Shorter and sweeter: the 16-item version of the SRS questionnaire shows better structural validity than the 20-item version in young patients with spinal deformity.

PURPOSE: In patients with adult spinal deformity, it was previously shown that 16 of the non-management items of the SRS-instrument showed a better fit to the theoretical four-factor model (pain, function, self-image, mental health) than did all 20 items. Whether the same phenomenon is observed in data from younger (< 20y) patients, for whom the questionnaire was originally designed, is not currently known. METHODS: Confirmatory factor analysis was used to evaluate the factor structure of the 20 non-management items of the SRS-instrument completed by 3618 young patients with spinal deformity (75.5% female; mean age, 15.0 ± 2.0 years) and of its equivalence across language versions (2713 English-speaking, 270 Spanish, 264 German, 223 Italian, and 148 French). The root mean square error of approximation (RMSEA) and comparative fit index (CFI) indicated model fit. RESULTS: Compared with the 20-item version, the 16-item solution significantly increased the fit (p < 0.001) across all language versions, to achieve good model fit (CFI = 0.96, RMSEA = 0.06). For both 16-item and 20-item models, equivalence across languages was not reached, with some items showing weaker item-loading for some languages, in particular German and French. CONCLUSION: In patients with adolescent idiopathic scoliosis, the shorter 16-item version showed a better fit to the intended 4-factor structure of the SRS-instrument. The wording of some of the items, and/or their equivalence across language versions, may need to be addressed. Questionnaire completion can be a burden for patients; if a shorter, more structurally valid version is available, its use should be encouraged.

What level of symptoms are patients with adult spinal deformity prepared to live with? A cross-sectional analysis of the 12-month follow-up data from 1043 patients.

INTRODUCTION: Previous studies suggest that a meaningful and easily understood measure of treatment outcome may be the proportion of patients who are in a "patient acceptable symptom state" (PASS). We sought to quantify the score equivalent to PASS for different outcome instruments, in patients with adult spinal deformity (ASD). METHODS: We analysed the following 12-month questionnaire data from the European Spine Study Group (ESSG): Oswestry Disability Index (ODI; 0-100); Numeric Rating Scales (NRS; 0-10) for back/leg pain; Scoliosis Research Society (SRS) questionnaire; and an item "if you had to spend the rest of your life with the symptoms you have now, how would you feel about it?" (5-point scale, dichotomised with top 2 responses "somewhat satisfied/very satisfied" being considered PASS+, everything else PASS-). Receiver operating characteristics (ROC) analyses indicated the cut-off scores equivalent to PASS+. RESULTS: Out of 1043 patients (599 operative, 444 non-operative; 51 ± 19 years; 84% women), 42% reported being PASS+ at 12 months' follow-up. The ROC areas under the curve were 0.71-0.84 (highest for SRS subscore), suggesting the questionnaire scores discriminated well between PASS+ and PASS-. The scores corresponding to PASS+ were > 3.5 for the SRS subscore (> 3.3-3.8 for SRS subdomains); ≤ 18 for ODI; and ≤ 3 for NRS pain. There were slight differences in cut-offs for subgroups of age, treatment type, aetiology, baseline symptoms, and sex. CONCLUSION: Most interventions for ASD improve patients' complaints but do not totally eliminate them. Reporting the percentage achieving a score equivalent to an "acceptable state" may represent a more stringent and discerning target for denoting treatment success in ASD. These slides can be retrieved under Electronic Supplementary Material.

Factor analysis of the SRS-22 outcome assessment instrument in patients with adult spinal deformity.

