Failure of conservative treatment for lumbar spinal stenosis in elderly patients.

Spinal stenosis syndrome affects mainly patients at their 5th-6th decades of life. There is a strong debate in the literature whether patients with spinal stenosis should be operated or treated conservatively. Our aim was to evaluate patients with lumbar spinal stenosis who were treated conservatively. All patients over 65 years of age who were handled conservatively in the private clinic of the senior author due to spinal stenosis syndrome were evaluated. There were 21 males and 15 females aged between 65 and 88 years. Intermittent claudication was the dominant clinical presentation. The radiological examination showed a frequent narrowing at the level L4-L5. All patients had a severe stenosis of less than 10mm diameter of the spinal canal. All patients underwent a conservative therapy which included physical therapy with ultrasound waves, short waves, and flexion exercises. All patients were offered to undergo an epidural or nerve root injection. Twenty-four patients agreed also to have one of these procedures to relieve their symptoms. All patients were followed between 6 and 10 months after the initial diagnosis. We used the Oswestry index category for evaluation. In all parameters the conservative treatment failed to improve the symptoms in the vast majority of patients. None of the patients was very satisfied with the results of conservative treatment while 33 patients (92%) were not so satisfied or unsatisfied with the results. We conclude that conservative treatment for lumbar spinal stenosis is not a success for elderly patients. These patients should be convinced to undergo operative treatment.

Endocrine alterations associated with extended time interval between estrus and ovulation in high-yield dairy cows.

Short fertile half-lives of the male and female gametes in the female tract necessitate accurate timing of artificial insemination. We examined the possible association between extension of the estrus to ovulation (E-O) interval and alterations in concentrations of estradiol, progesterone, and the preovulatory LH surge before estrus and ovulation. High-yielding Holstein cows (n = 74 from a total of 106) were synchronized and were examined around the time of the subsequent estrus. They were observed continuously for estrual behavior. Blood samples were collected before and after estrus, and ultrasound checks for ovulation were made every 4 h. About three-quarters of the cows exhibited short (but normal) E-O intervals of 22 to 25 h (25%) or normal intervals of 25 to 30 h (47%); 17% of them displayed a long (but normal) E-O interval of 31 to 35 h, and about 10% exhibited a very long E-O interval of 35 to 50 h. Extended E-O interval comprised estrus-to-LH surge and LH surge-to-ovulation intervals that were both longer than normal. Pronounced changes in hormonal concentrations were noted before ovulation in the very long E-O interval group of cows: progesterone and estradiol concentrations were reduced, and the preovulatory LH peak surge was markedly less than in the other 3 groups. Postovulation progesterone concentrations during the midluteal phase were lesser in the very long and the long E-O interval groups compared with those in the short and normal interval groups. Season, parity, milk yield, and body condition did not affect the estrus to LH surge, LH surge to ovulation, and E-O intervals. The results indicate an association between preovulatory-reduced estradiol concentrations and a small preovulatory LH surge, on the one hand, and an extended E-O interval, on the other hand. Delayed ovulation could cause nonoptimal timing of AI, a less than normal preovulatory LH surge that may be associated with suboptimal maturation of the oocyte before ovulation, or reduced progesterone concentrations before and after ovulation. All may be factors associated with poor fertility in cows with a very long E-O interval.

Penetration of ceftriaxone into the intervertebral disc.

Concentrations of ceftriaxone in serum and intervertebral disc tissue were determined with high-pressure liquid chromatography in forty-five patients after a single intravenous loading dose of 1000 milligrams given at different intervals before an operation on the spine. The mean serum concentrations in this study corresponded well with reported values. The mean tissue concentrations were 5.6 micrograms per gram (95 per cent confidence interval, 3.6 to 6.8 micrograms per gram) one to less than two hours after administration of the antibiotic, 6.4 micrograms per gram (95 per cent confidence interval, 2.8 to 10.0 micrograms per gram) two to less than four hours, and 3.6 micrograms per gram (95 per cent confidence interval, 0.6 to 6.6 micrograms per gram) at fourteen to less than sixteen hours. These drug concentrations exceed the minimum inhibitory concentration that was effective against 90 per cent of the bacteria for methicillin-sensitive Staphylococcus aureus; for Streptococcus pyogenes, agalactiae, viridans, pneumoniae, and bovis; and for community-acquired Enterobacteriaceae. The average serum-to-tissue ratio was 191:1 at less than one-half hour and 13:1 at less than one and a half hours. The lower values of the 95 per cent confidence intervals for the concentration of the antibiotic exceeded the minimum inhibitory concentrations in the disc tissue against most susceptible bacteria during the period between one and a half and four hours, but a larger bolus would be needed to maintain this level for a longer period (such as in a longer operation) and as prophylaxis against methicillin-sensitive Staphylococcus aureus and coagulase-negative staphylococci.

