The effect of prior back surgery on surgical outcome in patients operated on for lumbar spinal stenosis a matched-pair study

Summary It has been widely observed that the outcome after repeat lumbar surgery is rarely comparable to that of primary surgery. In particular, the results of repeat surgery for lumbar spinal stenosis (LSS) have not been favourable. We used a matched-pair format in an attempt to decrease the confounding factors so as to determine as exactly as possible the effect of prior back surgery on the LSS patients surgical outcome. The matching criteria were sex, age, myelographic findings, major symptom, and duration of symptoms. From one group of 251 patients without prior back surgery (SO patients) and another of fifty-three patients with one preceding back operation (RS patients), forty-one similar matched patients pairs (one SO and one RS-patient) were formed.There were 8 female and 33 male pairs. The mean age of the SO patients was 51.6 and of the RS patient 51.4 years, and the mean follow-up time was 4.6 and 4.4 years. The assessment of outcome was based on a subjective disability questionnaire. The SO patients fared significantly better than the RS patients (32.1 versus 41.3, P = 0.026). A short time interval between operations in the RS patients had a worsening effect on outcome, but this trend was not significant.We concluded that one preceding back operation had a worsening effect on the outcome of patients operated on for LSS. As a whole, the results of RS patients were unfavourable. The proper time for achieving good surgical results in LSS patients is the initial operation.     

Sjögren's Syndrome with Chronic Pancreatitis, Sclerosing Cholangitis, and Pulmonary Infiltrations

We report a patient with Sjögren's syndrome and multiple gastrointestinal manifestations who successfully responded to therapy with ursodeoxycholic acid. Our patient had sialoadenitis with dry mouth, dry eyes, arthralgia, chronic pancreatitis, sclerosing cholangitis, and pulmonary inflitrations. The first signs of disease were the symptoms of chronic pancreatitis followed by icterus, caused by extrahepatic bile duct obstruction. Sclerosing cholangitis was diagnosed by liver biopsy and endoscopic retrograde cholangiography. Sialoadenitis, causing dry mouth, was verified by buccal biopsy. Pulmonary infiltrations were seen on standard chest x-ray, and also shown by high-resolution computed tomography examination. Obstructive icterus and even pulmonary infiltration responded successfully to treatment with ursodeoxycholic acid.     

Phage types and genotypes of Shiga toxin-Producing Escherichia coli O157 in Finland

This study examined Shiga toxin-producing Escherichia coli (STEC) O157, using phage typing, pulsed-field gel electrophoresis, and typing of Shiga toxin variant genes by PCR with restriction fragment length polymorphism in an epidemiological survey of STEC O157 isolated from humans in Finland between 1990 and 1999.     

Factors influencing the provision of oral hygiene care following stroke: an application of the Theory of Planned Behaviour

Objectives: This study aimed to examine “intention to” and “performance of” oral hygiene care to stroke patients using the Theory of Planned Behavior.

Materials and methods: A large scale survey of 13 centers in Malaysia was conducted involving 806 nurses in relation to oral hygiene care intentions and practices. In addition, information on personal and environmental factors was collected.

Results: The response rate was 95.6% (778/806). The domains of the Theory of Planned Behavior were significantly associated with general intention to perform oral hygiene care: attitudes (β?=?0.21, p?p?p?p?<0.01), controlling for other factors. Knowledge scores, training, access to oral hygiene guidelines and kits, as well as working ward type were identified as key factors associated with intention and practice of oral hygiene care.

Conclusion: The Theory of Planned Behavior provides understanding of “intention to” and “performance of” oral hygiene care to stroke patients. Several provider and environmental factors were also associated with intentions and practices. This has implications for understanding and improving the implementation of oral hygiene care in stroke rehabilitation.

• Implications for Rehabilitation

• Oral hygiene care is crucial for stroke patients as it can prevent oral health problems and potentially life threatening events (such as aspiration pneumonia).

• Despite oral hygiene care being relative simple to perform, it is often neglected during stroke rehabilitation.

• A large-scale national survey was conducted to understand “intentions to” and “performance of” oral hygiene care to stroke patients using the Theory of Planned Behavior social cognition model.

• These study findings may have implications and use in promoting oral hygiene care to stroke patients:i) by understanding the pathways and influences to perform oral hygiene care.ii) to conduct health promotion and health education based on behavioral models such as Theory of Planned Behavior.

     

Methylprednisolone acetate induced release of cartilage proteoglycans: determination by high performance liquid chromatography.

