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MacMillan M, Cummins K, Fujioka K. What weight loss treatment options do geriatric patients with overweight and obesity want to consider? Obes Sci Pract 2016; 2:477-482. [PMID: 28090354 PMCID: PMC5192535 DOI: 10.1002/osp4.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 08/12/2016] [Accepted: 08/18/2016] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Since the 1990s, a number of weight loss medications have been removed from the USA and or European market because of adverse events associated with these medications. These medications include fenfluramine (heart valve thickening), sibutramine (cardiovascular risk) and rimonabant (depression). This history may affect a patient's desire to consider weight loss medications as an option for weight management. OBJECTIVE This descriptive study was designed to observe what treatment options the geriatric patient (age 65 or higher) seeking weight loss would like to consider, as well as the reasons they felt they struggled with overweight or obesity. METHODS A questionnaire was given to 102 geriatric patients with overweight or obesity before starting a weight loss programme at a weight management centre. The questionnaire asked the patient why they felt they were overweight or obese and what treatment options they wished to consider. The geriatric patients were matched with younger patients in body mass index and sex. RESULTS The three most common perceptions that geriatric patients felt were causes of their increased weight were 'lack of exercise' (76.2%), 'poor food choices' (59.4%) and 'cravings' (47.5%). When geriatric patients were asked what treatment options they would like to discuss, the four most common options requested were 'diet and healthy eating' (67.3%), weight loss medications (57.4%), a request for a 'metabolic work up' (55.4%) and 'exercise' (53.5%). These responses were no different from their younger cohorts. When geriatric patients with a body mass index of 35 or higher were given bariatric surgery as a treatment option, 21.9% marked it as a treatment option they would like to consider. CONCLUSIONS Over half of geriatric patients desired to discuss weight loss medications as a treatment option. Diet and exercise were also of strong interest, which is in line with current weight management guidelines.
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Affiliation(s)
- M. MacMillan
- MacMillan & Fujioka: Department of Diabetes and EndocrineScripps ClinicLa JollaCAUSA
| | - K. Cummins
- Cummins K: Department of PsychiatryUniversity of CaliforniaSan Diego, La JollaCAUSA
| | - K. Fujioka
- MacMillan & Fujioka: Department of Diabetes and EndocrineScripps ClinicLa JollaCAUSA
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Johns N, Tan BH, MacMillan M, Solheim TS, Ross JA, Baracos VE, Damaraju S, Fearon KCH. Genetic basis of interindividual susceptibility to cancer cachexia: selection of potential candidate gene polymorphisms for association studies. J Genet 2015; 93:893-916. [PMID: 25572253 DOI: 10.1007/s12041-014-0405-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cancer cachexia is a complex and multifactorial disease. Evolving definitions highlight the fact that a diverse range of biological processes contribute to cancer cachexia. Part of the variation in who will and who will not develop cancer cachexia may be genetically determined. As new definitions, classifications and biological targets continue to evolve, there is a need for reappraisal of the literature for future candidate association studies. This review summarizes genes identified or implicated as well as putative candidate genes contributing to cachexia, identified through diverse technology platforms and model systems to further guide association studies. A systematic search covering 1986-2012 was performed for potential candidate genes / genetic polymorphisms relating to cancer cachexia. All candidate genes were reviewed for functional polymorphisms or clinically significant polymorphisms associated with cachexia using the OMIM and GeneRIF databases. Pathway analysis software was used to reveal possible network associations between genes. Functionality of SNPs/genes was explored based on published literature, algorithms for detecting putative deleterious SNPs and interrogating the database for expression of quantitative trait loci (eQTLs). A total of 154 genes associated with cancer cachexia were identified and explored for functional polymorphisms. Of these 154 genes, 119 had a combined total of 281 polymorphisms with functional and/or clinical significance in terms of cachexia associated with them. Of these, 80 polymorphisms (in 51 genes) were replicated in more than one study with 24 polymorphisms found to influence two or more hallmarks of cachexia (i.e., inflammation, loss of fat mass and/or lean mass and reduced survival). Selection of candidate genes and polymorphisms is a key element of multigene study design. The present study provides a contemporary basis to select genes and/or polymorphisms for further association studies in cancer cachexia, and to develop their potential as susceptibility biomarkers of cachexia.
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Affiliation(s)
- N Johns
- Department of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK.
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Vincent HK, Percival S, Creasy R, Alexis D, Seay AN, Laura Ann Z, MacMillan M, Vincent KR. Acute Effects of Enhanced Eccentric and Concentric Resistance Exercise on Metabolism and Inflammation. ACTA ACUST UNITED AC 2014; 4. [PMID: 26807345 DOI: 10.4172/2165-7025.1000200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This study compared the metabolic, cardiopulmonary and inflammatory responses of novel acute machine based concentrically-focused resistance exercise (CON RX) and eccentrically-focused resistance exercise (ECC RX). Twenty healthy adults (26.8 ± 5.9 yrs; 25.4 ± 4.0 kg/m2) performed two work-matched RX exercise sessions. Cardiopulmonary responses, rating of perceived exertion (RPE), soreness, oxygen consumption; (VO2) were collected during each session. Blood lactate and levels of inflammatory cytokines interleukin-1 alpha (IL1α), interleukin-6 (IL6) and tumor necrosis factor-alpha (TNFα) were analyzed pre, post ad 24 hours post-exercise. HR were higher (5-15bpm) during ECC RX (p<.05). Soreness ratings were consistently higher post-ECC RX compared to CON RX. VO2 area under the curve was higher during ECC than CON (31,905 ml/kg/min vs 25,864 ml/kg/min; p<.0001). Post-ECC RX, TNFα levels increased compared to CON RX 23.2 ± 23.9% versus 6.3 ± 16.2% ( p=.021). ECC RX induced greater metabolic, cardiopulmonary and soreness responses compared to matched CON RX. This may be due to recruitment of additional stabilizer muscles and metabolic stress during the ECC RX. These factors should be considered when designing ECC RX programs particularly for untrained persons, older adults or those with history of cardiovascular disease.
