Vaccination and the health care worker.

Historically, health care worker vaccination has been a strategy to protect the health care worker from infectious work related risk. This article will discuss the transition to health care worker vaccination as a key patient safety initiative for hospitals and health care systems. As the case is evolving toward mandatory influenza vaccination of health care workers, we have outlined key success factors for a voluntary program in a rural frontier referral hospital. Additionally, pertussis vaccination for health care workers is discussed as to the patient safety aspects of a progressive approach further making the case for value creation on behalf of our patients we have the privilege of providing care.

Ultrasound-guided radiofrequency neurotomy in cervical spine: sonoanatomic study of a new technique in cadavers.

AIM: To develop an ultrasound-guided technique for radiofrequency (RF) cervical medial branch neurotomy and to validate the accuracy of this new method. MATERIALS AND METHODS: Five non-embalmed, fresh cadavers were used; three male and two female cadavers with a median age at death of 67.2 years (range 50-84 years). This study was conducted in two parts. First, two of the cadavers were used to define the sonographic target point for RF cervical medial branch neurotomy using high-resolution ultrasound (12 to 5 MHz). The needles were guided to five consecutive cervical medial branches in the cadavers under ultrasound guidance. Subsequently, the position of the ultrasound-guided needle was verified using C-arm fluoroscopy. Ultrasound-guided RF neurotomy was performed to the C5 medial branches in all five cadavers. In the three cadavers not used in the first part of the study, ultrasound-guided RF neurotomy without C-arm fluoroscopic confirmation was performed to the C3-C7 medial branches. The accuracy of neurotomy was assessed by pathological examination of the cervical medial branches obtained through cadaver dissection. RESULTS: In all five cadavers, the sonographic target point was identified in all C3-C7 segments with the 12 to 5 MHz linear transducer. In all 20 needle placements for the first and second cadavers, C-arm fluoroscopy validated proper needle tip positions. In all five cadavers, successful neurotomy was pathologically confirmed in 30 of 34 cervical medial branches. CONCLUSIONS: Ultrasound-guided cervical medial branch neurotomy was successfully performed in 30 of 34 cervical medial branches in five cadavers. However, before eliminating fluoroscopic validation of final needle tip positioning, the technique should be validated in symptomatic patients.

Absence of mitochondrial superoxide dismutase results in a murine hemolytic anemia responsive to therapy with a catalytic antioxidant.

Manganese superoxide dismutase 2 (SOD2) is a critical component of the mitochondrial pathway for detoxification of O2(-), and targeted disruption of this locus leads to embryonic or neonatal lethality in mice. To follow the effects of SOD2 deficiency in cells over a longer time course, we created hematopoietic chimeras in which all blood cells are derived from fetal liver stem cells of Sod2 knockout, heterozygous, or wild-type littermates. Stem cells of each genotype efficiently rescued hematopoiesis and allowed long-term survival of lethally irradiated host animals. Peripheral blood analysis of leukocyte populations revealed no differences in reconstitution kinetics of T cells, B cells, or myeloid cells when comparing Sod2(+/+), Sod2(-/-), and Sod2(+/-) fetal liver recipients. However, animals receiving Sod2(-/-) cells were persistently anemic, with findings suggestive of a hemolytic process. Loss of SOD2 in erythroid progenitor cells results in enhanced protein oxidative damage, altered membrane deformation, and reduced survival of red cells. Treatment of anemic animals with Euk-8, a catalytic antioxidant with both SOD and catalase activities, significantly corrected this oxidative stress-induced condition. Such therapy may prove useful in treatment of human disorders such as sideroblastic anemia, which SOD2 deficiency most closely resembles.

Intradiscal Electrothermal Annuloplasty (IDET): A Novel Approach for Treating Chronic Discogenic Back Pain.