A high performance liquid chromatography (HPLC) procedure suitable for the simultaneous determination of the molecular size and concentration of macromolecular hyaluronate and proteoglycans in synovial fluid has been developed. Irrigation of the equine tarsocrural joint with 20 ml physiological saline (PSS) caused a mild inflammation with an increase of proteoglycans in the synovial fluid over the baseline arthrocentesis control sample. Proteoglycan and hyaluronate in the synovial fluid did not interact to form hyaluronate-proteoglycan aggregates, but separated as distinct chromatographic peaks. This suggests that the cartilage derived proteoglycans in synovial fluid in the inflamed joint have been proteolytically cleaved from the non-covalent aggregates containing link protein and hyaluronate. Hyaluronidase digestion completely abolished the hyaluronate peak without affecting the proteoglycans. This seems to indicate that proteoglycan in synovial fluid is unable to interact with hyaluronate in synovial fluid to form cartilage type aggregates. Proteolytic degradation and the time dependent release into the synovial fluid of such digested proteoglycan also resulted from the intra-articular injection of methylprednisolone acetate into normal tarsocrural joints and joints irrigated with PSS. These proteoglycans were insensitive to hyaluronidase but may consist of a protein moiety with attached glycosaminoglycans, as suggested by their sensitivity to proteinase and keratanase/chondroitinase digestion. These observations with cartilage treated with methylprednisolone acetate and mildly stimulated articular cartilage are inconsistent with earlier work on osteoarthritic and rheumatoid articular cartilage and have interesting implications for the pathogenesis and for the therapeutic action of intraarticular corticosteroids. A rapid HPLC procedure applicable to unprocessed small volume samples of synovial fluid gives information simultaneously on hyaluronate and proteoglycan in synovial fluid which is not attainable with immunoradiometric or isotope tracer techniques. It therefore appears to be useful for the analysis of cartilage turnover and destruction in health and disease.     

Asparaginase‐associated pancreatitis in children with acute lymphoblastic leukaemia in the NOPHO ALL2008 protocol

L‐asparaginase is an important drug in the treatment of childhood acute lymphoblastic leukaemia (ALL). Treatment is associated with several toxicities, including acute pancreatitis. Clinical course, presentation, re‐exposure to L‐asparginase after pancreatitis and risk of recurrent pancreatitis within an asparaginase‐intensive protocol has been poorly reported. Children (1–17 years) on the ongoing Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2008 protocol with asparaginase‐associated pancreatitis (AAP) diagnosed between 2008 and 2012 were identified through the online NOPHO ALL toxicity registry. NOPHO ALL2008 includes eight or 15 doses of intramuscular pegylated L‐asparginase (PEG‐asparaginase) 1000 iu/m²/dose at 2–6 weeks intervals, with a total of 30 weeks of exposure to PEG‐asparaginase (clinicaltrials.gov no: NCT00819351). Of 786 children, 45 were diagnosed with AAP with a cumulative risk of AAP of 5·9%. AAP occurred after a median of five doses (range 1–13), and 11 d (median) from the latest administration of PEG‐Asparaginase. Thirteen patients developed pseudocysts (30%) and 11 patients developed necrosis (25%). One patient died from pancreatitis. Twelve AAP patients were re‐exposed to L‐asparginase, two of whom developed mild AAP once more, after four and six doses respectively. In conclusion, re‐exposure to PEG‐asparaginase in ALL patients with mild AAP seems safe.     

Changed gait pattern in patients with total knee arthroplasty but minimal influence of tibial insert design

Introduction Previous radiostereometric studies have revealed abnormal anterior-posterior translation of the femur in patients operated with AMK (DePuy, Johnson and Johnson, Leeds, UK) total knee arthroplasty (TKA). Based on these observations, we hypothesized that patients with TKA have an abnormal gait pattern, and that there are differences in kinematics depending on the design of the tibial joint area.

Method We used a gait analysis system to evaluate the influence of joint area design on the kinematics of the hip and knee during level walking. 39 TKA patients (42 knees) and 18 healthy age-matched controls were studied. Patients with 5° varus/valgus alignment or less were randomized to receive either a relatively flat or a concave tibial insert with retention of the posterior cruciate ligament. Patients who had more than 5° varus-valgus alignment and/or extension defect of 10° or more were randomized to receive the concave or a posterior-stabilized tibial component with resection of the posterior cruciate ligament.

Results Patients with TKA tended to have less hip and knee extension and decreased knee and hip extension moment than controls. They also tended to walk more slowly. TKA altered the gait pattern, but choice of implant design had little influence.

Interpretation In patients with a similar degree of degenerative joint disease and within the limits of the constraints offered by the prostheses under study, the choice of joint area constraint has little influence on the gait pattern.     

The evolving role of the personal support worker in home care in Ontario,Canada

To meet increasing demand for home care, the role of personal support workers (PSWs) is shifting from providing primarily personal and supportive care to include care activities previously provided by regulated health professionals (RHPs). Much of the research examining this shift focuses on specialty programmes, with few studies investigating the daily care being provided by PSWs, frequency of care activities being provided by PSWs, and characteristics of the population receiving more complex tasks. Between January and April 2015, a review of 517 home‐care service user charts was undertaken in Ontario, Canada, to: (1) describe the range of tasks being performed by PSWs in home care, (2) identify tasks transferred by RHPs to PSWs, and (3) examine characteristics of service users receiving transferred care. Findings indicate that normally, PSWs provide personal and supportive care commensurate with their training. However, in approximately one quarter of care plans reviewed, PSWs also completed more complex care activities transferred to them by RHPs. Service users receiving transferred care were older and had higher levels of cognitive and functional impairment. Although there is potential for the expansion of home‐care services through increased utilisation of PSWs, healthcare leadership must ensure that the right provider is being utilised at the right time and in the right place to ensure safe and effective quality care. Thus, several actions are recommended: PSW core competencies be clearly articulated, processes used to transfer care activities from RHPs to PSWs be standardised and a team‐based approach to the delivery of home‐care services be considered. Utilisation of a team‐based model can help establish positive relationships among home‐care providers, provide increased support for PSWs, allow for easier scheduling of initial training and ensure regular reassessments of PSW competence among PSWs providing added skills.