Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression.

STUDY DESIGN: A retrospective chart review was performed. OBJECTIVE: To determine whether preoperative spinal radiation increases the number of major wound complications in patients with cancer who have symptomatic spinal cord compression. SUMMARY OF BACKGROUND DATA: Many factors have increased the number of patients hospitalized with symptomatic spinal cord compression after spinal irradiation. The surgical management of metastatic spinal cord compression may be complicated by preoperative radiation. METHODS: A retrospective review of 123 patients admitted with symptomatic metastatic spinal cord compression from 1970 through 1996 was conducted. The final study population of 85 patients was separated into three treatment groups: 1) radiation only, 2) radiation followed by surgery, and 3) de novo surgery followed by radiation. RESULTS: The major wound complication rate for patients who had radiation before surgical decompression and stabilization was 32%, or threefold, higher than the 12% observed in patients who had de novo surgery (P < 0.05). No other clinical factor or condition predicted the development of a major wound complication. Patients treated initially with surgery had superior functional outcomes in an analysis stratified by Frankel grade (P < 0.05). Of the ambulatory patients who underwent de novo surgery, 75% remained ambulatory and continent 30 days after treatment, whereas only 50% of those treated with radiation before surgery had similar outcomes. CONCLUSIONS: Spinal radiation before surgical decompression for metastatic spinal cord compression is associated with a significantly higher major wound complication rate. In addition, preoperative spinal irradiation might adversely affect the surgical outcome.

Alzheimer's disease: correlation of the suppression of beta-amyloid peptide secretion from cultured cells with inhibition of the chymotrypsin-like activity of the proteasome.

Peptide aldehyde inhibitors of the chymotrypsin-like activity of the proteasome (CLIP) such as N-acetyl-Leu-Leu-Nle-H (or ALLN) have been shown previously to inhibit the secretion of beta-amyloid peptide (A beta) from cells. To evaluate more fully the role of the proteasome in this process, we have tested the effects on A beta formation of a much wider range of peptide-based inhibitors of CLIP than published previously. The inhibitors tested included several peptide boronates, some of which proved to be the most potent peptide-based inhibitors of beta-amyloid production reported so far. We found that the ability of the peptide aldehyde and boronate inhibitors to suppress A beta formation from cells correlated extremely well with their potency as CLIP inhibitors. Thus, we conclude that the proteasome may be involved either directly or indirectly in A beta formation.

Traumatic open anterior lumbosacral fracture dislocation. A report of two cases.

STUDY DESIGN: Case presentation. OBJECTIVES: To review the diagnosis and treatment of rare anterior lumbosacral fracture dislocations. SUMMARY OF BACKGROUND DATA: The severity of closed anterior and open and closed posterior lumbosacral dislocations has been documented; however, there have been no reports of open anterior lumbosacral dislocations in the literature. Two patients are reported who experienced acute open anterior lumbosacral fracture dislocations. METHODS: Review of the patient history and physical examination, radiologic review, operative techniques, and a review of the literature. RESULTS: Fractures healed in both patients, with no major infections. Both patients had persistent neurologic deficits at last follow-up. CONCLUSIONS: Open lumbosacral fracture dislocations are complex injuries that require diligence on the part of the surgeons involved the recognize the severity of the injury, to prevent or resolve any infectious process, to prevent further neurologic injury, and then to obtain and maintain alignment of the spine on the pelvis.

Presenilins--in search of functionality.

The discovery of the PS proteins, the complexities of their biochemistry and their potential involvement in signalling pathways and in apoptosis have galvanized research into AD. To date, the aspect of the functionality of the PSs most relevant to the pathology of AD is the effect of PS FAD mutants to increase the proportion of A beta 42 produced from cells. This, coupled to the observation that gamma-secretase cleavage is considerably reduced in neurons derived from PS-1 knockout mice, argues strongly that PS plays a very direct role in the proteolytic processing of APP.

The efficacy of pedicle screw/plate fixation on lumbar/lumbosacral autogenous bone graft fusion in adult patients with degenerative spondylolisthesis.

