Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England: secondary analysis of the Birthplace national prospective cohort study.

OBJECTIVE: To compare vaginal birth rates in women planning vaginal birth after caesarean (VBAC) at home versus in an obstetric unit (OU) and explore transfer rates in women planning home VBAC. DESIGN: Prospective cohort study. SETTING: OUs and planned home births in England. POPULATION: 1436 women planning VBAC in the Birthplace cohort, including 209 planning home VBAC. METHODS: We used Poisson regression to calculate relative risks adjusted for maternal characteristics. MAIN OUTCOMES: (i) vaginal birth and (ii) transfer from planned home birth to OU during labour or immediately after birth. SECONDARY OUTCOMES: (i) composite of maternal blood transfusion or admission to higher level care, (ii) stillbirth or Apgar score <7 at 5 minutes, (iii) neonatal unit admission. RESULTS: Planned VBAC at home was associated with a statistically significant increase in the chances of having a vaginal birth compared with planned VBAC in an OU (adjusted relative risk 1.15, 95% confidence interval 1.06-1.24). The risk of an adverse maternal outcome was around 2-3% in both settings, with a similar risk of an adverse neonatal outcome. Transfer rates were high (37%) and varied markedly by parity (para 1, 56.7% versus para 2+, 24.6%). CONCLUSION: Women in the cohort who planned VBAC at home had an increased chance of a vaginal birth compared with those planning VBAC in an OU, but transfer rates were high, particularly for women with only one previous birth, and the risk of an adverse maternal or perinatal outcome was around 2-3%. No change in guidance can be recommended. TWEETABLE ABSTRACT: Higher vaginal birth rates in planned VBAC at home versus in OU but 2-3% adverse outcomes and high transfer rate.

Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study.

OBJECTIVE: To explore and compare perinatal and maternal outcomes in women at 'higher risk' of complications planning home versus obstetric unit (OU) birth. DESIGN: Prospective cohort study. SETTING: OUs and planned home births in England. POPULATION: 8180 'higher risk' women in the Birthplace cohort. METHODS: We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures. MAIN OUTCOME MEASURES: Composite perinatal outcome measure encompassing 'intrapartum related mortality and morbidity' (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth. RESULTS: The risk of 'intrapartum related mortality and morbidity' or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31-0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure 'intrapartum related mortality and morbidity' (RR adjusted for parity 1.92, 95% CI 0.97-3.80). Maternal interventions were lower in planned home births. CONCLUSIONS: The babies of 'higher risk' women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.

The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study.

OBJECTIVES: To evaluate the impact of maternal BMI on intrapartum interventions and adverse outcomes that may influence choice of planned birth setting in healthy women without additional risk factors. DESIGN: Prospective cohort study. SETTING: Stratified random sample of English obstetric units. SAMPLE: 17,230 women without medical or obstetric risk factors other than obesity. METHODS: Multivariable log Poisson regression was used to evaluate the effect of BMI on risk of intrapartum interventions and adverse maternal and perinatal outcomes adjusted for maternal characteristics. MAIN OUTCOME MEASURES: Maternal intervention or adverse outcomes requiring obstetric care (composite of: augmentation, instrumental delivery, intrapartum caesarean section, general anaesthesia, blood transfusion, 3rd/4th degree perineal tear); neonatal unit admission or perinatal death. RESULTS: In otherwise healthy women, obesity was associated with an increased risk of augmentation, intrapartum caesarean section and some adverse maternal outcomes but when interventions and outcomes requiring obstetric care were considered together, the magnitude of the increased risk was modest (adjusted RR 1.12, 95% CI 1.02-1.23, for BMI > 35 kg/m(2) relative to low risk women of normal weight). Nulliparous low risk women of normal weight had higher absolute risks and were more likely to require obstetric intervention or care than otherwise healthy multiparous women with BMI > 35 kg/m(2) (maternal composite outcome: 53% versus 21%). The perinatal composite outcome exhibited a similar pattern. CONCLUSIONS: Otherwise healthy multiparous obese women may have lower intrapartum risks than previously appreciated. BMI should be considered in conjunction with parity when assessing the potential risks associated with birth in non-obstetric unit settings.

Transfers of women planning birth in midwifery units: data from the birthplace prospective cohort study.

OBJECTIVE: To examine the percentage of women transferred, reasons for transfer and factors associated with the transfer of women planning birth in midwifery units (MUs). DESIGN: Prospective cohort study. SETTING: All freestanding midwifery units (FMUs) and alongside midwifery units (AMUs) in England. PARTICIPANTS: Twenty-nine thousand, two hundred and forty-eight eligible women with a singleton, term and 'booked' pregnancy, planning birth in an MU between April 2008 and April 2010. METHODS: Multivariable logistic regression was used to explore the sociodemographic and clinical characteristics associated with transfer. MAIN OUTCOME MEASURES: Transfer during labour or within 24 hours of birth. RESULTS: Over one in four women were transferred from AMUs and over one in five from FMUs. In both types of MU, compared with multiparous women aged 25-29 years, nulliparous women aged <20 years had higher odds of transfer (FMU-adjusted odds ratio [OR], 4.5; 95% confidence interval [CI], 3.10-6.57; AMU-adjusted OR, 2.6; 95% CI, 2.18-2.06), and the odds of transfer increased with increasing age. Nulliparous women aged ≥ 35 years in FMUs had 7.4 times the odds of transfer (95% CI, 5.43-10.10) and, in AMUs, 6.0 times the odds of transfer (95% CI, 4.81-7.41). Starting labour care after 40 weeks of gestation and the presence of complicating conditions at the start of labour care were also independently associated with a higher risk of transfer. CONCLUSIONS: Transfer from MUs is common, especially for first-time mothers. This study provides evidence on the maternal characteristics associated with an increased risk of transfer, which can be used to inform women's choices about place of birth.