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Affiliation(s)
- H K Vincent
- Department of Orthopaedics and Rehabilitation, Interdisciplinary Center for Musculoskeletal Training and Research, University of Florida, USA
| | - S Percival
- Department of Food Science and Nutrition, University of Florida, USA
| | - R Creasy
- Department of Food Science and Nutrition, University of Florida, USA
| | - D Alexis
- Department of Orthopaedics and Rehabilitation, Interdisciplinary Center for Musculoskeletal Training and Research, University of Florida, USA
| | - A N Seay
- Department of Orthopaedics and Rehabilitation, Interdisciplinary Center for Musculoskeletal Training and Research, University of Florida, USA
| | - Zdziarski Laura Ann
- Department of Orthopaedics and Rehabilitation, Interdisciplinary Center for Musculoskeletal Training and Research, University of Florida, USA
| | - M MacMillan
- Department of Orthopaedics and Rehabilitation, Interdisciplinary Center for Musculoskeletal Training and Research, University of Florida, USA
| | - K R Vincent
- Department of Orthopaedics and Rehabilitation, Interdisciplinary Center for Musculoskeletal Training and Research, University of Florida, USA
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Nemecek E, Carpenter P, He W, Ellis K, Seber A, Woolfrey A, MacMillan M, Eapen M, Davies S, Frangoul H. Outcome Of Unrelated Donor Blood And Marrow Transplantation (BMT) For Children With Acute Lymphoblastic Leukemia (ALL) In Third Remission. Biol Blood Marrow Transplant 2010. [DOI: 10.1016/j.bbmt.2009.12.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tomblyn MB, DeFor TE, MacMillan M, Higgins PD, Dusenbery KE, Weisdorf DJ. Hematopoietic cell transplantation (HCT) for acute lymphoblastic leukemia (ALL): 25-year experience at the University of Minnesota. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.7001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7001 Background: HCT is frequently used for management of ALL. Methods: We reviewed the records of 623 consecutive patients (63% male, median age 13 years) treated with myeloablative TBI-containing conditioning and either autologous or allogeneic transplantation between 1980 and 2005 at the University of Minnesota. Donor types were autologous (34%), related (45%), unrelated (16%) or cord (11%). Disease status at transplant was CR1 (24%), CR2 (50%), CR3 (18%) and relapse (8%). Univariate and multivariate analyses were performed for clinical endpoints including overall survival (OS), progression free survival (PFS), relapse, treatment-related mortality (TRM), and Grades II-IV acute and chronic graft versus host disease (GVHD). Results: Median follow-up among survivors was 8.3 years (1.0–22.9). The estimated incidence of acute GVHD was 42% and chronic GVHD was 16%. At 5 years, OS, PFS, and relapse were estimated at 29%, 26%, and 43% respectively. 5-year OS for each group: autologous (17%, 12–22%), related (35%, 29–41%), matched unrelated (42%, 29–55%), mismatched unrelated (21%, 11–33%), and cord blood (46%, 33–59%). TRM at 2 years was 28%. Multivariate analysis for OS, PFS, relapse and TRM for donor type is shown ( Table ). Acute GVHD was more frequent with unrelated donors (p<0.01) but similar for related donors and cords. Presence of acute GVHD led to improved PFS (RR 0.6, 0.4–0.7, p<0.01) and decreased relapse (RR 0.5, 0.3–0.8, p<0.01) at 1 year. 5-year OS improved significantly from 1980–1984 (28%, 20–37%) to 2000–2005 (45%, 33–56%), p < 0.01. Conclusions: Allogeneic HCT results in a durable PFS, although TRM is increased with unrelated mismatched donors. As expected, autologous HCT results in increased relapse rates. Despite significant mismatch, umbilical cord HCT led to similar OS, PFS, relapse, TRM and chronic GVHD compared to related donor HCT. Development of acute GVHD decreases relapse, resulting in improved PFS. No significant financial relationships to disclose. [Table: see text]
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Wells M, Raab G, MacBride S, Bell N, MacKinnon K, Munro A, Samuel L, MacDougall R, MacMillan M. 688 Prevention and management of radiation skin reactions: a randomised controlled trial of skin care approaches in patients with breast, head and neck and anorectal cancer. EJC Suppl 2003. [DOI: 10.1016/s1359-6349(03)90719-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Trudeau VL, Spanswick D, Fraser EJ, Larivière K, Crump D, Chiu S, MacMillan M, Schulz RW. The role of amino acid neurotransmitters in the regulation of pituitary gonadotropin release in fish. Biochem Cell Biol 2001; 78:241-59. [PMID: 10949077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Both glutamate and gamma-aminobutyric acid (GABA) are involved in pituitary hormone release in fish. Glutamate serves 2 purposes, both as a neurotransmitter and as a precursor for GABA synthesis. Glutamate can be catabolized to GABA by the actions of 2 distinct but related enzymes, glutamate decarboxylase 65 (GAD65) and GAD67. They derive from 2 different genes that likely arose from an early gene duplication prior to the emergence of teleosts more than 400 million years ago. There is good evidence for the involvement of GABA in luteinizing hormone (LH) release in fish. The mechanism of GABA action to stimulate LH release appears to be a combination of effects on GnRH release, potentiation of gonadotropin hormone-releasing hormone (GnRH) action, and in some cases directly at the LH cell. These actions appear to be dependent on such factors as sex or sex steroid levels, and there may also be species differences. Nevertheless, the stimulatory effects of GABA on LH are present in at least 4 fish species. In contrast, convincing data for the inhibitory effects of GABA on LH release have only been observed in 1 fish species. The sites and mechanisms of action of amino acid neurotransmitters on LH release have yet to be fully characterized. Both 130N-methyl-D-aspartic acid (NMDA) and S-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) type glutamate receptors are likely to have important roles. We suggest that it is a receptor similar to the GABA(A) type which mediates the effects of GABA on LH release in fish, at least partially acting on the GnRH neuron, but likely directly acting at the gonadotroph as well. GABA may also be involved in regulating the release of other pituitary hormones in fish, namely follicle stimulating hormone (FSH = GTH-I), prolactin, and growth hormone. Based on the findings described in this review, a working model for the involvement of glutamate and GABA in the regulation of LH release in teleost fish is proposed.
