[Translated article] Less superior adjacent syndrome and lower reoperation rate. Medium- and long-term results of cervical arthroplasty versus anterior cervical arthrodesis: Systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To compare medium- and long-term postoperative surgical results, especially the adjacent syndrome rate, adverse event rate, and reoperation rate, of patients operated on with cervical arthroplasty or anterior cervical arthrodesis in published randomized clinical trials (RCTs), at one cervical level.

METHODS

Systematic review and meta-analysis. Thirteen RCTs were selected. The clinical, radiological and surgical results were analyzed, taking the adjacent syndrome rate and the reoperation rate as the primary objective of the study.

RESULTS

Two thousand nine hundred and sixty three patients were analyzed. The cervical arthroplasty group showed a lower rate of superior adjacent syndrome (P<0.001), lower reoperation rate (P<0.001), less radicular pain (P=0.002), and a better score of neck disability index (P=0.02) and SF-36 physical component (P=0.01). No significant differences were found in the lower adjacent syndrome rate, adverse event rate, neck pain scale, or SF-36 mental component. A range of motion of 7.91° was also found at final follow-up, and a heterotopic ossification rate of 9.67% in patients with cervical arthroplasty.

CONCLUSION

In the medium and long-term follow-up, cervical arthroplasty showed a lower rate of superior adjacent syndrome and a lower rate of reoperation. No statistically significant differences were found in the rate of inferior adjacent syndrome or in the rate of adverse events.

Less superior adjacent syndrome and lower reoperation rate. Medium- and long-term results of cervical arthroplasty versus anterior cervical arthrodesis: Systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To compare medium- and long-term postoperative surgical results, especially the adjacent syndrome rate, adverse event rate, and reoperation rate, of patients operated on with cervical arthroplasty or anterior cervical arthrodesis in published randomized clinical trials (RCTs), at one cervical level.

METHODS

Systematic review and meta-analysis. Thirteen RCTs were selected. The clinical, radiological and surgical results were analyzed, taking the adjacent syndrome rate and the reoperation rate as the primary objective of the study.

RESULTS

Two thousand nine hundred and sixty three patients were analyzed. The cervical arthroplasty group showed a lower rate of superior adjacent syndrome (P<0.001), lower reoperation rate (P<0.001), less radicular pain (P=0.002), and a better score of neck disability index (P=0.02) and SF-36 physical component (P=0.01). No significant differences were found in the lower adjacent syndrome rate, adverse event rate, neck pain scale, or SF-36 mental component. A range of motion of 7.91 degrees was also found at final follow-up, and a heterotopic ossification rate of 9.67% in patients with cervical arthroplasty.

CONCLUSION

In the medium and long-term follow-up, cervical arthroplasty showed a lower rate of superior adjacent syndrome and a lower rate of reoperation. No statistically significant differences were found in the rate of inferior adjacent syndrome or in the rate of adverse events.

Bacterial lipopolysaccharide forms aggregates with apolipoproteins in male and female rat brains after ethanol binges

Alcohol binge drinking allows the translocation of bacterial lipopolysaccharide (LPS) from the gut to the blood, which activates the peripheral immune system with consequences in neuroinflammation. A possible access/direct signaling of LPS to/in the brain has not yet been described under alcohol abuse conditions. Apolipoproteins are compounds altered by alcohol with high affinity to LPS which may be involved in its transport to the brain or in its elimination. Here, we explored the expression of small components of LPS, in its free form or bound to apolipoproteins, in the brain of female and male rats exposed to alcohol binges. Animals received ethanol oral gavages (3 g/kg every 8 h) for 4 days. LPS or its components (Lipid A and core), LPS-binding protein, corticosterone, lipoproteins (HDL, LDL), apolipoproteins (ApoAI, ApoB, and ApoE), and their receptors were measured in plasma and/or in nonperfused prefrontal cortex (PFC) and cerebellum. Brain LipidA-apolipoprotein aggregates were determined by Western blotting and confirmed by co-immunoprecipitation. In animals exposed to alcohol binges: 1) plasma LPS-binding protein was elevated in both sexes; 2) females showed elevations in plasma ApoAI and corticosterone levels; 3) Lipid A formed aggregates with ApoAI in the female PFC and with ApoB in males, the latter showing Toll-like receptor 4 upregulation in PFC but not females. These results suggest that small bacterial components are present within the brain, forming aggregates with different apolipoproteins, depending on the sex, after alcohol binge intoxications. Results may have implications for the crosstalk between alcohol, LPS, and neuroinflammation.

