Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS)

Purpose

Spine surgery rates are increasing worldwide. Treatment failures are often attributed to poor patient selection and inappropriate treatment, but for many spinal disorders there is little consensus on the precise indications for surgery. With an aging population, more patients with lumbar degenerative spondylolisthesis (LDS) will present for surgery. The aim of this study was to develop criteria for the appropriateness of surgery in symptomatic LDS.

Methods

A systematic review was carried out to summarize the current level of evidence for the treatment of LDS. Clinical scenarios were generated comprising combinations of signs and symptoms in LDS and other relevant variables. Based on the systematic review and their own clinical experience, twelve multidisciplinary international experts rated each scenario on a 9-point scale (1 highly inappropriate, 9 highly appropriate) with respect to performing decompression only, fusion, and instrumented fusion. Surgery for each theoretical scenario was classified as appropriate, inappropriate, or uncertain based on the median ratings and disagreement in the ratings.

Results

744 hypothetical scenarios were generated; overall, surgery (of some type) was rated appropriate in 27 %, uncertain in 41 % and inappropriate in 31 %. Frank panel disagreement was low (7 % scenarios). Face validity was shown by the logical relationship between each variable’s subcategories and the appropriateness ratings, e.g., no/mild disability had a mean appropriateness rating of 2.3 ± 1.5, whereas the rating for moderate disability was 5.0 ± 1.6 and for severe disability, 6.6 ± 1.6. Similarly, the average rating for no/minimal neurological abnormality was 2.3 ± 1.5, increasing to 4.3 ± 2.4 for moderate and 5.9 ± 1.7 for severe abnormality. The three variables most likely (p < 0.0001) to be components of scenarios rated “appropriate” were: severe disability, no yellow flags, and severe neurological deficit.

Conclusion

This is the first study to report criteria for determining candidacy for surgery in LDS developed by a multidisciplinary international panel using a validated method (RAM). The panel ratings followed logical clinical rationale, indicating good face validity. The work refines clinical classification and the phenotype of degenerative spondylolisthesis. The predictive validity of the criteria should be evaluated prospectively to examine whether patients treated “appropriately” have better clinical outcomes.     

二甲双胍对人肝癌Hep-G2细胞表皮生长因子及其受体表达的影响

目的 观察二甲双胍对人肝癌Hep-G2细胞表皮生长因子（EGF）及其受体（EGFR）的影响.方法 体外培养人肝癌Hep-G2细胞,用不同浓度二甲双胍进行干预,3-（4,5-二甲基噻唑-2）-2,5-二苯基四氨唑溴盐法检测二甲双胍对Hep-G2细胞生长的影响;Hoechst 33342染色荧光显微镜观察细胞的形态学变化,流式细胞术观察细胞凋亡;蛋白质印迹法（Western blot）检测EGF、EGFR的表达.结果 二甲双胍对肝癌细胞的活性具有明显的抑制作用,且呈剂量依赖性;以10 mmol/L作用终浓度抑制效果最明显,其48 h的细胞吸光度为（0.477 ±0.025）,与对照组（0.602±0.026）比较差异有统计学意义（P＜0.01）;逐渐增加二甲双胍的作用浓度,细胞凋亡率随之逐渐增加,药物组细胞凋亡率分别为（10.76±0.96）％、（20.77±1.16）％,与对照组（5.21±0.13）％相比差异均有统计学意义（P＜0.05）;Hoechst33342染色可见明显的细胞皱缩,核染色质浓缩,核碎裂等凋亡形态学变化;Western blot结果显示,EGF及其受体蛋白的表达随着二甲双胍作用浓度的增加而逐渐下调.结论 在体外,二甲双胍能够抑制人肝癌Hep-G2细胞增殖及诱导细胞凋亡,其抗肿瘤机制可能与细胞内EGF及EGFR表达下调有关.     

Influences of Gender on Complication Rate and Outcome after Roux-en-Y Gastric Bypass: Data Analysis of More Than 10,000 Operations from the German Bariatric Surgery Registry

Background

Since 1 January 2005, bariatric surgery has been monitored in Germany. All related data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg.

Methods

Data collection regarding obesity and metabolic surgery was started in an online database in 2005. Follow-up data are collected once a year. Participation in the quality assurance study is voluntary.

Results

Since 2005, 10,330 Roux-en-Y gastric bypass (RYGB) procedures have been performed in Germany. In total, 8,013 patients were female and 2,317 were male. Male patients suffered significantly more comorbidities than female patients. The men also had higher body mass indexes (BMIs) and ages than the women at the time of operation. Data on the gender-specific aspects of RYGB from the Nationwide Survey of Bariatric Surgery in Germany (GBSR) showed a significant difference in anastomotic insufficiency at the gastro-entero-anastomosis. The leakage rate was 2.37 % (55/2,317) in men and 1.68 % (135/8,013) in women. Additionally, specific complication and mortality rates were significantly higher in male than in female patients.