PURPOSE: Designed for patients with adolescent idiopathic scoliosis, the SRS-22 is now widely used as an outcome instrument in patients with adult spinal deformity (ASD). No studies have confirmed the four-factor structure (pain, function, self-image, mental health) of the SRS-22 in ASD and under different contexts. Factorial invariance of an instrument over time and in different languages is essential to allow for precise interpretations of treatment success and comparisons across studies. This study sought to evaluate the invariance of the SRS-22 structure across different languages and sub-groups of ASD patients. METHODS: Confirmatory factor analysis was performed on the 20 non-management items of the SRS-22 with data from 245 American English-, 428 Spanish-, 229 Turkish-, 95 French-, and 195 German-speaking patients. Item loading invariance was compared across languages, age groups, etiologies, treatment groups, and assessment times. A separate sample of SRS-22 data from 772 American surgical patients with ASD was used for cross-validation. RESULTS: The factor structure fitted significantly better to the proposed four-factor solution than to a unifactorial solution. However, items 14 (personal relationships), 15 (financial difficulties), and 17 (days off work) consistently showed weak item loading within their factors across all language versions and in both baseline and follow-up datasets. A trimmed SRS (16 non-management items) that used the four least problematic items in each of the four domains yielded better-fitting models across all languages, but equivalence was still not reached. With this shorter version there was equivalence of item loading with respect to treatment (surgery vs conservative), time of assessment (baseline vs 12 months follow-up), and etiology (degenerative vs idiopathic), but not age (< vs ≥50 years). All findings were confirmed in the cross-validation sample. CONCLUSION: We recommend removal of the worst-fitting items from each of the four domains of the SRS-instrument (items 3, 14, 15, 17), together with adaptation and standardization of other items across language versions, to provide an improved version of the instrument with just 16 non-management items.

Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial†.

Background: Perioperative tranexamic acid (TXA) use can reduce bleeding and transfusion requirements in several types of surgery, but level I evidence proving its effectiveness in major spine surgery is lacking. This study was designed to investigate the hypothesis that TXA reduces perioperative blood loss and transfusion requirements in patients undergoing major spine procedures. Methods: We conducted a multicentre, prospective, randomized double-blind clinical trial, comparing TXA with placebo in posterior instrumented spine surgery. Efficacy was determined based on the total number of blood units transfused and the perioperative blood loss. Other variables such as the characteristics of surgery, length of hospital stay, and complications were also analysed. Results: Ninety-five patients undergoing posterior instrumented spine surgery (fusion of >3 segments) were enrolled and randomized: 44 received TXA (TXA group) and 51 received placebo (controls). The groups were comparable for duration of surgery, number of levels fused, and length of hospitalization. Transfusion was not required in 48% of subjects receiving TXA compared with 33% of controls (P = 0.05). Mean number of blood units transfused was 0.85 in the TXA group and 1.42 with placebo (P = 0.06). TXA resulted in a significant decrease in intraoperative bleeding (P = 0.01) and total bleeding (P = 0.01) relative to placebo. The incidence of adverse events was similar in the two groups. Conclusions: TXA did not significantly reduce transfusion requirements, but significantly reduced perioperative blood loss in adults undergoing major spinal surgery. Clinical trial registration: NCT01136590.

The Core Outcome Measures Index (COMI) is a responsive instrument for assessing the outcome of treatment for adult spinal deformity.

INTRODUCTION: The Core Outcome Measures Index for the back (COMI-back) is a very brief instrument for assessing the main outcomes of importance to patients with back problems (pain, function, symptom-specific well-being, quality of life, disability). However, it might be expected to be less responsive than a disease-specific instrument when evaluating specific pathologies. In patients with adult spinal deformity, we compared the performance of COMI-back with the widely accepted SRS-22 questionnaire. METHODS: At baseline and 12 months after non-operative (N = 121) and surgical (N = 83) treatment, patients (175 F, 29 M) completed the following: COMI-back, SRS-22, Oswestry Disability Index (ODI) and SF-36 PCS. At 12 months' follow-up, patients also indicated on a 15-point Global Rating of Change Scale (GRCS) how their back problem had changed relative to 1 year ago. Construct validity for the COMI-back was assessed by the correlation between its scores and those of the comparator instruments; responsiveness was assessed with receiver operating characteristics (ROC) analysis of COMI-back change scores versus the criterion 'treatment success' (dichotomized GRCS). RESULTS: Baseline values for the COMI-back showed significant (p < 0.0001) correlations with SRS-22 (r = -0.85), ODI (r = 0.83), and SF-36 PCS (r = -0.82) scores; significantly worse scores for all measures were recorded in the surgical group. The correlation between the change scores (baseline to 12 months) for COMI and SRS-22 was 0.74, and between each of these change scores and the external criterion of treatment success were: COMI-back, r = 0.58; SRS-22, r = -0.58 (each p < 0.0001). The ROC areas under the curve for the COMI-back and SRS-22 change scores were 0.79 and 0.82, respectively. CONCLUSION: Both baseline and change scores for the COMI-back correlated strongly with those of the SRS-22, and differed significantly in surgical and non-operative patients, suggesting good construct validity. With the "change in the back problem" serving as external criterion, COMI-back showed similar external responsiveness to SRS-22. The COMI-back was well able to detect important change. Coupled with its brevity, which minimizes patient burden, these favourable psychometric properties suggest the COMI-back is a suitable instrument for use in registries and can serve as a valid instrument in clinical studies emerging from such data pools.

