therapy for high-risk Ewing's sarcoma does not improve prognosis.

PURPOSE: To determine whether consolidation therapy with high-dose melphalan, etoposide, and total-body irradiation (TBI) with autologous stem-cell support would improve the prognosis for patients with newly diagnosed metastatic Ewing's sarcoma (ES). PATIENTS AND METHODS: Thirty-two eligible patients with newly diagnosed ES metastatic to bone and/or bone marrow were enrolled onto this study. Treatment was initially comprised of five cycles of induction chemotherapy (cyclophosphamide, doxorubicin, and vincristine alternating with ifosfamide and etoposide) and local control. Peripheral-blood stem-cell collection was performed after the second cycle of chemotherapy, with delay if the bone marrow was persistently involved. If patients had a good response to initial therapy, they proceeded to consolidation therapy with melphalan, etoposide, TBI, and stem-cell support. RESULTS: Of the 32 eligible patients, 23 proceeded to high-dose therapy consolidation. Of the nine patients who did not proceed to consolidation, four were secondary to progressive disease and two were secondary to toxicity. Three patients died from toxicity during the high-dose phase of the therapy. The majority of the patients who underwent high-dose consolidation therapy experienced relapse and died with progressive disease. Two-year event-free survival (EFS) for all eligible patients is 20%. The 2-year post-stem-cell reconstitution EFS for the subset of 23 patients who received consolidation therapy is 24%. Analysis of peripheral-blood stem-cell collections by molecular techniques for minimal residual disease showed contamination of at least some samples by tumor cells in all three patients with available data. CONCLUSION: Consolidation with high-dose melphalan, etoposide, TBI, and autologous stem-cell support failed to improve the probability of EFS in this cohort of patients with newly diagnosed metastatic ES.

Molecular dynamics and (2)H-NMR study of the influence of an amphiphilic peptide on membrane order and dynamics.

A molecular dynamics simulation of a fully hydrated model membrane consisting of 12 molecules of 1, 2-dimyristoyl-sn-glycero-3-phosphocholine, one amphiphilic peptide with the sequence acetyl-Lys-Lys-Gly-Leu(16)-Lys-Lys-Ala-amide, and 593 water molecules was performed for 1.06 ns (Belohorcova, K., J. H. Davis, T. B. Woolf, and B. Roux. 1997. Biophys. J. 73:3039-3055). The analysis presented here is primarily focused on the phospholipid component and the results are compared with experimental (2)H-NMR studies of the lipid component of mixtures of the same peptide and lipid at a molar ratio of 1:32, and with earlier studies of closely related peptide/lipid mixtures. The phospholipid chain and headgroup isomer populations and isomerization rates compare favorably with previous simulations and experimental measurements. Of particular interest is the effect of the peptide on the phospholipid headgroup and hydrocarbon chain orientational order calculated from the simulation, which also agree well with experimental measurements performed on this and closely related systems. Comparison of the experimental results with the simulations not only shows that there is significant agreement between the two methods, but also provides new insight into the effect of the peptide on the lipid dynamics. In particular, these results confirm that a membrane spanning peptide has little effect on lipid chain order, and bilayer thickness if its hydrophobic length closely matches the lipid hydrocarbon thickness. In addition, we find that the peptide can have a strong ordering effect if it is longer than the lipid hydrophobic thickness.

1H and (13)C NMR of multilamellar dispersions of polyunsaturated (22:6) phospholipids.

The polyunsaturated fatty acid docosahexaenoic acid (DHA) makes up approximately 50% of the lipid chains in the retinal rod outer segment disk membranes and a large fraction of the lipid chains in the membranes of neuronal tissues. There is an extensive literature concerned with the dietary requirements for essential fatty acids and the importance of DHA to human health, but relatively little research has been done on the physical properties of this important molecule. Using (1)H and (13)C MAS NMR measurements of dispersions of 1-palmitoyl-2-docosahexaenoyl-phosphatidylcholine in excess phosphate buffer, we have unambiguously assigned most of the resonances in both the (1)H and (13)C NMR spectra. We were able to use cross-polarization spectroscopy to follow the transfer of polarization from specific (1)H nuclei not only to their directly bonded (13)C but also to those (13)C that are in close proximity, even though they are not directly bonded. Cross-peaks in two-dimensional cross-polarization spectra revealed a close association between the choline headgroup and at least part of the DHA chain but not with the palmitate chain. Finally, we examined the dynamics of the different parts of this lipid molecule, using rotating frame spin-lattice relaxation measurements, and found that methylene groups of both chains experience important motions with correlation times in the 10-micros range, with those for the palmitate chain being approximately 50% longer than those of the DHA chain. The choline headgroup and the chain terminal groups have significantly shorter correlation times, and that part of the dipolar interaction that is fluctuating at these correlation times is significantly smaller for these groups than it is for the palmitate and DHA chain methylenes.

Diamond-blackfan anemia and cyclosporine therapy revisited.

