327 To Fuse or Not to Fuse: The Elderly Patient with Lumbar Stenosis and Low-Grade Spondylolisthesis. Systematic Review and Meta-Analysis of Randomised Controlled Trials

Aim

The optimum surgical intervention for elderly patients with lumbar spinal stenosis(LSS) and low-grade degenerative-spondylolisthesis(LGDS) has been extensively debated. We conducted a systematic review and meta-analysis of randomised-controlled-trials(RCTs) comparing the effectiveness of decompression-alone against gold-standard decompression-with-fusion(D+F) in elderly patients with LSS and LGDS.

Method

A systematic literature search was performed on published databases from inception to October-2021. English-language RCTs of elderly patients (mean age over-65) with LSS and LGDS, who had undergone DA or D+F were included. The quality and weight of evidence was assessed, and a meta-analysis performed.

Results

Seven RCTs (n=581; mean age:65.9 years; 59.9% female) were included. There was no difference in visual-analogue-scale(VAS) scores of back-pain(BP) or leg-pain(LP) at mean follow-up of 28.6 months between both DA and D+F groups (BP: mean-difference (MD)-0.22, 95%CI:-0.76–0.32; LP: MD:-0.26, 95%CI:-0.79–0.27). In addition, subgroup analysis of long-term follow-up (>3 years) showed lower VAS scores for BP and LP in patients who underwent DA (BP MD:-1.70, 95%CI:-2.8-(-0.60); LP MD:-1.00, 95%CI:-1.77-(-0.23)). No difference in disability, measured by Oswestry-Disability-Index(ODI) scores, was found between both groups (MD:0.50, 95%CI: -3.31–4.31). However, patients in DA group had less hospital complications and fewer adverse events (total-surgical-complications OR:0.57, 95%CI:0.36–0.90), despite a higher rate of post-operative DS (OR:8.63, 95%CI:3.35–22.26).

Conclusions

DA is not inferior to D+F in elderly patients with LSS and LGDS. DA has better pain outcomes at three-years follow-up and carries lower risk hospital-complications and fewer adverse-events. Surgeons should weigh these findings with increased risk of DS-progression.

Pharmacokinetic/pharmacodynamic analysis of adjunctive perampanel in subjects with partial-onset seizures

OBJECTIVES

Explore perampanel pharmacokinetics (PK) in all subjects (aged ≥12 years) vs adolescents (aged ≥12 to ≤17 years) with partial-onset seizures (POS) and identify factors explaining between-subject variability in efficacy using a population PK/pharmacodynamic (PD) analysis.

MATERIALS & METHODS

Population PK analysis was performed using nonlinear mixed-effect modeling with data from phase II/III randomized, double-blind, placebo-controlled studies of adjunctive perampanel in POS. Perampanel exposure was predicted for all subjects and adolescents. Population PK/PD analyses were performed using data from phase III studies to explore the relationship between perampanel exposure and 28-day average seizure frequency and responder probability.

RESULTS

Pooled perampanel PK data from 1318 subjects were described by a one-compartment disposition model. In the absence of antiepileptic drugs (AEDs) affecting perampanel PK, estimated perampanel apparent clearance (CL/F) was 0.668 L/h (all subjects) and 0.682 L/h (adolescent subjects). Co-administration of carbamazepine and oxcarbazepine/phenytoin reduced perampanel exposure. Gender, Asian race (excluding Japanese or Chinese), and increasing alanine aminotransferase lowered perampanel CL/F, but differences were small and not considered clinically relevant. Adolescent outcomes were similar to the total population. Based on PK/PD data from 1748 subjects, percent reduction in 28-day average seizure frequency from baseline and responder probability increased with increasing perampanel exposure; concomitant CYP3A-inducing AEDs lowered perampanel exposure but did not impact the slope for responder probability.

CONCLUSIONS

These results are consistent with previous analyses but expand on these through inclusion of a larger number of patients from different ethnic groups, and demonstrate that outcomes were similar between adults and adolescents.

A20 deletion is associated with copy number gain at the TNFA/B/C locus and occurs preferentially in translocation-negative MALT lymphoma of the ocular adnexa and salivary glands

