Limited Intervention in Adult Scoliosis-A Systematic Review

BACKGROUND/OBJECTIVES

Adult scoliosis is traditionally treated with long-segment fusion, which provides strong radiographic correction and significant improvements in health-related quality of life but comes at a high morbidity cost. This systematic review seeks to examine the literature behind limited interventions in adult scoliosis patients and examine the best approaches to treatment.

METHODS

This is a MEDLINE- and PubMed-based literature search that ultimately included 49 articles with a total of 21,836 subjects.

RESULTS

Our search found that long-segment interventions had strong radiographic corrections but also resulted in high perioperative morbidity. Limited interventions were best suited to patients with compensated deformity, with decompression best for neurologic symptoms and fusion needed to treat neurological symptoms secondary to up-down stenosis and to provide stability across unstable segments. Decompression can consist of discectomy, laminotomy, and/or foraminotomy, all of which are shown to provide symptomatic relief of neurologic pain. Short-segment fusion has been shown to provide improvements in patient outcomes, albeit with higher rates of adjacent segment disease and concerns for correctional loss. Interbody devices can provide decompression without posterior element manipulation. Future directions include short-segment fusion in uncompensated deformity and dynamic stabilization constructs.

CONCLUSIONS

Limited interventions can provide symptomatic relief to adult spine deformity patients, with indications mostly in patients with balanced deformities and neurological pain.

Intrapulmonary arteries respond to serotonin and adenosine triphosphate in broiler chickens susceptible to idiopathic pulmonary arterial hypertension

This study examined factors contributing to increased vascular resistance and plexiform lesion formation in broiler chickens susceptible to idiopathic pulmonary arterial hypertension (IPAH). A diet supplemented with excess tryptophan (high-Trp diet), the precursor for serotonin, was used to accelerate the development of IPAH. Broilers fed the high-Trp diet had higher pulmonary arterial pressures than broilers fed the control diet, and plexiform lesion incidences tended to be higher (P = 0.11) in the high-Trp group than in the control group at 30 d of age. The intrapulmonary arteries were assessed for vasoconstriction in response to serotonin and adenosine triphosphate (ATP) and for activities of key metabolic enzymes for serotonin and ATP. The pulmonary artery (defined as the first major branch of the pulmonary artery inside the lung) and the primary pulmonary arterial rami (defined as the second major branch of the pulmonary artery inside the lung) both exhibited vasoconstriction in response to serotonin and ATP. This is the first study to demonstrate purinergic-mediated vasoconstriction in intrapulmonary arteries from broilers. Arteriole responsiveness did not differ between broilers fed the control diet or the high-Trp diet. Therefore, the high-Trp diet enhanced the development of IPAH but did not affect the artery's sensitivity to serotonin or ATP. Monoamine oxidase activity, responsible for the breakdown of serotonin, was severely impaired in pulmonary arteries from broilers in the high-Trp group. Accordingly, serotonin may persist longer and elicit an amplified response in broilers fed the high-Trp diet.

Development of diagnostic criteria for serious non-AIDS events in HIV clinical trials

PURPOSE

Serious non-AIDS (SNA) diseases are important causes of morbidity and mortality in the HAART era. We describe development of standard criteria for 12 SNA events for Endpoint Review Committee (ERC) use in START, a multicenter international HIV clinical trial.

METHODS

SNA definitions were developed based upon the following: (1) criteria from a previous trial (SMART), (2) review of published literature, (3) an iterative consultation and review process with the ERC and other content experts, and (4) evaluation of draft SNA criteria using retrospectively collected reports in another trial (ESPRIT).

RESULTS

Final criteria are presented for acute myocardial infarction, congestive heart failure, coronary artery disease requiring drug treatment, coronary revascularization, decompensated liver disease, deep vein thrombosis, diabetes mellitus, end-stage renal disease, non-AIDS cancer, peripheral arterial disease, pulmonary embolism, and stroke. Of 563 potential SNA events reported in ESPRIT and reviewed by an ERC, 72% met "confirmed" and 13% "probable" criteria. Twenty-eight percent of cases initially reviewed by the ERC required follow-up discussion (adjudication) before a final decision was reached.

CONCLUSION

HIV clinical trials that include SNA diseases as clinical outcomes should have standardized SNA definitions to optimize event reporting and validation and should have review by an experienced ERC with opportunities for adjudication.