La calidad de la información sobre escoliosis disponible online en español. Un estudio de evaluación / The quality of information on scoliosis available online in spanish. An evaluation study

Introducción. Más de un 50% de padres y/o pacientes utilizan Internet para informarse sobre aspectos de la escoliosis idiopática. Material y métodos. En 5 buscadores populares (Google, Yahoo, Bing, Lycos, Ask) se introdujo el término de búsqueda «escoliosis» y los primeros 20 resultados de cada buscador fueron utilizados para el estudio. Tras rechazar las duplicidades, archivos de vídeos o imagen, se obtuvo una lista de 25 webs, adecuadas para el análisis. La calidad se evaluó según 3 escalas: DISCERN (calidad de la información médica; rango de menor a mayor calidad es de 15 a 80), HONcode (criterios de acreditación de calidad de páginas web; rango de de menor a mayor es de 15 a 0), y grado de idoneidad de la información para padres y pacientes con escoliosis idiopática (rango de menor a mayor es de 0 a 9). Resultados. DISCERN: media 38 (DE = 10,48); el 24% de las páginas superaba el percentil 75 (> 45). HONcode: media 6,9 (DE = 1,8); el 28% de las páginas superaba el percentil 75 (< 5,5). Grado de idoneidad: media 4,3 (DE = 1,75); el 24% de las páginas superaban el percentil 75 (> 5). Conclusiones. En términos generales la calidad de la información es aceptable, pero muy pocas páginas pueden considerarse idóneas para padres y pacientes con escoliosis idiopática (AU)

Introduction. More than 50% of parents and/or patients use Internet to learn about aspects of idiopathic scoliosis. Material and methods. The search term «scoliosis» was introduced into five popular search engines (Google, Yahoo, Bing, Lycos, Ask). The first 20 results of each one were used for the analysis. After rejecting duplicates, video or image files, a list of 25 websites that were adequate for analysis was obtained. Quality was assessed with three scales: DISCERN (Quality of medical information; range of low to high quality with 15 to 80) HONcode (Quality of accreditation web criteria; range of low to high quality of 15 to 0), and Degree of Adequacy of information for parents and patients with idiopathic scoliosis (range of low to high quality going of 0 to 9). Results. DISCERN: median 38 (SD=10.48); 24% of pages exceeded the 75th percentile (>45). HONcode: median 6.9 (SD=1.8); 28% of pages exceeded the 75th percentile (<5.5). Degree of Adequacy: median 4.3 (DS=1.75); 24% pages exceeded the 75th percentile (>5). Conclusions. In general terms, the quality of the information is acceptable. However, very few pages can be considered as suitable for parents and patients with idiopathic scoliosis (AU)

Postoperative urinary tract infection and surgical site infection in instrumented spinal surgery: is there a link?

A potential relationship between postoperative urinary tract infection (UTI) and surgical site infection (SSI) following posterior spinal fusion and instrumentation (PSFI) was investigated. A retrospective review was performed of prospectively collected demographic, clinical and microbiological data of 466 consecutive patients (median age, 53.7 years (interquartile range (IQR) 33.8-65.6); 58.6% women) undergoing PSFI to identify those with UTI in the first 4 weeks and SSI in the first 12 weeks after PSFI. Overall, 40.8% had an American Society of Anesthesiologists score of >2, and 49.8% had undergone fusion of more than three segments. Eighty-nine patients had UTI, 54 had SSI, and 22 had both conditions. In nine of the 22 (38%) cases, the two infections were caused by the same microorganism. The urinary tract was the probable source of SSI by Gram-negative bacteria in 38% (8/21) of cases. On multivariate analysis, UTI (OR 3.1, 95% CI 1.6-6.1; P 0.001) and instrumentation of more than three segments (OR 2.7, 95% CI 1.1-6.3; P 0.024) were statistically associated with SSI. Patients receiving ciprofloxacin for UTI had higher microbial resistance rates to fluoroquinolones at SSIs (46.13%) than those without ciprofloxacin (21.9%), although the difference did not reach statistical significance (p 0.1). In our series, UTI was significantly associated with SSI after PSFI. On the basis of our results, we conclude that further efforts to reduce the incidence of postoperative UTI and provide adequate empirical antibiotic therapy that avoids quinolones whenever possible may help to reduce SSI rates and potential microbial resistance.