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Affiliation(s)
- V L Trudeau
- Department of Biology, University of Ottawa, ON, Canada.
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Trudeau VL, Spanswick D, Fraser EJ, Larivière K, Crump D, Chiu S, MacMillan M, Schulz RW. The role of amino acid neurotransmitters in the regulation of pituitary gonadotropin release in fish. Biochem Cell Biol 2000. [DOI: 10.1139/o99-075] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Both glutamate and γ-aminobutyric acid (GABA) are involved in pituitary hormone release in fish. Glutamate serves 2 purposes, both as a neurotransmitter and as a precursor for GABA synthesis. Glutamate can be catabolized to GABA by the actions of 2 distinct but related enzymes, glutamate decarboxylase 65 (GAD65) and GAD67. They derive from 2 different genes that likely arose from an early gene duplication prior to the emergence of teleosts more than 400 million years ago. There is good evidence for the involvement of GABA in luteinizing hormone (LH) release in fish. The mechanism of GABA action to stimulate LH release appears to be a combination of effects on GnRH release, potentiation of gonadotropin hormone-releasing hormone (GnRH) action, and in some cases directly at the LH cell. These actions appear to be dependent on such factors as sex or sex steroid levels, and there may also be species differences. Nevertheless, the stimulatory effects of GABA on LH are present in at least 4 fish species. In contrast, convincing data for the inhibitory effects of GABA on LH release have only been observed in 1 fish species. The sites and mechanisms of action of amino acid neurotransmitters on LH release have yet to be fully characterized. Both N-methyl-D-aspartic acid (NMDA) and S-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) type glutamate receptors are likely to have important roles. We suggest that it is a receptor similar to the GABAA type which mediates the effects of GABA on LH release in fish, at least partially acting on the GnRH neuron, but likely directly acting at the gonadotroph as well. GABA may also be involved in regulating the release of other pituitary hormones in fish, namely follicle stimulating hormone (FSH = GTH-I), prolactin, and growth hormone. Based on the findings described in this review, a working model for the involvement of glutamate and GABA in the regulation of LH release in teleost fish is proposed. Key words: glutamate, GABA, luteinizing hormone, muscimol, patch clamp electrophysiology, reproduction, fish.
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Martin GJ, Haid RW, MacMillan M, Rodts GE, Berkman R. Anterior cervical discectomy with freeze-dried fibula allograft. Overview of 317 cases and literature review. Spine (Phila Pa 1976) 1999; 24:852-8; discussion 858-9. [PMID: 10327505 DOI: 10.1097/00007632-199905010-00004] [Citation(s) in RCA: 162] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of 317 patients to determine the efficacy of allogeneic fibula arthrodesis after anterior cervical discectomy. OBJECTIVE To examine the efficacy of allogeneic fibula as an alternative fusion substrate after anterior cervical discectomy, and to determine the effects of cigarette smoking on the healing of fibula allografts. SUMMARY OF BACKGROUND DATA The use of autogeneic iliac crest is associated with graft harvest complications in up to 20% of patients. Most studies reporting on the use of allogeneic iliac crest cite a high collapse rate. Few studies exist that note the efficacy of allogeneic fibula in this procedure and the effects of cigarette smoking on fusion rate. METHODS From 1988 to 1993, 317 patients underwent grafting by the Smith-Robinson technique with allogeneic fibula after anterior cervical discectomy. Patients who described themselves as habitual cigarette smokers or who smoked during the perioperative or postoperative period were categorized as smokers. All patients were immobilized in a rigid cervical orthosis (Philadelphia collar) for at least 10 weeks postoperatively. RESULTS A minimum of 2 years follow-up was achieved in 289 patients. In all, 162 men and 127 women had a total of 311 levels grafted, and the mean follow-up period was 33 months (range, 24 to 51 months). Of patients who received allogeneic fibula at one level, 90% (242/269) achieved radiologic fusion. The fusion rate was 92% (182/198) among nonsmokers compared with 85% (60/71) among smokers (not a statistically significant difference; P = 0.120). After two-level procedures, 72% (13/18) of the patients showed fusion. The fusion rate was 50% (2/4) among smokers compared with 79% (11/14) among nonsmokers (P = 0.53). When one-level arthrodesis (90%) was compared with two-level arthrodesis (72%), the difference approached statistical significance (P = 0.054). Neither of the two patients, both nonsmokers, who received grafts at three levels achieved fusion. There were no infections, and no grafts collapsed. Two grafts extruded (0.6%), but these were partial and did not require reoperation. Both patients fused and constituted the only patients with more than 10 degrees of angulation in the series. Graft subsidence occurred in 5% (17/311) of the grafts, mostly in the beginning of the series, and was not problematic. This phenomenon was thought to have been caused by overaggressive removal of the cortical endplate. CONCLUSION Allogeneic fibula is an effective substrate for use in achieving fusion after anterior cervical discectomy. Maximal results are achieved with its use at one level in nonsmokers. Cigarette smoking decreased the fusion rate with allogeneic fibula in the anterior cervical spine, but not by a statistically significant amount.
