Anterior lumbar interbody fusion: does stable anterior fixation matter?

The purpose of this study was to compare the outcome of anterior lumbar interbody fusion without instrumentation (uninstrumented ALIF) against that with stable anterior cage fixation using Hartshill horseshoe instrumentation (ALIF-HH) for similar severity of disc disease. Between April 1994 and June 1998 the senior author N.R.B. performed 29 instrumented ALIF procedures with a Hartshill horseshoe cage (ALIF-HH). Between 1990 and 1998, the other senior author (J.M.H.), together with another senior consultant orthopaedic surgeon, performed 27 noninstrumented ALIF procedures using corticocancellous iliac crest autograft. All the patients in both groups had single-level fusion. An independent assessor (S.M.) performed the entire review. The mean follow-up was 4.7 years (2.3-7.9 years) in the uninstrumented ALIF group and 3.0 years (2.1-4.4 years) in the ALIF-HH group. There was subsidence of graft in four patients in the uninstrumented ALIF group. It is reasonable to assume that there was no pseudarthrosis in the ALIF-HH group. This difference was statistically significant (two-sided P-value =0.0425). On subjective score assessment, there was a satisfactory outcome (score0.05). On classification by the Oswestry Index into four categories, we found no difference in outcome between the two groups: 83.3% ( n=20) had a satisfactory outcome (defined as Excellent or Better) with ALIF and 77.8% ( n=21) had a satisfactory outcome with ALIF-HH using the Oswestry Disability Index for post-operative assessment ( P>0.05). The results of this study indicate that the Hartshill horseshoe cage does improve the fusion rate, but does not affect clinical outcome.

Circumferential and posterolateral fusion for lumbar disc disease

Clinical outcome of low back fusion is unpredictable. There are various reports discussing the merits and clinical outcome of these two procedures. The patients were selected from a population of patients who had chronic low back pain unresponsive to conservative treatment. Thirty-six instrumented posterolateral fusions and 35 instrumented circumferential fusions with posterior lumbar interbody fusions were done simultaneously. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging scans, and provocative discography in all the patients. Posterolateral fusion or anterior lumbar interbody fusion was done for internal disc disruption. The Oswestry disability index, subjective scoring, and assessment of fusion were done at a minimum followup of 2 years. On subjective scoring assessment there was a satisfactory outcome of 63.9% (23 patients) in the posterolateral fusion group and 82.8% (29 patients) in the posterior lumbar interbody fusion group. On assessment by the Oswestry index no difference was found in outcome between the two groups. The posterolateral fusion group had a 63.9% satisfactory outcome and the posterior lumbar interbody fusion group had an 80% satisfactory outcome using the Oswestry disability index for postoperative assessment. There was 61.1% improvement in working ability in the posterolateral fusion group and 77.1% improvement in the posterior lumbar interbody fusion group which was not statistically significant. The authors consider instrumented circumferential fusion with posterior lumbar interbody fusion better than instrumented posterolateral fusion for managing chronic disabling low back pain.

Does provocative discography screening of discogenic back pain improve surgical outcome?

The value of preoperative provocative discography in the setting of discogenic low back pain was investigated by evaluating surgical outcomes. Seventy-three consecutive patients who underwent posterolateral interbody and posterior spinal arthrodesis for discogenic low back pain refractory to nonoperative management were reviewed. Chronologically, the first 41 patients (group A) were indicated without discography, whereas the remaining 32 (group B) had been indicated only if their pain had been reproduced during disc injection. The two groups were similar in demographic, psychometric, and radiologic parameters. Average follow-up time in group A was 2.8 years and in group B it was 2.4 years, both with a 2-year minimum. Using modified Oswestry scoring, group A and group B patients had satisfactory outcomes of 75.6% and 81.2%, respectively. This difference was neither statistically significant nor suggestive. In this study, provocative discography screening did not improve surgical outcomes after circumferential fusion for lumbar discogenic back pain.

Fetal outcome in mothers with impaired glucose tolerance in pregnancy

A 75 g oral glucose tolerance test was carried out on 953 pregnant women who were identified on the basis of clinical risk factors. The tests were analysed by the WHO criteria: 826 were normal, 120 showed impaired glucose tolerance, and 7 identified diabetes. A number of obstetric and perinatal outcome measures were compared between the groups with normal and impaired glucose tolerance, and also with 135 women who had pre-existing Type 1 diabetes and delivered during the study period. There was no significant difference in the incidence of antenatal complications between mothers with normal and impaired glucose tolerance. There was a higher rate of induced labour (p < 0.05) and caesarean section (p < 0.01) in the impaired glucose tolerance group compared to the normal group, but no difference in fetal outcome or neonatal morbidity. All of these outcome measures were increased in the Type 1 diabetic pregnancies.