Activation of mitogen- and stress-activated kinase 1 is required for proliferation of breast cancer cells in response to estrogens or progestins.

Growth of breast cancers is often dependent on ovarian steroid hormones making the tumors responsive to antagonists of hormone receptors. However, eventually the tumors become hormone independent, raising the need to identify downstream targets for the inhibition of tumor growth. One possibility is to focus on the signaling mechanisms used by ovarian steroid hormones to induce breast cancer cell proliferation. Here we report that the mitogen- and stress-activated kinase 1 (MSK1) could be a potential druggable target. Using the breast cancer cell line T47D, we show that estrogens (E2) and progestins activate MSK1, which forms a complex with the corresponding hormone receptor. Inhibition of MSK1 activity with H89 or its depletion by MSK1 short hairpin RNAs (shRNAs) specifically abrogates cell proliferation in response to E2 or progestins without affecting serum-induced cell proliferation. MSK1 activity is required for the transition from the G1- to the S-phase of the cell cycle and inhibition of MSK1 compromises both estradiol- and progestin-dependent induction of cell cycle genes. ChIP-seq experiments identified binding of MSK1 to progesterone receptor-binding sites associated with hormone-responsive genes. MSK1 recruitment to epigenetically defined enhancer regions supports the need of MSK1 as a chromatin remodeler in hormone-dependent regulation of gene transcription. In agreement with this interpretation, expression of a histone H3 mutated at S10 eliminates the hormonal effect on cell proliferation and on induction of relevant target genes. Finally, we show that E2- or progestin-dependent growth of T47D cells xenografted in immunodefficient mice is inhibited by depletion of MSK1, indicating that our findings are not restricted to cultured cells, and that MSK1 plays an important role for hormone-dependent breast cancer growth in a more physiological context.

Implant survival after deep infection of an instrumented spinal fusion.

This study evaluates the long-term survival of spinal implants after surgical site infection (SSI) and the risk factors associated with treatment failure. A Kaplan-Meier survival analysis was carried out on 43 patients who had undergone a posterior spinal fusion with instrumentation between January 2006 and December 2008, and who consecutively developed an acute deep surgical site infection. All were appropriately treated by surgical debridement with a tailored antibiotic program based on culture results for a minimum of eight weeks. A 'terminal event' or failure of treatment was defined as implant removal or death related to the SSI. The mean follow-up was 26 months (1.03 to 50.9). A total of ten patients (23.3%) had a terminal event. The rate of survival after the first debridement was 90.7% (95% confidence interval (CI) 82.95 to 98.24) at six months, 85.4% (95% CI 74.64 to 96.18) at one year, and 73.2% (95% CI 58.70 to 87.78) at two, three and four years. Four of nine patients required re-instrumentation after implant removal, and two of the four had a recurrent infection at the surgical site. There was one recurrence after implant removal without re-instrumentation. Multivariate analysis revealed a significant risk of treatment failure in patients who developed sepsis (hazard ratio (HR) 12.5 (95% confidence interval (CI) 2.6 to 59.9); p < 0.001) or who had > three fused segments (HR 4.5 (95% CI 1.25 to 24.05); p = 0.03). Implant survival is seriously compromised even after properly treated surgical site infection, but progressively decreases over the first 24 months.

Nueva estrategia para mejorar la medida de la calidad de vida en la escoliosis idiopática: adición de la dimensión de deformidad percibida al cuestionario de la Scoliosis Research Society (SRS-22) / New strategy for the improvement of the measurement of quality of life in idiopathic scoliosis: addition of a perceived deformity dimension to the questionnaire of the Scoliosis Research Society (SRS-22)