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Affiliation(s)
- G J Martin
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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MacMillan M, Fessler RG, Gillespy M, Montgomery WJ. Percutaneous lumbosacral fixation and fusion: anatomic study and two-year experience with a new method. Neurosurg Clin N Am 1996; 7:99-106. [PMID: 8835150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This anatomic and clinical study describes a transsacral, percutaneous approach for fixation and fusion of the L5-S1 disc. A tunnel is created into the L5-S1 disc from this approach, permitting disc removal, bone grafting, and placement of two nine-millimeter diameter titanium screws into the body of L5. There were no complications referable to screw placement, and eight of nine patients had successful fusion.
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Affiliation(s)
- M MacMillan
- Department Orthopaedic, University of Florida, Gainesville 32610-0246, USA
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MacMillan M, Glowczewskie F. Biomechanical analysis of a new anterior spine implant for post-corpectomy instability. J Spinal Disord 1995; 8:56-61. [PMID: 7711370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Corpectomies in the lumbar and thoracic spine are sometimes necessary in the treatment of vertebral tumor, trauma, and degeneration. The resultant defect creates marked instability. Present methods to correct this problem involve spanning the defect with structural bone graft and applying either anterior or posterior instrumentation. Some investigators have designed vertebral replacements that distract and wedge into the corpectomy site. This study investigates a proposed prosthesis with a unique method of fixation: a vertebral replacement is fixed to the bodies above and below by screws that are oriented rostrally and caudally. This fixation prevents cantelever bending of the screws, migration of the implant, and possibly visceral damage by the placement of the device. This study investigates the biomechanical performance of this device in flexion, extension, and axial loading in a calf spine model. In comparison with normal spines, this device restored the biomechanical strength of the spine to at least normal levels in all planes tested. It appears that a device of this design may be useful for the reconstruction of vertebral diseases and may reduce the need for more extensive surgeries.
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Affiliation(s)
- M MacMillan
- University of Florida, Department of Orthopaedics, Gainesville 32610-0246, USA
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Gilliam J, Brunt D, MacMillan M, Kinard RE, Montgomery WJ. Relationship of the pelvic angle to the sacral angle: measurement of clinical reliability and validity. J Orthop Sports Phys Ther 1994; 20:193-9. [PMID: 7987379 DOI: 10.2519/jospt.1994.20.4.193] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There is a need to better document the reliability and validity of assessment measures used in physical therapy. Studies documenting the reliability of measurement of the pelvic angle and its relationship to sacral motion are presently inconclusive. The purpose of this study was twofold. First, we wanted to determine the reliability and validity of a goniometric measurement of the pelvic angle. We also wanted to test the hypothesis that there is a relationship between the pelvic angle and the sacral angle. Intertester and intratester reliability of goniometric pelvic angle measurements of 23 healthy young adults were examined using three different raters. Radiographic measurements of the pelvic and sacral angle using two raters and goniometric measurement of the pelvic angle using a single rater were taken from 15 patients with low back pain who had been referred for X-rays. Intraclass correlation coefficients (ICCs) of intratester reliability for goniometric measurements of the pelvic angle were .93, .96, and .96. The intertester reliability was .95. The ICCs for intratester reliability for radiological measurements were .92 and .95 for the sacral angle and .98 for both measurements of the pelvic angle. Intertester reliability coefficients were .86 and .88, respectively. The Pearson correlation coefficients for the goniometric and radiological measurements of the pelvic angle were .85 and .68. A comparison of the radiological and goniometric measurements of the pelvic angle with the sacral angle demonstrated low average correlations of .43 and .58, respectively. The results indicate a high level of correlation between and within testers for goniometric measurements of the pelvic angle but only a fair correlation between goniometric and radiological measurements of the pelvic angle.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Gilliam
- Department of Physical Therapy, University of Florida, Gainesville
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Vo P, MacMillan M. The aging spine: clinical instability. South Med J 1994; 87:S26-35. [PMID: 8178199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Clinical instability of the spine is an intensely controversial subject, and its diagnosis, especially in the aging, is difficult. Yet success in its management rests on accurate diagnosis. Because both clinical presentation and radiographic manifestations are nonspecific, the diagnosis of clinical instability lies in understanding the biomechanics involved, in recognizing the relevant radiographic manifestations, and, most importantly, in correlating those observations with the patient's clinical history and physical examination. Stabilization is the treatment of choice for clinical instability. Strengthening of the dynamic stabilizers, especially early in the course of the disease, may prevent or alleviate the incapacitating symptoms of instability, and further research into this area should be undertaken. Static stabilization by bracing has not proved effective, and spinal fusion carries a high risk of complication. Fusion should be reserved for patients whose diagnosis is clear and whose symptoms are recalcitrant to conservative management. Further understanding of clinical spinal instability in the aging will require more precise definition of terms and better standardization of criteria for its diagnosis, management, and research.
