Ponte Osteotomies With Pedicle Screw Instrumentation in the Treatment of Adolescent Idiopathic Scoliosis

STUDY DESIGN

Review of prospective database.

OBJECTIVES

To report the results of Ponte osteotomy with pedicle screw instrumentation for major thoracic adolescent idiopathic (AIS) curves.

SUMMARY OF BACKGROUND DATA

Ponte osteotomy for achieving coronal and sagittal correction of major thoracic curves in AIS with pedicle screw instrumentation is a widespread technique, but results have not been well described.

METHODS

Review of 87 consecutive AIS patients with Lenke 1-4 curves who underwent Ponte osteotomies and pedicle screw instrumentation by 2 surgeons at a single institution. Surgical details, blood loss, and complications were recorded. We evaluated coronal and sagittal radiological measurements and Scoliosis Research Society-22 (SRS-22) questionnaire scores over 2-year follow-up.

RESULTS

The mean preoperative thoracic coronal Cobb angle was 57° ± 9.7°, fulcrum flexibility was 47.2%, and lateral Cobb angle was 17.8° ± 4°. The mean estimated blood loss (EBL), expressed as percent estimated blood volume, was 35.8 ± 20.5 mL. There was significant improvement in coronal thoracic Cobb angle, percent correction, and apical vertebral translation over 2-year follow-up (p < .05). In hypokyphotic curves, there was a significant increase in lateral thoracic T5-T12 kyphosis from 8.1° to 18.3° (p < .001). In hyperkyphotic curves, mean lateral thoracic T5-T12 kyphosis improved from 45° to 26° (p < .001). Median SRS-22 domains were higher after treatment (p < .05). Complications included significant hypotension (1), EBL greater than 75% estimated blood volume (2), and wound infection needing drainage (2). There were neuromonitoring signal changes in 7 patients but no significant neurological complications.

CONCLUSIONS

In this case series of major thoracic AIS curves treated with segmental pedicle screw instrumentation and Ponte osteotomies, there was an improvement in the coronal and sagittal radiological parameters. A prospective controlled study is needed to determine whether pedicle screw instrumentation and Ponte osteotomies influence outcomes and complications.

Gating of attentional effort through the central thalamus

The central thalamus plays an important role in the regulation of arousal and allocation of attentional resources in the performance of even simple tasks. To assess the contribution of central thalamic neurons to short-term adjustments of attentional effort, we analyzed 166 microelectrode recordings obtained from two rhesus monkeys performing a visuomotor simple reaction time task with a variable foreperiod. Multiunit responses showed maintained firing rate elevations during the variable delay period of the task in ∼24% of recording sites. Simultaneously recorded local field potentials demonstrated significant decreases in power at ∼10-20 Hz and increases in power at 30-100 Hz during the delay period when compared against precue baselines. Comparison of the spectral power of local field potentials during the delay period of correct and incorrect trials showed that, during incorrect trials, similar, but reduced, shifts of spectral power occurred within the same frequency bands. Sustained performance of even simple tasks requires regulation of arousal and attention that combine in the concept of "attentional effort". Our findings suggest that central thalamic neurons regulate task performance through brief changes in firing rates and spectral power changes during task-relevant short-term shifts of attentional effort. Increases in attentional effort may be reflected in changes within the central thalamic local populations, where correct task performance associates with more robust maintenance of firing rates during the delay period. Such ongoing fluctuations of central thalamic activity likely reflect a mix of influences, including variations in moment-to-moment levels of motivation, arousal, and availability of cognitive resources.

Concurrent tethered cord release and growing-rod implantation-is it safe?

Study Design Retrospective case series from one institution with a comparison control group. Objective To evaluate the safety of concomitant tethered cord release and growing-rod insertion in individuals with early onset scoliosis. Methods We retrospectively reviewed patients who underwent concurrent tethered cord release and growing-rod insertion. We compared our data to a comparison control group of eight patients who underwent staged tethered cord release and growing-rod insertion. Results We identified three patients meeting criteria. There were no neurological complications in the three patients who underwent concomitant surgery. Average immediate postoperative curve correction was 43.3 degrees (47.6%). We identified seven patients who underwent staged surgery from a multicenter prospective database. No neurological complications were reported, and average immediate postoperative correction was 35.1 degrees (46.2%). Conclusion We believe that concurrent tethered cord release and growing-rod insertion can be performed safely with the use of multimodality neurophysiological monitoring techniques.