Objective. This one-year pilot outcome study was designed to investigate prospectively a series of patients with chronic discogenic back pain who underwent intradiscal electrothermal annuloplasty (IDET). Patients with chronic discogenic low back pain usually respond poorly to conservative medical care. Spinal fusion procedures have yielded mixed results. IDET is a new procedure to heat the intervertebral disc for the purpose of relieving discogenic pain. This study presents the one-year results for the first 32 patients undergoing the IDET procedure. The objective of this article is to determine the safety and efficacy of the IDET procedure in patients with chronic discogenic back pain. Methods. Utilizing standard discographic technique, the disc was heated using a navigable intradiscal catheter with a temperature-controlled thermal resistive coil. Six-month and one-year outcomes were assessed comparatively within subjects using a Roland-Morris (RM) questionnaire and a Visual Analog Scale (VAS), and between subjects using the NASS Low Back Pain Outcome Assessment Instrument Satisfaction Index and a general activity scale modified from the back pain/disability scale from the same instrument. The results from the individual outcome measures were combined to generate an overall outcome of favorable, nonfavorable, and no change. Results. There were no significant differences between overall outcome measures at 6-month and 12-month follow-ups. At 12 month follow-up the VAS had a mean decrease of 1.84 (sd = 2.38) and the RM had a mean decrease of 4.03 (sd = 4.82). 78.1% of patients stated that the procedure met their expectations or that they would undergo the same treatment for the same outcome. 53.1% of patients stated that their overall activity level was either better or much better compared to before the procedure. Overall, 62.5% had a favorable outcome, 12.5% nonfavorable, and 25% no change. Patients with excellent or good catheter positions and those with low pressure sensitive discs on preoperative discography had the most favorable outcomes. There were no significant complications. Conclusions. One-year pilot study outcome results suggest that IDET may be an effective, minimally invasive treatment for chronic discogenic low back pain.

The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes.

STUDY DESIGN: A multicenter, retrospective study of long-term surgical and nonsurgical patient outcomes, after lumbar discography. OBJECTIVES: To investigate the efficacy and surgical outcome predictive value of categorizing positive discography findings, using a pressure x pain provocation categorization system. BACKGROUND: With the use of pressure-controlled manometric discography, improved and more specific diagnostic categorization is possible. The literature suggests that more specific categorization of positive discographic findings may predict surgical and nonsurgical outcomes. Studies have shown that intertransverse fusions may not fully protect the disc from anterior loading. Consequently, in patients who have low-pressure-sensitive discs, surgery that includes interbody fusion should provide a more favorable long-term outcome than intertransverse fusion only. METHODS: Long-term outcome was ascertained in 96 patients who had lumbar discography and subsequently underwent interbody fusion alone, combined fusion, intertransverse fusion or no surgery. Patients were retrospectively placed into specific diagnostic categories, according to a four-point scale. Progressively restrictive subgroups, beginning with the entire sample and ending with the most sensitive group (chemically sensitive), were examined for long-term surgical outcome differentiation. RESULTS: There were no significant differences in long-term surgical outcome across the entire sample. However, significant outcome differences existed across the subgroup of patients with chemically sensitive discs. In this group, patients undergoing interbody/combined fusion had a significantly better outcome than patients who had intertransverse fusion. Nonsurgical patients had the worst outcome overall. CONCLUSIONS: Patients with highly (chemically) sensitive discs appear to achieve significantly better long-term outcomes with interbody/combined fusion than with intertransverse fusion. Patients without disc surgery have the least favorable outcome. Precise prospective categorization of positive discographic diagnoses may predict outcomes from treatment, surgical or otherwise, thereby greatly facilitating therapeutic decision-making.

Nucleolar accumulation of poly (A)+ RNA in heat-shocked yeast cells: implication of nucleolar involvement in mRNA transport.