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Affiliation(s)
- P Vo
- Department of Orthopaedics, University of Florida, Gainesville 32610-0246
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Abstract
OBJECTIVE This study investigated the ability to predict maximal functional lifting capacity from peak isometric lumbar extension torque and submaximal lifting mechanics. METHODS Peak isometric lumbar extension torques were measured on 26 healthy men and women, ages 18 to 39 years. In addition, their lifting mechanics were evaluated while they lifted a submaximal load. Each subject's maximal lifting capacity (kg) then was predicted from the peak torque and submaximal kinetic analysis using a linear regression model. RESULTS Mean values for the predicted and actual maximum weight the subjects lifted were not significantly different (50.3 +/- 15.6 kg and 48.5 +/- 17.0 kg, respectively, P > or = 0.05). The correlation between predicted and criterion values was high (r = 0.96), and the total error of the prediction was 5.1 kg, which represented 10.5% of the actual maximum value. CONCLUSIONS This multi-faceted functional assessment model involving biomechanical analysis of a submaximal lift and maximal isometric lumbar extension strength accurately predicted a subject's maximum functional lifting capacity.
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Affiliation(s)
- D L Wheeler
- Departments of Orthopaedics, University of Florida, Gainesville
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Abstract
STUDY DESIGN A correlational design was used to compare the lumbar spine's total sagittal range of motion (ROM) within a chronic low back pain patient population (n = 42) using three different measurement systems. OBJECTIVES To compare, within a back pain patient population, the relationship of ROM measurements obtained from a motion analysis system (SPINETRAK), a lumbar extension rehabilitation device (MedX), and liquid inclinometers. METHODS Total lumbar sagittal ROM was determined with each device in each subject as part of patients' standard clinical evaluation. RESULTS Results indicated that the motion analysis system is significantly correlated with the liquid inclinometers and mildly correlated with the MedX. Inclinometer and MedX ROM measurements are also significantly correlated. To assess individual differences, dependent t tests were performed. Results indicated that the SPINETRAK yielded significantly lower ROM than the inclinometer or the MedX. The MedX and inclinometer measures did not significantly differ. CONCLUSIONS This report shows that, depending on the device and procedures used, the lumbar sagittal ROM within a chronic low back pain population vary significantly.
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Affiliation(s)
- F R Shirley
- Shands Hospital Spinal Treatment and Rehabilitation Physical Therapy, University of Florida
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Abstract
Spinal fixation devices can be used to form a rigid construct with the spine to replace bone, restore alignment, maintain position, and prevent motion in the treatment of fractures, degenerative disease, neoplasm, and congenital deformities. Because most spinal constructs will eventually fail if bone fusion does not occur, bone graft material is often used along with the implant to promote fusion. Conventional radiographs, obtained in two projections, remain the mainstay of implant evaluation, demonstrating the position of the spinal elements, hardware, graft material, and evidence of complication. Possible complications connected with use of fixation devices include intraoperative soft-tissue injuries, postoperative hematomas, and infection. The components (through incorrect use, malpositioning at surgery, and later dislodgment or fracture) may also contribute to complications such as instability; failure of fusion; or pain, with possible resultant neurologic damage. Bone graft material can migrate or hypertrophy, resulting in impingement on the spinal canal or neural foramen. Radiologists should be familiar with the various spinal fixation devices and techniques to better identify evolving complications.
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Affiliation(s)
- R M Slone
- Department of Radiology, University of Florida, College of Medicine, Gainesville
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17
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Abstract
Spinal fixation devices are used in the thoracic and lumbosacral spine to stabilize the spine, reduce deformities and fractures, and replace abnormal vertebrae. A bone fusion is usually attempted along with placement of the instrumentation because in most cases the hardware would eventually fail if it were used alone. The thoracolumbar spine is inherently unstable, and early operative intervention improves mobilization and rehabilitation. In some cases of lumbar spinal pain, surgical intervention is necessary for the treatment of conditions such as herniated disks, spondylolysis with spondylolisthesis, and degenerative disease with scoliosis. Surgical procedures consist of posterior (posterior elements) and anterior (vertebral body) fixation. Radiologists face continual changes in both surgical technique and instrumentation and should be knowledgeable about the devices available and the biomechanical principles that direct their use. They need to work with their surgical colleagues to become familiar with the techniques used at their institutions.
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Affiliation(s)
- R M Slone
- Department of Radiology, University of Florida, College of Medicine, J. Hills Miller Health Center, Gainesville 32610-0374
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Abstract
Spinal fixation devices provide stability and restore anatomic alignment in the treatment of fractures, degenerative disease, infection, and tumors and correct congenital deformities such as those seen in scoliosis. The devices provide immediate stability but are not strong enough to withstand prolonged stress and eventually fail, in most cases, if bone fusion does not occur. Bone graft material is often used to promote fusion and to replace bone after resection. Internal fixation is used to maintain position and alignment and to prevent motion as the spine fuses. Plates and rods are attached to the vertebral body or posterior elements with wire, screws, and hooks. Screws and wire can also be used alone as a means of fixation. Surgical techniques and instrumentation have advanced in recent years, and radiologists are exposed to a myriad of devices. They need to be able to identify the various plates, screws, wiring techniques, and grafts used most commonly and to understand their function in the cervical spine for fusions and treatment of fractures and degenerative disease.
