Intravenous pulse methylprednisolone for induction of remission in severe ANCA associated Vasculitis: a multi-center retrospective cohort study.

BACKGROUND: Intravenous pulse methylprednisolone (MP) is commonly included in the management of severe ANCA associated vasculitis (AAV) despite limited evidence of benefit. We aimed to evaluate outcomes in patients who had, or had not received MP, along with standard therapy for remission induction in severe AAV. METHODS: We retrospectively studied 114 consecutive patients from five centres in Europe and the United States with a new diagnosis of severe AAV (creatinine > 500 µmol/L or dialysis dependency) and that received standard therapy (plasma exchange, cyclophosphamide and high-dose oral corticosteroids) for remission induction with or without pulse MP between 2000 and 2013. We evaluated survival, renal recovery, relapses, and adverse events over the first 12 months. RESULTS: Fifty-two patients received pulse MP in addition to standard therapy compared to 62 patients that did not. There was no difference in survival, renal recovery or relapses. Treatment with MP associated with higher risk of infection during the first 3 months (hazard ratio (HR) 2.7, 95%CI [1.4-5.3], p = 0.004) and higher incidence of diabetes (HR 6.33 [1.94-20.63], p = 0.002), after adjustment for confounding factors. CONCLUSIONS: The results of this study suggest that addition of pulse intravenous MP to standard therapy for remission induction in severe AAV may not confer clinical benefit and may be associated with more episodes of infection and higher incidence of diabetes.

Stand-alone anterior lumbar interbody fusion for treatment of degenerative spondylolisthesis.

We sought to evaluate the clinical and radiologic efficacy of stand-alone anterior lumbar interbody fusion (ALIF) for low grade degenerative spondylolisthesis, the favoured surgical management approach at our institution. The optimal approach for surgical management of spondylolisthesis remains contentious. We performed a prospective analysis of all consecutive patients with low grade lumbar spondylolisthesis who underwent ALIF between 2009 and 2013 by a single surgeon (n=27). The mean age was 64.9 years with a male to female ratio of 14:13. There were 32 levels operated and the average preoperative spondylolisthesis was 14.8%, which reduced to 6.4% postoperatively and 9.4% at the latest follow-up (p=0001). Postoperative disc height was increased to 175% of preoperative values and was statistically significant (p<0.001) and remained improved with an overall change of 139% at the latest follow-up. The radiological fusion rate was 91%. The 12-Item Short Form Health Survey (SF-12) mental and physical component summary improved from 31.7 to 43.0 (p=0.007) and from 35.4 to 51.7 (p=0.0026), respectively. The mean visual analogue scale pain score improved from 7.6 to 2.2 (p<0.001), and the mean Oswestry disability index improved from 56.9 to 17.8% (p<0.0001). The overall clinical success rate was 93%. The posterior disc height correlated with spondylolisthesis reduction (p=0.04) and the only clinical factor affecting reduction was body mass index (p=0.04). The present study provides encouraging short term results for stand-alone ALIF as a procedure for low grade lumbar degenerative spondylolisthesis. Future studies should include adequately powered, prospective, multicentre registry studies with long term follow-up to allow a better assessment of the relative benefits and risks.

The impact of specialist trauma service on major trauma mortality.

INTRODUCTION: Trauma services throughout the world have had positive effects on trauma-related mortality. Australian trauma services are generally more consultative in nature rather than the North American model of full trauma admission service. We hypothesized that the introduction of a consultative specialist trauma service in a Level I Australian trauma center would reduce mortality of the severely injured. METHODS: A 10-year retrospective study (January 1, 2002-December 31, 2011) was performed on all trauma patients admitted with an Injury Severity Score (ISS) > 15. Patients were identified from the trauma registry, and data for age, sex, mechanism of injury, ISS, survival to discharge, and length of stay were collected. Mortality was examined for patients with severe injury (ISS > 15) and patients with critical injury (ISS > 24) and compared for the three periods: 2002-2004 (without trauma specialist), 2005-2007 (with trauma specialist), and 2008-2011 (with specialist trauma service). RESULTS: A total of 3,869 severely injured (ISS > 15) trauma patients were identified during the 10-year period. Of these, 2,826 (73%) were male, 1,513 (39%) were critically injured (ISS > 24), and more than 97% (3,754) were the victim of blunt trauma. Overall mortality decreased from 12.4% to 9.3% (relative risk, 0.75) from period one to period three and from 25.4% to 20.3% (relative risk, 0.80) for patients with critical injury. A 0.46% per year decrease (p = 0.018) in mortality was detected (odds ratio, 0.63; p < 0.001). For critically injured (ISS > 24), the trend was (0.61% per year; odds ratio, 0.68; p = 0.039). CONCLUSION: The introduction of a specialist trauma service decreased the mortality of patients with severe injury, the model of care should be considered to implement state- and nationwide in Australia. LEVEL OF EVIDENCE: Epidemiologic study, level III.