Seasonal differences in progesterone production by luteinized bovine thecal and granulosa cells.

This study examined seasonal differences in progesterone (P4) production by granulosa cells (GC) and thecal cells (TC) that were luteinized in vitro during the winter or the summer; it also compared plasma P4 concentrations of lactating dairy cows in the two seasons. First-wave dominant follicles obtained from Holstein cows were dissected on day 6 of the cycle, GC and TC were separated, enzymatically dispersed, and cultured for 9 days in media containing 1% fetal calf serum, forskolin (10 micromol/mL) and insulin (2 microg/mL), to induce cell luteinization. All experimental procedures were identical and characteristics of the follicles were similar in the two seasons. During 9 days of culture, P4 production by luteinized GC was higher in winter than in summer, but the difference only tended to be significant. In contrast, luteinized TC produced three times as much P4 in winter as in summer (324 versus 100 ng/10(5)cells). In the in vivo experiment, P4 concentrations in plasma collected during entire estrous cycles in winter and summer were compared. The cows were, on average, at 70 days postpartum and yielded similar amounts of milk. Concentrations of progesterone in plasma were significantly higher in winter than in summer; during the mid-luteal phase the difference between the two seasons was 1.5 ng/mL. These results indicate that chronic effects of heat-stress are possibly carried over from an impaired follicle to an impaired corpus luteum (CL), and that luteinized TC are more susceptible to heat-stress than luteinized GC.

Delayed effect of progesterone on endometrial morphology in dairy cows.

Two experiments were conducted to investigate the effect of vaginal progesterone (P4) administered during the luteal phase, on endometrial morphology during the subsequent oestrous cycle. In experiment 1, lactating Holstein cows were allotted to three groups: (1) Control group in which cows remained untreated; (2) The CIDR group in which cows were treated with two P4-containing controlled intravaginal-drug releasing devices (CIDR) during days (d) 6-12 of the cycle; and (3) The PG + CIDR group of cows that received two prostaglandin F2 alpha (PGF2 alpha) injections on d 6 and 7 of the oestrous cycle, to regress the corpus luteum (CL), and were treated with CIDRs on d 6-12, like the CIDR group. All cows were slaughtered on d 3 of the subsequent oestrous cycle. In experiment 2, cows were allotted to three groups: (1) Control cows that remained untreated; (2) CIDR cows that were treated with two CIDRs from d 6 to 15; and (3) Early PG cows that received three i.m. injections of PGF2 alpha on d 3 and 4 of the oestrous cycle to reduce plasma P4. All cows were slaughtered on d 15 of the subsequent cycle. In both experiments, blood was collected during the treated and subsequent cycles to determine P4 and oestradiol (E2) concentrations, and tissue samples from the uterine horn ipsilateral to the CL were collected on the day of slaughter to evaluate endometrial morphology. In both experiments, plasma P4 differed between treatments during the treated cycle but no differences in P4 and E2 concentrations were recorded during the subsequent cycle. In experiment 1, the endometrial morphology of the cows from CIDR and PG + CIDR groups differed from that found in the control group: The surface epithelium was medium to high and the glands were round and tortuous, as compared with low epithelium and oblong glands in the control. In addition, the density of blood vessels and the level of edema was higher in the CIDR-treated cows than in the control cows. In experiment 2, the endometrial morphology of the CIDR-treated group differed from that of the control and early PG groups: Low surface epithelium and oblong glands in the former compared with high epithelium and tortuous glands in the latter. In summary, P4 supplementation during the luteal phase had delayed effect on endometrial morphology at different stages of the subsequent oestrous cycle.

Operative treatment for hip fractures in patients 100 years of age and older: is it justified?

OBJECTIVES: To evaluate a unique group of elderly patients over 100 years of age who had hip fractures. DESIGN: Retrospective database analysis. SETTINGS: Academic teaching hospital. PATIENTS: All patients who had hip fractures between January 1990 and December 2001 and were over 100 years old were included. INTERVENTION: In this study, we evaluated the age, gender, type of fracture, type of treatment, background disease, rehabilitation, and time until death of all patients over 100 years, whether treated operatively or nonoperatively. RESULTS: Twenty-three patients (17 females and 6 males) were identified with ages ranging from 100 to 107 (mean: 101.8). The group had 4 subcapital and 19 pertrochanteric fractures and between 1 and 4 major background diseases. Four patients were treated nonoperatively (1 due to major pneumonia and 3 refused the operative procedure). Three of those 4 patients died in the same month of admission, and 1 patient died during the second month. Among the 19 patients who underwent operation, 17 patients have died, living between 0 and 78 months (mean: 13.8) postoperatively. Two are still alive (21 and 45 months) after the operation. Eight patients died prior to 6 months, and 11 lived more than a year after the operation. A comparison between these 2 groups showed greater major background disease in the patients who died prior to 6 months (P < 0.05). CONCLUSIONS: Most hip fractures in patients over 100 years of age are pertrochanteric. Patients with 2 or more major background diseases have an increased risk for dying in the first 6 months after the operation. Most patients having operations in this age group had a postoperative reduction in mobility status and in performing basic activities of daily living.