Transport of mRNA from the nucleus to the cytoplasm plays an important role in gene expression in eukaryotic cells. In wild-type Schizosaccharomyces pombe cells poly(A)+ RNA is uniformly distributed throughout the nucleoplasm and cytoplasm. However, we found that a severe heat shock blocks mRNA transport in S. pombe, resulting in the accumulation of bulk poly(A)+ RNA, as well as a specific intron-less transcript, in the nucleoli. Pretreatment of cells with a mild heat shock, which induces heat shock proteins, before a severe heat shock protects the mRNA transport machinery and allows mRNA transport to proceed unimpeded. In heat-shocked S. pombe cells, the nucleolar region condensed into a few compact structures. Interestingly, poly(A)+ RNA accumulated predominantly in the condensed nucleolar regions of the heat-shocked cells. These data suggest that the yeast nucleolus may play a role in mRNA transport in addition to its roles in rRNA synthesis and preribosome assembly.

Nucleolar accumulation of poly (A)+ RNA in heat-shocked yeast cells: implication of nucleolar involvement in mRNA transport.

Transport of mRNA from the nucleus to the cytoplasm plays an important role in gene expression in eukaryotic cells. In wild-type Schizosaccharomyces pombe cells poly(A)+ RNA is uniformly distributed throughout the nucleoplasm and cytoplasm. However, we found that a severe heat shock blocks mRNA transport in S. pombe, resulting in the accumulation of bulk poly(A)+ RNA, as well as a specific intron-less transcript, in the nucleoli. Pretreatment of cells with a mild heat shock, which induces heat shock proteins, before a severe heat shock protects the mRNA transport machinery and allows mRNA transport to proceed unimpeded. In heat-shocked S. pombe cells, the nucleolar region condensed into a few compact structures. Interestingly, poly(A)+ RNA accumulated predominantly in the condensed nucleolar regions of the heat-shocked cells. These data suggest that the yeast nucleolus may play a role in mRNA transport in addition to its roles in rRNA synthesis and preribosome assembly.

The prevalence and clinical features of internal disc disruption in patients with chronic low back pain.

STUDY DESIGN: This was a cross-sectional analytic study of patients with chronic low back pain. OBJECTIVE: To investigate whether the criteria for internal disc disruption, as adopted by the International Association for the Study of Pain, could be satisfied in patients with chronic low back pain and to test whether there were any conventional clinical features that could identify this condition. SUMMARY OF BACKGROUND DATA: Internal disc disruption has been postulated as an important cause of low back pain. To diagnose this condition, the International Association for the Study of Pain taxonomy requires that pain be reproduced on provocation discography and that computed tomography discography reveal internal disc disruption, provided that as a control, stimulation of at least one other disc fails to reproduce pain. METHODS: Ninety-two consecutive patients with chronic low back pain and no history of previous lumbar surgery were studied. Each patient underwent a standard physical examination. Computed tomography discography was performed at a minimum of two levels. RESULTS: The diagnostic criteria for internal disc disruption were fully satisfied in 39% of patients, most commonly at L5-S1 and L4-L5. None of the clinical tests used could differentiate between those patients with internal disc disruption and other patients. CONCLUSIONS: A diagnosis of internal disc disruption can be made in a significant proportion of patients with chronic low back pain, but no conventional clinical test can discriminate patients with internal disc disruption from patients with other conditions.

Contemporary concepts in spine care. Epidural steroid injections.

Epidural steroid injections are commonly used for the management of lumbosacral radicular syndromes. The literature is replete with case reports and noncontrolled studies, but relatively few controlled studies exist. The well-designed studies that are available, however, do show a significantly positive pain reducing benefit from lumbar epidural steroid injections. This Contemporary Concepts review summarizes theoretic concepts, clinical applications, and data from the literature regarding the use of lumbar epidural steroid injections and provides current recommendations and suggestions for future research.

The value of the provocation response in lumbar zygapophyseal joint injections.

