The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression

Post-operative management after lumbar surgery is inconsistent leading to uncertainty amongst surgeons and patients about post-operative restrictions, reactivation, and return to work. This study aimed to review the evidence on post-operative management, with a view to developing evidence-based messages for a patient booklet on post-operative management after lumbar discectomy or un-instrumented decompression. A systematic literature search produced a best-evidence synthesis of information and advice on post-operative restrictions, activation, rehabilitation, and expectations about outcomes. Evidence statements were extracted and developed into patient-centred messages for an educational booklet. The draft text was evaluated by peer and patient review. The literature review found little evidence for post-operative activity restrictions, and a strong case for an early active approach to post-operative management. The booklet was built around key messages derived from the literature review and aimed to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice on self-management. Feedback from the evaluations were favourable from both review groups, suggesting that this evidence-based approach to management is acceptable and it has clinical potential.     

The effect of duration of symptoms on standard outcome measures in the surgical treatment of spinal stenosis

The effect of the duration of symptoms on the outcome of lumbar decompression surgery is not known. The aim of our study was to determine the predictors of functional outcome of lumbar decompression surgery for degenerative spinal stenosis with particular emphasis on the duration of symptoms. In this prospective cohort study, we recruited 100 patients with a full data set available at 1-year and 85% at 2-year follow-ups: 49 females and 51 males with an average age of 62 (range 52–82). The pre- and post-operative outcome measures were Oswestry disability index (ODI), low back outcome score (LBOS), pain visual analogue score (VAS), modified somatic perception (MSP) and modified Zung depression (MZD) score. Dural tear occurred in 14%, and there was one post-operative extra-dural heamatoma. Overall, the ODI improved from a pre-operative of 56 (±13) to a 1-year ODI of 40 (±22) and at 2-year ODI of 40 (±21). The VAS improved from an average of 8 to 5.2 at 1 year and 4.9 at 2 years. There was a statistical significant association between symptom duration and the change in ODI (P=0.007 at 1-year follow-up, P=0.001 at 2-year follow-up), LBOS (P=0.001 at 1-year follow-up, P<0.001 at 2-year follow-up) and VAS (P=0.003 at 1-year follow-up, P=0.001 at 2-year follow-up). Subgroup analyses showed that patients with symptom duration of less than 33 months had a more favourable result. In addition, the patients who rated the operation as excellent had a statistically significantly shorter duration of symptoms. We have not found a predictive value for age at operation, MSP or MZD. The number of levels of decompression and the different types of decompression surgery did not influence the surgical results. Our study indicates that the symptom duration of more than 33 months has a less favourable functional outcome.     

Prevention of periarticular heterotopic ossification after endoprosthetic hip joint replacement by means of Diclofenac

This prospective study involves 644 patients who received ossification prophylaxis by means of the drug diclofenac after implantation (87.5%) or revision (12.5%) of a total hip endoprosthesis between August 1992 and June 1994. One hundred patients (15.5%) stopped the treatment because of side-effects of the drug, and medication was stopped when gastrointestinal troubles occurred. The follow-up examination after 6 months revealed ossification of HO degree 1 according to Brooker in 13.8% of cases, of degree 2 in 4.8%, and of degree 3 in 1.4% of cases. Severe HO of degree 4 was not observed at all, and 80% of the patients exhibited no ossification what ever. Thus, in comparison to our own studies and to the literature, diclofenac must be regarded as an extremely effective drug for the prevention of ossification. Received: 20 December 1996     

The nature of feeding in infants with unrepaired cleft lip and/or palate compared with healthy noncleft infants.