Cinderella had a champion

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Pure XY gonadal dysgenesis presenting as secondary amenorrhea. A case report

Secondary amenorrhea developed after two years of normal menstruation. On investigation, the patient's karyotype was 46,XY, the serum testosterone and free androgen index were elevated, and bilateral gonadoblastomas and dysgerminomas were found in the gonads. The uterus, fallopian tubes and vagina were normal. The gonads were removed and chemotherapy given because of lymphadenopathy.

Accelerated retinopathy and nephropathy in diabetic pregnancy

We report a case of severe deterioration in sight despite good metabolic control in a pregnant diabetic patient which has not recovered at two years post-delivery. This was accompanied by a deterioration in renal function which similarly has not improved.

Increased interleukin 2 receptor expression in post-gestational women: relationship to impaired glucose tolerance and islet cell antibodies in pregnancy

Fifteen women with positive islet cell antibodies were identified in a group of 115 consecutive patients found to have impaired glucose tolerance in pregnancy. These subjects were postulated to be at increased risk of later developing type 1 diabetes mellitus. They were examined post--partum for HLA types known to be associated with this disease and for any increase in Interleukin 2 receptor expression or alteration of T cell subsets of possible relevance to its pathogenesis. Fifteen women negative for islet antibodies and with normal glucose tolerance during previous pregnancy and 15 women with a normal fasting plasma glucose who had never been pregnant were studied as controls. Using flow cytometric techniques a significant increase in both the number and proportion of activated (Interleukin 2 receptor, CD25) lymphocytes in the peripheral blood of women who had islet cell antibodies and previous impaired glucose tolerance in pregnancy was found (0.14 +/- SE 0.03 x 10(9)/l; 7.1 +/- 1.1%) when compared with normal parous controls (0.09 +/- 0.01 x 10(9)/l; 4.2 +/- 0.6%), p less than 0.01 x 10(9)/l; showed significant increases when compared with nulliparous controls (0.04 +/- 0.01 x 10(9)/l; 2.1 +/- 0.2%), p less than 0.01. No differences were detected between the three groups with respect to total T-lymphocytes (CD3), helper T-lymphocytes (CD4), suppressor cytotoxic T-lymphocytes (CD8), or the inducer of suppressor (Leu 3+/Leu 8+) subset of T-lymphocytes. Three women persistently islet cell antibody positive, two of whom were HLA DR4, showed impaired glucose tolerance at the time of lymphocyte subset analysis, while two further patients, one DR3 and the other DR4, had developed type 1 (insulin-dependent) diabetes. No correlation between increased Interleukin 2 receptor expression and glucose intolerance was demonstrated. We conclude that islet cell antibody positive women with impaired glucose tolerance during pregnancy are at increased risk of later developing type 1 diabetes but that heightened immune activation present in these women is in part a post-pregnancy phenomenon.

Urinary albumin excretion in diabetic pregnancy

We have analysed the results of urinary albumin excretion in timed overnight urine samples once every two weeks during pregnancy and post-natally in 25 non-diabetic women and 14 women with Type 1 (insulin-dependent) diabetes who were Albustix negative and had urinary albumin excretion less than 15 micrograms.min-1 at conception. Urinary albumin excretion did not vary significantly in the first two trimesters in either group and at 28 weeks was 2.73 micrograms.min-1 (0.32-251.68) (median and range) in the diabetic women and 2.53 micrograms.min-1 (0.90-13.37) in control patients (not significant). During the third trimester urinary albumin excretion increased, and levels were significantly higher in diabetic patients from 36 weeks (9.37 (0.9-31.78) vs 3.52 (0.19-33.74) micrograms.min-1, p less than 0.01) until delivery. In both groups, urinary albumin excretion reached a peak within the week following delivery - diabetic 17.42 micrograms.min-1 (2.03-46.64), control subjects 16.29 micrograms.min-1 (1.53-35.56), but six weeks after delivery, levels were similar to those in early pregnancy. The effect of pregnancy on urinary albumin excretion in these diabetic women would appear to be an exaggeration of the normal pattern, with levels returning to normal post-delivery. It is not possible to know if this has significance for future renal function, but it would be important to investigate this phenomenon in patients who already have raised urinary albumin excretion at conception.