OBJECTIVE: To determine the relationship between pain provocation and the analgesic response in lumbar zygapophyseal joint blocks. DESIGN: Consecutive patients undergoing intraarticular zygapophyseal joint blocks for the investigation of low back pain were included in this prospective study. SETTING: The referred sample was from the metropolitan areas of New Orleans and San Francisco. PATIENTS: Ninety patients with low back pain of > 3 months' duration and no history of lumbar surgery. INTERVENTIONS: All patients underwent one or more intraarticular injections of radiographic contrast followed by lignocaine (lidocaine) 2% into zygapophyseal joints between L2-3 and L5-S1. Those with definite responses at one or more levels underwent confirmatory blocks using 0.5% bupivacaine. OUTCOME MEASURES: Provocation of familiar pain and relief of pain after the injection of local anesthetic. Patients were assessed by an independent observer. RESULTS: A total of 203 joints were studied. Adopting liberal criteria, either exact or similar reproduction of pain on the one hand correlated with either definite or complete relief of pain after a single, analgesic block on the other (p < 0.0001). However, when more stringent criteria were adopted, such as response to a confirmatory block using bupivacaine, there was no significant association. CONCLUSIONS: This study calls into question the validity of pain provocation alone as a criterion standard in patients undergoing diagnostic lumbar zygapophyseal joint blocks.

Pain from the lumbar zygapophysial joints: a test of two models.

One hundred seventy-six consecutive patients with chronic low-back pain and no history of previous lumbar surgery were studied to test the clinical criteria of Fairbank et al. and Helbig and Lee for zygapophysial joint pain. All patients underwent a history, examination, and a series of zygapophysial joint injections or blocks of the medial branches of the dorsal ramus with lignocaine. Those patients responding to the first series of blocks were given confirmatory blocks using bupivacaine. None of the clinical features tested was found to be associated with response to the confirmatory block. The Fairbank et al. and Helbig and Lee criteria were shown to be unreliable in distinguishing pain of zygapophysial joint origin from pain of other origins.

The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints.

One hundred and seventy-six consecutive patients with chronic low back pain and no history of previous lumbar surgery were studied to determine the false-positive rate of single diagnostic blocks of the lumbar zygapophysial joints. All patients underwent diagnostic blocks using lignocaine. Those patients who obtained definite or complete relief from these blocks subsequently underwent confirmatory blocks using bupivacaine. Eighty-three patients (47%) had a definite or greater response to the initial, lignocaine injection at one or more levels but only 26 (15%) had a 50% or greater response to a confirmatory injection of 0.5% bupivacaine. Using the response to confirmatory blocks as the criterion standard, the false-positive rate of uncontrolled diagnostic blocks was 38% and the positive predictive value of these blocks was only 31%. Because the positive predictive value of a test is lower when the pre-test probability (prevalence) is low, and because the prevalence of lumbar zygapophysial joint pain is likely to be less than 50%, uncontrolled diagnostic blocks will always be associated with an unacceptably low positive predictive value. These features render uncontrolled diagnostic blocks unreliable for the diagnosis of lumbar zygapophysial joint pain not only in epidemiologic studies but also in any given patient.

Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?

STUDY DESIGN: This study is a prospective cross-sectional analytic study. OBJECTIVES: The authors determined the prevalence and clinical features of patients with pain stemming from the lumbar zygapophysial joints. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated a wide range of prevalence for zygapophysial joint pain and conflicting results with regard to clinical signs. METHODS: One hundred and seventy-six consecutive patients with chronic low back pain were investigated with a series of screening zygapophysial joint blocks using lignocaine and confirmatory blocks using bupivacaine. RESULTS: Forty-seven percent of patients had a definite or greater response to the screening injection at one or more levels but only 15% had a 50% or greater response to a confirmatory block. Response to zygapophysial joint injection was not associated with any single clinical feature or set of clinical features. CONCLUSIONS: The zygapophysial joint is an important source of pain but the existence of a "facet syndrome" must be questioned.

The relative contributions of the disc and zygapophyseal joint in chronic low back pain.