Reelin Plasma Levels Identify Cognitive Decline in Alcohol Use Disorder Patients During Early Abstinence: The Influence of APOE4 Expression

BACKGROUND

Apolipoprotein E (APOE)-4 isoform, reelin, and clusterin share very-low-density liporeceptor and apolipoprotein E receptor 2 receptors and are related to cognition in neuropsychiatric disorders. These proteins are expressed in plasma and brain, but studies involving plasma expression and cognition are scarce.

METHODS

We studied the peripheral expression (plasma and peripheral blood mononuclear cells) of these proteins in 24 middle-aged patients with alcohol use disorder (AUD) diagnosed at 4 to 12 weeks of abstinence (t = 0) and 34 controls. Cognition was assessed using the Test of Detection of Cognitive Impairment in Alcoholism. In a follow-up study (t = 1), we measured reelin levels and evaluated cognitive improvement at 6 months of abstinence.

RESULTS

APOE4 isoform was present in 37.5% and 58.8% of patients and controls, respectively, reaching similar plasma levels in ε4 carriers regardless of whether they were patients with AUD or controls. Plasma reelin and clusterin were higher in the AUD group, and reelin levels peaked in patients expressing APOE4 (P < .05, η2 = 0.09), who showed reduced very-low-density liporeceptor and apolipoprotein E receptor 2 expression in peripheral blood mononuclear cells. APOE4 had a negative effect on memory/learning mainly in the AUD group (P < .01, η2 = 0.15). Multivariate logistic regression analyses identified plasma reelin as a good indicator of AUD cognitive impairment at t = 0. At t = 1, patients with AUD showed lower reelin levels vs controls along with some cognitive improvement.

CONCLUSIONS

Reelin plasma levels are elevated during early abstinence in patients with AUD who express the APOE4 isoform, identifying cognitive deterioration to a great extent, and it may participate as a homeostatic signal for cognitive recovery in the long term.

Upregulation of TLR4/MyD88 pathway in alcohol-induced Wernicke’s encephalopathy: Findings in preclinical models and in a postmortem human case

Wernicke’s encephalopathy (WE) is a neurologic disease caused by vitamin B1 or thiamine deficiency (TD), being the alcohol use disorder its main risk factor. WE patients present limiting motor, cognitive, and emotional alterations related to a selective cerebral vulnerability. Neuroinflammation has been proposed to be one of the phenomena that contribute to brain damage. Our previous studies provide evidence for the involvement of the innate immune receptor Toll-like (TLR)4 in the inflammatory response induced in the frontal cortex and cerebellum in TD animal models (animals fed with TD diet [TDD] and receiving pyrithiamine). Nevertheless, the effects of the combination of chronic alcohol consumption and TD on TLR4 and their specific contribution to the pathogenesis of WE are currently unknown. In addition, no studies on TLR4 have been conducted on WE patients since brains from these patients are difficult to achieve. Here, we used rat models of chronic alcohol (CA; 9 months of forced consumption of 20% (w/v) alcohol), TD hit (TDD + daily 0.25 mg/kg i.p. pyrithiamine during 12 days), or combined treatment (CA + TDD) to check the activation of the proinflammatory TLR4/MyD88 pathway and related markers in the frontal cortex and the cerebellum. In addition, we characterized for the first time the TLR4 and its coreceptor MyD88 signature, along with other markers of this proinflammatory signaling such as phospo-NFκB p65 and IκBα, in the postmortem human frontal cortex and cerebellum (gray and white matter) of an alcohol-induced WE patient, comparing it with negative (no disease) and positive (aged brain with Alzheimer’s disease) control subjects for neuroinflammation. We found an increase in the cortical TLR4 and its adaptor molecule MyD88, together with an upregulation of the proinflammatory signaling molecules p-NF-ĸB and IĸBα in the CA + TDD animal model. In the patient diagnosed with alcohol-induced WE, we observed cortical and cerebellar upregulation of the TLR4/MyD88 pathway. Hence, our findings provide evidence, both in the animal model and the human postmortem brain, of the upregulation of the TLR4/MyD88 proinflammatory pathway in alcohol consumption–related WE.