Wrist fusion in patients with severe quadriplegic cerebral palsy

We report clinical and radiographic outcomes of wrist fusion achieved with pin or plate fixation in 14 patients with severe quadriplegic cerebral palsy (CP) (19 wrists). Average patient age at the time of surgery was 16.8 ± 1.7 years (14-20 years). Mean follow-up time for the 14 patients was 5.9 ± 3.1 years (range, 1-11 years). Indication for surgery was severe wrist deformity that interfered with hygienic care. Few complications occurred, and outcomes were satisfactory. Statistically significant mean difference was shown between the pre- and postoperative radiographic angles (37°, P = 0.001, and 24°, P = 0.04, for lateral and anteroposterior views, respectively). Caregivers reported that appearance was the most perceived rationale for surgery (63 %). Improved hygienic care was the primary perceived benefit. The majority (88 %) were satisfied with the results. We recommend wrist fusion to improve hygienic care, positioning, and appearance of the wrist, hand, and fingers in patients with severe quadriplegic CP.

Hookah smoking, nass chewing, and oesophageal squamous cell carcinoma in Kashmir, India

BACKGROUND

Although cigarette smoking is an established risk factor for oesophageal squamous cell carcinoma (ESCC), there is little information about the association between other smoking and smokeless tobacco products, including hookah and nass, and ESCC risk. We conducted a case-control study in Kashmir Valley, India, where hookah smoking, nass chewing, and ESCC are common, to investigate the association of hookah smoking, nass use, and several other habits with ESCC.

METHODS

We recruited 702 histologically confirmed ESCC cases and 1663 hospital-based controls, individually matched to the cases for age, sex, and district of residence from September 2008 to January 2012. Conditional logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Ever-hookah smoking (OR=1.85; 95% CI, 1.41-2.44) and nass chewing (OR=2.88; 95% CI, 2.06-4.04) were associated with ESCC risk. These associations were consistent across different measures of use, including intensity, duration, and cumulative amount of use, and after excluding ever users of the other product and cigarette smokers. Our results also suggest an increased risk of ESCC associated with ever-gutka chewing and -bidi smoking. However, the latter associations were based on small number of participants.

CONCLUSION

This study shows that hookah and nass use are associated with ESCC risk. As prevalence of hookah use seems to be increasing among young people worldwide, these results may have relevance not only for the regions in which hookah use has been a traditional habit, but also for other regions, including western countries.

Liver transplantation from hepatitis B surface antigen-positive donors

One possibility to increase the organ pool is to use grafts from hepatitis B virus (HBV) surface antigen (HBsAg)-positive donors, but few data are currently available in this setting. Herein, we reviewed the outcome of 92 liver transplantations using allografts from HBsAg-positive donors in the United States (1990-2009). They had experienced HBV-related (n = 68) or HBV-unrelated disease (n = 24). There was no difference between patients who received HBsAg-positive versus HBsAg-negative allografts based on age, Model for End-stage Liver Disease (MELD) score, length of stay, wait time, and donor risk index. HBsAg-positive allografts were more likely to be imported and used in MELD exceptional cases. Allograft and patient survival were comparable between the two groups. HBsAg-positive allografts deserve consideration when no other organ is available in a suitable waiting time in the present era of highly effective antiviral therapy.

Outcomes of posterior titanium spinal instrumentation in neuromuscular scoliosis patients

OBJECTIVES

In this study, we aimed to characterize the outcomes of posterior spinal fusion (PSF) using titanium instrumentation in neuromuscular scoliosis (NMS) patients with a special focus on deformity correction and correction maintenance.

