Chiropractors as Primary Spine Care Providers: precedents and essential measures.

Chiropractors have the potential to address a substantial portion of spinal disorders; however the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other health care professions such as podiatry/chiropody, physiotherapy and naturopathy have successfully gained public and professional trust, increases in scope of practice and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the health care system, the establishment of a 'primary spine care provider' may be a worthwhile niche position to create for society's needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders. Such changes have already been achieved by the chiropractic profession in Switzerland, Denmark, and New Mexico, whose examples may serve as important templates for renewal here in Canada.

Les chiropraticiens ont la possibilité de traiter une partie importante des affections vertébrales, mais le taux d'utilisation des services de chiropratique est resté faible et largement inchangé depuis des décennies. D'autres professions de la santé telles que la podologie, la physiothérapie et la naturopathie ont réussi à gagner la confiance du public et des professionnels, améliorer leur champ de pratique et développer des créneaux distincts au sein des systèmes de soins de santé dominants. En raison de la lourde charge que placent les soins de la colonne vertébrale sur le système de soins de santé, la création d'un « prestataire de soins primaires de la colonne vertébrale ¼ pourrait combler un créneau utile pour satisfaire les besoins de la société. Les chiropraticiens pourraient assumer ce rôle, mais non sans avoir d'abord examiné et amélioré leur approche de la gestion des affections vertébrales. Ces transformations ont déjà été réalisées par la profession chiropratique en Suisse, au Danemark et au Nouveau-Mexique. Leurs exemples peuvent servir de modèles importants pour la réforme au Canada.

Discovery of a Jupiter/Saturn analog with gravitational microlensing.

Searches for extrasolar planets have uncovered an astonishing diversity of planetary systems, yet the frequency of solar system analogs remains unknown. The gravitational microlensing planet search method is potentially sensitive to multiple-planet systems containing analogs of all the solar system planets except Mercury. We report the detection of a multiple-planet system with microlensing. We identify two planets with masses of approximately 0.71 and approximately 0.27 times the mass of Jupiter and orbital separations of approximately 2.3 and approximately 4.6 astronomical units orbiting a primary star of mass approximately 0.50 solar mass at a distance of approximately 1.5 kiloparsecs. This system resembles a scaled version of our solar system in that the mass ratio, separation ratio, and equilibrium temperatures of the planets are similar to those of Jupiter and Saturn. These planets could not have been detected with other techniques; their discovery from only six confirmed microlensing planet detections suggests that solar system analogs may be common.

Results and future of carotid endarterectomy in a medium-sized Finnish central hospital.

BACKGROUND AND AIMS: Carotid endarterectomies (CEA) should, by general agreement, be performed only at specialised institutions and on patients who are expected to have a low rate of complications, i.e., a 6% surgical risk for patients with symptomatic and a 3% risk for patients with asymptomatic carotid artery disease. We have reviewed the midterm results after CEA in a medium-sized Finnish central hospital to audit whether our results fulfil current quality standards. PATIENTS, MATERIALS AND METHODS: There were 116 consecutively operated patients at the Päijät-Häme Central Hospital during the years 1999-2003 on whom 122 CEAs were made. All CEAs were performed by conventional methods and shunts and patches were used when necessary. RESULTS: The overall survival rate was 81.0% during the 3.6 +/- 1.5 years [range 1.3-6.3 years] follow-up. The incidence of early major stroke was 2.5% and of late major stroke 1.6%. Other complications included cranial nerve deficit (2.5%), wound haematoma (3.3%) and postoperative hypertension (3.3%) or hypotension (2.5%). Significant changes in medication were needed after surgery in several patient subgroups. CONCLUSIONS: The results of CEA at the Päijät-Häme Central Hospital are at least acceptable. The primary prevention of strokes with pharmacotherapy needs aggressive improvement.

Sensitivity of the Procleix HIV-1/HCV assay for detection of human immunodeficiency virus type 1 and hepatitis C virus RNA in a high-risk population.

The Procleix HIV-1/HCV Assay is a high-throughput nucleic acid test for the simultaneous detection of human immunodeficiency virus type 1 (HIV-1) and hepatitis C virus (HCV) RNA during blood donor screening. This study evaluated the clinical sensitivity of the Procleix assay and assessed the assay's ability to identify HIV-1- and HCV-infected individuals undetected by standard serologic tests. Plasma samples were obtained prospectively from 539 individuals at high risk for HIV-1 and HCV infection at seven clinics affiliated with Johns Hopkins University. Samples were tested in the Procleix HIV-1/HCV Assay and, if reactive, were then tested in the Procleix HIV-1 and HCV discriminatory assays to differentiate the source of viral RNA positivity. Of these 539 subjects, 287 (53.2%) tested reactive in the Procleix HIV-1/HCV Assay. In discriminatory assay testing, 12 of 287 subjects (4.2%) were reactive for HIV-1 RNA only, 260 (90.6%) were reactive for HCV RNA only, and 11 (3.8%) were coinfected with HIV-1 and HCV. The clinical sensitivity for samples tested neat was 100% for HIV-1 and 99.3% for HCV. Three subjects with Procleix HCV reactive/seronegative results seroconverted upon follow-up and were confirmed as Procleix HCV yield cases. The Procleix HIV-1/HCV Assay is a highly sensitive test that detects ongoing and early HIV-1 and HCV infection in a significant number of subjects at high risk for these diseases. Confirmation of Procleix yield cases upon follow-up demonstrated the ability of the Procleix HIV-1/HCV Assay to detect the presence of HIV-1 and HCV in blood earlier than standard serologic tests.