Hip replacement for adults with unreduced congenital dislocation. A new surgical technique

Total hip replacement for adults with unreduced congenital dislocation presents a difficult problem because soft-tissue contractures usually prevent sitting at the normal anatomical level. Extensive soft-tissue division or a high-level acetabulum leads to reduced function and poor fixation of the components. We describe a new technique for hip replacement in such cases. The shortened abductors and flexors are released proximally and excision of the upper third of the ilium allows them to be repaired without tension, while providing bone graft to reconstruct the acetabular roof. We report 12 such replacements in 10 patients with good results and few early complications.

Is centralized hospital care necessary for all insulin-dependent pregnant diabetics?

A retrospective population study in Northern Ireland examined the benefits of centralized care in insulin-dependent diabetic pregnancies. In the 5 years 1979-1983, there were 139, 250 deliveries in Northern Ireland and of these 221 pregnancies occurred in 187 insulin-dependent diabetic patients; 100 were managed entirely in peripheral maternity units, 61 were referred from a peripheral unit to the Royal Maternity Hospital, Belfast and 60 were managed entirely in this central referral hospital. The patients referred from the periphery had the worst past obstetric history with a combined perinatal mortality rate of 200 per 1000. During the study period the perinatal mortality rate was 107 for the referred pregnancies, 33 for those managed entirely in the peripheral units and 18 for those managed at the Royal Maternity Hospital. If those pregnancies terminated for fetal abnormality, and deaths beyond the perinatal period are included, the figures for total fetal loss were 15.5%, 5.5% and 7.1% respectively. Overall the major congenital malformation rate was 7.5%, and for the respective groups 6.5%, 3.0% and 13.0%. For the general population during the same period the perinatal mortality rate was 1.4% and the major congenital malformation rate was 2.5%. Thus it is suggested that only peripheral hospitals which can offer combined antenatal/endocrine care and with a neonatal intensive care unit should undertake the management of the pregnant diabetic.

A comparison of plating and traction in the treatment of tibial shaft fractures

A consecutive series of fractures of the tibial shaft was studied over a 4-year period. A total of 115 fractures in 115 patients were found to be unstable and therefore unsuitable for immediate treatment in a plaster cast. Sixty-three fractures were treated by internal fixation using AO dynamic compression plates and 52 patients were treated by calcaneal traction. The two treatment groups were compared and it was found that overall each spent a similar time in hospital but the surgically treated group required a minimum of two admissions. The surgically treated group healed 6 weeks sooner than the conservatively treated group but there was an overall complication rate of 30 per cent related to the internal fixation. One hundred and three patients were seen for clinical review, and the incidence of joint stiffness is discussed.

Acetabular cup failure after total hip replacement

Fracture of the polyethylene acetabular cup is a rare late complication of total hip replacement. Five cases are reported. In each one this followed a fall, and involved a Müller arthroplasty which had previously been symptomless. It is postulated that ridges or other irregularities of bone, produced by keying holes, could lead to areas of thin cement and potential weakness of support for the cup.

Physical and psychological health of children of Type 1 (insulin-dependent) diabetic mothers

No difference was found at paediatric assessment, or by a psychologically-based maternal and teacher questionnaire of the emotional state or academic achievement, between 123 children of Type 1 (insulin-dependent) diabetic mothers and 124 children of non-diabetic mothers. The groups were closely matched for maternal age, sex and position in sibship of the child, and age and home environment of the mother. The children of diabetic mothers had all been delivered before week 38 of gestation.

Diabetic retinopathy in pregnancy

The records of 23 insulin-dependent diabetics who had serial ophthalmological examinations during pregnancy and afterwards were reviewed. Fourteen pregnancies occurred in 10 patients with no retinopathy; 30% of these patients had obstetric complications. The mean birthweight was 3.5 kg. Ophthalmological status was unchanged in this group. In eight patients with background retinopathy during 10 pregnancies the obstetric complication rate was 70% and mean birthweight 3.3 kg. During pregnancy there was no evidence of progression of retinopathy. One patient developed proliferative retinopathy 4 years later. Five patients had proliferative retinopathy. The mean age (32 years) and duration of diabetes at index pregnancy (18 years) was greater than for the other groups. All patients developed pre-eclampsia and mean birthweight was 2.8 kg. Four of these patients required argon laser photocoagulation in association with pregnancy for progressive retinopathy; one died subsequently from end-stage diabetic nephropathy; the other four have maintained their pre-pregnancy visual acuity from 4 to 10 years.