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Affiliation(s)
- R M Slone
- Department of Radiology, University of Florida, College of Medicine, Gainesville 32610-0374
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Cassisi JE, Robinson ME, O'Conner P, MacMillan M. Trunk strength and lumbar paraspinal muscle activity during isometric exercise in chronic low-back pain patients and controls. Spine (Phila Pa 1976) 1993; 18:245-51. [PMID: 8441940 DOI: 10.1097/00007632-199302000-00012] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The purpose of this study was to describe trunk strength and lumbar paraspinal muscle activity across five angles of flexion during isometric exercise and rest in chronic low-back pain patients and control subjects. High muscle tension as measured by surface integrated electromyography is predicted by a muscle spasm model, and low muscle tension is predicted by a muscle deficiency model. Prior lumbar surgery had no affect on peak torque or maximum surface integrated electromyography data. Both groups produced greater torque and less surface integrated electromyography in more flexed positions. Chronic low-back pain patients exhibited lower peak torque and lower maximum surface integrated electromyography bilaterally during isometric extension effort across all angles. A muscle deficiency model of chronic low back pain was supported by these data and a muscle spasm model was not supported. Discriminant analyses indicated that monitoring maximum surface integrated electromyography of lumbar muscles during isometric effort facilitates classification of chronic low-back pain patients. Future directions are discussed in terms of applying psychophysiologic methods to pain rehabilitation.
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Affiliation(s)
- J E Cassisi
- Department of Psychology, Illinois Institute of Technology, Chicago
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20
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Abstract
A total of 104 patients underwent transpedicular spinal instrumentation using the Cotrel-Dubousset (71 cases) or the Texas Scottish Rite Hospital (33) screw-rod system. Surgery was performed for lumbar vertebral column instability secondary to fractures (28 cases), spondylolisthesis (29), tumors (four), vertebral osteomyelitis (two), or postoperative causes (41). Pseudoarthrodesis due to failure of a prior fusion was present in 37 cases. The 55 men and 49 women (mean age 47 years, range 18 to 87 years) all presented with severe back pain. Signs or symptoms of neural compression were noted in 96 patients. Surgery consisted of neural decompression, internal fixation, and autogenous iliac bone grafting. Spondylolistheses were fused in situ, without reduction; otherwise, major spinal deformities were corrected. A total of 516 pedicle screws were placed. The mean extent of fusion was 2.7 motion segments (range one to six motion segments). A 96% fusion rate was obtained with a mean follow-up period of 20 months. There were no operative deaths. Major complications included one spinal epidural hematoma, three isolated nerve root deficits (two transient, one permanent), and three wound infections (two deep, one superficial). Instrument failure eventually developed in 18 patients; nine were asymptomatic with a solid fusion and did not require further treatment and the other nine were symptomatic or had a pseudoarthrosis and required operative revision. Pedicle screw-rod fixation offers biomechanical advantages compared to other forms of internal fixation for the lumbar spine. It enables short-segment fixation with preservation of lumbar lordosis and adjacent normal motion segments. This technique provides a highly successful method to obtain arthrodesis, even with prior pseudoarthrosis.
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Affiliation(s)
- C A Dickman
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville
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21
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Zelop C, Nadel A, Frigoletto FD, Pauker S, MacMillan M, Benacerraf BR. Placenta accreta/percreta/increta: a cause of elevated maternal serum alpha-fetoprotein. Obstet Gynecol 1992; 80:693-4. [PMID: 1383899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To investigate the relationship between elevated maternal serum alpha-fetoprotein (MSAFP) and abnormal placental adherence (placenta accreta/percreta/increta). METHODS We reviewed the MSAFP levels of 11 women who had cesarean hysterectomies because of placenta accreta/percreta/increta. The control group consisted of 14 women who delivered by cesarean because of placenta previa but who had no abnormal placental adherence. RESULTS Five of the 11 women with placenta accreta/percreta/increta had elevated MSAFP, whereas all 14 controls had normal levels. CONCLUSION These results indicate a significant association between elevated MSAFP and placenta accreta/percreta/increta (P = .017). Patients with an unexplained elevation of MSAFP as well as placenta previa may be at increased risk for abnormal placental adherence.
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Affiliation(s)
- C Zelop
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
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22
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MacMillan M. ENB recognises midwifery as a separate profession. Midwives Chron 1992; 105:151. [PMID: 1296135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
Two studies investigated the use of lumbar integrated electromyography (iEMG) during flexion-extension exercises of the lumbar spine. The first study compared the iEMG fatigue slopes of 12 pain-free controls during a standardized isotonic workout with a heavy weight and a light weight. Results indicated that the slopes of the iEMG across flexion-extension repetition was negative in both conditions, with the heavy weight producing significantly steeper fatigue slopes. In the second study, iEMG was compared from 16 chronic low back pain (CLBP) patients and 12 asymptomatic controls during isotonic exercise. Integrated EMG was recorded during 18 lumbar extension-flexion cycles (3 min) at a standard pace. Each subject exercised at a weight equal to 60% of his maximum isometric torque produced at the most extended position. Results indicated significantly less iEMG was produced by the CLBP group during both concentric and eccentric exertion. For both groups, eccentric exertion produced significantly less iEMG than concentric exertion. The groups showed significantly different iEMG fatigue slopes, with the control group showing declining iEMG by repetition, while the CLBP group showed flatter, slightly increasing iEMG. This occurred for both eccentric and concentric comparisons. A muscle deficiency model of CLBP is supported and results suggest the importance of endurance factors in addition to strength in rehabilitation efforts. Results also suggest the possibility of using this methodology for detecting insincere efforts in lumbar spine assessment.
