Extreme lateral interbody fusion (XLIF) as a treatment for acute spondylodiscitis: Leeds spinal unit experience.

Extreme lateral interbody fusion (XLIF) is a minimally invasive lateral trans-psoas approach to the thoraco-lumbar spine that enables surgical debridement of the disc space and facilitates fusion. Previous reports are limited to case series, which have no outcomes measuring improvement. We aim to determine the effectiveness of XLIF in the treatment of patients with spondylodiscitis. We performed a cohort study over four years (2008-2011). Patients were treated with XLIF if they met our selection criteria - symptoms suggestive of discitis with consistent imaging and intractable back pain making patients bedbound. Patients were excluded if medically unfit for surgery. Pre and post-operative VAS and ODI scores were used as formal outcome measures. 14 patients were included and at 12 months, median VAS and ODI scores had improved 4.0 (95% CI, 1.9-6.5) (p = 0.005) and 37.0% (95% CI, 10.7-53.7) (p = 0.015) respectively. All patients with available imaging showed evidence of fusion. Patients typically received 6-8 weeks of antibiotics and all showed normalisation of inflammatory markers. At 5 year follow-up, median VAS and ODI were still improved at 3.0 (95% CI, 1.7-4.4) (p = 0.01) and 40% (95% CI, 10-52) (p = 0.028) respectively. The median length of inpatient stay was 10 days (range 4-40 days). This is the first study to demonstrate that the XLIF technique can significantly improve pain in discitis patients using validated formal outcome measurements. This technique could therefore potentially be used to reduce pain in patients with discitis, help them to mobilise earlier and reduce the duration of their hospital stay.

Academia and MMC: uncomfortable bed-fellows?

In the changing times of Modernising Medical Careers (MMC), the role of research in training remains unclear. Here we discuss the merits of research in surgical training, new avenues for academia during MMC and the obstacles that trainees may face.

Incomplete cellular depopulation may explain the high failure rate of bovine ureteric grafts.

BACKGROUND: The aim was to assess the results of a decellularized bovine ureter graft (SynerGraft) for complex venous access. METHODS: Bovine ureter conduits were implanted in patients with a failed fistula or access graft in whom native vessels were unsuitable as conduits. Graft histories were obtained from all patients who had undergone this procedure at one institution. Failed grafts were explanted and subjected to histological examination. A sample of fresh bovine ureter was immunostained for galactose (alpha1 --> 3) galactose (alpha-Gal). RESULTS: Nine patients with a median age of 46 (range 25-70) years underwent complex venous access surgery between August 2004 and November 2006 using a SynerGraft. Graft types included loop superficial femoral artery to stump of long saphenous vein (four patients), loop brachial artery to vein (two), brachial artery to axillary vein (two) and left axillary artery to innominate vein (one). Three grafts developed aneurysmal dilatation and two thrombosed. Histological assessment of the explanted bovine ureters revealed acute and chronic transmural inflammation. Immunostaining of fresh bovine ureter suggested residual cells and the xenoantigen alpha-Gal. CONCLUSION: Graft failure with aneurysmal dilatation and thrombosis in complex arteriovenous conduits using bovine ureter may be due to residual xenoantigens.

Randomized clinical trial of the effects of methylprednisolone on renal function after major vascular surgery.

BACKGROUND: Perioperative renal dysfunction following abdominal aortic aneurysm (AAA) repair is multifactorial and may involve hypotension, hypoxia and ischaemia-reperfusion injury. Studies of cardiac and hepatic transplant surgery have demonstrated beneficial effects on renal function of high-dose methylprednisolone administered before surgery. METHODS: Twenty patients undergoing elective open AAA repair were randomized to receive either methylprednisolone 10 mg/kg or dextrose (control) before induction of anaesthesia. Blood was analysed for a panel of cytokines representative of T helper cell type 1 and 2 subsets. Urine was analysed for subclinical markers of renal dysfunction (albumin, alpha(1)-microglobulin and N-acetyl-beta-D-glucosaminidase). RESULTS: Data from 18 patients were analysed. Both groups demonstrated glomerular and proximal convoluted tubular dysfunction that was unaffected by steroid treatment. Steroid administration increased serum levels of urea and creatinine (both P < 0.001). The steroid group had increased interleukin 10 levels (P = 0.005 compared to controls). There were no differences between groups in overall surgical complications, length of intensive care unit (P = 0.821) and hospital (P = 0.719) stay, or 30-day mortality. CONCLUSION: Methylprednisolone administration altered the cytokine profile favourably but adversely affected postoperative renal function.

Cerebellopontine angle meningioma resulting in middle-ear polyp.

Extracranial spread of meningiomas to involve the middle ear is very rare. We present the case of a 43-year-old woman with a known cerebellopontine angle meningioma who subsequently presented with left-sided otalgia and a middle-ear mass extruding through the tympanic membrane due to local invasion of the meningioma. The tumour was excised surgically. A discussion of the relevant literature is also presented.

1,000 forensic outpatients: a descriptive study.

The case notes and court reports of 1,000 consecutive outpatient referrals to a regional forensic outpatient service were studied retrospectively. Socio-demographic, psychiatric and forensic information was collected. The sample was predominantly male, Caucasian and relatively young in comparison with a general psychiatric population. The commonest source of referral was from defense solicitors and the commonest reason for referral was for a court report. A wide range of diagnoses and offences were noted. A number of differences were found in the frequency of gender, ethnicity and diagnosis according to the source of, and reason for, referral.

An evaluation of the preoperative information given to patients by intensive care nurses.

In many hospitals it is common practice for nurses working in intensive care units to visit patients on the ward when a stay in the intensive care unit is anticipated following elective surgery. The purpose of the preoperative visit is to minimise fear and anxiety by preparing patients for their admission by providing information about the unit, the equipment used and responding to any questions. However, although there is extensive evidence to support the advantages of information--giving prior to stressful events the author could find no evaluation of the type of information given by intensive care staff. The purpose of the study was three fold. Firstly to discover the type of information patients would like to receive. Secondly to use this data in compiling a booklet which could be used to supplement the preoperative visit. Thirdly to evaluate the contents of the booklet. Postoperatively 20 patients evaluated the booklet by means of a self-administered questionnaire. These were completed 48 h after their transfer from the unit. Overall patients were satisfied with the information contained in the booklet but felt they required additional advice about their proposed surgery and needed more time to absorb the information they had been given.

Pharmacokinetics of lithium in patients treated with controlled release lithium formulations.

There has long been discussion as to the relative merits of the lithium formulations available in the UK. Two of these have been shown to exhibit similar pharmacokinetics in normal volunteers and both are now marketed as controlled release formulations. In this study the serum lithium profiles of these formulations were compared in patients at two centres during the first 4 h after the dose, and at 24 h. We were unable to show any significant difference between the formulations in respect of maximum serum lithium concentrations or the concentration at each time point.