Outcomes of cervical arthroplasty versus anterior cervical arthrodesis: a systematic review and meta-analysis of randomized clinical trials with a minimum follow-up of 7-year

PURPOSE

Compare the outcomes of randomized clinical trials of cervical disc arthroplasty (CDA) versus anterior cervical discectomy with fusion (ACDF), with a minimum follow-up of 7 years.

METHODS

Nine randomized clinical trials were selected. The clinical, radiological, and surgical outcomes were analyzed, including functional and pain scores, range of motion, adjacent segment degeneration, adverse events, and need for reoperation.

RESULTS

2664 patients were included in the study. Pooled results indicated that the CDA group had a significantly higher overall success rate (p < 0.001), a higher improvement in the neck disability index (NDI) (p = 0.002), less VAS arm pain (p = 0.01), and better health questionnaire SF-36 physical component (p = 0.01) than ACDF group. Likewise, the pooled results indicated a significantly higher motion rate (p < 0.001), less adjacent syndrome (p < 0.05), and a lower percentage of reoperation (p < 0.001) in the CDA group. There were no significant differences between the CDA and ACDF groups in the neck pain scale (p = 0.11), the health questionnaire SF-36 mental component (p = 0.10), and in adverse events (p = 0.42).

CONCLUSION

In long-term follow-up, CDA showed a better overall success rate, better improvement in NDI, less VAS arm pain, better health questionnaire SF-36 physical component, a higher motion rate, less adjacent syndrome, and less reoperation rate than ACDF. No significant differences were found in the neck pain scale, SF-36 mental component, and in adverse events.

Is routine blood typing and screening necessary for degenerative cervical spine surgery patients in specialty surgical hospitals?

BACKGROUND

Blood loss warranting transfusion is a relatively rare requirement for degenerative cervical spine surgery. Despite this rarity, pretransfusion testing (blood typing, screening, and cross-matching) has become routine in most parts of the world. We sought to determine if such routine testing is necessary for patients who undergo degenerative cervical spine surgery patients in specialty surgical hospitals by (1) measuring the current rate of intraoperative transfusions in degenerative cervical spine surgery and (2) identifying risk factors for transfusions.

STUDY METHODS

Retrospective review was performed on patients who underwent degenerative cervical spine surgery in two institutions. Demographic and baseline clinical and laboratory data were collected and analyzed to identify predictors of transfusion. Bivariate and multivariate logistic regression analysis was performed to identify perioperative transfusion risk factors.

RESULTS

Overall transfusion rate was 1.9% (7/372), with no emergent transfusions. Decreases between preoperative and postoperative hemoglobin and hematocrit were 1.4 (SD 1.1) g/dL and 7.2 (SD 4.1) %, respectively. Multivariate logistic regression identified preoperative Hgb lower than 12 gr/dl (OR 27.62; 95% CI 4.31-176.96; p < 0.001) as significant independent transfusion risk factor. The receiver operating characteristic (ROC) curve for the model showed a very good discriminatory power with an area under the curve of 0.91.

DISCUSSION

Our study suggests that pretransfusion testing for all patients undergoing degenerative cervical spine surgery is unnecessary. We recommend that only patients with preoperative Hgb lower than 12 gr/dl would routinely need pretransfusion testing.

