Intradiscal vacuum phenomenon matches lumbar spine degeneration patterns in an ageing population.

PURPOSE: Intra-Discal Vacuum phenomenon (IDVP) is well-recognised, yet poorly visualised and poorly understood radiological finding in disc degeneration, particularly with regard to its role in spinal alignment. CT analysis of the lumbar spine in an aging population aims to identify patterns associated with IDVP including lumbopelvic morphology and associated spinal diagnoses. METHODS: An analysis was performed of an over-60s population sample of 2020 unrelated abdominal CT scans, without acute spinal presentations. Spinal analysis included sagittal lumbopelvic reconstructions to assess for IDVP and pelvic incidence (PI). Subjects with degenerative pathologies, including previous vertebral fractures, auto-fusion, transitional vertebrae, and listhesis, were also selected out and analysed separately. RESULTS: The prevalence of lumbar spine IDVP was 50.3% (955/1898) and increased with age (125 exclusions). This increased in severity towards the lumbosacral junction (L1L2 8.3%, L2L3 10.9%, L3L4 11.5%, L4L5 23.9%, and L5S1 46.3%). A lower PI yielded a higher incidence of IDVP, particularly at L5S1 (p < 0.01). A total of 292 patients had IDVP with additional degenerative pathologies, which were more likely to occur at the level of isthmic spondylolisthesis, adjacent to a previous fracture or suprajacent to a lumbosacral transitional vertebra (p < 0.05). CONCLUSIONS: This study identified the prevalence and severity of IDVP in an aging population. Sagittal patterns that influence the pattern of IVDP, such as pelvic incidence and degenerative pathologies, provide novel insights into the function of aging spines.

The surgical outpatient clinic and the environment.

Rising global temperatures will have a radical impact on the environment where global warming is associated with weather extremes such as thunderstorms and droughts which can affect the regional ecosystems. The healthcare sector is a major emitter of greenhouse gasses. Within healthcare, the outpatient clinic is responsible for a considerable sum of emissions. These can be organized under scopes 1, 2 and 3 as described in the Greenhouse Gas Protocol where scope 1 accounts for direct emissions from healthcare facilities, scope 2 is emissions from purchased electricity and scope 3 is indirect emissions including procurement and waste. Emissions and mitigation strategies from the surgical outpatient clinic are outlined under each scope of the Greenhouse Gas Protocol. These include using insulation materials, renovating or building new facilities, incorporating renewable energy sources and utilizing more efficient appliances. Telehealth and virtual clinics have been shown to be an effective method of delivering care while avoiding the combustion of fossil fuels to facilitate patient transport. In addition, virtual set-ups are cost effective and have not been proven to compromise patient safety when implemented correctly.

Acidosis significantly alters immune checkpoint expression profiles of T cells from oesophageal adenocarcinoma patients.

Tumour acidosis contributes to cancer progression by inhibiting anti-tumour immunity. However, the effect of acidosis on anti-tumour T cell phenotypes in oesophageal adenocarcinoma (OAC) is unknown. Therefore, this study investigated the effect of acidosis on anti-tumour T cell profiles and if immune checkpoint blockade (ICB) could enhance anti-tumour T cell immunity under acidosis. Acidic conditions substantially altered immune checkpoint expression profiles of OAC patient-derived T cells, upregulating TIM-3, LAG-3 and CTLA-4. Severe acidosis (pH 5.5) significantly decreased the percentage of central memory CD4+ T cells, an effect that was attenuated by ICB treatment. ICB increased T cell production of IFN-γ under moderate acidosis (pH 6.6) but not severe acidosis (pH 5.5) and decreased IL-10 production by T cells under severe acidic conditions only. A link between lactate and metastasis was also depicted; patients with nodal metastasis had higher serum lactate levels (p = 0.07) which also positively correlated with circulating levels of pro-angiogenic factor Tie-2. Our findings establish that acidosis-induced upregulation of immune checkpoints on T cells may potentially contribute to immune evasion and disease progression in OAC. However, acidic conditions curtailed ICB efficacy, supporting a rationale for utilizing systemic oral buffers to neutralize tumour acidity to improve ICB efficacy. Study schematic-PBMCs were isolated from OAC patients (A) and expanded ex vivo for 7 days using anti-CD3/28 +IL-2 T cell activation protocol (B) and further cultured for 48 h under increasing acidic conditions in the absence or presence of immune checkpoint blockade (nivolumab, ipilimumab or dual nivolumab + ipilimumab) (C). Immunophenotyping was then carried out to assess immune checkpoint expression profiles and anti-tumour T cell phenotypes (D). Serum lactate was assessed in OAC patients (E-F) and levels were correlated with patient demographics (G) and the levels of circulating immune/pro-angiogenic cytokines that were determined by multiplex ELISA (H). Key Findings-severe acidic conditions upregulated multiple immune checkpoints on T cells (I). Efficacy of ICB was curtailed under severe acidic conditions (J). Circulating lactate levels positively correlated with circulating levels of pro-angiogenic factor tie-2 and higher serum lactate levels were found in patients who had nodal metastasis (K).

THE EFFECT OF MEDICATED INTRA-ANAL PACKING ON DECREASING OF ACUTE POST-OPERATIVE URINARY RETENTION INCIDENCE AFTER OPEN HEMORRHOIDECTOMY.