A total of 18 patients with grade I or II degenerative spondylolisthesis fused three levels or fewer with autogenous bone graft were entered at three clinical sites. After 2 years, these patients were found to have a fusion rate of 89%. A statistical analysis of these results compared with those in the literature showed that patients with spondylolisthesis who underwent fusion with pedicle screw instrumentation were > 3 times more likely to fuse than comparable patients implanted without a pedicle screw/plate system. The pedicle screw/plate system used in this study was shown to be an effective method of facilitating lumbar or lumbosacral fusion with autogenous bone graft for adult patients with a primary indication of grade I or II degenerative spondylolisthesis.

Type 2 diabetes. Patient practices, and satisfaction with GP care.

OBJECTIVE: To document patients' practices and management of DM2, their satisfaction with diabetes care and their quality of life and functional status. DESIGN: Anonymous questionnaire completed by 467 patients recruited by 204 GPs in 124 practices in the Perth metropolitan area. RESULTS: Patients reported an adequate amount of monitoring for stable DM2. However, they lacked awareness of diabetes risk factors and complications from which they already suffered. Some 90% of patients reported a high level of satisfaction with GP care and only 2.4% of patients had more than a moderate degree of functional disability. CONCLUSION: Patients have a high level of satisfaction about the diabetes care received from their general practitioner. However, they lack awareness of their risk factors and complications of diabetes. A simple strategy is proposed to improve these deficits and to share the responsibility for diabetes care between patient and doctor.

The effect of pedicle screw/plate fixation on lumbar/lumbosacral autogenous bone graft fusions in patients with degenerative disc disease.

STUDY DESIGN: A prospective, multi-center Investigational Device Exemption Study was carried out in the United States using a pedicle screw and plate system to perform a fusion in patients with degenerative disc disease or spondylolisthesis. The patients' pain function, complications, and fusion status were evaluated and compared with literature controls. OBJECTIVES: To study the safety and efficacy of the ISF pedicle screw/plate system. This article focuses only on those study patients with degenerative disc disease treated with autogenous bone grafts and compares the results to those of similar patients treated without instrumentation, as reported in the literature. SUMMARY OF BACKGROUND DATA: Twenty-eight patients were in the subgroup studied--patients with degenerative disc disease who had fusions with autogenous bone graft. This study was conducted at four clinical sites with a 2-year follow-up. Patient follow-up was greater than 95% at all time points. METHODS: To be considered a patient with degenerative disc disease, radiographs had to demonstrate a collapse of the disc, the presence of bone erosion, or the compression of the vertebrae as the primary spinal abnormality. Spinal fusion must have been the recommended surgical treatment for discogenic pain. The fusion status was evaluated by the operating surgeon and an independent reviewer. RESULTS: After 2 years, this subset of patients (n = 28) with degenerative disc disease who had lumbar/lumbosacral fusion with autogenous bone graft was found to have a pseudarthrosis rate of 0%. Eight articles in the literature were found to be valid noninstrumented literature controls with which this subgroup could be compared. The average pseudarthrosis rate in the control group was 32%. CONCLUSIONS: A statistical analysis showed that patients with degenerative disc disease who underwent fusion without pedicle screw instrumentation were over 24 times more likely to have a pseudarthrosis than comparable patients implanted with a pedicle screw/plate system. Regarding the most important goal in performing a spinal fusion--fusion of the spine--the pedicle screw/plate system used in this study was shown to be a safe and efficacious method of facilitating fusion with autogenous bone graft for this patient population.

Transpedicular instrumentation and short-segment fusion of thoracolumbar fractures: a prospective study using a single instrumentation system.

Eleven patients were prospectively treated with bilateral short-segment transpedicular instrumentation using the Posterior Segment Fixator (Ace Medical Co., Los Angeles, CA, U.S.A.) construct combined with posterolateral fusion using autogenous iliac crest bone graft for the treatment of thoracolumbar vertebral fractures. All patients were evaluated clinically, radiographically, and functionally for a minimum of 2 years (mean 33 months). Four of the 11 patients (36.3%) had breakage or disengagement of the caudad screws during this interval. During the follow-up period, the angle of kyphosis increased an average of 12.9 degrees. The loss of correction was greater in those patients in whom the instrumentation failed (22 degrees) than in those patients in whom it did not (7.7 degrees). Five of the patients (45.5%) had a progressive increase in the angle of kyphosis of 10 degrees or more. At follow-up, the average loss of anterior vertebral body height for all 11 patients was 14% when compared with the body height that had been attained at surgery. Six of these patients (54.5%) had 10% or more loss of anterior body height. Despite the high incidence of failure of the instrumentation, progressive increase in the angle of kyphosis, and progressive loss of anterior vertebral body height, there was no worsening in the patients' Frankel grade postoperatively. The high rate of hardware failure and major postoperative loss of fracture reduction associated with this construct suggest that posterior short-segment pedicle-screw instrumentation with the Posterior Segment Fixator was not adequate to ensure stabilization of thoracolumbar fractures in this small group of patients. Maintenance of postoperative fracture reduction was the most consistent predictor of satisfactory functional outcome.