Introducción. El cuestionario de la Scoliosis Research Society (SRS-22) es un instrumento válido para valorar la calidad de vida en la escoliosis idiopática. No obstante, la correlación entre las puntuaciones del cuestionario y el valor angular de la curva escoliótica es poco relevante. Otros instrumentos de medida de la salud percibida han mostrado mejores correlaciones con el ángulo de Cobb. El objetivo del estudio es medir la relación del SRS-22 con la magnitud de la escoliosis y valorar si esta relación puede mejorar al añadir otras dimensiones medidas por otros cuestionarios. Material y método. Se estudiaron 101 pacientes con escoliosis que completaron los cuestionarios SRS-22 y Walter Reed Visual Assessment Scale (WRVAS), un cuestionario de escalas icónicas que mide la deformidad percibida. El análisis se realizó mediante regresión múltiple para calcular el coeficiente de determinación (r2), con el ángulo de Cobb como variable dependiente. También se estudió la consistencia interna del instrumento, básico y modificado. Resultados. El cuestionario SRS-22 explicó el 17% de la varianza (r2=0,17, p<0,05). Al añadir el WRVAS, se alcanzó una varianza explicada del 45% con respecto a la variable ángulo de Cobb. La consistencia interna del SRS-22 se mantuvo tras la adición del WRVAS. Discusión. El SRS-22 permite una medida válida y fiable de la calidad de vida en la escoliosis. No obstante, la capacidad de este instrumento para explicar el ángulo de Cobb, que es la medida estándar de la escoliosis, puede mejorar al añadir una nueva dimensión que mida la deformidad percibida (AU)

Background. The Scoliosis Research Society Questionnaire (SRS-22) is a valid instrument for assessing health-related quality of life (HRQOL) in patients with idiopathic scoliosis. However, the correlation between the questionnaire scores and the magnitude of the scoliotic curve is of little relevance. Other patient-reported outcome instruments have demonstrated better correlations with the Cobb angle. The purpose of this study has been to measure the relationship of the SRS-22 with the magnitude of the scoliosis and to evaluate if this relationship can be improved after adding other domains from other outcome instrument. Methods We studied 101 patients with scoliosis who filled out the SRS-22 questionnaires and the Walter Reed Visual Assessment Scale (WRVAS), the latter of which provides a deeper understanding of body image than the SRS-22 by using drawings of the deformity. The analysis was made using the multiple regression analysis to calculate the coefficient of determination (r2), with the Cobb angle as the dependent variable. Internal consistency of the modified and basic instrument was also determined. Results. The basic SRS-22 explained 17% of variance (r2=0.17, P<.05). With addition of the WRVAS, 45% of Cobb variance was explained. Internal consistency of SRS-22 was not poorer following these changes. Conclusions. The SRS-22 questionnaire accounts for 17% of the variance (r2=0.17, P<.05). When the WRVAS was added, a variance explaining 45% in regards to the variable Cobb angle was reached. The internal consistence of SRS-22 was maintained after adding the WRVAS. Discussion. The SRS-22 allows for a valid and reliable measurement of the quality of life of scoliosis. However, the ability of this instrument to explain the Cobb angle (standard measure in scoliosis) can be improved by adding a new dimension measuring perceived deformity (AU)

Individualized antibiotic prophylaxis reduces surgical site infections by gram-negative bacteria in instrumented spinal surgery.

PURPOSE: Surgical site infection (SSI) can be a challenging complication after posterior spinal fusion and instrumentation (PSFI). An increasing rate of SSI by gram-negative bacteria (GNB) has been observed. Current guideline recommendations have not been effective for preventing infection by these microorganisms. METHODS: Retrospective cohort study comparing two consecutive groups of patients undergoing PSFI at a single institution. Cohort A includes 236 patients, operated between January 2006 and March 2007, receiving standard preoperative antibiotic prophylaxis with cefazolin (clindamycin in allergic patients). Cohort B includes 223 patients operated between January and December 2009, receiving individualized antibiotic prophylaxis and treatment based on preoperative urine culture. Cultures were done 3-5 days before surgery in patients meeting one of the following risk criteria for urinary tract colonization: hospitalization longer than 7 days, indwelling catheter, neurogenic bladder, history of urinary incontinence, or history of recurrent urinary tract infection. RESULTS: Twenty-two (9.3%) patients in cohort A developed SSI, 68.2% due to GNB. 38 (17%) patients in cohort B were considered at risk for GNB colonization; preoperative urine culture was positive in 14 (36%). After adjusted antibiotic prophylaxis, 15 (6.27%) patients in cohort B developed SSI, 33.4% due to GNB. A statistically significant reduction in GNB SSI was seen in cohort B (Fisher's exact test, p = 0.039). CONCLUSION: Higher preoperative GNB colonization rates were found in patients with neurogenic bladder or indwelling catheters. Preoperative bacteriological screening, treatment for bacteriuria, and individualized antibiotic prophylaxis were effective for reducing GNB SSI.