Lactoperoxidase inhibits glucosyltransferases from Streptococcus mutans in vitro.

This study examines the possible effect of the antimicrobial peroxidase system on the activity of streptococcal glucosyltransferases B, C and D (GtfB, GtfC and GtfD), either in solution (GtfB and GtfC) or when adsorbed to hydroxyapatite (GtfC and GtfD) at pH 6.5. The lactoperoxidase (LP) system (LP, H(2)O(2), SCN(-)) had no effect on the activity of dissolved GtfC, but the activity of dissolved GtfB was enhanced. The LP system, however, strongly inhibited the activities of both GtfC and GtfD in their adsorbed form. LP enzyme, without its substrates, inhibited all three Gtf enzymes: GtfB and GtfC in concentrations between 10 and 100 microg/ml in liquid phase and adsorbed GtfC and GtfD in concentrations between 25 and 50 microg/ml. This inhibition was in part abolished in liquid phase, but not in solid phase, if the substrates of LP were added. This study shows that the lactoperoxidase system can exert inhibitory activity against streptococcal Gtfs without generating oxidizing agents.

Healing of bronchial allografts in pigs.

Our purpose was to investigate the healing of bronchial grafts in a porcine experimental model. Via left thoracotomy, a 2.5 cm long bronchial stump was anastomosed back to the same animal (autograft) or to another pig (allograft). Autotransplanted bronchi (six pigs) healed very well without infection. Allotransplantation without immunosuppression (eight pigs) was followed in all cases by rejection with formation of major bronchopleural fistula. After allotransplantation with triple-drug immunosuppressive medication (seven pigs), three pigs showed infection-free healing, but the anastomoses were slightly stenosed at the time of sacrifice (mean 30 d), while four had bronchopleural fistula. The study thus showed the healing ability of totally avascular bronchial graft in pigs to be very good when it is autotransplanted, but poor when allotransplanted without immunosuppressive treatment.

Bioabsorbable self-reinforced poly-L-lactide, metallic, and silicone stents in the management of experimental tracheal stenosis.

The aim of the present study was to compare, in rabbits, the biocompatibility and suitability of a bioabsorbable spiral stent made of self-reinforced poly-L-lactide (SR-PLLA) in the management of experimental tracheal stenosis with stents made of metal and silicone. Tracheobronchial stenosis, and its management, is still problematic because stenoses are not always amenable to surgical resection and reconstruction, especially concerning anastomotic problems and stenosis after lung transplantation. Stenosis can be handled with stenting, although the ideal stent has yet to be developed; all the stents available have their disadvantages. Because stenting of the airways can be only temporary, stents made of bioabsorbable materials, theoretically, offer benefits. Tracheal stenosis was created in rabbits by the extramucosal resection of cartilaginous arches of the cervical trachea. After a few weeks, the animals were operated on again, and those stenoses that had developed were dilated with a balloon. Stents then were implanted in the area of stenosis to keep the dilated trachea open. All the animals in the group with silicone stents had to be killed because of respiratory difficulties: their stents had a tendency to occlude because of internal encrustation, and they developed a hyperplastic polyp at the ends of the stents. The SR-PLLA and metallic stents were tolerated well, and after follow-up ended the animals were put to death. This experimental study showed that silicone stents had a tendency to occlude and that stents made of metal and of SR-PLLA were well tolerated and can be used in the management of airway stenosis.

Small airway obliteration in a new swine heterotopic lung and bronchial allograft model.