PATIENTS AND METHODS

Between 2002 and 2004, nine patients (5 girls and 4 boys; mean age 14.9±2.3 years; range 11 to 19 years) with NMS who underwent PSF using titanium instrumentation were retrospectively analyzed. The mean height at surgery was 154.6±14.2 cm (range, 136-173 cm) and the mean weight was 59.4±19.2 kg (range, 26-114 kg). The mean follow-up duration was 3.7 years (range, 2-5 years). Preoperative data included demographics, curve type, and surgical indication. Rod size, fusion levels, duration of the operation (min), estimated blood loss (cc), and length of stay in hospital (day) were also evaluated intraoperatively. Postoperative data included correction of deformity, maintenance of correction, and complications. Radiographic measurements were obtained from standing posterior-anterior and lateral spinal radiographs at preoperative, postoperative (at first week after standing; i.e. first erect) and last follow-up visits. The data obtained were analyzed using descriptive statistic methods (mean, standard deviation, median, frequency and percentage).

RESULTS

Dramatic improvements in the spinal deformities were observed in the patients with NMS who underwent PSF using titanium instrumentation. Mean preoperative Cobb angle was reduced from 69.7 degrees to 16.2 degrees at first erect following surgery (at first week; 77% correction). Two-year follow-up revealed that this correction sustained (mean 14.8 degrees). However, moderate to severe postoperative complications requiring careful monitoring were reported.

CONCLUSION

Our study results showed that PSF with titanium instrumentation in pediatric NMS patients demonstrated satisfactory outcomes during the follow-up period. However, further large-scale studies with a long-term follow-up results are required to generalize the results regarding PSF using titanium instrumentation in these patients.

Effectiveness and safety of posterior titanium instrumentation in children with adolescent idiopathic scoliosis: a prospective study

OBJECTIVES

This study aims to determine the effectiveness and the relative safety of posterior spinal fusion with titanium instrumentation in children with adolescent idiopathic scoliosis (AIS).

PATIENTS AND METHODS

A prospective cohort (case-only) study was conducted to determine this effectiveness and safety. There were 24 patients (21 girls, 3 boys; mean age 14.1±1.8 years; range 11 to 17 years) who underwent surgery between January 2002 and December 2003 in our clinic, with a minimum of two years follow-up. Upper thoracic, thoracic, and thoracolumbar coronal curves as well as kyphosis from T5-T12 were measured as main outcome variables and repeated measure ANOVA was used to assess the data.

RESULTS

The main thoracic curve (coronal plane) correction achieved at the first erect period (the first 4 weeks postoperative) (mean 12.21±9.78 degrees), this correction was maintained at 24 months follow-up (mean 15.71±7.15 degrees) and both were significantly lower than the preoperative values (mean 57.0±12.75 degrees), (p<0.001). Sagittal plane (kyphosis angle between T5-T12) curve was not worsened by posterior titanium instrumentation and it was 19.50±10.53 degrees preoperatively, 16.45±6.68 degrees at the first erect period and 17.73±8.40 degrees at the 24 months follow-up (p=0.74). There were no evidence of pseudoarthrosis, no loss of correction and no infections.

CONCLUSION

Posterior titanium instrumentation in the treatment of AIS is effective due to its ability to achieve and maintain curve correction. Further, this instrumentation does not worsen hypokyphosis and is safe since there were no adverse events.

DYNAMIC SCAPHOLUNATE DISSOCIATION IN A CHILD

We describe a case of dynamic scapholunate dissociation in a skeletally immature ten-year-old girl. The patient presented for pain in the anatomical snuffbox and swelling over the dorsum of the wrist and hand. Standard static and dynamic radiographs of the wrist did not reveal any pathology. Magnetic resonance imaging was inconclusive. The scapholunate dissociation was diagnosed by wrist arthroscopy, reduced, and stabilised using standard techniques. Full and pain-free motion of the wrist was restored.