STUDY DESIGN: A prospective cross-sectional analytic approach was taken. OBJECTIVES: This study sought to determine the relative contribution of the disc and the zygapophyseal joint as a pain source in patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Previous studies have employed either zygapophyseal joint blocks or discography, but in no studies have both procedures been performed. METHODS: Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints. RESULTS: Thirty-six patients (39%) had at least one positive discogram as defined by exact pain reproduction, an abnormal image, and a negative control. Eight patients responded to both a screening zygapophyseal joint block using lignocaine and a confirmatory block using bupivacaine. Only three patients had both a positive discogram and a symptomatic zygapophyseal joint. CONCLUSIONS: In patients with chronic low back pain, the combination of discogenic pain and zygapophyseal joint pain is uncommon.

Response to steroid and duration of radicular pain as predictors of surgical outcome.

Prolonged structural compromise of spinal nerve roots can lead to chronic changes that surgical decompression might not be able to reverse. In this study, it was hypothesized that if there were a reversible structural pain component, a steroid injected into the patient's symptomatic nerve root should provide temporary pain relief and that these patients should have a favorable surgical outcome. It also was hypothesized that duration of radicular symptoms would correlate inversely with surgical outcome. For postoperative relief of radicular pain, the results showed that patients with pain lasting less than 1 year had a positive surgical result (89%), regardless of response to steroid. Patients with pain lasting more than 1 year and who have had a positive response to steroid injected into the symptomatic nerve root (roots) had a positive surgical outcome of 85%. Patients who did not respond to the steroid and had pain for more than 1 year (95%) generally had a poor surgical outcome. Although the poor outcome in the last group might be explained in some cases by an inadequate structural correction, inadequate stabilization, or functional reasons, the majority of these failures represented irreversible changes in the neural structures.

Differential distribution of factors involved in pre-mRNA processing in the yeast cell nucleus.

The yeast cell nucleus has previously been shown to be divided into two regions by a variety of microscopic approaches. We used antibodies specific for the 2,2,7-trimethylguanosine cap structure of small nuclear ribonucleic acids (snRNAs) and for a protein component of small nuclear ribonucleoprotein particles to identify the distribution of small nuclear ribonucleoprotein particles within the yeast cell nucleus. These studies were performed with the fission yeast Schizosaccharomyces pombe and the budding yeast Saccharomyces cerevisiae. By using immunofluorescence microscopy and immunoelectron microscopy, most of the abundant snRNAs were localized to the portion of the nucleus which has heretofore been referred to as the nucleolus. This distribution of snRNAs is different from that found in mammalian cells and suggests that the nucleolar portion of the yeast nucleus contains functional domains in addition to those associated with RNA polymerase I activity.

Normal magnetic resonance imaging with abnormal discography.

In degenerative lumbar spine disease, recent studies have supported the clinical usefulness of discography, especially when used with computed tomography (CT) scanning. The role and capabilities of magnetic resonance imaging (MRI) scanning are currently evolving and being defined. This study reviews a series of patients with prolonged disabling symptoms who had normal MRI scans and abnormal discography. Discograms and discogram-CT scans may at times allow detection of clinically correlative and significant pathology (usually annular disruptions) not suggested by MRI scanning. This fact should be considered in patients with normal MRI scanning and continuing unexplained symptomatology.

Painful lumbar end-plate disruptions: a significant discographic finding.

Of the 692 discs injected during lumbar discograms, end-plate disruptions with leakage of contrast material into the vertebral bodies were noted in 14 discs. Although gentle pressure was applied during the injections, severe fully concordant pain was reproduced in four (28.3%) discs, moderately severe and fully concordant pain in nine (64.3%) discs, and mild discordant pain in one (7.4%) disc. This is compared to 11.2% of the remaining 678 discs without end-plate disruption that reproduced severe concordant pain, 31.1% with moderately severe concordant pain, 17.1% with mild pain, and 40.6% without any pain reproduction. The difference between pain frequency in discs with end-plate disruption and those without is statistically significant (P less than .001). This suggests that end-plate disruptions may be related to painful segments.