BACKGROUND: We studied a heterotopic large-animal model with obliterative airway lesions caused by allograft rejection. METHODS: Lung fragments (1 cm3) with airways (LB), and 1 to 2 mm diameter bronchi alone (B) were implanted subcutaneously in 11 domestic piglets weighing 20 kg. Six animals each received 40 implants from nonrelated donors without immunosuppression (group A). Another 5 animals had autograft implants (group U). The implants were harvested consecutively for histologic analysis over 3 months in group A and 6 months in group U. RESULTS: In group U, the initial ischemia caused mild to moderate epithelial damage with moderate metaplasia but with a return to normal ciliary epithelium within 1 month. Transient mild luminal obliteration with granulation tissue and mononuclear cells was observed during the first weeks, but after 4 weeks the lumen was patent and filled with mucus. In the bronchial wall, moderate fibrosis developed in LB implants, whereas mild fibrosis was seen in B implants. In group A, the epithelium was totally absent by 2 weeks, and mild inflammation, fibrosis, and destruction of the cartilage with pericartilaginous mononuclear accumulation were observed in the bronchial wall. Small airways were gradually obliterated between days 7 and 21, initially by granulation tissue and mononuclear cells and later by progressive fibrosis. CONCLUSIONS: In this model, autografted airway implants stayed patent for at least 6 months, whereas total luminal obliteration histologically resembling obliterative bronchiolitis developed in allografts within 21 days. Because small airways, including bronchioli, can be transplanted with the use of this model, it may be useful for research into the causes of airway obliteration, which may be relevant to the pathogenesis of obliterative bronchiolitis in lung recipients.

Obliterative lesions in small airways in an immunosuppressed porcine heterotopic bronchial allograft model.

We have recently developed a heterotopic large-animal model for research into obliterative lesions in small airways caused by allograft rejection. In this model, the small airways of subcutaneously implanted allografts gradually obliterate, whereas autografts remain patient. Twenty lung fragments and 20 segments of bronchi were implanted in domestic pigs weighing 20 kg from non-related donors. The histology of five animals receiving daily cyclosporine A (CsA) (10 mg/kg), azathioprine (2 mg/kg) and methylprednisolone (20 mg), Group C, was compared with that of six animals without immunosuppression, Group A. Four animals received monotherapy with CsA (10 mg/kg) or methylprednisolone (3 mg/kg). The histological findings were graded from 0 to 3 on the basis of implants harvested repeatedly over 3 months. Epithelial destruction and bronchial obliteration was rapid and permanent in all the allografts. Inflammation and fibrosis of the bronchial wall was less prominent in Group C than in Group A and the onset of fibrosis was delayed. Cartilage degeneration and pericartilagineous inflammation were significantly less severe in Group C (P < 0.05). Monotherapy was less potent than triple therapy. This large-animal model is useful for studying the effects of immunosuppressive drugs on obliterative airway disease.

Comparison of tissue reactions in the tracheal mucosa surrounding a bioabsorbable and silicone airway stents.

BACKGROUND: Treatment of tracheobronchial stenosis is problematic. Conservative methods include stenting the stenotic area, but an ideal stent has not yet been developed. Bioabsorbable airway stents offer benefits; the extraction of the device is unnecessary, and the airway preserves its normal function after stent resorption. The aim of this study was to examine the suitability of self-reinforced poly-L-lactide as a material for an airway stent. METHODS: A spiral airway stent made of 0.7-mm wire of self-reinforced poly-L-lactide was implanted operatively in 9 rabbits intratracheally; silicone stents served as controls. RESULTS: Silicone stents had a tendency to become stenosed with encrustation material and to develop a hyperplastic polyp at both ends. Self-reinforced poly-L-lactide stents were well tolerated and caused no foreign body reaction, and they had a tendency to penetrate into the tracheal wall. They had disappeared at the end of the follow-up of 10 months. CONCLUSIONS: This experimental study showed that bioabsorbable self-reinforced poly-L-lactide is a promising material for an airway stent for treatment of airway stenosis.

Comparison of urethral reaction to full silicone, hydrogen-coated and siliconised latex catheters.

Indwelling urinary catheter may induce an inflammatory reaction or even stricture of the urethra. Catheter encrustation and urinary infection are other disadvantages associated with long-term catheterisation. In the present study, 77 male patients were catheterised randomly as part of their normal treatment with 1 of 3 different types of catheter: 22 siliconised latex, 28 hydrogel-coated latex and 27 full silicone catheters. The mean duration of catheterisation was 2.2 days. The urethral inflammatory reaction was assessed from cytological urethral swab specimens. Catheter encrustation was studied using scanning electron microscopic (SEM) analysis. The full silicone catheters induced the mildest degree of inflammation in the urethra, the percentage mean of inflammatory cells in smears being 20%. In both latex catheter groups the value was 36%. Neither the age of the patients nor the duration of catheterisation had any effect on the inflammatory reaction, which was more marked in patients with haemodynamic abnormalities. The hydrogel coating effectively prevented encrustation, while siliconised latex catheters were the least resistant to encrustation. The inflammatory reaction was variable in all patients. The use of urethral catheters should be restricted and suprapubic tubes should be used instead, particularly in patients with shock-like circulatory changes. By developing the biocompatibility and physical properties of urinary catheters, more compatible devices may be manufactured.