Osteochondrosis: common causes of pain in growing bones

Osteochondrosis is a term used to describe a group of disorders that affect the growing skeleton. These disorders result from abnormal growth, injury, or overuse of the developing growth plate and surrounding ossification centers. The exact etiology of these disorders is unknown, but genetic causes, repetitive trauma, vascular abnormalities, mechanical factors, and hormonal imbalances may all play a role. Legg-Calvé-Perthes disease is a hip disorder that causes hip pain, an atraumatic limp, and knee pain. Osgood-Schlatter and Sinding-Larsen-Johannson diseases are common causes of anterior knee pain that is aggravated by jumping activities and kneeling. Sever disease causes heel pain that is exacerbated by activity and wearing cleats. It often mimics Achilles tendinitis and is treated with activity and shoe modifications, heel cups, and calf stretches. Freiberg disease and Köhler bone disease often cause foot pain and are disorders of the metatarsal head and navicular bone, respectively. Radiographs show sclerosis, flattening, and fragmentation of bone in both diseases. Elbow pain can be caused by medial epicondyle apophysitis or Panner disease. Medial epicondyle apophysitis is exacerbated by frequent throwing and is treated with throwing cessation and acetaminophen or nonsteroidal anti-inflammatory drugs. Panner disease is the most common cause of lateral-sided elbow pain in children younger than 10 years. It may or may not be associated with frequent throwing, and it resolves spontaneously. Scheuermann disease causes back pain and a humpback deformity from vertebral bone anterior wedging.

Complications of growing-rod treatment for early-onset scoliosis: analysis of one hundred and forty patients

BACKGROUND

Previous reports have indicated high complication rates associated with non-fusion surgery in patients with early-onset scoliosis. This study was performed to evaluate the clinical and radiographic complications associated with growing-rod treatment.

METHODS

Data from the multicenter Growing Spine Study Group database were evaluated. Inclusion criteria were growing-rod treatment for early-onset scoliosis and a minimum of two years of follow-up. Patients were divided into treatment groups according to rod type (single or dual) and rod location (subcutaneous or submuscular). Complications were categorized as wound, implant, alignment, and general (surgical or medical). Surgical procedures were classified as planned and unplanned.

RESULTS

Between 1987 and 2005, 140 patients met the inclusion criteria and underwent a total of 897 growing-rod procedures. The mean age at the initial surgery was six years, and the mean duration of follow-up was five years. Eighty-one (58%) of the 140 patients had a minimum of one complication. Nineteen (27%) of the seventy-one patients with a single rod had unplanned procedures because of implant complications, compared with seven (10%) of the sixty-nine patients with dual rods (p ≤ 0.05). Thirteen (26%) of the fifty-one patients with subcutaneous rod placement had wound complications compared with nine of the eighty-eight patients (10%) with submuscular rod placement (p ≤ 0.05). The patients with subcutaneous dual rods had more wound complications, more prominent implants, and more unplanned surgical procedures than did those with submuscular dual rods (p ≤ 0.05). The risk of complications occurring during the treatment period decreased by 13% for each year of increased patient age at the initiation of treatment. The complication risk increased by 24% for each additional surgical procedure performed.

CONCLUSIONS

Regardless of treatment modality, the management of early-onset scoliosis is prolonged; therefore, complications are frequent and should be expected. Complications can be reduced by delaying initial implantation of the growing rods if possible, using dual rods, and limiting the number of lengthening procedures. Submuscular placement reduces wound and implant-prominence complications and reduces the number of unplanned operations.

A method for content uniformity determination of atenolol and losartan potassium in combined tablet dosage form

A simple, accurate, rapid, specific and reproducible UV spectrophotometric method was developed for estimation of content uniformity of atenolol and losartan potassium in its combined tablet dosage form. The method involves formation and solving the simultaneous equation using 226.4 and 254 nm as two wavelengths for atenolol and losartan, respectively. Developed method was employed to determine the atenolol and losartan content in ten individual tablet units of five market formulations. Methanol was used as solvent. The method was validated. From the results, it was concluded that all brands are within the content uniformity limit, 85-115%.

Executive function and attention span in euthymic patients with bipolar 1 disorder

This is a cross sectional comparison study to assess executive function and attention span in euthymic patients with bipolar 1 disorder. It compares the performance of these two cognitive domains in 40 patients with bipolar 1 disorder to that of 40 healthy normal subjects using Trail Making (TMT), Digit Span (Forward and Backward) and Verbal Fluency (VF) tests. The association between demographic, clinical characteristics and performance in all tests were examined. Patients with bipolar illness showed significant impairment with moderate to large effect sizes (VF = 0.67, TMT A = 0.52, TMT B = 0.81, Digit Forward = 0.97, Digit backward = 1.10) in all tasks of executive and attention functioning. These impairments are observed in the absence of active mood symptoms while duration and severity of illness are not found to have an effect on both cognitive domains. Medications received by patients with bipolar disorder have significant association with performance on executive tasks. The results of this study add on to the existing global evidence of cognitive impairment in bipolar illness despite its cross cultural differences. Its presence in the absence of mania, depression or mixed episode indicates that cognitive impairment is stable even after symptoms recovery.