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Affiliation(s)
- M E Robinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville 32610
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Abstract
In this study, the test-retest reliability of lumbar isometric strength testing in patients with chronic low back pain (CLBP) was assessed. Isometric torque measurements were obtained from 89 patients with CLBP at seven different angles of lumbar flexion. Because previous studies have demonstrated significant strength differences between male and female subjects, separate data analyses were performed for each gender. Results indicated moderate to high reliability for patients with CLBP when tested at individually determined angles of flexion within their idiosyncratic range of motion (ROM) (female subjects: r = .59-.96, P less than .05, SEE = 12.0-24.2 N.m; male subjects: r = .71-.93, P less than .05, SEE = 25.1-62.1 N.m). For comparison with previously published data on asymptomatic controls, an additional set of analyses was conducted for subjects with full lumbar ROM. Similar reliability was demonstrated for this subsample (female subjects: r = .57-.93, P less than .05, SEE = 12.4-27.9 N.m; male subjects: r = .63-.93, P less than .05, SEE = 34.2-44.2 N.m). The authors concluded that isometric lumbar extension torque could be reliably measured in patients with CLBP at multiple positions within the full ROM, although reliability decreased at the most extended positions. The demonstrated reliability will allow researchers to assess treatment effects and group differences without undue concern for artifact attributable to measurement error.
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Affiliation(s)
- M E Robinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville 32610
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25
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MacMillan M. RCM lobbies politicians on maternity services. Midwives Chron 1991; 104:360. [PMID: 1779900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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al-Muzairai IA, Dolhain R, Taylor Y, Stewart KN, MacMillan M, Catto GR, MacLeod AM. Influence of antiidiotypic antibody activity on renal transplant outcome. Kidney Int 1991; 40:80-5. [PMID: 1921159 DOI: 10.1038/ki.1991.183] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The presence of cytotoxic HLA antibodies (Ab1) against donor lymphocytes in pretransplant sera is almost always associated with rapid rejection of the renal transplant. We have investigated the possibility that antiidiotypic antibodies (Ab2) to cytotoxic HLA antibodies might modulate the immune response and favorably influence renal allograft outcome. The role of antibodies (Ab3) which potentiate the cytotoxic effect of Ab1 was also studied. Pretransplant sera from 63 patients were tested for inhibitory or potentiating activity in the short antiidiotypic assay. Inhibitory activity was detected in 30 patients and in 28 the transplant survived more than a year. Of patients without antibody activity 11 of 17 had grafts surviving more than one year, and of those showing potentiating activity 11 of 16 were functioning at a year. The difference in transplant survival between the first group and the other two groups was statistically significant (P less than 0.05). There was no significant difference in survival rates between the latter two groups. Potentiating activity is therefore not an independent predictor of transplant failure, whereas the presence of antiidiotypic antibody activity did correlate with improved allograft survival.
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Affiliation(s)
- I A al-Muzairai
- Department of Medicine and Therapeutics, University of Aberdeen, Scotland, United Kingdom
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MacMillan M. Correction to milk news. Nurs Stand 1991; 5:42. [PMID: 27524152 DOI: 10.7748/ns.5.24.42.s45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In the last paragraph of the article headlined 'Coalition discourages breast milk substitutes' (Nursing Standard News February 6), you identify Joan McDowall as an RCN Officer.
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Abstract
The properties of the omentum and its effect on spinal neurologic disease was investigated. Omental pedicle grafts were transferred to the laminectomized lumbar spines of nine neurologically normal dogs. Grafts were placed on either the dura or the spinal cord. Interruption of the graft's circulation was examined. To study the effect, the artery of the graft was injected with contrast and the graft-dura interface studied histologically. All injected specimens demonstrated vascular connections from the graft to the neural elements. The graft was found to decrease postoperative perineural scarring. The omentum appears to possess properties that could be applied to improve outcomes in spinal surgery.
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Affiliation(s)
- M MacMillan
- Department of Orthopaedics, College of Medicine, University of Florida
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Graves JE, Pollock ML, Carpenter DM, Leggett SH, Jones A, MacMillan M, Fulton M. Quantitative assessment of full range-of-motion isometric lumbar extension strength. Spine (Phila Pa 1976) 1990; 15:289-94. [PMID: 2141187 DOI: 10.1097/00007632-199004000-00008] [Citation(s) in RCA: 113] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The purpose of this study was to evaluate the reliability and variability of repeated measurements of isometric (IM) lumbar extension (LB EXT) strength made at different joint angles. Fifty-six men (age, 29.4 +/- 10.7 years) and 80 women (age, 24.3 +/- 9.1 years) completed IM LB EXT strength tests on 3 separate days (D1, D2, and D3). On D1 and D2, subjects completed two tests (T1 and T2) separated by a 20- to 30-minute rest interval. For each test, IM LB EXT strength was measured at 72, 60, 48, 36, 24, 12, and 0 degrees of lumbar extension. Mean IM strength values, within-day reliability coefficients, and test variability over the seven angles improved from D1 to D2 (D1: mean, 160.0 to 304.1 N.m, r = 0.78 to 0.96, SEE = 37.6 to 46.9 N.m; D2: mean, 176.3 to 329.1 N.m, r = 0.94 to 0.98, SEE = 29.0 to 34.4 N.m). Mean strength values leveled off by D3 (174.5 to 317.0 N.m). The most reliable test results showed that the IM LB EXT strength curves were linear and descending from flexion to extension and ranged from 235.8 +/- 85.2 to 464.9 +/- 150.7 N.m for men (extension to flexion) and from 134.6 +/- 53.2 to 237.3 +/- 71.9 N.m for women. Lumbar extension strength was clearly greatest in full flexion, which is in contrast to previously reported results. One practice test was required to attain the most accurate and reliable results. These data indicate that repeated measures of IM LB EXT strength are highly reliable and can be used for the quantification of IM LB EXT strength through a range of motion.