The Royal Maternity Hospital, Belfast. Fifty glorious years 1933-1983. Presidential address to the Ulster Medical Society, 20th October 1983

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Endometrial carcinoma after cyclical oestrogen-progestogen therapy for Turner's syndrome

A case of endometrial adenocarcinoma in a patient with Turner's syndrome who had received long term combined oestrogen-progestogen therapy is described.

Further studies on age and trypanosome infection rates in glossina pallidipes aust., g. palpalis fuscipes newst. and g. brevipalpis newst. in Uganda

Between June 1964 and May 1965, samples of Glossina pallidipes Aust., G. palpalis fuscipes Newst. and G. brevipalpis Newst. were caught in an area on the north-eastern shore of Lake Victoria in Uganda. Both males and females were classified into age-categories according to the degree of wear of the wings. Females were also classified into ovarian age-categories according to the exact or approximate number of ovulations that had taken place. All were examined for presence of infections with Trypanosoma, which were classified as vivax-type, congolense-type or brucei-type according to their location in the flies.

The percentage compositions of the samples by wing-fray category are compared. The mean wing-fray category of females of G. palpalis fuscipes and G. brevipalpis was somewhat lower, and that of females of G. pallidipes somewhat higher, than that of the corresponding males. However, the figures for infection rate in females of all three species were higher than in the corresponding males, significantly so in G. pallidipes and G. palpalis fuscipes, and it seems probable that the mean age of females, at least of the two latter species, was greater than that of males. Among females, the range of calendar ages of flies in the various fray categories was wide.

The physiological age-determination method, in which females older than about 42 days are classified iDto four age-categories, does not extend sufficiently far to give a reasonable pattern for the age-composition of any of the species at Lugala, and many of the individuals caught must have been more than about 80 days old.

Seasonal fluctuations in mean wing-fray and in the proportion of old flies in the population were correlated with changes in infection rate of females of G. palpalis fuscipes but not of females of G. pallidipes. Among males of neither species were seasonal fluctuations in mean fray correlated with changes in infection rate, though among those of G. palpalis fuscipes the two varied similarly between June and February.

Females of G. pallidipes and G. palpalis fuscipes about 31–42 days old had significantly fewer brucei-type infections than those over 42 days old, and either the developmental cycle in the field must normally be longer than that recorded in laboratory investigations or many of the flies must become infected when more than just a few days old.

Studies on age and trypanosome infection rate in females of Glossina pallidipes Aust., G. palpalis fuscipes Newst. and G. brevipalpis Newst. in Uganda

During 1964–65, 1,646 newly emerged females of Glossina pallidipes Aust., 1,898 of G. palpalis fuscipes Newst. and 2,528 of G. brevipalpis Newst. were marked and released in an area on the north-eastern shore of Lake Victoria in Uganda so that, by examination of those subsequently recaptured, the relation between physiological and calendar age could be determined. In the light of the results, records of physiological age and trypanosome infections in large numbers of wild-caught females of the same three species caught in the same area in 1962–63 were examined, together with published observation on the animals on which they fed, and the effects of age and food-animals on the incidence of infections were investigated.

Physiological age was determined by examination of the reproductive system and was expresses as the exact or approximate number of ovulations that had taken place. Infections with Trypanosoma were classified as brucei-type, vivax-type or congolense-type, and the last two as mature (infective) or immature, according to the sites in which trypanosomes were found in the flies. All brucei-type infections were regarded as mature.

The relation between physiological and calender age indicated that the length of the ovulation cycle was 11 days in G. pallidipes, 11 1/2 in G. brevipalpis and about 15 in G. palpalis fuscipes, but from other evidence that the last figure should have been about 11 days it is considered that ovulation was retarded in the released females of G. palpalis fuscipes.

The incidence of mature vivax- and congolense- type infections rose with age in all three species, beginning for the most part when flies were about a fortnight old. Brucei-type infections were rare and were found only in flies more than about 35 days old; nearly all flies with such infections also had one or both of the other types. The incidence of immature vivax-type infections rose with age up to about 25 days and then levelled off, which suggests that all eventually became mature. Immature congolense-type infections were rare.