Infection rate after spine surgery in cerebral palsy is high and impairs results: multicenter analysis of risk factors and treatment

Infection is a serious complication of surgery to correct scoliosis in patients with cerebral palsy (CP). We obtained multicenter representative figures for deep and superficial infection rates, analyzed risk factors and treatment outcomes, and compared deformity correction relative to infection. We retrospectively reviewed 157 patients who had posterior spinal fusion for CP at one of eight centers. Preoperative and intraoperative variables were subjected to multivariate analysis to determine factors predictive of infection. There were 16 wound infections (10%; nine deep, seven superficial). Only two study factors predicted infection: higher preoperative white blood cell count (8.5 versus 6.4 [in those without infection] x 10(3)) and use of a unit rod (15% versus 5% for bent rods). Fourteen patients underwent irrigation and débridement procedures. Five infections required 2 months or longer to resolve. Two had implant removal. Final curve correction was lower for those with deep infections than those without (67% versus 53%, respectively). We noted a trend toward greater percentages of pain at last followup in those with deep infection than in those without infection (50% versus 18%, respectively) but the study was not adequately powered to confirm this point. Our infection rate in scoliosis surgery for CP was higher than that for most elective spinal deformity surgery.

LEVEL OF EVIDENCE

Level III, retrospective case-control study. See Guidelines for Authors for a complete description of levels of evidence.

Collective diffusion in colloid-polymer suspensions: relative role of thermodynamics and hydrodynamics

Theories such as the mode coupling theory (MCT) have seen recent success in predicting the kinetic arrest boundaries and resultant flow properties of colloidal suspensions. A key assumption of such theories is that interparticle forces and equilibrium structure control slow dynamics and gelation, not long-time many-body hydrodynamics. Here we report measurements of short-time collective diffusivities of colloid-polymer suspensions aimed at elucidating the relative contributions of hydrodynamics and thermodynamics as a phase transition or gelation boundary is approached. The experimental system is a hard sphere octadecyl silica suspension to which nonadsorbing polystyrene is added. Two different polymer molecular weights are chosen such that they give rise to a liquid-liquid or a gel transition as the colloid volume fraction or polymer concentration is increased. The short-time diffusivities are measured for each polymer molecular weight as a function of polymer concentration and colloid volume fraction. At a fixed polymer molecular weight and concentration, the colloid volume fraction is varied from dilute to concentrated and near the phase separation boundary. It is found for all measured colloid volume fractions that the diffusivities decrease linearly with increasing strength of the polymer-mediated depletion attraction at a fixed polymer molecular weight. Comparisons are made with theoretical predictions in the dilute limit. When the effects of thermodynamics are normalized out by multiplying the measured diffusivities with the suspension structure factor, it is found that the hydrodynamic effects are essentially those of hard spheres independent of the range and strength of depletion attraction.

High-risk behaviours among juvenile prison inmates in Pakistan

OBJECTIVES

To assess the sexual- and drug-use-related risk behaviours of male juvenile detainees in Karachi, Pakistan.

DESIGN

Cross-sectional study.

METHODS

A cross-sectional study was conducted of prison inmates aged 15-21 years in Karachi Juvenile Prison in 2002. In total, 321 inmates were interviewed about sexual orientation and behaviours, and knowledge about human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). Urine specimens were collected and tested for Chlamydia trachomatis and Neisseria gonorrhoeae using ligase chain reaction.