The genetic basis of MALT lymphoma is largely unknown. Characteristic chromosomal translocations are frequently associated with gastric and pulmonary cases, but are rare at other sites. We compared the genetic profiles of 33 ocular adnexal and 25 pulmonary MALT lymphomas by 1 Mb array-comparative genomic hybridization (CGH) and revealed recurrent 6q23 losses and 6p21.2-6p22.1 gains exclusive to ocular cases. High-resolution chromosome 6 tile-path array-CGH identified NF-kappaB inhibitor A20 as the target of 6q23.3 deletion and TNFA/B/C locus as a putative target of 6p21.2-22.1 gain. Interphase fluorescence in situ hybridization showed that A20 deletion occurred in MALT lymphoma of the ocular adnexa (8/42=19%), salivary gland (2/24=8%), thyroid (1/9=11%) and liver (1/2), but not in the lung (26), stomach (45) and skin (13). Homozygous deletion was observed in three cases. A20 deletion and TNFA/B/C gain were significantly associated (p<0.001) and exclusively found in cases without characteristic translocation. In ocular cases, A20 deletion was associated with concurrent involvement of different adnexal tissues or extraocular sites at diagnosis (p=0.007), a higher proportion of relapse (67% versus 37%) and a shorter relapse-free survival (p=0.033). A20 deletion and gain at TNFA/B/C locus may thus play an important role in the development of translocation-negative MALT lymphoma.

Miscellaneous rare paratesticular tumors

A few uncommon but distinctive tumors may preferentially involve the paratestis. The 3 unusual tumors that represent the focus of this discussion are the ovarian-type epithelial tumors (OTET), the desmoplastic small round cell tumor (DSRCT), and the melanotic neuroectodermal tumor of infancy (MNTI). The OTETs are testicular homologues of their more common namesake counterparts that arise in the ovary. Most frequent of these are serous tumors of borderline malignancy, with fewer cases of serous carcinomas or other forms of mullerian differentiation. DSRCT is an increasingly recognized, aggressive, "small blue cell" neoplasm with distinctive clinical and pathologic features. These polyphenotypic tumors characteristically, but not invariably, arise in intimate association with the serosal membrane of the peritoneal cavity and harbor a signature translocation-t(11;22)(p13,q12). In the paratestis they often involve the surface of the epididymis. The MNTI is an enigmatic, histologically distinctive, low-grade neoplasm occasionally encountered in the epididymis. Recognition of its features is essential to avoid misdiagnosis as a more aggressive "small blue cell" neoplasm and consequent therapeutic mismanagement. Primary hematopoietic tumors of the paratesticular structures are rare. There appears to be a tendency for young men to have low-grade lymphomas with an indolent course and older patients to develop higher-grade tumors. Plasmacytoma and granulocytic sarcoma of the paratestis are even more rare and are often susceptible to misinterpretation. Finally, metastatic tumors and a variety of other very rare neoplasms are discussed.

Extensive transmission of Mycobacterium tuberculosis from a child

BACKGROUND AND METHODS

Young children rarely transmit tuberculosis. In July 1998, infectious tuberculosis was identified in a nine-year-old boy in North Dakota who was screened because extrapulmonary tuberculosis had been diagnosed in his female guardian. The child, who had come from the Republic of the Marshall Islands in 1996, had bilateral cavitary tuberculosis. Because he was the only known possible source for his female guardian's tuberculosis, an investigation of the child's contacts was undertaken. We identified family, school, day-care, and other social contacts and notified these people of their exposure. We asked the contacts to complete a questionnaire and performed tuberculin skin tests.

RESULTS

Of the 276 contacts of the child whom we tested, 56 (20 percent) had a positive tuberculin skin test (induration of at least 10 mm), including 3 of the child's 4 household members, 16 of his 24 classroom contacts, 10 of 32 school-bus riders, and 9 of 61 day-care contacts. A total of 118 persons received preventive therapy, including 56 young children who were prescribed preventive therapy until skin tests performed at least 12 weeks after exposure were negative. The one additional case identified was in the twin brother of the nine-year-old patient. The twin was not considered infectious on the basis of a sputum smear that was negative on microscopical examination.

CONCLUSIONS

This investigation showed that a young child can transmit Mycobacterium tuberculosis to a large number of contacts. Children with tuberculosis, especially cavitary or laryngeal tuberculosis, should be considered potentially infectious, and screening of their contacts for infection with M. tuberculosis or active tuberculosis may be required.

Polyglandular autoimmune syndrome type 2 presenting for the first time during pregnancy

We report a case of polyglandular autoimmune deficiency presenting during pregnancy which was associated with a favourable outcome for both mother and fetus (apart from fetal growth retardation) with appropriate replacement therapy and adequate steroid cover at the time of delivery.

Craniocerebral plasmacytoma: MR features

We report the MR imaging findings in two patients with solitary craniocerebral plasmacytoma, a benign plasma cell tumor that can arise from the skull, the dura, or, rarely, the brain. In both patients, the lesion was extraaxial and nearly isointense with gray matter on T2-weighted MR images, and diffusely enhanced after administration of contrast material, bearing some similarities to meningioma. A diagnosis of solitary craniocerebral plasmacytoma should be considered when a mass with these imaging features is seen, because total excision may not be necessary for this radiosensitive tumor.