Progesterone production and clearance in cyclic ewes passively immunized against progesterone.

The effects of passive immunization of ewes against progesterone on plasma progesterone concentrations and on the metabolic clearance rate (MCR) and production rate (PR) of progesterone were investigated. Three treatment groups were studied: 1) nonimmunized controls, 2) ewes passively immunized with antiprogesterone serum, and 3) immunized progestagen-treated ewes, treated concomitantly with anti-serum and with a synthetic progestagen that is not bound by the antiserum. Progesterone levels in the immunized ewes reached a maximum of 27.7+/-4.8 nmol/l and were significantly higher (P<0.05) than in the nonimmunized controls (9.2+/-1.1 mol/l) or the immunized progestagen-treated ewes (15.6+/-1.6 nmol/l). Mean progesterone MCR in the immunized ewes was 1.6+/-0.5 and 2.1+/-0.3 liter/min on Days 7 and 13 of the estrous cycle, respectively, compared with 0.8+/-0.2 and 1.4+/-0.3 liter/min, respectively, in nonimmunized controls. The progesterone production rate in the immunized ewes was significantly higher than in nonimmunized controls, and reached 12.0+/-2.2 and 19.7+/-1.6 nmol/min on Days 7 and 13 of the estrous cycle, respectively, compared with 4.6+/-0.6 and 10.0+/-2.5 nmol/min in nonimmunized controls (P<0.03 for both comparisons). Treatment with progestagen had no significant effect on progesterone MCR or PR of immunized ewes. The LH pulse frequency on Days 10 to 11 of the cycle was 0.7+/-0.3, 1.8+/-0.3 and 0.0+/-0.0 pulses/6 h in the control, immunized and immunized progestagen-treated groups, respectively (P<0.05). It is concluded that the increased plasma progesterone levels in the immunized ewes are the result of an increased progesterone production rate, which may have been induced by an increase in gonadotrophin secretion or by a direct effect of the anti-progesterone serum on the ovary.

The effect of active immunization against progesterone on plasma concentrations of total and free progesterone, estradiol-17beta and LH in the cyclic ewe.

Nine mature cyclic ewes were actively immunized against progesterone which was rendered immunogenic by conjugation to bovine serum albumin (BSA). Seven control ewes were immunized with BSA. In ewes immunized against progesterone, the concentration of total plasma progesterone increased to 24.3 ng/ml vs 2.8 ng/ml in control animals (P<0.001). However, immunization did not affect the plasma levels of free, unbound progesterone. The correlation coefficient between total plasma progesterone concentrations on Days 4 to 11 of the estrous cycle and antibody titer was r=0.983. Estradiol-17beta concentrations in immunized ewes were higher than in controls on Days 6 to 15 of the estrous cycle (P approximately 0.05). Frequent sampling for LH over a 6-h period on Days 2, 5, 8, 11 and 14 of the cycle revealed no significant differences in the frequency and amplitude of LH pulses between immunized and control ewes. The immunized ewes had estrous cycles of normal length and maintained normal pregnancies. It is suggested that the immunized cyclic ewe is capable of maintaining adequate levels of free progesterone by greatly increasing progesterone synthesis, thus neutralizing the effect of the antibodies.

Management of reproduction in dairy heifers based on the synchronization of estrous cycles.