Muscle dysfunction and exercise limitation in adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) can lead to ventilatory restriction, respiratory muscle weakness and exercise limitation. However, both the causes and the extent of muscle dysfunction remain unclear. The aim of our study is to describe muscle weakness and its relationship to lung function and tolerance to exercise in AIS patients. Lung and muscle function, together with exercise capacity, were assessed in 60 patients with pronounced spinal deformity (>40 degrees) and in 25 healthy volunteers. Patients with AIS had only mild to moderate abnormal ventilatory patterns, the most frequent of which were restrictive abnormalities. The function of respiratory and limb muscles and exercise capacity were below normal limits in AIS patients, and were significantly lower than in controls. Exercise capacity was found to correlate with the function of inspiratory, expiratory, upper limb and lower limb muscles which, in addition, were reciprocally interrelated. Multivariate analysis showed that lower limb muscle function is the main contributor to exercise intolerance. There appeared to be no connection between spinal deformity and lung function, muscle function or exercise capacity. We conclude that AIS patients show generalised muscle dysfunction which contributes to the reduction in their exercise capacity, even in the absence of severe ventilatory impairment.

Ética y legislación en la investigación clínica / Ethics and legislation

La investigación desarrolla hipótesis de trabajo que requieren la utilización de pacientes o animales de experimentación. En ocasiones aborda aspectos que pueden tener repercusiones graves para la humanidad. Desde que desarrolló el código de Nurenberg, después de la II guerra mundial, se han establecido controles con leyes, declaraciones, comisiones para reducir los riesgos de todo proyecto científico y de las personas o animales que participan en él (AU)

Research entails working hypotheses requiring the use of test patients or animals. There are times when it broaches aspects that could have serious repercussions for human beings. Since the Nuremberg code was devised after World War II, controls have been put in place by way of laws, declarations, committees to limit the risks of any scientific project and of the people or animals participating in it (AU)

Human adipose tissue-derived mesenchymal stromal cells as vehicles for tumor bystander effect: a model based on bioluminescence imaging.

Human adipose tissue mesenchymal stromal cells (AMSCs) share common traits, including similar differentiation potential and cell surface markers, with their bone marrow counterparts. Owing to their general availability, higher abundance and ease of isolation AMSCs may be convenient autologous delivery vehicles for localized tumor therapy. We demonstrate a model for tumor therapy development based on the use of AMSCs expressing renilla luciferase and thymidine kinase, as cellular vehicles for ganciclovir-mediated bystander killing of firefly luciferase expressing tumors, and noninvasive bioluminescence imaging to continuously monitor both, tumor cells and AMSCs. We show that the therapy delivering AMSCs survive long time within tumors, optimize the ratio of AMSCs to tumor cells for therapy, and asses the therapeutic effect in real time. Treatment of mice bearing prostate tumors plus therapeutic AMSCs with the prodrug ganciclovir induced bystander killing effect, reducing the number of tumor cells to 1.5 % that of control tumors. Thus, AMSCs could be useful vehicles to deliver localized therapy, with potential for clinical application in inoperable tumors and surgical borders after tumor resection. This approach, useful to evaluate efficiency of therapeutic models, should facilitate the selection of cell types, dosages, therapeutic agents and treatment protocols for cell-based therapies of specific tumors.

Colecistitis aguda como causa de muerte tras cirugía por estenosis del canal lumbar / Acute cholecystitis as cause of death after surgery for lumbar canal stenosis

La colecistitis aguda posquirúrgica se ha descrito fundamentalmente como una complicación de cirugía mayor abdominal o torácica, y en ocasiones asociada a cirugía del aparato locomotor. En cirugía del raquis se ha asociado a grandes procedimientos como la corrección de deformidades en el adulto. Los factores de riesgo más reconocidos son la restricción hídrica, fiebre, fenómenos hemolíticos, trasfusiones sanguíneas múltiples, trastornos nutricionales, fármacos (anestésicos, codeína, atropina, meperidina, morfina) y alteraciones hemodinámicas. Existe un riesgo especialmente elevado cuando confluyen varios de ellos en un paciente sometido a una situación de estrés físico como la cirugía. El diagnóstico de la colecistitis aguda posoperatoria suele ser difícil, al quedar frecuentemente enmascarado por el procedimiento quirúrgico inicial. Deberá existir un alto índice de sospecha ante todo paciente que tras un posoperatorio inmediato favorable desarrolle fiebre, leucocitosis y dolor abdominal. La confirmación ecográfica y la instauración rápida del tratamiento oportuno son el único modo de disminuir la elevada tasa de mortalidad de esta complicación