Conclusions

Metabolic and obesity surgery is becoming increasingly popular in Germany. Data from the GBSR show significant differences in preoperative comorbidities and postoperative complication and mortality rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.     

French Spine Surgery Society guidelines for management of spinal surgeries during COVID-19 pandemic

Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019 in China, various measures have been adopted in order to attenuate the impact of the virus on the population. With regard to spine surgery, French physicians are devoted to take place in the national plan against COVID-19, the French Spine Surgery Society therefore decided to elaborate specific guidelines for management of spinal disorders during COVID-19 pandemic in order to prioritize management of patients. A three levels stratification was elaborated with Level I: Urgent surgical indications, Level II: Surgical indications associated to a potential loss of chance for the patient and Level III: Non-urgent surgical indications. We also report French experience in a COVID-19 cluster region illustrated by two clinical cases. We hope that the guidelines formulated by the French Spine Surgery Society and the experience of spine surgeons from a cluster region will be helpful in order optimizing the management of patients with urgent spinal conditions during the pandemic.     

糖尿病对冠状动脉旁路移植术围手术期影响的临床研究

目的探讨糖尿病对冠状动脉旁路移植术(CABG)的影响.方法1512例患者接受CABG,其中糖尿病患者(DM组)328例,非糖尿病患者(NDM组)1184例.单变量统计分析两组术前危险因素和术后并发症.结果两组患者住院费用[DM组(6.11±2.4)万元;NDM组(5.63±2.2)万元;P＞0.05]、切口并发症(DM组:10.1%;NDM组8.9%;P＞0.05)、输血量[DM组(807.6±654.3)ml;NDM组(814.6±662.2)ml;P＞0.05]等方面差异无显著意义.两组患者术后严重并发病:低心排(DM组:1.5%;NDM组1.9%;P＞0.05)、心律失常(DM组:14.6%;NDM组15.2%;P＞0.05)、围术期心肌缺血(PMI)(DM组:1.2%;NDM组1.5%;P＞0.05)以及死亡率(DM组:1.52%;NDM组0.84%;P＞0.05)差异无显著意义.结论糖尿病患者经适当控制病情以后,CABG可以如同非糖尿病患者一样安全地实施.     

西京-87型鼓泡式氧合器应用于70公斤以上患者临床评价

在心脏外科飞速发展的今天,人工心肺机的好坏直接影响心内直视手术的顺利进行及术后各种并发症的发生,我院1989年12月至1998年5月共施行体外循环手术3572例,其中70公斤以上者106例,有54例应用了西京-87型鼓泡式氧合器收到了良好的效果.54例患者,男48例,女6例,年龄平均41(19～59)岁;体重70～88kg,平均75.6kg;体表面积平均1.82m~2;冠状动脉阻闭时间10～142分钟,平均52分钟;灌注时间22～434分钟,平均104分钟;氧血比值为0.3～0.6:1;静脉血氧饱和度维持在65%～80%.用西京-87型鼓泡式氧合器,优选了适宜孔径的氧弥散器,从而解决了大体重病人氧合差的问题.体重最高者达88kg,氧血比例0.6:1～0.5:1,静脉血氧饱和度能维持在65%～80%.体现了该氧合器氧合性能好,而且携氧量高,既使应用于长时间或高流量灌注也能维持较稳定的氧合状态.而且热交换系统达到了降复温标准系数,在高体重患者降复温过程效果满意.本氧合器祛泡性能良好,对防止气栓的发生起到了保障.全组未见动脉气栓及脑缺氧症者.该氧合器氧血比值小,氧合性能好,而且集氧合、热交换、祛泡、过滤和贮血于一体,从而对血液有形成都份破坏程度减轻.对减少心、脑、肺、肾的并发症起到了良好的作用.西京-87型鼓泡式氧合器适用于不同体重患者的心内直视手术体外循环灌     

国产支架型人工血管的实验研究与临床应用

目的研究和开发国产支架型人工血管经腔内治疗动脉疾病.方法1993年6月至1999年8月,用北京地区杂种狗24条,分别制作了腹主动脉瘤(8条)、降胸主动脉瘤(6条)、升主动脉瘤(4条)、主动脉弓瘤(4条)和动静脉瘘(2条)模型,用自制的支架型人工血管置入.置于腹主动脉的支架是编织式镍钛合金记忆金属,长3cm,直径8cm;胸主动脉支架是联体不锈钢“Z“型支架,长3cm,直径2cm.覆膜均为国产超薄涤纶人工血管.临床应用20例,男17例,女3例.主动脉夹层11例,肾下腹主动脉瘤7例和创伤性动静脉瘘2例.结果17条狗术后存活,分别于2、4、8周获取标本,支架型人工血管通畅良好,无血栓形成.临床病例中,有1例腹主动脉瘤并发肾功能不全,于术后20天血液透析中死于心肌梗塞,其余病人均被成功治疗.随访2个月至5年,除1例夹层动脉瘤术后3个月支架移位外,所有病人恢复良好.结论自制的支架型人工血管费用低,操作简便,应用前景可观.