RESULTS

A substantial proportion (n=111, 34.6%) of the participants were sexually active. Sixty-two (19%) and 67 (21%) had had sex with a male or female before incarceration, respectively. Twenty-seven (8.4%) participants had an STI, and 50% of the 109 sexually active participants had had multiple sexual partners. Use of addictive substances was associated with sexual activity. The mean knowledge score computed from the sum of 16 items was 4.7, with a median of 2.9. A large proportion (40%) of participants knew about condoms, but very few (3.4%) had ever used one. The mean+/-standard deviation risk score from nine items was 2.4+/-1.7. On the basis of behavioural and biological markers, 117 (36.4%) participants had high-risk behaviour. In multivariate logistic regression analysis, knowledge, risk perception and age were predictive of higher risk.

CONCLUSIONS

HIV risk behaviours are common among adolescent inmates. Although inmates do have knowledge about modes of transmission and condom use, the use of condoms is significantly low. Interventions are needed for behavioural change among this group.

Recurrent multifocal primary amyloidosis of urinary bladder

Primary localized amyloidosis of bladder is rare. We report a case of recurrence of multifocal primary amyloidosis of urinary bladder. Cystoscopy revealed a diffuse left lateral wall lesion with normal surrounding mucosa. Histopathological examination of the specimen revealed urinary bladder amyloidosis with negative surgical margins. Recurrent urinary bladder amyloidosis was confirmed 3 months after the first resection. Close follow-up is recommended.

Neurophysiological detection of impending spinal cord injury during scoliosis surgery

BACKGROUND

Despite the many reports attesting to the efficacy of intraoperative somatosensory evoked potential monitoring in reducing the prevalence of iatrogenic spinal cord injury during corrective scoliosis surgery, these afferent neurophysiological signals can provide only indirect evidence of injury to the motor tracts since they monitor posterior column function. Early reports on the use of transcranial electric motor evoked potentials to monitor the corticospinal motor tracts directly suggested that the method holds great promise for improving detection of emerging spinal cord injury. We sought to compare the efficacy of these two methods of monitoring to detect impending iatrogenic neural injury during scoliosis surgery.

METHODS

We reviewed the intraoperative neurophysiological monitoring records of 1121 consecutive patients (834 female and 287 male) with adolescent idiopathic scoliosis (mean age, 13.9 years) treated between 2000 and 2004 at four pediatric spine centers. The same group of experienced surgical neurophysiologists monitored spinal cord function in all patients with use of a standardized multimodality technique with the patient under total intravenous anesthesia. A relevant neurophysiological change (an alert) was defined as a reduction in amplitude (unilateral or bilateral) of at least 50% for somatosensory evoked potentials and at least 65% for transcranial electric motor evoked potentials compared with baseline.

RESULTS

Thirty-eight (3.4%) of the 1121 patients had recordings that met the criteria for a relevant signal change (i.e., an alert). Of those thirty-eight patients, seventeen showed suppression of the amplitude of transcranial electric motor evoked potentials in excess of 65% without any evidence of changes in somatosensory evoked potentials. In nine of the thirty-eight patients, the signal change was related to hypotension and was corrected with augmentation of the blood pressure. The remaining twenty-nine patients had an alert that was related directly to a surgical maneuver. Three alerts occurred following segmental vessel clamping, and the remaining twenty-six were related to posterior instrumentation and correction. Nine (35%) of these twenty-six patients with an instrumentation-related alert, or 0.8% of the cohort, awoke with a transient motor and/or sensory deficit. Seven of these nine patients presented solely with a motor deficit, which was detected by intraoperative monitoring of transcranial electric motor evoked potentials in all cases, and two patients had only sensory symptoms. Somatosensory evoked potential monitoring failed to identify a motor deficit in four of the seven patients with a confirmed motor deficit. Furthermore, when changes in somatosensory evoked potentials occurred, they lagged behind the changes in transcranial electric motor evoked potentials by an average of approximately five minutes. With an appropriate response to the alert, the motor or sensory deficit resolved in all nine patients within one to ninety days.

CONCLUSIONS

This study underscores the advantage of monitoring the spinal cord motor tracts directly by recording transcranial electric motor evoked potentials in addition to somatosensory evoked potentials. Transcranial electric motor evoked potentials are exquisitely sensitive to altered spinal cord blood flow due to either hypotension or a vascular insult. Moreover, changes in transcranial electric motor evoked potentials are detected earlier than are changes in somatosensory evoked potentials, thereby facilitating more rapid identification of impending spinal cord injury.