Subcutaneous Radiographic Measurement: A Marker to Evaluate Surgical Site Infection Risk in Elderly Hip Fracture Patients

Objectives: Obesity is a documented comorbidity that is prevalent in the elderly population and a known predictor for surgical site infection (SSI). Body mass index is a convenient method to classify obesity, but it fails to account for fat distribution. The objective of our study was to evaluate the association between surgical site infection and a subcutaneous radiographic measurement (SRM) in elderly hip fracture patients. Materials and Methods: A retrospective case-control study was conducted to compare SRMs at the hip in patients diagnosed with surgical site infection after hip fracture surgery with patients that were not diagnosed with surgical site infection. Each case was matched to two controls. An SRM was defined as the distance from the tip of the greater trochanter to the skin following a perpendicular line to the femoral diaphysis in anteroposterior hip radiographs. Clinical diagnosis of acute surgical site infection was based on Tsukayama criteria. Results: Patients with an SRM greater than 6.27cm had a 7-fold increase in the odds of surgical site infection (OR=7.42, 95% Confidence Interval (CI)=3.01-18.28, p<0.001) compared to those with smaller measurements. The odds ratio (OR) for infection of patients with an ASA score of 3 was 15.82(95% CI=5.11-48.9, p-value<0.001) A statistically significant difference between cases and controls was also found when SRM at the hip was analyzed as a continuous variable. Patients with an infection had a 2.24cm (95% CI=1.59 - 2.90; p<0.001) greater mean SRM. Conclusion: Results of our study suggest an association between the SRM at the hip and the risk of SSI in elderly patients with surgically treated hip fractures. SRM may be a helpful tool for evaluating the risk of SSI in elderly hip fracture patients.

[First non-autologous vascular access for hemodialysis: PTFE fistula]

INTRODUCTION

Since 1999 to 2003 we have tried to perform an antebraquial "loop" PTFE fistula (PTFEa) as first vascular access for hemodialysis in patients without suitable superficial venous system.

MATERIAL AND METHODS

We have performed a prospective study to analyze the results (permeability and complications) with this approach.

RESULTS

We could perform 44 PTFEa in 46 consecutive patients (in two cases we used the axillary vein as return vessel). Early failure was 0%. One year primary and secondary permeability were 66% and 90% respectively.

CONCLUSIONS

PTFEa is a good solution as first vascular access in patients without a suitable superficil venous system.

TSH stimulates leptin secretion by a direct effect on adipocytes

Leptin is a circulating hormone secreted by adipose tIssue which acts as a signal to the central nervous system where it regulates energy homeostasis and neuroendocrine processes. Although leptin modulates the secretion of several pituitary hormones, no information is available regarding a direct action of pituitary products on leptin release. However, it has been pointed out that leptin and TSH have a coordinated pulsatility in plasma. In order to test a direct action of TSH on in vitro leptin secretion, a systematic study of organ cultures of human omental adipose tIssue was performed in samples obtained at surgery from 34 patients of both sexes during elective abdominal surgery. TSH powerfully stimulated leptin secretion by human adipose tIssue in vitro. In contrast, prolactin, ACTH, FSH and LH were devoid of action. These results suggest that leptin and the thyroid axis maintain a complex and dual relationship and open the possibility that plasmatic changes in TSH may contribute to the regulation of leptin pulses.

Purification and characterization of the endogenous inhibitor for proteinase B from Schizosaccharomyces pombe

A rapid purification procedure for the endogenous inhibitor of proteinase yspB from Schizosaccharomyces pombe is described. Starting from a boiled extract, the purification procedure included an ionic exchange chromatography and two reverse phase chromatographies using a HPLC system. The molecular mass of the purified polypeptide was estimated to be 8,100 Da by gel filtration. The isoelectric point of the inhibitor was found to be 5.3 after electrofocusing of a purified preparation. The amino acid composition of the proteinase yspB inhibitor was analyzed after acid hydrolysis. The calculated number of residues was 67 and the corresponding molecular mass 7370 Da. There are several differences in the molecular characteristics between the inhibitor from Schizosaccharomyces pombe and the corresponding inhibitor previously purified from Saccharomyces cerevisiae which might reflect the evolutionary divergence between the two yeast genera.

