Magnetic resonance imaging predictors of surgical outcome in degenerative lumbar spinal stenosis

Purpose

To identify any MRI predictors for surgical outcomes of patients with degenerative lumbar spinal stenosis (DLSS) having instrumented posterior decompression (IPD) surgery.

Materials and methods

Seventy patients with DLSS who underwent IPD were reviewed retrospectively. The clinical score of each patient was assessed using the JOAS (Japanese Orthopedics Association Scoring) system, which is mainly based on the subjective symptoms and physical signs of the patients before (JOAS-I) and after (JOAS-II) surgery. Healing rate (HR) was calculated as: [(JOAS-II) ? (JOAS-I)] × 100/[15 ? (JOAS-I)]. HR >50 % was considered clinical improvement. Radiological stenosis was assessed on MRI and was graded from 0 to 3 at the laminectomy level in terms of thecal sac-nerve root compression, foraminal stenosis, and facet degeneration.

Results

Mean HR of the improved patients (n = 39) was 81.94; HR of the unimproved patients (n = 31) was 34.75 (p < 0.05). There was no statistical difference in radiological stenosis parameters between the two groups (p > 0.05). HR was worse in patients with severe facet degeneration.

Conclusions

Surgical outcomes of DLSS depend on multiple variables. It is not possible to predict the outcomes by assessing only one parameter. The possible outcomes should be analyzed by considering all the factors individually.     

A Comparison of Outcomes for Younger and Older Adult Patients Undergoing Surgery for Primary Hyperparathyroidism

Background

In adolescents and young adults, primary hyperparathyroidism (PHPT) is an uncommon diagnosis. We compared the clinical characteristics of these patients to those of older adult patients with PHPT. We hypothesized that PHPT in adolescents and young adults is more often caused by single-gland disease and is amenable to minimally invasive parathyroidectomy (MIP).

Methods

We retrospectively reviewed the medical records of 452 consecutive patients who had surgery for PHPT. Patients ranged in age from 13 to 94?years and were dichotomized into younger (age <30?years, n?=?17, 3.8%) and older (age ??30?years, n?=?435, 96.2%) patients. Continuous baseline and intraoperative and postoperative measures were not normally distributed and were summarized with medians and interquartile ranges (IQRs). Groups were compared using Wilcoxon rank sum test or Fisher exact test, and significance was set at P?Results Median [IQR] age was 24 [23?C27] years for the younger group and 58 [51?C66] years for the older group. Though not statistically significant, a smaller proportion of the younger patients compared with the older patients had a positive ^99mTc-sestamibi scan (71%; 95% confidence interval [95% CI]?=?44?C90% vs. 83%; 95% CI?=?79?C86%) and showed a suspected parathyroid adenoma on ultrasound (65%; 95% CI?=?38?C86% vs. 80%; 95% CI?=?76?C83%). The younger and older age groups did not significantly differ on preoperative serum PTH levels (median [IQR]: 111 [76?C145] pg/ml vs 110 [84?C152] pg/ml; P?=?.73 respectively). The younger group had higher serum calcium levels (11.6 [11.1?C12.2] mg/dl) compared with the older group (11.1 [10.7?C11.5] mg/dl; P?=?.01). MIP was performed less frequently on the younger patients (70.6%) compared with older patients (88.7%; P?=?0.04). Though the incidence of a single adenoma was somewhat more frequent in older patients (90%; 95% CI?=?87?C93%) than in younger patients (82%; 95% CI?=?57?C96%) it was the most frequent cause of PHPT in the younger patients. The younger and older groups did not significantly differ on percent drop from baseline for intraoperative PTH monitoring (81.7 vs 79.3%; P?=?.46), respectively.

Conclusions

Younger patients with PHPT present with significantly higher serum calcium levels than older patients. However, younger patients are less likely to localize abnormal parathyroid glands on sestamibi or ultrasound. Though younger patients appear to have a higher incidence of hyperplasia compared with older patients, single gland disease is still the overall most frequent cause. Our data suggest that MIP should be more frequently considered in younger patients because of the high incidence of single gland disease.     