The risk of progression of scoliosis in cerebral palsy patients after intrathecal baclofen therapy

STUDY DESIGN

Retrospective radiographic and medical chart review with matched control group.

OBJECTIVE

To identify the effect of intrathecal baclofen on the incidence of scoliosis, rate of curve progression, and pelvic obliquity compared with a matched cohort.

SUMMARY OF BACKGROUND DATA

Although intrathecal baclofen therapy (ITB) has been shown to be effective in decreasing spasticity, case reports have described some children receiving ITB in whom progressive scoliosis was noted; other authors have described no effect on the spinal column. A controlled study has not been performed.

METHODS

All patients with spastic CP treated with ITB between 1997 and 2003 at a single institution were reviewed. A total of 107 patients undergoing ITB for a minimum of 2 years were identified, of which 26 patients subsequently developed or had progression of scoliosis. Twenty-five age, gender, and gross motor function classification system (GMFCS) score-matched quadriplegic CP patients with scoliosis who did not receive ITB constituted the control group used to compare the rate of curve progression and pelvic obliquity.

RESULTS

The average curve progression for the baclofen group after pump implantation was 16.3 degrees per year; and for the control group was 16.1 degrees per year. Both groups' curves progressed over time during growth (P = 0.001), but baclofen did not have an independent effect on curve progression (P = 0.181). Average pelvic obliquity for the 2 groups increased over time (P = 0.001), but there was no difference between the groups (P = 0.536). Twelve of 57 patients (21%) developed scoliosis after pump implantation during a mean of 3.6 years of follow-up. Thirty of 92 matched control patients (32%) not treated with ITB within the same time interval had scoliosis by maturity.

CONCLUSION

This study demonstrates that ITB has no significant effect on curve progression, pelvic obliquity, or the incidence of scoliosis when compared with an age, gender, and GMFCS score-matched control group of patients with spastic CP without ITB.

Syndromic management training for non-formal care providers in Pakistan improves quality of care for sexually transmitted diseases STD care: a randomized clinical trial

We conducted a randomized, controlled, three-armed trial to assess whether training in syndromic management, with provision of packets, could improve the quality of STD services provided among non-formal care providers. The quality of STD case management service, observed by "incognito patients" in both intervention groups, improved substantially compared to the control group (p < 0.05). The training-and-packets group performed better in service delivery, HIV-testing referral, and condom provision when compared to the training-only group (all p < 0.05). The training-and-packets group also retained more knowledge and practiced more skillfully at six months post-intervention when compared to the training-only group (p < 0.05). Exit interviews of clients suggested that 81% of providers in the intervention groups offered advice on condom use when compared to none of those in the control group (p < 0.001). Syndromic management training and free syndrome packets for non-formal providers had a positive impact on the quality of STD care among the trained providers.

Reduced mortality with right-lobe living donor compared to deceased-donor liver transplantation when analyzed from the time of listing

Right lobe living donor liver transplantation (RLDLT) is not yet a fully accepted therapy for patients with end-stage liver failure in the Western hemisphere because of concerns about donor safety and inferior recipient outcomes. An outcome analysis from the time of listing for all adult patients who were listed for liver transplantation (LT) at our center was performed. From 2000 to 2006, 1091 patients were listed for LT. One hundred fifty-four patients (LRD; 14%) had suitable live donors and 153 (99%) underwent RLDLT. Of the remaining patients (DD/Waiting List; n = 937), 350 underwent deceased donor liver transplant (DDLT); 312 died or dropped off the waiting list; and 275 were still waiting at the time of this analysis. The LRD group had shorter mean waiting times (6.0 months vs. 9.8 months; p < 0.001). Although medical model for end-stage liver disease (MELD) scores were similar at the time of listing, MELD scores at LT were significantly higher in the DD/Waiting List group (15.4 vs. 19.5; p = 0.002). Patients in Group 1 had a survival advantage with RLDLT from the time of listing (1-year survival 90% vs. 80%; p < 0.001). To our knowledge, this is the first report to document a survival advantage at time of listing for RLDLT over DDLT.