[The biological aftereffects of preoperative and palliative percutaneous biliary drainage]

Biological repercussions in 78 patients with malignant obstructive jaundice in whom percutaneous biliary drainage was performed, are reported. In 37 cases drainage was done during operation while 41 were palliative. Biochemistry, proteinogram, hematological studies, renal function and immunology were assessed 15.7 +/- 3.4 days postoperatively and 25.2 +/- 4.7 days in palliative drainage. Results show a significant improvement of all parameters, more important in preoperative drainages especially in those combining percutaneous and internal drainage techniques.

The proteolytic system of the fission yeast Schizosaccharomyces pombe

Proteinase and peptidase activities of the fission yeast Schizosaccharomyces pombe were investigated. Several intracellular proteolytic enzymes were found: two endoproteinases, one carboxypeptidase, one aminopeptidase and one dipeptidyl-aminopeptidase. In addition, proteinase inhibitors were detected. In fresh crude extracts an activation procedure is needed to measure maximal activities of endoproteinases and carboxypeptidase, whose level is markedly dependent on growth medium composition and on growth phase, while aminopeptidase and dipeptidyl-aminopeptidase activities are very little, if at all, regulated by the carbon source.

[Evaluation of transparietal hepatic cholangiography in the diagnosis of cholestatic syndrome]

Three hundred and thirty-two percutaneous cholangiograms were done in 313 patients. The etiology was benign in 137 cases and malignant in 152 instances. The level of obstruction was correctly localized in 97.8% of cases. The total sensitivity was 88.5% and specificity 95.9%. Positive predictive value 95.4% and negative predictive value 89.6%. Major complications occurred in 3.3% of cases. Complications occurred more frequently when the bile ducts were dilated. They were not related to the number of attempts to puncture ther biliary tree or the experience of the physician.

[Adenocarcinoma of the cardia: results of distal esophagectomy and total enlarged gastrectomy using left thoracophrenolaparotomy]

An analysis was made of the results obtained in terms of postoperative complications, mortality and the 5-year survival rate in a series of 23 patients diagnosed as adenocarcinoma of the cardias who underwent total gastrectomy with distal esophagectomy via left thoracophrenolaparotomy, with esophagojejunostomy on a Roux-en-Y loop. We consider the results as favorable and conclude that this procedure has an application in adequately selected patients.

[Non-excisional treatment of spontaneous rupture of the esophagus]

We present 7 personal cases of Boerhaave syndrome, 6 treated surgically and one managed with conservative measures. Boerhaave's syndrome is one of the most serious gastro-intestinal perforation pictures. Although its frequency is scant, because of its seriousness it is important to be aware of it for early diagnosis. While a prompt diagnosis is important in any pathology, it is even more so in this syndrome since there is a clear relationship between the time lapse from perforation to the onset of treatment and the rate of survival. Although we present one case cured medically, this is exceptional and treatment is eminently surgical and should be as early as possible. The technique that provides the best results and an excellent morbimortality rate in relation to efficacy is primary suture followed by a fundal patch. In delayed cases with patients in deteriorated condition, other techniques can be considered. Due to its initial severity and a tendency to postoperative complications, the patient should be closely controlled, and correct antibiotic therapy and complete parenteral support nutrition are very important in treatment.

