Surgery versus prolonged conservative treatment for sciatica.

BACKGROUND: Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known. METHODS: We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups. RESULTS: Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (P=0.13). Relief of leg pain was faster for patients assigned to early surgery (P<0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%. CONCLUSIONS: The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. (Current Controlled Trials number, ISRCTN26872154 [controlled-trials.com].).

Identification and characterization of major degradation products of risperidone in bulk drug and pharmaceutical dosage forms.

Acid, base and oxygen stability of risperidone, a novel anti-psychotic drug, has been evaluated storing the sample in solution phase. One of the major degradation products has been identified and characterized by using techniques namely IR, MS and NMR after isolation by preparative LC. The other major degradation product has been identified with help of MS/MS data and by co-eluting in analytical LC with the available standard. The effect of acid and base resulted in the formation of hydroxy risperidone and the effect of oxygen lead to the formation of N-oxide of risperidone. The two major degradation products in the dosage forms were also characterized as 9-hydroxy risperidone and N-oxide of risperidone, after enrichment through preparative LC, by LC-MS/MS and HPLC. Structural elucidation of degradation product leading to the formation of N-oxide of risperidone is discussed in detail.

Renal malignant fibrous histiocytoma.

The clinical, radiographic, and pathologic findings of 2 cases of malignant fibrous histiocytoma (MFH) of the renal capsule are reported and the 17 previous cases in the literature reviewed. Preoperative differentiation from renal adenocarcinoma was precluded by the overlap in clinical, laboratory, and radiologic findings, although MFH usually presented with a normal urine analysis and less parenchymal involvement on imaging studies. Pathologic differential diagnosis and therapeutic approaches are presented.

Ovarian pregnancies with Dalkon Shield IUCDs in situ: laparoscopic visualization.

Two ovarian pregnancies coexistent with intra-uterine contraceptive devices are described. In one case, the ovary appeared to contain a cyst at laparoscopy and rupture of the cyst and extrusion of the fetus were witnessed. In the second case, a hemorrhagic ovarian cyst bled at laparoscopy and laparotomy resulted in the diagnosis of ovarian pregnancy. These two cases reveal that laparoscopic examination could be misleading and result in inappropriate management if the diagnosis of ovarian pregnancy is not entertained. The cases described add to the growing number of reports of extrauterine pregnancies occurring in patients using intra-uterine contraceptive devices.

Thyroglossal duct carcinoma.

Primary carcinoma of the thyroglossal duct is rare. This discussion reports two cases and reviews the 50 previously reported in the literature. The criteria for diagnosis include evidence of a thyroglossal duct remnant and a normal thyroid gland. The differentiation from cystic metastases to lymph nodes is pointed out. The histologic types parallel those of carcinoma of the thyroid gland, papillary carcinoma being the most common and having a generally favorable prognosis. The clinical presentation of these tumors is similar to that with benign cysts and thus is of limited value in the diagnosis.