Management of type 2 diabetes in Western Australian metropolitan general practice.

The purpose of this study was: (1) to record GP opinions, practices and outcomes for the care of Type 2 Diabetes Mellitus (DM2), (2) compare practice facilities and process of care with a criterion of recommended competent care and (3) determine if there were any differences between vocationally registered and non-vocationally registered GPs. A random sample of 204 metropolitan doctors from 124 practices was selected and an audit performed on 467 of their patient records. GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs. Over 80% regard uncomplicated DM2 as a condition for general practice management. However, only 15% conducted an annual diabetes check, 9% had a diabetic register, 6% a diabetic recall system and 8% used a diabetic health care checklist for monitoring their patients. The most commonly recorded processes of medical audit in the previous 12 months were: blood pressure (94%), duration of diabetes (72%), blood glucose (70%), diet (66%), body weight (56%), HBA1c (52%) and ophthalmoscopy (50%). The least commonly recorded processes of care were body mass index (5%), inspection of the feet (18%), enquiries about vaginitis or impotence (23%). The amount of exercise, alcohol and tobacco was recorded in only 34% of records. Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers. Vocationally registered (VR) doctors had better records, higher process of care scores and more were willing to participate in the study than non-vocationally registered (NVR) doctors. However, there was no difference in metabolic control between patients from either group. The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters. The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs.

Health education poster: a teaching model for clinical medical students.

The teaching of health education or health promotion to medical students is often difficult because they have little experience on which to base their learning. They have limited clinical knowledge and in particular their awareness of the value of and the opportunities for health promotion in general practice is limited. The problem-oriented teaching method described here attempts to make the subject interesting and relevant by asking students, while in their practice attachments, to identify areas of need for health promotion or health education and then to prepare a poster, with supportive background and research, to satisfy that need for display in their given practice.

Supervised role-play in the teaching of the process of consultation.

Supervised role-play is presented as a method for teaching the process of the medical consultation. The process of the consultation is reviewed and a brief description of supervised role-play is given with some of its advantages and disadvantages. Some simple devices used in the method are explained with examples. The 'living' nature of the consultation is emphasized and an active method of teaching is advocated.

One-stage posterolateral decompression and stabilization for primary and metastatic vertebral tumors in the thoracic and lumbar spine.

During the past decade, anterior approaches to the spine have been shown to be much more effective than laminectomy for the relief of pain and neurological deficits due to vertebral metastases. Laminectomy has failed because it does not allow adequate decompression of epidural lesions anterior to the thecal sac. In an effort to combine the advantages of the posterior approach with an adequate decompression, a one-stage posterolateral decompression-stabilization procedure was performed on nine patients with thoracolumbar spine tumors. The approach has been used for decompression and stabilization after thoracolumbar burst fractures. Marked lasting improvement was seen in all six patients with preoperative neurological deficits and in four patients with severe back pain and/or radiculopathy. Three nonambulators and two marginal ambulators could walk postoperatively without assistance. Of five patients who were working preoperatively, four returned full-time to their prior occupations. Three patients had serious complications, including one early postoperative death. No patient deteriorated neurologically due to the procedure. Although the series is small, it demonstrates that adequate one-stage decompression-stabilization of spinal epidural lesions is possible via the posterolateral approach and should be considered in certain cases as an alternative to the anterior approach.

Long-term results of chymopapain injections.

A 10- to 14-year follow-up questionnaire of 146 patients treated for sciatica from a herniated nucleus pulposus by chymopapain (Discase) injection revealed a durable, satisfactory result in 66%. In the 102 patients rated as excellent or good, 5% required surgical discectomy 50-82 months after injection. One-, two-, and three-level injections were performed and the number of levels injected did not influence the success of the procedure or the subsequent need for open surgical intervention. There was no correlation shown between the incidence of job change or unemployment and the number of levels injected.