Effect of fractionation and pyrolysis on fuel properties of poultry litter

Raw poultry litter has certain drawbacks for energy production such as high ash and moisture content, a corrosive nature, and low heating values. A combined solution to utilization of raw poultry litter may involve fractionation and pyrolysis. Fractionation divides poultry litter into a fine, nutrient-rich fraction and a coarse, carbon-dense fraction. Pyrolysis of the coarse fraction would remove the corrosive volatiles as bio-oil, leaving clean char. This paper presents the effect of fractionation and pyrolysis process parameters on the calorific value of char and on the characterization of bio-oil. Poultry litter samples collected from three commercial poultry farms were divided into 10 treatments that included 2 controls (raw poultry litter and its coarse fraction having particle size greater than 0.85 mm) and 8 other treatments that were combinations of three factors: type (raw poultry litter or its coarse fraction), heating rate (30 or 10 degrees C/min), and pyrolysis temperature (300 or 500 degrees C). After the screening process, the poultry litter samples were dried and pyrolyzed in a batch reactor under nitrogen atmosphere and char and condensate yields were recorded. The condensate was separated into three fractions on the basis of their density: heavy, medium, and light phase. Calorific value and proximate and nutrient analysis were performed for char, condensate, and feedstock. Results show that the char with the highest calorific value (17.39 +/- 1.37 MJ/kg) was made from the coarse fraction at 300 degrees C, which captured 68.71 +/- 9.37% of the feedstock energy. The char produced at 300 degrees C had 42 +/- 11 mg/kg arsenic content but no mercury. Almost all of the Al, Ca, Fe, K, Mg, Na, and P remained in the char. The pyrolysis process reduced ammoniacal-nitrogen (NH4-N) in char by 99.14 +/- 0.47% and nitrate-nitrogen (NO3-N) by 95.79 +/- 5.45% at 500 degrees C.

Determination of the underlying cause of death in three multicenter international HIV clinical trials

PURPOSE

Describe processes and challenges for an Endpoint Review Committee (ERC) in determining and adjudicating underlying causes of death in HIV clinical trials.

METHOD

Three randomized HIV trials (two evaluating interleukin-2 and one treatment interruption) enrolled 11,593 persons from 36 countries during 1999-2008. Three ERC members independently reviewed each death report and supporting source documentation to assign underlying cause of death; differences of opinion were adjudicated.

RESULTS

Of 453 deaths reported through January 14, 2008, underlying causes were as follows: 10% AIDS-defining diseases, 21% non-AIDS malignancies, 9% cardiac diseases, 9% liver disease, 8% non-AIDS-defining infections, 5% suicides, 5% other traumatic events/accidents, 4% drug overdoses/acute intoxications, 11% other causes, and 18% unknown. Major reasons for unknown classification were inadequate clinical information or supporting documentation to determine cause of death. Half (51%) of deaths reviewed by the ERC required follow-up adjudication; consensus was eventually always reached.

CONCLUSION

ERCs can successfully provide blinded, independent, and systematic determinations of underlying cause of death in HIV clinical trials. Committees should include those familiar with AIDS and non-AIDS-defining diseases and have processes for adjudicating differences of opinion. Training for local investigators and procedure manuals should emphasize obtaining maximum possible documentation and follow-up information on all trial deaths.

Diagnosis and management of inflammatory bowel disease

The chronic, unpredictability of inflammatory bowel disease makes it difficult for patients to cope. In fact several studies quoted by Cox (1995) found that the Majority of IBD patients, even the one's who considered themselves "well," experienced some impairment in quality of life. Early detection of IBD is essential in developing patient confidence and providing motivation for cooperation in treatment. Irvine (1997) conducted a study dealing with the quality of life issues with IBD and concluded that despite impairments, most patients with IBD overcame the obstacles imposed by their illness and managed to remain productive members of society. Similar management (with anti-inflammatory drugs) makes differentiating between Crohn's disease and ulcerative colitis during the early stages of the disease, unnecessary. Situations that require differentiation include: right sided pain or tenderness, steatorrhea, nutritional deficiencies, or a palpable mass (Macrae & Bhathal, 1997). Although IBD continues to be of unknown etiology, recent advances and further study in the areas of the immune system, genetics and environmental influences may provide helpful treatment options in the future. For now, the clinician/patient goal must be to maintain adequate nutrition, promote healing, treat complications, and maintain an optimal lifestyle.

Fluorescence imaging in human identity testing

We have investigated the use of fluorescence detection and the FluorImager S1 System (Molecular Dynamics) for analyzing a comprehensive set of human DNA typing tests. We used an alkaline phosphatase-conjugated YNH24 oligonucleotide probe to the repeat-containing D2S44 locus to detect both alleles in 50 ng of human genomic DNA (0.025 amol) by Southern hybridization using a chemifluorescent substrate. We used a similar approach to quantify human DNA using an enzyme-conjugated oligonucleotide probe to the D17Z1 locus. Both fluorescent nucleic acid gel staining and direct fluorescent labeling methods were tested to detect PCR-based D1S80 and short tandem repeat (STR) multiplex allele profiles. The fluorescent staining method sensitively detected these allelic profiles in both denaturing and non-denaturing acrylamide gels using a simple, 10-min procedure. Fluorescent primers eliminate the doublet band patterns often seen with staining methods, which label both strands of the amplified products. This complicates interpretation of STR typing tests. Only one primer for each locus is labeled, so only one strand of the DNA product is detected. Fluorescein end-labeled primers were used in multiplex PCR to amplify, detect and type STRs.