OBJECTIVE: Feeding difficulties are reported widely in infants with cleft lip and/ or palate. There is, however, a paucity of objective information about the feeding patterns of these infants. This study compared patterns of feeding in infants with unrepaired cleft lip and palate with healthy noncleft infants of a similar age. SETTING: North Thames Regional Cleft Centre. The noncleft cohort was recruited from West Middlesex University Hospital, a general hospital with similar demographics. PARTICIPANTS: Fifty newborn infants with nonsyndromic complete unilateral cleft lip and palate or a cleft of the soft and at least two thirds of the hard palate who were referred to the North Thames Regional Cleft Centre participated. Parents of 20 randomly selected, noncleft infants agreed to participate. MAIN OUTCOME MEASURES: Feeding patterns were rated using the Neonatal Oral Motor Assessment Scale. Additional objective information was collected using the Great Ormond Street Measurement of Infant Feeding (Masarei et al., 2001; Masarei, 2003). RESULTS: Infants with nonsyndromic complete unilateral cleft lip and palate or a cleft of the soft and at least two thirds of the hard palate had less efficient sucking patterns than their noncleft peers had. They used shorter sucks (mean difference, 0.30 second; p < .0005), a faster rate of sucking (mean difference, 34.20 sucks/second; p < .0005), higher suck-swallow ratios (mean difference, 1.87 sucks/swallow; p < .0005), and a greater proportion of intraoral positive pressure generation (mean difference, 45.97% positive pressure; p < .0005). CONCLUSIONS: This study demonstrated that the sucking patterns of infants with nonsyndromic complete unilateral cleft lip and palate or a cleft of the soft and at least two thirds of the hard palate differ from those of their noncleft peers.     

LYMPHOCYTE ACTIVATION IN SUBACUTE SCLEROSING PANENCEPHALITIS VIRUS AND CYTOMEGALOVIRUS INFECTIONS : IN VITRO STIMULATION IN RESPONSE TO VIRAL-INFECTED CELL LINES

Efforts to stimulate lymphocytes from measles seropositive and two patients with subacute sclerosing panencephalitis (SSPE) with either commercially available measles virus or virus isolated from a known case of SSPE failed to show any significant data using a microculture assay. Similar results were obtained using lymphocytes from two patients with active cytomegalovirus (CMV) infections and CMV seropositive individuals using CMV suspensions. On the other hand, lymphocytes from the patients with subacute sclerosing panencephalitis exhibited in vitro blastogenesis in culture with SSPE virus-infected HeLa cells. Similarly, lymphocytes from the CMV-infected patients demonstrated blastogenesis when cocultivated with CMV-infected WI-38 cells. This affords a new method for determining the cell-mediated immune capacity of patients with "slow" virus diseases.     

DDT thins shells of eggs from mallard ducks maintained onad libitum or controlled-feeding regimens

Mallard ducks were fed diets containing various levels of technical DDT or chemically purep,p'-DDT, or dieldrin. Either technical DDT orp,p'-DDT at 20 ppm or greater, or dieldrin at 10 ppm caused a statistically significant reduction in eggshell thickness, weight, and calcium. Shells of eggs from ducks fed 40 ppm ofp,p'-DDT were about 20% thinner than those from control ducks, and shells of eggs from ducks fed 10 ppm of dieldrin were about 6% thinner than those from controls. The reduction in eggshell thickness was linear with increasing dose of DDT to 40 ppm, and with increasing dose of dieldrin through all levels studies. Eggshell thinning occurred regardless of whether the diets containing DDT were fed underad libitum or controlled conditions. DDT fed at 200 ppm was lethal to the ducks. Neither DDT nor dieldrin affected weight of the eggs or rate of egg production.Published with the approval of the Director of the North Dakota Agricultural Experiment Station as Journal Article No. 462.     

Malignant rabbit fibroma virus: observations on the culture and histopathologic characteristics of a new virus-induced rabbit tumor

The clinical, histopathologic, and cultural characteristics of a newly isolated poxvirus, malignant rabbit fibroma virus (MV), were investigated. MV was isolated from tumors induced by an uncloned stock of Shope fibroma virus (SFV). MV, SFV, and rabbit myxoma virus were compared. Similarly to myxoma virus, MV grew to higher titer in vitro than did SFV and produced plaques rather than foci on rabbit kidney cell monolayers. Unlike the local, self-limited fibroblastic proliferations observed in SFV recipients, MV and myxoma caused a fulminant clinical syndrome characterized by malignant histology, metastases, and supervening fatal gram-negative infection with Pasteurella multocida. MV induced a large, protuberant local tumor and discrete metastases histologically resembling myxosarcomas. Draining lymph nodes contained metastases and showed diffuse cortical hyperplasia. Kupffer's cells were prominent in the liver, and macrophages were abundant in the splenic sinusoids. The lungs and trachea were spared, but the conjunctiva and nasal mucosa showed squamous metaplasia and atypia, with overlying Pasteurella infection and underlying tumor. Myxoma virus infection produced similar mucosal changes, but both of these as well as the epidermis overlying the myxomas showed cytoplasmic virus inclusions. Neither the skin nor the epithelial surfaces overlying MV-induced tumors nor the tumors themselves contained virus inclusions. Thus the tumor syndrome caused by MV differed from other known rabbit tumors. Endonuclease restriction digests showed that the MV genome resembled, but was distinct from, rabbit myxoma virus. Opportunistic infection associated with MV-induced disseminated tumor may be an experimental model for the infectious complications that often supervene in host-tumor relationships.     