G. pallidipes had the highest total infection rate and G. brevipalpis the lowest. The percentage of order flies in the samples was, however, greater in the later than in G. palpalis fuscipes, which suggests that age is not the sole factor determining infection rate. Food-animals appeared to influence it, since the infection rates of the three species were proportional to the percentages of meals obtained from Bovids.

The age at which females were inseminated was lowest in G. palpalis fuscipes, greatest in G. pallidipes and intermediate in G. brevipalpis. Abnormal ovulation cycles were rare in wild-caught flies, and few females that from their age should have been pregnant were found with an empty uterus.

Seasonal and diurnal variations in physiological age and trypanosome infection rate of females of Glossina pallidipes Aust., G. palpalis fuscipes Newst. and G. brevipalpis Newst

A series of 24-hr. catches of Glossina from bait-oxen was carried out during 16 months in 1962–63 at Lugala, Uganda, where G. pallidipes Aust., G. palpalis fuscipes Newst. and G. brevipalpis Newst. occur. Female flies were dissected to determine their physiological age and the presence or absence of trypanosomes. Five age-categories were distinguished, depending on whether a fly had ovulated 0, 1, 2, 3 or more (4 + ) times. Flies remained in each of the first four categories for about 11 days and the fifth therefore comprised those over 40–50 days old. Trypanosome infections were classified as brucei-type, vivax-iype or congolense-type (i.e., attributable to trypanosomes of the groups of Trypanosoma brucei, T. vivax and T. congolense) according to the sites in which they were found.

In all three species of Glossina, vivax-tjpe infections were commonest and alone showed seasonal fluctuations in incidence. Infections of the brucei-type were rare. The total infection rate (all types) in G. pallidipes and G. palpalis fuscipes was highest in or immediately after months of greatest rainfall and relatively lower in dry months; the highest infection rates in G. brevipalpis occurred a month later than those of the other two species. Over 80 per cent, of infections in all three were found in category 4+ flies, the percentage of which in the catches varied in much the same way as the total infection rate, suggesting not only that the flies live longest during wet periods but also that fluctuations of infection rate are largely due to changes in mean age. The regression of total infection rate on percentage of category 4 + flies was significant for G. palpalis fuscipes over 14 months, and for G. pallidipes over 12 months, but insignificant for G. brevipalpis.

The age-composition of catches of G. pallidipes and G. brevipalpis but not G. palpalis fuscipes varied during the day. In G. pallidipes, the percentage of older flies was higher in the middle of the day than in the early morning and late evening, and these contrasts were reflected in the infection rate, which was highest in samples taken in the middle of the day. In G. brevipalpis, the percentage of oldier flies and also the infection rate were lower during the night than during the day.

Estimates were made of the mean number of bites by infected females that would be received by one ox in one day. The number varied from month to month, with peaks shortly after periods of high rainfall, mainly as a result of changes in fly density and relatively little as a result of changes in infection rate. G. pallidipes, the most numerous species, was responsible for most of the potentially infective bites.

Seasonal abundance and diurnal variations in activity of some Stomoxys and Tabanidae in Uganda

The results are described of 202 24-hr, catches of Stomoxys and Tabanids on cattle at Lugala on the north-eastern shore of Lake Victoria, and also of six 24-hr, catches at Sukulu, 33 miles from Lugala, all of which were made in 1961–63.

Species of Tabanus and Ancala were more abundant in open grassland than inside the edge of the lake-shore forest. Stomoxys nigra, Macq. and S. Calcitrans (L.) were equally numerous in both situations, whereas S. omega Newst. was most abundant inside the forest edge.

Many species were caught during all months of the year. In both catching areas, there were seasonal rises in numbers of nearly all species between May and August and again in November or December, that is, towards the end of the rains and early in the dry seasons. At one of the two areas there was also a large increase in catch of a few species in April, in the middle of the main wet season.

Diurnal activity of Tabanus and Ancala was greatest near the middle of the day, the exact timing of the peak varying with season. Four species of Haematopota exhibited morning and evening peaks with lower activity at midday, and a rather rare fifth species was apparently more active in the middle of the day. Three species of Stomoxys were also most active in the morning and late evening, but peak activity of a fourth species, S. calcitrans, occurred shortly after midday. Activity during the night was rare.