Function after spinal treatment,exercise and rehabilitation (FASTER): improving the functional outcome of spinal surgery

Background  

The life-time incidence of low back pain is high and diagnoses of spinal stenosis and disc prolapse are increasing. Consequently, there is a steady rise in surgical interventions for these conditions. Current evidence suggests that while the success of surgery is incomplete, it is superior to conservative interventions. A recent survey indicates that there are large differences in the type and intensity of rehabilitation, if any, provided after spinal surgery as well as in the restrictions and advice given to patients in the post-operative period.     

Critical appraisal of the revised Ghent criteria for diagnosis of Marfan syndrome

Radonic T, de Witte P, Groenink M, de Bruin‐Bon RACM, Timmermans J, Scholte AJH, van den Berg MP, Baars MJH, van Tintelen JP, Kempers M, Zwinderman AH, Mulder BJM. Critical appraisal of the revised Ghent criteria for diagnosis of Marfan syndrome. Marfan syndrome (MFS) is a connective tissue disorder with major features in cardiovascular, ocular and skeletal systems. Recently, diagnostic criteria were revised where more weight was given to the aortic root dilatation. We applied the revised Marfan nosology in an established adult Marfan population to define practical repercussions of novel criteria for clinical practice and individual patients. Out of 180 MFS patients, in 91% (n = 164) the diagnosis of MFS remained. Out of 16 patients with rejected diagnosis, four patients were diagnosed as MASS (myopia, mitral valve prolapse, borderline non‐progressive aortic root dilatation, skeletal findings and striae) phenotype, three as ectopia lentis syndrome and in nine patients no alternative diagnosis was established. In 13 patients, the diagnosis was rejected because the Z‐score of the aortic root was <2, although the aortic diameter was larger than 40 mm in six of them. In three other patients, the diagnosis of MFS was rejected because dural ectasia was given less weight in the revised nosology. Following the revised Marfan nosology, the diagnosis of MFS was rejected in 9% of patients, mostly because of the absence of aortic root dilatation defined as Z‐score ≥2. Currently used Z‐scores seem to underestimate aortic root dilatation, especially in patients with large body surface area (BSA). We recommend re‐evaluation of criteria for aortic root involvement in adult patients with a suspected diagnosis of MFS.     

Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status

Withholding and withdrawing dialysis are subjects of major concern to nephrologists, because both result in a significant number of end-stage renal disease (ESRD) patient deaths. The medical literature on withholding dialysis is extremely limited, and that on withdrawing dialysis consists mainly of retrospective studies from the 1980s. The present study was conducted to identify ways to improve dialysis decision making by providing a current understanding of how decisions to withhold or withdraw dialysis are being made and by examining whether some patients who might benefit from dialysis are not being referred. In 1995, 22 of 27 (82%) nephrologists practicing in West Virginia agreed to participate in a year-long prospective study in which they completed forms on each patient from whom they withheld or withdrew dialysis. Seventy-six of a random sample of 214 (36%) primary care physicians returned questionnaires describing their practice experience in 1995 with patients with advanced chronic renal failure. The nephrologists withdrew dialysis from 60 of 822 (7%) patients. Academic nephrologists who had received education in the ethics and law of stopping dialysis withdrew it from a greater percentage of patients than those in private practice (12% v 6%; P = 0.009). Patients who were withdrawn more often resided in nursing homes (37% v 2%; P < 0.0001). Twenty-one patients (37%) lacked decision-making capacity at the time the decision was made to withdraw dialysis. Advance directives were available for 13 of the 21 (62%) patients: eight of the 10 treated by academic nephrologists and five of the 11 treated by private practice nephrologists. Academic nephrologists found advance directives to be helpful in decision making to withdraw dialysis of incapacitated patients more often than nephrologists in private practice (70% v 9%; P = 0.004). Nephrologists withheld dialysis from 25 of 357 (7%) ESRD patients compared with 42 of 193 (22%) withheld by primary care physicians (P < 0.001). In deciding not to refer a patient for a dialysis evaluation, 25% of primary care physicians did not consult a nephrologist; 60% cited age as a reason not to refer. These findings suggest that dialysis decision making might be improved by educating nephrologists about the ethics and law of withdrawing dialysis and about how to implement successfully advance care planning so that advance directives will be present and helpful when decisions need to be made for incapacitated dialysis patients. Education of primary care physicians about when to refer patients with chronic renal failure for a dialysis evaluation might also result in more referrals for patients who will benefit from dialysis.