Digitally reinforced hematoxylin-eosin polarization technique in diagnosis of rectal amyloidosis

AIM:To investigate the efficacy of the digitally reinforced hematoxylin-eosin polarization(DRHEP)technique for detection of amyloidosis in rectal biopsies.METHODS:One hundred hematoxylin-eosin(HE)stained rectal biopsies with Congo-red(CR)-positive amyloid depositions and 50 control cases with CRnegative amyloid-mimicking areas were scanned blinded to the CR results for amyloid depositions under both bright and polarized light,and digitally photographed using the DRHEP technique,to accentuate the faint birefringence observed in HE slides under polarization.The results of DRHEP and HE evaluation were statistically correlated with CR polarization results with respect to presence and localization of amyloid deposits as well as amyloid types.RESULTS:Amyloid deposits showed yellowish-green birefringence by DRHEP,which allowed identification of amyloidosis in 41 HE-unsuspected cases(P=0.016),31 of which only had vascular deposits.True positivity was higher,and false negativity and positivity were lower by DRHEP,compared to evaluation by HE(69%,31%,and 0.8%vs 33%,67%,and 33%,respectively;P<0.0001).The sensitivity,specificity,accuracy,and positive and negative predictive values for DRHEP were69%,98%,78.6%,98.5%,and 61.25%,respectively.Reasons for DRHEP false negativity were presence of extensive background birefringence in 12 cases,absence of CR birefringent vessel in 3 cases,and missing of the tiny deposits in 9 cases,which could be improved by experience,especially in the latter case.No correlation was found between age,gender,sites of deposits,or amyloid types.CONCLUSION:The DRHEP technique improves diagnostic accuracy when used as an adjunct or a prior step to CR staining,especially for cases with limited tissues for further analysis.     

Targeted inhibition of gene expression of pancreatitis-associated proteins exacerbates the severity of acute pancreatitis in rats

BACKGROUND: Pancreatitis-associated protein (PAP) is a secretory protein not normally expressed in healthy pancreas but highly induced during acute pancreatitis. While PAP has been shown to be anti-bacterial and anti-apoptotic in vitro, its definitive biological function in vivo is not clear. METHODS: To elucidate the function of PAP, antisense oligodeoxyribonucleotides (AS-PAP) targeting all three isoforms of PAP were administered via intrapancreatic injections (5 mg kg day, 2 days) to rats prior to induction of pancreatitis. RESULTS: Severity of pancreatitis and cytokine gene expression in peripheral blood mononuclear cells (PBMC) were evaluated. Administration of AS-PAP, but not the scrambled oligodeoxyribonucleotide (SC-PAP) control, reduced pancreatitis-induced PAP expression by 55.2 +/- 6.4%, 44.0 +/- 8.9%, and 38.9 +/- 10.7% for PAP isoforms I, II, and III, respectively, compared to saline-treated controls (P < 0.05 for all). Inhibition of PAP expression significantly worsened pancreatitis: serum amylase activity, pancreas wet weight (reflecting edema), and serum C-reactive protein levels all increased in AS-PAP-treated animals compared to SC-PAP-treated controls (by 3.5-, 1.7-, and 1.7-fold, respectively; P < 0.05 for all). Histopathologic evaluation of pancreas revealed worsened edema, elevated leukocyte infiltration, and fat necrosis after AS-PAP treatment. Gene expressions of IL-1 microm and IL-4 were significantly higher in PBMC isolated from AS-PAP-treated rats compared to SC-PAP controls. CONCLUSION: This is the first in vivo evidence indicating that PAP mediates significant protection against pancreatic injury. Our data suggest that PAP may exert its protective function by suppressing local pancreatic as well as systemic inflammation during acute pancreatitis.     

The Effect of Helicobacter pylori on Insulin Resistance

Helicobacter pylori causes a lifelong infection in the stomach after exposure. H. pylorihas been shown to be associated with peptic ulcer and gastric cancer development. Moreover, it is held responsible for some other nongastric diseases. Among them, coronary heart disease attracts much debate. Many studies have demonstrated a close relationship between insulin resistance and atherosclerosis. Chronic inflammation and alterations in counter-regulatory hormones are deemed responsible for the etiology of insulin resistance. We aimed to examine the effect of H. pylori on insulin resistance. Sixty-three patients were enrolled in the study. Patients were divided into two groups according to H. pylori presence. HOMA-IR (homeostasis model assessment of insulin resistance) level was used to assess insülin resistance. Thirty-six patients were H. pylori positive and 27 were H. pylori negative. There was no difference between the two groups with regard to age, gender, or body mass index. HOMA-IR level was 1.73± 1.1 in the H. pylori-negative group, whereas it was 2.56 ± 1.54 in the H. pylori-positive group (P < 0.05). This study provides the first direct evidence for an association between chronic H. pylori infection and insulin resistance.