Exposure of the anterior spine: technique and experience with 66 patients.

PURPOSE: Anterior spinal fusion has become an increasingly popular technique used by orthopedic surgeons for a variety of lower spine pathology. At our institution urologists have assisted as retroperitoneal surgeons in achieving exposure of the appropriate spinal disk space. We report our experience with anterior spinal fusion in 66 patients. MATERIALS AND METHODS: Since 1991 we have performed 66 exposures using the flank, modified Gibson, thoracoabdominal, paramedian and midline transperitoneal approaches. Exposure of each level has subtle technical issues which are reviewed. RESULTS: During the study 34 men and 32 women 24 to 74 years old (mean age 43.8) underwent discectomy and anterior fusion of the spine. Access from T12 through L5-S1 interspace was required, and exposure of multiple spinal levels was necessary in 27. There was 1 death from massive pulmonary embolism in a patient with widely metastatic lung cancer. Retrograde ejaculation was reported by 2 men. There have been no episodes of deep or superficial wound infection and no ureteral or major vascular injuries. CONCLUSIONS: As surgeons of the retroperitoneum urologists have an important role in providing our orthopedic colleagues with safe, adequate exposure to the anterior surface of the spine during discectomy and anterior fusion.

Calreticulin: an intracellular Ca++-binding protein abundantly expressed and regulated by androgen in prostatic epithelial cells.

Calreticulin was identified in a screen for androgen-response genes in the rat ventral prostate. Northern blot and Western blot analyses in the rat model showed that both calreticulin messenger RNA and protein are down-regulated by castration and up-regulated by androgen replacement in the prostate. Northern blot analysis showed that calreticulin expression level in the prostate is much higher than that in seminal vesicles, heart, brain, muscle, kidney, and liver. The regulation of calreticulin expression by androgen is only observed in the prostate and seminal vesicles, two male secondary sex organs. The induction of calreticulin by androgen in prostate organ culture partially resists protein synthesis inhibition, suggesting that calreticulin is a direct androgen-response gene. In situ hybridization and immunohistochemistry studies showed that calreticulin is an intracellular protein in prostatic epithelial cells. Because calreticulin is a major intracellular Ca++-binding protein with 1 high-affinity and 25 low-affinity Ca binding sites, our observations suggest that calreticulin is a promising candidate that mediates androgen regulation of intracellular Ca++ levels and/or signals in prostatic epithelial cells. The expression of calreticulin is also regulated by androgen in the mouse and human prostate, suggesting that androgen regulation and function of calreticulin in the prostate are conserved evolutionarily.

Predicting survival from in-hospital CPR: meta-analysis and validation of a prediction model.

OBJECTIVE: To better clarify patient factors that predict survival from in-hospital cardiopulmonary resuscitation (CPR), using two methods: 1) meta-analysis and 2) validation of a prediction model, the pre-arrest morbidity (PAM) index. DESIGN: Meta-analysis of previously published studies by standard techniques. Retrospective chart review of validation sample. SETTING: University-affiliated teaching hospital. PATIENTS/PARTICIPANTS: Meta-analytic sample of 21 previous studies from 1965-1989. The validation sample consisted of all patients surviving resuscitation from the authors' hospital during the period September 1986 to January 1991. A matched sample of patients who did not survive from the same time period was used as the comparison group. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The strongest negative predictors of survival, by meta-analysis, were renal failure (r = 0.088, p < 0.0002), cancer (r = 0.08, p < 0.0002), and age more than 60 years (r = 0.063, p < 0.006). Sepsis (r = 0.046, p < 0.02), recent cerebrovascular accident (CVA) (r = 0.038, p < 0.04), and congestive heart failure (CHF) class III/IV (r = 0.036, p < 0.05) were weaker negative predictors. Presence of acute myocardial infarction (AMI) was a significant positive predictor of survival (r = 0.15, p < 0.0001). The PAM score was highly predictive of survival in a logistic regression model (p < 0.0003, R2 = 9.6%). No patient who survived to discharge had a PAM score higher than 8. CONCLUSION: Meta-analysis reveals that the most significant negative predictors of survival from CPR are renal failure, cancer, and age more than 60 years, while AMI is a significant positive predictor. The PAM index is a useful method of stratifying probability of survival from CPR, especially for those patients with high PAM scores, who have essentially no chance of survival.