OBJECTIVE: The aim: To evaluate the effect of decreasing post-operative anal pain and spasm on the rate of post-surgical acute urinary obstruction in patients undergoing hemorrhoidectomy. PATIENTS AND METHODS: Materials and methods: The study was conducted from April 2013 to April 2019 on 571 patients that were undergoing conventional hemorrhoidectomy. The operation was followed by using the medicated intra-anal packing and then the patients were monitored postoperatively for the first 24 hours for the incidence of postoperative urinary retention. The hypothesis of this study was that the acute urinary retention is the most common post-operative complication of the anal surgeries and that the irritation-blockade mechanism which is induced due to anal skin injury is the main cause of that obstruction. Thus, reducing the incidence of this mechanism will reduce urinary retention and post-operative pain. RESULTS: Results and conclusions: The results found that 569 (99.64%) patients were showed no signs of urinary retention with the exception of only two (0.35%) patients were showed signs of urinary retention. Finally, it was concluded that usage of medicated anal-packing methods was of benefit in decreasing the rate of postoperative urinary retention due to its effect in decreasing postoperative anal pain and spasm.

Natural History of IntraDiscal Vacuum Phenomenon and its role in Advanced Disc Degeneration.

STUDY DESIGN: Observational serial CT analysis of the lumbar spine in a normal-aging population. OBJECTIVE: Assess the natural history of IntraDiscal Vacuum Phenomenon and its role in disc degeneration. Summary of Background Data: The natural history of disc degeneration is well described but our understanding of the end stage of pathogenesis remains incomplete. MRI loses accuracy with advanced degeneration, becoming hyporesonant and indistinct. Cadaveric specimens display adaptive changes in the disc with loss of the hydrostatic capacity of the nucleus, increased intra-discal clefts and end-plate impermeability. IDVP is associated with advanced disc degeneration and CT is the optimal modality to visualise this, yet these insights remain unreported. METHODS: Subjects only included historic CT abdomen scans of those over 60 years of age without acute or relevant spinal pathology, with a diagnosis of at least one level with IDVP on the original CT scan and all of whom had a similar scan >7 years later. A history of clinically significant back pain was also recorded. RESULTS: CT scans included 360 levels in 29 males and 31 females (mean 68.9 years), displaying 82 levels of IDVP, with a second scan included after a mean of 10.3 years, Most levels displayed the same level of severity (persisted, 45) compared to where some progressed (26), regressed (8) and fused (3) (P<0.01). There was also an increased incidence, 37/60 (62%) of developing IDVP at another level. Disc heights were reduced with increased severity of IDVP. A record of back pain was evident in 31/60 subjects, which was not significantly worse in those with worsening severity or additional level involvement over the study period. CONCLUSION: As disc degeneration advances, the associated IDVP persists in most cases, displaying a plateauing of severity over long periods, but rarely with progression to autofusion.

Current Status and Advancements in Platelet-Rich Plasma Therapy.

Platelet-rich plasma (PRP) as a treatment modality has been around for the last four decades, but only truly gained popularity over the last 10 to 15 years in medicine, in a variety of fields ranging from regenerative medicine to infertility treatment. It has gained popularity, especially in treating musculoskeletal conditions where the bulk of research has been performed and published. There is level I evidence available supporting its efficacy in the treatment of osteoarthritis (OA), epicondylitis, bursitis, compressive neuropathy, plantar fasciitis, muscular injuries and osteochondral lesions. Most published research with regards to PRP has been focused on knee OA (limited research in shoulder, elbow, and foot and ankle OA), lateral epicondylitis and carpal tunnel syndrome, whereas spinal and hand conditions have limited research available. Tendinopathies and partial tendon tears have conflicting evidence available, with level I evidence supporting PRP's use in rotator cuff tendinopathies and tears, with contradictory level I evidence discouraging its use in patella and Achilles tendinopathies and tears. The available evidence regarding the use of PRP continues to produce conflicting results, but despite this, there is an ongoing increase in the popularity and use of PRP in patients with musculoskeletal conditions.

Use of vascular clipping system in kidney transplantation in syria: a study of 30 cases.

The aim of this study is to report our experience in the use of vascular clipping system (VCS) in kidney transplantation (KT), and to discuss its potential clinical benefits for the patients compared with the traditional anastomosis method (suture method). Between October 1985 and December 2000, 350 cases of KT from living related donors (LRD) were performed in the Kidney Transplantation Unit at the Al-Mouassat University Hospital in Damascus, Syria. Between October 1999 and December 2000, 30 cases (21 males and 9 females) of KT were performed using VCS. The mean age of the patients was 32.7 years (14-52). HLA typing showed HLA haplo-identical matching in 22 patients and HLA identical matching in eight. Twenty left kidneys and 10 right kidneys were resected from LRD. VCS was used in 22 arterial and 30 venous anastomosis. We used the Vascular Clip Applier/large 2.0-Auto suture Company-Connecticut-USA. Vessel anasto-mosis was performed end to end between renal and hypogastric arteries and end to side between renal and external iliac vein for all 30 patients. Immunosuppression treatment was with cyclosporine, azathioprine and prednisolone in all patients. The follow-up period was 5-16 months. All the patients were alive at the end of the follow-up period. The other cases of KT (320 patients) were performed by traditional anastomosis method (suture). The time of arterial anastomosis was 12-20 minutes (mean 16) for the suture method versus 7-10 minutes (mean 7.5) for the VCS method The time of venous anastomosis was 15-25 minutes (mean 20) for the suture method versus 7-9 minutes (mean 8.5) for the VCS method. The number of transfused packed red cell units per operation was 1-2 units in the suture method versus 0-1 unit in the VCS method. We observed 17 cases of acute tubular necrosis (ATN) in the 320 cases in whom the suture method was used versus no case in the 30 patients receiving VCS. Vascular anastomosis using VCS shortens the warm ischemia time, reduces packed red cell units transfused and the occurrence of ATN, and thus improves the function of kidney graft.