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Affiliation(s)
- J E Graves
- Department of Medicine, University of Florida, Gainesville
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Abstract
Preoperative antibiotics are an important measure taken to prevent infection in joint replacement surgery. The local availability of these antibiotics in the operative site is absolutely necessary to ensure adequate prophylaxis against contaminant bacteria. Because pulsatile-lavage rapid-recovery systems have become a routine technique of bone preparation in joint reconstruction, we chose to study the effect of these systems on local antibiotic concentrations. We further investigated the effect of irrigation with and without use of a limb tourniquet. For our study, we obtained 23 bone specimens in 16 patients undergoing joint reconstruction (14) or amputation (2). The patients were classified into one of four groups based on whether a tourniquet was applied during the procedure and whether the bone specimens were irrigated. In addition, matched blood samples were obtained to establish that therapeutic serum levels were achieved. Nine patients contributed 13 bone specimens, which underwent vigorous irrigation in vitro. None of these specimens had detectable levels of antibiotics, regardless of whether a tourniquet was used. Seven patients yielded 10 bone specimens, which were not irrigated. Five of these seven patients had detectable levels of antibiotics. In addition, the specimens from limbs without tourniquets had levels that averaged 0.51 microgram/ml while those with tourniquets averaged below 0.2 microgram/ml. Therefore, the use of vigorous irrigation in bone preparation has a significant deleterious effect on the local presence of previously administered systemic antibiotics. This effect is compounded if the operative site is isolated from continuous blood flow by use of a tourniquet. We therefore recommend that additional measures be taken to ensure that adequate antibiotic levels are present.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M MacMillan
- Gainesville Veterans Medical Center, Florida
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32
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MacMillan M, Gross RH. A simplified technique of distal femoral screw insertion for the Grosse-Kempf interlocking nail. Clin Orthop Relat Res 1988:252-9. [PMID: 3335100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Failure accurately to determine distal femoral screw hole position can sometimes prolong operating time for placing an interlocking Grosse-Kempf rod. The described technique allows the distal femoral screw holes to be localized accurately with minimal radiation exposure. This technique utilizes readily available instruments and is not technically demanding.
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Affiliation(s)
- M MacMillan
- Gainesville Veterans Area Medical Center, Florida
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33
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Abstract
An experimental method of approximating severed flexor tendons in zone II that allows immediate postoperative mobilization is described. The repair uses a nonabsorbable suture anchored into the severed tendon in zone III. This experimental repair was performed on one foot in each of 18 adult, white Leghorn chickens. The control side used the modified Kessler technique to repair the zone II laceration. The animals were prevented from weight-bearing activities but were allowed active motion of the foot for 5 to 6 weeks postoperatively. The results demonstrated a marked diminution in flexor tendon adhesions, with intrinsic tendon collagen formation serving to reconstitute tendon continuity on the experimental side. The breaking strengths of the two repair methods were equivalent. These results suggest that this method may allow primary repair of tendon injuries in zone II, with minimal formation of adhesions.
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Ablett RF, MacMillan M, Sole MJ, Toal CB, Anderson GH. Free tyrosine levels of rat brain and tissues with sympathetic innervation following administration of L-tyrosine in the presence and absence of large neutral amino acids. J Nutr 1984; 114:835-9. [PMID: 6726452 DOI: 10.1093/jn/114.5.835] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The tyrosine concentration of fasted rats was measured in plasma, brain and tissues receiving sympathetic innervation after L-tyrosine (200 mg/kg) was administered alone or in the presence of an equimolar cocktail containing isoleucine, leucine and valine. In the samples taken at 15, 30, 45, 60, 120 or 180 minutes, the highest concentrations of L-tyrosine were observed in plasma, heart, adrenal gland and kidney at 15 minutes, but in interscapular brown adipose tissue at 15 and 30 minutes and in brain at 15-60 minutes. The decline from peak concentrations was slower in brain, kidney and interscapular brown adipose tissue than in plasma, but in all tissues examined, control levels of free tyrosine were attained by 180 minutes postadministration . Competing large neutral amino acids reduced the maximal uptake of tyrosine in the brain by 48% but had no effect in the other tissues examined.
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MacMillan M. Madness - or just a case of sadness? Psychodrama with a group of psychiatric patients. Nurs Times 1980; 76:1310-3. [PMID: 6902215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Blumenthal I, MacMillan M, Costalos C. Letter: Lumbar puncture in transient hydrocephalus. Lancet 1976; 1:756. [PMID: 56581 DOI: 10.1016/s0140-6736(76)93144-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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