A girl with Diamond-Blackfan anemia diagnosed in infancy started cyclosporine A (CSA) therapy at 9 years and 8 months of age after experiencing unacceptable side effects while receiving prednisone. Since then, she has been followed-up for more than 4 years. She exhibited a dramatic response to CSA, with weaning and then cessation of steroid therapy after 5 months. She has remained transfusion-independent. Attempts to discontinue CSA therapy have been unsuccessful. Relapse of the anemia has occurred in the context of viral infections with missed CSA doses. The major clinical problem during treatment has been recurrent oral aphthous ulceration, which responds to topical therapy. She is currently maintained on CSA 100 mg twice daily with a hemoglobin of 10.2 g/dL and a reticulocyte count of 1.6%. A trial of CSA therapy should be considered in patients with Diamond-Blackfan anemia in whom steroid therapy has failed before a transfusion program is instituted or alternative donor stem cell transplantation is entertained.

Drowning without aspiration: is this an appropriate diagnosis?

It has been reported that 10-15% of drowning victims do not aspirate water. We have revisited the original studies quoted to reach this conclusion and find it is without foundation. Sudden cardiac standstill is known to occur on land and, therefore, may also occur when the victim is in water. In the absence of the common finding of significant pulmonary edema in the victim's respiratory system, to conclude his or her death was caused by "drowning without aspiration" is unwise. All causes of sudden death that might occur in which respiration may not take place should receive serious consideration when examining bodies with such findings that are found in water.

Rural trauma: the challenge for the next decade.

Improving the care of trauma patients in a rural environment requires that several important issues be addressed. First, a universal definition of what constitutes "rural" must be established. We propose that a combined effort of the Federal Government and the Committee on Trauma of the American College of Surgeons develop this definition. Second, data on rural trauma demographics and outcome must be collected in a national database. We propose that this database be incorporated in the "TRACS" database of the Committee on Trauma of the American College of Surgeons. Such a database will allow a "needs assessment analysis of existing care in rural environments and facilitate planning and implementation of efficient systems of care. Funding for the rural database should come from the federal government. Finally, increased public awareness of problems unique to rural trauma care is necessary. The rural trauma subcommittee of the ACSCOT should go from an ad hoc committee to a standing committee with the American College of Surgeons Committee on Trauma. We propose a national conference on rural trauma care hosted by the federal government for the purpose of addressing these issues and simultaneously increasing public awareness.

A flowsheet for documenting independent nursing visits after breast surgery.

PURPOSE/OBJECTIVES: To redesign a postoperative flowsheet already used in clinical practice with patients who have undergone breast surgery to reflect documentation of assessments and interventions noted on each nursing visit. DATA SOURCES: Memorial Sloan-Kettering Cancer Center Standards of Practice for Ambulatory Care, clinical experience, and published articles. DATA SYNTHESIS: A comprehensive flowsheet was redesigned to provide consistency in documentation and reflect current needs of patients who have undergone breast surgery who are in ambulatory care. CONCLUSIONS: Implementation of the new flowsheet has decreased staff documentation time during busy office practices and accurately reflects the nursing care provided to patients after breast surgery. IMPLICATIONS FOR NURSING PRACTICE: Consistency in patient care can be maintained and efficiency can be increased with use of a comprehensive flowsheet.

13C-13C rotational resonance in a transmembrane peptide: a comparison of the fluid and gel phases.

A comparative study of two doubly 13C labeled amphiphilic transmembrane peptides was undertaken to determine the potential of rotational resonance for measuring internuclear distances through the direct dipolar coupling in the presence of motion. The two peptides, having the sequence acetyl-K2-G-L16-K2-A-amide, differed only in the position of 13C labels. The first peptide, [1-13C]leu(11):[alpha-13C]leu(12), had labels on adjacent residues, at the carbonyl of leu(11) and the alpha carbon of leu(12). The second, [1-13C]leu(8):[alpha-(13)/C]leu(11), was labeled on consecutive turns of the alpha-helical peptide. The internuclear distance between labeled positions of the first peptide, which for an ideal alpha helix has a value of 2.48 A, is relatively independent of internal flexibility or peptide conformational change. The dipolar coupling between these two nuclei is sensitive to motional averaging by molecular reorientation, however, making this peptide ideal for investigating these motions. The internuclear distance between labels on the second peptide has an expected static ideal alpha-helix value of 4.6 A, but this is sensitive to internal flexibility. In addition, the dipolar coupling between these two nuclei is much weaker because of their larger separation, making this peptide a much more difficult test of the rotational resonance technique. The dipolar couplings between the labeled nuclei of these two peptides were measured by rotational resonance in the dry peptide powders and in multilamellar dispersions with dimyristoylphosphatidylcholine in the gel phase, at -10 degrees C, and in the fluid phase, at 40 degrees C. The results for the peptide having adjacent labels can be readily interpreted in terms of a simple model for the peptide motion. The results for the second peptide show that, in the fluid phase, the motionally averaged dipolar coupling is too small to be measured by rotational resonance. Rotational resonance, rotational echo double resonance, and related techniques can be used to obtain reliable and valuable dipolar couplings in static solid and membrane systems. The interpretation of these couplings in terms of internuclear distances is straightforward in the absence of molecular motion. These techniques hold considerable promise for membrane protein structural studies under conditions, such as at low temperatures, where molecular motion does not modulate the dipolar couplings. However, a typical membrane at physiological temperatures exhibits complex molecular motions. In the absence of an accurate and detailed description of both internal and whole body molecular motions, it is unlikely that techniques of this type, which are based on extracting distances from direct internuclear dipolar couplings, can be used to study molecular structure under these conditions. Furthermore, the reduction in the strengths of the dipolar couplings by these motions dramatically reduces the useful range of distances which can be measured.