Low cost, patient acceptable, local analgesia approach to gynaecological outpatient surgery. A review of 817 consecutive procedures

The objective of this study was to evaluate safety, cost effectiveness and patient acceptability, of performing a wide variety of gynaecological procedures, including endometrial resections, in a clinic using only local analgesia. Eight hundred and seventeen consecutive gynaecological procedures were performed under local analgesia only, with no sedation, including endometrial resections, cone biopsies, terminations of pregnancy, hysteroscopies, and local vaginal and plastic vulval procedures, as well as many combined procedures (figure 1) in a day-surgery ward annexe in the Department of Gynaecology, St John's District General Hospital, Chelmsford Essex. The main outcome measures were patient acceptability, safety and encountered side-effects of procedures performed under local analgesia as well as evaluation of cost-effectiveness and reduction in theatre waiting list times. A high degree of safety and patient acceptability was achieved, with other considerable benefits being short waiting times and much quicker recovery. The only complications were from the endometrial resection group, with only 8 (3.6%) of these requiring intravenous sedation intraoperatively, and 6 (2.7%) requiring overnight admission. No transfers to theatre during any procedure occurred. Savings per procedure, in cost and in patient's time, were very considerable.

CONCLUSION

The local analgesia approach for a wide variety of gynaecological procedures in a combined outpatient theatre is safe and is highly acceptable to patients. There are also considerable benefits in cost and patient convenience, with a reduction in operating list waiting time, which in the current economic climate are worth considering.

Transcervical resection of the endometrium using intracervical block only. A review of 278 procedures

The objective of this study was to assess the efficacy and safety aspects of performing transcervical endometrial resection (T.C.R.E.) on a selected group of 278 patients with menstrual disorders under local analgesia (intracervical block) only. Patient acceptance of the procedure was high, with only 3 cases not completed due to insufficient analgesia (1.07%), although a further 9 (3.2%) were completed with the help of intravenous sedation. Patient satisfaction at 4 months was 90%. There were 4 perforations (1.4%), but no laparotomy was required. Five cases (1.7%) of haemorrhage required a Foley catheter, with 1 needing a transfusion. There was no case of clinically evident glycine overload. Twelve patients required an overnight stay. Patient acceptance of T.C.R.E. under local analgesia, and the incidence of major complications, compared favourably with other published series, including a series of 330 cases performed concurrently by the same operators under general anaesthesia.

The efficacy of the pipelle endometrial biopsy in detecting endometrial carcinoma

The purpose of this study was to determine the efficacy rate of the Pipelle endometrial biopsy sampler (Pipelle de Cornier) (1) in detecting endometrial carcinoma, and to analyze the tumour variables that may influence the success rate. Thirty seven women with known endometrial carcinoma were tested preoperatively; there were 25 correct diagnoses (67%), the remaining 12 cases (33%) failed to demonstrate the correct diagnosis: 4 showed 'atypical epithelium', 2 showed 'atypical hyperplasia', 3 showed 'nonspecific epithelium' and the remaining 3 showed 'necrotic hyalinized material'. All cases were analyzed with respect to several tumour parameters, including the degree of differentiation, tumour volume, depth of invasion, and the extent to which the tumour filled the endometrial cavity. Poor results were obtained in well differentiated, low volume, and minimally invasive tumours, i.e. most early tumours, precluding its use as a screening tool. A positive biopsy can save patients the time, cost, and inconvenience of a dilatation and curettage. However, in the light of these findings, a nonspecific finding should be interpreted with caution.

Dissecting aneurysms of the main trunk of the superior mesenteric artery

We treated four symptomatic patients who were admitted with a spontaneous and isolated dissecting aneurysm of the superior mesenteric artery. All four patients underwent operation. The superior mesenteric artery was repaired by means of either a bypass graft in two cases or an endoaneurysmorraphy in the latter two cases. Complete symptomatic relief with no postoperative complications was achieved in every case. The arterial repairs remained patent, and the patients remained free of symptoms, with follow-up ranging from 6 to 47 months. The available literature on this unusual lesion is reviewed.

Recovery after childbirth: a preliminary prospective study

This prospective study examined the time for 93 women to cease to feel discomfort in their perineal areas after the births of their first babies. Sixty-two of the women had experienced a spontaneous delivery that did not require forceps assistance. In 58 patients, an episiotomy was performed. Of the 35 women in whom an episiotomy was not performed, 24 women required sutures and only four women did not suffer any perineal damage. The median time for perineal comfort in general (including walking and sitting) was one month (range, zero to six months); 20% of women took more than two months to achieve general perineal comfort. For comfort during sexual intercourse, the median time was three months (range, one to more than 12 months); 20% of women took longer than six months to achieve comfort during sexual intercourse. Factors that were associated with discomfort for longer than the median time were delivery by forceps; spontaneous vaginal (not perineal) tears; and, in the three to four days after the birth, oedema and the breakdown of muscle or skin sutures. There was no significant difference in these times between patients who did not undergo an episiotomy and those who underwent an episiotomy without a forceps delivery.

