[Surgical Treatment of Degenerative Lumbar Stenosis and Spondylolisthesis: Clinical Practice Guideline]. / Chirurgická lécba degenerativní lumbální stenózy a spondylolistézy: klinický doporucený postup.

PURPOSE OF THE STUDY This article presents the evidence and the rationale for the recommendations for surgical treatment of degenerative lumbar stenosis (DLS) and spondylolisthesis that were recently developed as a part of the Czech Clinical Practice Guideline (CPG) "The Surgical Treatment of the Degenerative Diseases of the Spine". MATERIAL AND METHODS The Guideline was drawn up in line with the Czech National Methodology of the CPG Development, which is based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We used an innovative GRADE-adolopment method that combines adoption and adaptation of the existing guidelines with de novo development of recommendations. In this paper, we present three adapted recommendations on DLS and a recommendation on spondylolisthesis developed de novo by the Czech team. RESULTS Open surgical decompression in DLS patients has been evaluated in three randomized controlled trials (RCTs). A recommendation in favour of decompression was made based on a statistically significant and clinically evident improvement in the Oswestry Disability Index (ODI) and leg pain. Decompression may be recommended for patients with symptoms of DLS in the event of correlation of significant physical limitation and the finding obtained via imaging. The authors of a systematic review of observational studies and one RCT conclude that fusion has a negligible role in the case of a simple DLS. Thus, spondylodesis should only be chosen as an adjunct to decompression in selected DLS patients. Two RCTs compared supervised rehabilitation with home or no exercise, showing no statistically significant difference between the procedures. The guideline group considers the post-surgery physical activity beneficial and suggests supervised rehabilitation in patients who have undergone surgery for DLS for the beneficial effects of exercise in the absence of known adverse effects. Four RCTs were found comparing simple decompression and decompression with fusion in patients with degenerative lumbar spondylolisthesis. None of the outcomes showed clinically significant improvement or deterioration in favour of either intervention. The guideline group concluded that for stable spondylolisthesis the results of both methods are comparable and, when other parameters are considered (balance of benefits and risks, or costs), point in favour of simple decompression. Due to the lack of scientific evidence, no recommendation has been formulated regarding unstable spondylolisthesis. The certainty of the evidence was rated as low for all recommendations. DISCUSSION Despite the unclear definition of stable/unstable slip, the inclusion of apparently unstable cases of DS in stable studies limits the conclusions of the studies. Based on the available literature, however, it can be summarized that in simple degenerative lumbar stenosis and static spondylolisthesis, fusion of the given segment is not justified. However, its use in the case of unstable (dynamic) vertebral slip is undisputable for the time being. CONCLUSIONS The guideline development group suggests decompression in patients with DLS in whom previous conservative treatment did not lead to improvement, spondylodesis only in selected patients, and post-surgical supervised rehabilitation. In patients with degenerative lumbar stenosis and spondylolisthesis with no signs of instability, the guideline development group suggests simple decompression (without fusion). Key words: degenerative lumbar stenosis, degenerative spondylolisthesis, spinal fusion, Clinical Practice Guideline, GRADE, adolopment.

Clinical signs of alcohol intoxication and importance of blood alcohol concentration testing in alcohol dependence.

OBJECTIVES: The goal of the study was to find out if and what is a difference between clinical signs of alcohol intoxication (AI) and a detected blood alcohol concentration (BAC) among the patients with syndrome of alcohol dependence. BACKGROUND: The relation between BAC and clinical assessment of AI is a complicated issue. People with dependence form a special group due to their altered tolerance to alcohol. METHODS: Clinical, prospective study of 1,277 patients seeking treatment for alcohol-related problems. The average age was 43.1 (SD ± 11.8) years, 74 % males. Alcohol dependence and diagnosis of AI was done by a psychiatrist during a standard examination. This was followed by a laboratory testing for the presence of alcohol in the exhaled air calculated into BAC. The clinical and laboratory findings were compared in a descriptive and statistical way under codes Y 91 and Y 90 in accordance with the ICD-10/WHO diagnostic criteria. RESULTS: The clinical signs of AI were found in 275 (22 %) patients. Of these, 57 (21 %) showed no presence of alcohol in blood laboratory testing. Alcohol was found in blood in 383 (30 %) patients, of whom 165 (43 %) did not show the clinical signs of AI. 21 % had no clinical signs of AI at BAC ≥ 2 ‰. CONCLUSIONS: Our findings showed that there was a substantial discrepancy between the clinical signs of AI and the detected BAC in people with dependence. These differences do not seem to result from insufficient diagnostic skills of the physicians but they are rather due to the non-specific nature of the signs, which can be of different etiology. Therefore, an enhanced diagnostic alertness and routine laboratory testing for the presence of alcohol is important, especially in the emergency and addiction medicine (Fig. 2, Ref. 19).

[Weight gain among the patients in methadone maintenance program as come-back to population norm]. / Priberanie na hmotnosti pacientov v metadónovom udrziavacom programe ako návrat k populacnej norme.

BACKGROUND: Clinical experience reveals a weight increase among patients with opiate dependence after their admission to methadone maintenance treatment (MMT). The objective of the present study was to find out whether there was a significant weight increase among MMT patients, and if so, to what extent this change in weight differed from the existing statistical norm of the general population. METHODS AND RESULTS: The sample consisted of 274 MMT patients of the CPLDZ Bratislava with the average age of 26.3 years, 69% were males. Only those patients were included into the study that had stayed in MMT for at least one year. Two main comparisons of their body mass index (BMI) were done: 1. at entry into MMT, and one year after entry; 2. a comparison of BMI one year after treatment entry with BMI of the general Slovak population. Underweight was present in 10% of the patients entering MMT, 72% had BMI within a normal range, 15% were overweight, and 3% were obese. A significant shift towards higher BMI categories was reported one year after treatment entry: 5%, 58%, 29% and 8%, respectively (p < 0.001), which is still significantly lower than in the general population: 4%, 49%, 34% a 13% (p < 0.001). CONCLUSIONS: Our results indicate that weight increase in MMT patients should not be considered a direct side-effect, because it is not possible to differentiate between a drug effect and changed behavioural eating stereotypes that could be identical to those in the general population.