The results of a surgical program for interrupted aortic arch

Seventy-one patients with interrupted arch entered the Boston Children's Hospital between Jan. 1, 1974, and Jan. 1, 1987, of whom 63 underwent an operation. Type B was the most prevalent form of interrupted arch, and ventricular septal defect alone was the commonest coexisting cardiac anomaly. Among the 63, the 30-day and the 1-, 5-, and 10-year survival rates were 61%, 52%, 48%, and 47%, respectively. The mortality rate declined strikingly during the experience, and by multivariate analysis in patients with coexisting ventricular septal defect operated on in 1986, the probability of death within 2 weeks of repair was only 7%. Also, preoperative therapy became progressively more intense and more prolonged. The complication of left ventricular outflow tract obstruction developed in eight of the 33 patients undergoing repair of interrupted arch and of isolated ventricular septal defect. The time-related freedom from this complication was 97%, 78%, and 58% at 1 month, 1 year, and 3 years, respectively. Seven of the eight patients underwent a surgical procedure directed against the left ventricular outflow tract obstruction, and all have survived. Recurrent or persistent aortic arch obstruction became evident after repair in 15 patients and appeared more frequently and earlier after direct anastomosis than after tube graft repair. All patients had either reoperation or balloon dilation, but all were alive at follow-up. Most surviving patients are active and without symptoms. Inferences: An aggressive surgical program can result in survival and a good clinical state for at least 10 years after birth of over 40% of patients born with interrupted arch. Multiple anatomic bases account for the development of left ventricular outflow tract obstruction in about 50% of the patients undergoing repair of interrupted arch with coexisting ventricular septal defect. Repair by direct anastomosis combined with repair of the coexisting defect whenever possible is optimal therapy.     

alpha-Fetoprotein levels and hepatic alterations during chemical carcinogenesis in C57BL/6N mice.

Hepatocellular carcinomas were induced by administration of acetylaminofluorene or chlordane to C57BL/6N mice. Lesions which closely resembled the neoplastic nodule described as a putative premalignant lesion in rats were evident. alpha-Fetoprotein elevations were noted only in the presence of the malignant lesions for both carcinogens. In this regard, the responses of these mice were similar to those seen during spontaneous hepatocarcinogenesis.     

Chemical antroneurolysis with and without highly selective vagotomy

Because of the lower recurrence rate of ulceration when vagotomy is accompanied by antrectomy, we studied the effects of combining submucosal denervation of the antrum (antroneurolysis) with highly selective vagotomy (HSV). Chemical antroneurolysis (CANL) was performed by submucosal injection of 50% ethanol. In two gastric fistula dogs HSV produced a significant decrease in peak acid output (PAO) in response to 0.2 U/kg insulin (5.42 ± 0.46 → 3.32 ± 0.99 meq/15 min, P < 0.06). Subsequent CANL caused no further decrease in PAO (3.54 ± 0.52 meq/15 min). In three gastric fistula dogs, initial CANL yielded a slight increase in PAO (5.42 ± 0.46 → 7.30 ± 1.04 meq/15 min, P < 0.01). Subsequent HSV lowered PAO significantly below control (2.27 ± 0.74 meq/15 min, P < 0.001). Response to serial doses of betazole and pentagastrin was not significantly changed by any operation, except that CANL followed by HSV led to a decreased response to pentagastrin. Gastric motility, peristalsis, and emptying times were essentially unchanged. The response of four dogs with Heidenhain pouches to test meals was studied before and after CANL. Peak acid output following a test meal was not significantly changed (0.385 ± 0.078 → 0.392 ± 0.083. P > 0.92). CANL produced no change in maximum serum gastrin rise above basal in response to a test meal either in four pouch dogs (47.4 ± 2.54 → 40.9 ± 3.69 pg/ml, P > 0.13) or in four normal dogs (27.5 ± 3.41 → 33.8 ± 4.47 pg/ml, P > 0.16). Basal gastrins were also unchanged. In conclusion, we feel that CANL provides no significant advantage over HSV, while increasing its complexity.