Israeli-Holstein breed dairy heifers (n=571), 13 to 15 mo old, were utilized in two experiments. In Experiment 1, the reproductive performance of synchronized heifers was compared with that of untreated controls. The heifers in both groups were inseminated following the detection of estrus. In Experiment 2, all heifers were synchronized and inseminated following the detection of estrus. Half of the animals in this experiment also received one or two fixed-time inseminations 72 and 96 h after the last synchronization treatment. Synchronization of estrous cycles was performed by two prostaglandin F2alpha (PG) injections given 12 d apart. In the control group of Experiment 1, observation of estrous behavior and insemination of heifers detected in estrus were carried out daily throughout the experiment. In the synchronized groups of Experiments 1 and in 2, the management of reproduction consisted of estrus detection followed by the insemination of heifers in estrus carried out only during 6 d of every 3 wk. Five days following the second PG injection, 86% of the heifers were detected in estrus, 71% of them at 49 to 96 h after treatment. In Experiment 1, age at first insemination, age at conception, and conception rate were, respectively, 425 d, 446 d and 54% in the control group vs 432 d (P<0.02), 449 d and 62% in the PG-treated group. In Experiment 2, the respective figures were 436 d, 462 d and 59% in the group inseminated following the detection of estrus vs 427 d (P<0.002), 464 d and 51% (P<0.05) in the group in which heifers were inseminated at estrus and also received one or two fixed-time inseminations.

Rehabilitation after knee immobilization in octogenarians with patellar fractures.

Between January 1990 and December 1999, 14 octogenarians (8 women and 6 men) underwent surgery for comminuted patellar fracture. Average patient age was 83 years (range: 80-88 years). Follow-up ranged from 1-8 years (mean: 3.5 years). Ten of 14 patients were totally independent, whereas 4 patients used a cane for mobilization. Twelve patients had background diseases. Patients underwent operative treatment with tension band wires followed by cast immobilization (knee in approximately 10 degrees of flexion) for 6 weeks. Immediate full weight bearing was initiated in all patients, and intense rehabilitation was performed after cast removal to increase range of motion. Complete union was noted for all fractures. All patients but 1 had an active extension lag of 10 degrees-20 degrees before physiotherapy and maximum flexion was 70 degrees. After physiotherapy, 4 patients regained full active extension and all patients achieved >100 degrees of flexion. Twelve of 14 patients returned to their pre-injury functional level. A slight deterioration was noted in 2 patients. Although knee immobilization may cause severe limitation in range of motion, its use in elderly patients followed by intense rehabilitation is advocated and showed good results.

The time of oestrus and ovulation following various synchronisation techniques using progesterone impregnated intravaginal devices.

Progesterone releasing intravaginal devices (PRIDs) were used in 4 experiments involving 67 cattle to study the effect of the stage of the oestrous cycle and of oestradiol benzoate (ODB) administration on the time interval from PRID removal to oestrus and/or ovulation. Cows in which PRIDs were inserted on days 2 to 4 of the oestrous cycle for 14 days were subsequently observed by endoscopy to ovulate significantly later than cows given identical treatments on days 13 and 14 of the cycle. The concentration of progesterone was higher in the former group at the time PRIDs were removed and remained at a higher level for 3 days thereafter. The length of the oestrous cycle of untreated heifers was significantly longer than in heifers treated for 12 days with PRIDs only inserted on day 3 of cycle (19.7 v 18.2; p less than 0.01). Treatment with PRIDs inserted for 12 days together with ODB further shortened the cycle length from 18.2 days to 16.9 days (p less than 0.01). The intervals from PRID removal to onset of standing oestrus in heifers treated with PRID only and those treated with PRID and ODB were 80h and 45h, respectively (p less than 0.01); the respective variances were 280 and 4; p less than 0.01). Plasma progesterone concentration, at PRID removal, was 3 times higher in heifers treated with PRID only than in heifers treated with PRID and ODB (p less than 0.01) and the interval from PRID removal to the lowest progesterone value following it was 3.8 ad 1.2 days for the 2 groups, respectively (p less than 0.05). The study indicated that the stage of oestrous cycle at PRID insertion is an important factor which influences the interval from withdrawal of PRIDs to ovulation. The results suggest closer synchronisation would follow insertion in the mid-luteal phase (Day 13 to 14) or use of ODB treatment at the time of insertion of PRIDs.

[Relief of chronic cervical pain after selective blockade of zygapophyseal joint].

Osteoarthrosis of the zygapophyseal joint (Z-joint) is a potential cause of chronic cervical pain. The diagnosis of thirty patients, with pain of more than 12 months duration and with no history of trauma, was confirmed with intra-articular fluoroscopy-guided infiltration of anesthetic. The patients were subsequently treated with intra-articular corticosteroids (Depo-Medrol 40 mg). Visual Analogue Scale was used for evaluation purposes. The mean time for relapse of 50 percent of the pre-injection level of pain was 12.47 +/- 1.89 weeks, significantly longer than 3 days as reported in patients similarly treated following whiplash neck injury. At this point selective blockade of Z-joints may be offered as an adjunct for diagnostic and therapeutic purposes for patients with chronic neck pain due to facet osteoarthrosis in the ambulatory setup.