Colposuspension for the treatment of female urinary incontinence

Between June 1, 1983 and June 30, 1988, 174 patients with stress incontinence were treated with a colposuspension operation; 144 patients were cured, 30 remained wet. Sixteen patients who remained wet had detrusor instability; 9 of these were cured by anticholinergic medications. Of 25 patients who had dual pathology 19 were cured. Seventy nine patients had urinary tract infections. Two patients had ureteric obstruction due to kinking; it is postulated that this can be an infrequent and sometimes unavoidable complication.

[Multiple lesions in primary hyperparathyroidism. Nosologic approach]

Surgical exploration identified 40 patients with several enlarged parathyroid glands (two to five) out of a retrospective series of 500 cases of primary hyperthyroidism. Complete clinicopathological correlations were available in 27 cases (19 women and 8 men). Seven patients had a history of Wermer's syndrome (type I, MEN). Final diagnosis was as follows: double adenomas, 11 cases; primary hyperplasia, 16 cases. In two cases, there was a clear-cell hyperplasia, 16 cases. In two cases, there was a clear-cell hyperplasia with massive involvement of four parathyroid glands. The fourteen other cases presented with predominantly chief-cell hyper plasia; the involvement of the parathyroid glands was frequently asymmetrical, mainly or exclusively confined to two enlarged glands in 9 cases. The authors conclude that when a patient presents with two enlarged parathyroid glands, two diagnoses are possible--double adenoma or asymmetrical hyperplasia. Since anatomical study of the two enlarged glands is not always sufficient for accurate classification of the lesions, it is advisable to make a histological examination of a third.

[Caustic digestive stenosis involving the hypopharynx. Esophagopharyngoplasty using a right ileocolic graft]

The authors describe an oesophago-laryngoplastic technique using a retrosternal ileocolic graft and involving anterior pharyngotomy above the hyoid bone. The technique was applied to five cases of major destructive lesions of the hypopharynx with fibrotic stenosis, due to severe burns of the upper digestive tract by ingestion of caustic substances. Continuity between the oral cavity and the digestive tract was re-established in all cases.

[High ectopia of a parathyroid adenomas of the "parathymus". 2 cases]

The third brachial pouch gives rise to the thymus and antero-inferior part of the parathyroid gland (P3). A P3 gland can develop in any region of the migration pathway of the thymus from the angle of the jaw to the pericardium. Rare high ectopia of a parathyroid adenoma of the "parathymus" was detected in two patients during repeat operations for primary hyperparathyroidism.

[Oesophagectomy without thoracotomy. 5 cases (author's transl)]

The authors describe an original technique of excision in severe caustic burns of the upper digestive tract: oesophagectomy without thoracotomy. The new procedure avoids the wide pleural opening of the thoracic approach, which leads to frequent and often fatal respiratory and infectious complications, whereas extrapleural drainage of the mediastinum has always proved effective and safe. Five technically successful operations were performed in one year. One patient died on the 10th post-operative day of tracheal necrosis related of the burn and 4 patients survived. These preliminary results are encouraging.

[Pre-operative detection of parathyroid adenomas with ultrasound echography (author's transl)]

Pre-operative ultrasound echography (USE) was performed in 24 patients with primary hyperparathyroidism. Surgical exploration showed 23 adenomas and was negative in 2 cases. USE gave 14 true positive, 3 false positive, 4 true negative and 6 false negative results. The specificity of the method was 79% and its sensitivity 93%. These figures are similar to those of recently published series. USE is a delicate but rewarding technique. In the hands of sonographists trained in cervical ultrasonography, it might eventually be used routinely to localize parathyroid tumours prior to surgery.

[The estimation of parathormone in primary hyperparathyroidism (author's transl)]

In a recent series of 110 cases of primary hyperparathyroidism, estimations of plasma immuno-parathormone (PTH) were carried out in fifty two patients. This estimation proved reliable, making possible the confirmation of the diagnosis. In the absence of renal insufficiency, there was a highly positive relationship between PTH levels and plasma calcium. The relationship between PTH and the weight of the parathyroid tumour was less significant. For technical reasons, this long and difficult estimation cannot be used on a routine basis. However, it is most useful in cases in which other laboratory findings are not typical.

The Interaction between Rubber and Liquids. VII. The Heats and Entropies of Dilution of Natural Rubber by Various Liquids

Calorimetric measurements of the heats of mixing of seven liquids with dihydromyrcene are used to estimate the heats of dilution of rubber by these liquids. Combining the results with free energies calculated from vapor pressure gives entropies of dilution which show significant deviations from the present statistical theory. A thermodynamic study of rubber + methyl alcohol shows similar but larger deviations. This work forms part of a program of fundamental research on rubber undertaken by the Board of the British Rubber Producers' Research Association.