Post-surgical acute cholecystitis has been described mainly as a complication of major abdominal or thoracic surgery sometimes associated with musculoskeletal surgery. In spine surgery it has been related to large-scale procedures such as the correction of deformities in adults. The most frequently mentioned risk factors are hydric restriction, fever, hemolytic phenomena, multiple blood transfusions, nutritional disorders, certain drugs (anesthetics, codeine. atropine, meperidine, morphine) and hemodynamic alterations. The risk is especially high when several of the factors above co-occur in a single patient subjected to a physically stressful situation like surgery. Diagnosis of acute postoperative cholecystitis is often challenging since the condition is often marked by the initial surgical procedure. Symptoms like fever, leucocytosis and abdominal pain after a favorable immediate post-op should put us on guard. Sonographic confirmation and the quick implementation of appropriate treatment are the only way of reducing the high death toll of this complication (AU)

Analysis of nutritional parameters in idiopathic scoliosis patients after major spinal surgery.

OBJECTIVE: The aim of the study is to investigate the evolution of nutritional parameters after major spinal surgery in patients with idiopathic scoliosis. METHODS: This retrospective study included 31 patients with a mean age of 18 y, diagnosed with idiopathic scoliosis. The following variables were analyzed: demographic, surgical (type, number of fused segments, duration, and blood loss), nutritional assessment (proteins, albumin, prealbumin, transferrin, lymphocytes, and body mass index), and duration of hospitalization at different time points. Statistical analyses were performed with the SPSS 6.1 software. RESULTS: Before surgery, nutritional status was normal in all patients. At 24-48 h after surgery, statistically significant decrease with respect to preoperative values was recorded for all the parameters studied: proteins (P < 0.001), albumin (P < 0.001), prealbumin (P < 0.01), transferrin (P < 0.001), and lymphocytes (P < 0.001). CONCLUSION: Our results showed a significant postoperative decrease in the nutritional parameters analyzed in a previously well-nourished population considered to be at low risk for nutritional depletion.

Nuevas perspectivas en el tratamiento quirúrgico de las enfermedades graves de la caja torácica que cursan con afectación respiratoria / New Approaches to the surgial treatment of severe thoracic cage diseases

No disponible

Survivorship analysis of Cotrel-Dubousset instrumentation in idiopathic scoliosis.

This study presents a survivorship analysis of Cotrel-Dubousset instrumentation in the surgical treatment of idiopathic scoliosis. Between 1987 and 1995, a total of 133 patients with idiopathic scoliosis received posterior spine fusion and instrumentation with the CD system at our center. The patients' mean age at surgery was 16.5 years (range 11-43 years). The magnitude of the thoracic scoliosis averaged 62.7 degrees (range 40 degrees -125 degrees ) and that of the lumbar curve was 58.8 degrees (range 40 degrees -100 degrees ). On average, 12.2 segments were fused (range 8-17) and, excluding the rods, 14.1 implants were set for each patient (range 10-21). Survivorship analysis was carried out using the Kaplan-Meier method. Implant removal was considered the terminal event, or "death". The effect of several variables on survival rate was determined with the Cox regression method. The patients remained in the study for 56.7 months (range 2-120 months). One-hundred and ten patients were withdrawn ("censored"): 90 "alive" (did not require repeat surgery and attended follow-up control in 1997) and 20 "lost" (did not attend control in 1997). Twenty-three patients attained the terminal event of implant removal for a variety of reasons: acute infection (three cases), late infection (ten cases), implant failure requiring revision (six cases) and local pain (four cases). The survival rate was 95.5% at 3 months, 94.7% at 6 months, 93.9% at 1 year, 91.5% at 2 years, 82.2% at 5 years and 76.5% at 10 years. The magnitude of the curves, total number of implants and number of fused segments did not correlate with survival probability. A positive correlation was found between survival rate and correction loss between surgery and last control. A survival rate of 76.5% at 10 years is unexpectedly low. Current data suggest that the incapacity to maintain correction after initial surgery plays a major roll in the long-term evolution of Cotrel-Dubousset instrumentation.