Interaction of the local anesthetics dibucaine and tetracaine with sarcoplasmic reticulum membranes. Differential scanning calorimetry and fluorescence studies

The local anesthetics dibucaine and tetracaine inhibit the (Ca2+ + Mg2+)-ATPase from skeletal muscle sarcoplasmic reticulum [DeBoland, A. R., Jilka, R. L., & Martonosi, A. N. (1975) J. Biol. Chem. 250, 7501-7510; Suko, J., Winkler, F., Scharinger, B., & Hellmann, G. (1976) Biochim. Biophys. Acta 443, 571-586]. We have carried out differential scanning calorimetry and fluorescence measurements to study the interaction of these drugs with sarcoplasmic reticulum membranes and with purified (Ca2+ + Mg2+)-ATPase. The temperature range of denaturation of the (Ca2+ + Mg2+)-ATPase in the sarcoplasmic reticulum membrane, determined from our scanning calorimetry experiments, is ca. 45-55 degrees C and for the purified enzyme ca. 40-50 degrees C. Millimolar concentrations of dibucaine and tetracaine, and ethanol at concentrations higher than 1% v/v, lower a few degrees (degrees C) the denaturation temperature of the (Ca2+ + Mg2+)-ATPase. Other local anesthetics reported to have no effect on the ATPase activity, such as lidocaine and procaine, did not significantly alter the differential scanning calorimetry pattern of these membranes up to a concentration of 10 mM. The order parameter of the sarcoplasmic reticulum membranes, calculated from measurements of the polarization of the fluorescence of diphenylhexatriene, is not significantly altered at the local anesthetic concentrations that shift the denaturation temperature of the (Ca2+ + Mg2+)-ATPase.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of local anesthetics on the passive permeability of sarcoplasmic reticulum vesicles to Ca2+ and Mg2+

Sarcoplasmic reticulum vesicles are used here as model membrane system to question the hypothesis of enhancement of permeability of cations by anesthetics, particularly that of Ca2+ and of Mg2+. The effects of dibucaine (up to 800 microM), tetracaine (up to 2 mM), lidocaine (up to 10 mM) and procaine (up to 10 mM) on the permeability of these membranes to Ca2+ and Mg2+ have been measured. We have used an experimental approach based on the light scattering method (Kometani, T. and Kasai, M. (1978) J. Membrane Biol. 41, 295-308). It has been found that all the local anesthetics cited above markedly increase the permeability of sarcoplasmic reticulum vesicles to Mg2+ and, in the concentration range tested herein, only dibucaine and tetracaine increase the permeability to Ca2+. The kinetic analysis of the time dependence of the light-scattering data after the osmotic shock shows that, in the absence of local anesthetics, the Mg2+ influx can be described as proceeding through a unique type of channel. However, Ca2+ influx appears to involve two channel of different kinetic properties. Because the relative fraction of both types of Ca2+ channel is similar to the average ratio between light and heavy vesicles in unfractionated sarcoplasmic reticulum, we suggest that each type of channel can be preferentially located in one of these fractions. The determined rate constants for Ca2+ permeability through both types of channel are 0.77 +/- 0.08 min-1 (fast channels) and 0.025 +/- 0.005 min-1 (slow channels) and that for Mg2+ is 0.08 +/- 0.02 min-1. These results agree with data obtained by other groups using different experimental approaches. Dibucaine and tetracaine significantly alter the rate of Mg2+ and Ca2+ influx through the slow channels. In addition, these two local anesthetics also produce the effect that the Mg2+ influx cannot be described with only one exponential process, thus suggesting a differential effect on vesicles of different density. The increase of Ca2+ and Mg2+ permeability by dibucaine and by tetracaine is found at concentrations of these drugs that do not produce a noticeable inhibition of the (Ca2+ + Mg2+)-ATPase activity of sarcoplasmic reticulum vesicles.

[Happy puppet or Angelman's syndrome. Review apropos of 3 cases]

Angelman's or "happy puppet" syndrome is a disorder of unknown etiology characterized by severe or profound mental retardation with deepest involvement of language, frequent smile and laughter and a happy appearance of every patient. Constant somatic features are microcephaly with braquicephaly, wide face, prognathism, occipital flattening and protruding tongue. Their movements are incoordinated and ataxic, giving them a puppet-like aspect. Electroencephalographic abnormalities are constant and severe but they usually have sporadic epileptic seizures. Only about fifty cases have been reported, affecting both sexes and belonging to different continents and reaces, but authors think the disorder is more frequent. First three patients of Spanish literature are presented and findings of "happy puppet" syndrome are commented.