Flunarizine protects neurons from death after axotomy or NGF deprivation.

Systemically administered flunarizine enhanced neuronal survival in lumbar sensory ganglia in newborn rats after axotomy. Flunarizine-treated rats lost 71 percent fewer neurons than the untreated control rats at the end of 1 week. In cell culture, flunarizine at 30 to 40 microM also prevented neuronal death in nerve growth factor-dependent embryonic sensory and sympathetic neurons after the abrupt withdrawal of neurotrophic support. The drug may cause this effect by acting at an intracellular site, one distinct from its blockade of voltage-dependent calcium channels.

National Health and Nutrition Examination Survey III thyroid-stimulating hormone (TSH)-thyroperoxidase antibody relationships demonstrate that TSH upper reference limits may be skewed by occult thyroid dysfunction.

CONTEXT: The setting of the TSH upper reference limit impacts the diagnosis of mild hypothyroidism and is currently controversial. OBJECTIVE: Our objective was to evaluate factors influencing the TSH reference range. DESIGN: Nonpregnant subjects aged 12 yr and older from National Health and Nutrition Examination Survey III were used to study the relationships between TSH, thyroid peroxidase antibodies (TPOAb), and thyroglobulin antibodies in different ethnic groups. RESULTS: TPOAb prevalence was lowest (<3%) when TSH was between 0.1 and 1.5 mIU/liter in women and between 0.1 and 2.0 mIU/liter in men and progressively increased to above 50% when TSH exceeded 20 mIU/liter. TSH reference range parameters (2.5th, 50th, and 97.5th percentiles) were analyzed according to thyroid antibody status, race/ethnicity, and age for the 14,202 subjects made up of non-Hispanic Blacks (B), non-Hispanic whites (W), and Mexican-Americans (M) who did not report thyroid disease or taking thyroid-altering medications and whose total T(4) was within the reference range. For each age group of each ethnicity, the inclusion of antibody-positive subjects increased TSH medians and upper limits (97.5th percentiles). The TSH upper limit was lower for the entire B cohort vs. W or M. However, this difference was lost when age cohorts with a similar prevalence of TPOAb (B age 40-49 yr vs. W and M age 20-29 yr) were compared. CONCLUSIONS: Ethnic differences in TSH were not present when populations with the same relative frequency of thyroid antibodies were compared. TSH upper reference limits may be skewed by TPOAb-negative individuals with occult autoimmune thyroid dysfunction.

A Site-Specific, Weather-Based Disease Regression Model for Sclerotinia Blight of Peanut.

In North Carolina, losses due to Sclerotinia blight of peanut, caused by the fungus Sclerotinia minor, are an estimated 1 to 4 million dollars annually. In general, peanut (Arachis hypogaea) is very susceptible to Sclerotinia blight, but some partially resistant virginia-type cultivars are available. Up to three fungicide applications per season are necessary to maintain a healthy crop in years highly favorable for disease development. Improved prediction of epidemic initiation and identification of periods when fungicides are not required would increase fungicide efficiency and reduce production costs on resistant and susceptible cultivars. A Sclerotinia blight disease model was developed using regression strategies in an effort to describe the relationships between modeled environmental variables and disease increase. Changes in incremental disease incidence (% of newly infected plants of the total plant population per plot) for the 2002-2005 growing seasons were statistically transformed and described using 5-day moving averages of modeled site-specific weather variables (localized, mathematical estimations of weather data derived at a remote location) obtained from SkyBit (ZedX, Inc.). Variables in the regression to describe the Sclerotinia blight disease index included: mean relative humidity (linear and quadratic), mean soil temperature (quadratic), maximum air temperature (linear and quadratic), maximum relative humidity (linear and quadratic), minimum air temperature (linear and quadratic), minimum relative humidity (linear and quadratic), and minimum soil temperature (linear and quadratic). The model explained approximately 50% of the variability in Sclerotinia blight index over 4 years of field research in eight environments. The relationships between weather variables and Sclerotinia blight index were independent of host partial resistance. Linear regression models were used to describe progress of Sclerotinia blight on cultivars and breeding lines with varying levels of partial resistance. Resistance affected the rate of disease progress, but not disease onset. The results of this study will be used to develop site- and cultivar-specific spray advisories for Sclerotinia blight.

Analysis of Factors That Influence the Epidemiology of Sclerotinia minor on Peanut.

In North Carolina, sclerotia of Sclerotinia minor germinate myceliogenically to initiate infections on peanut. The effects of soil temperature and soil matric potential (ψM on germination and growth of S. minor have not been well characterized, and little is known about relative physiological resistance in different parts of the peanut plant. Laboratory tests examined the ability of the fungus to germinate, grow, and infect detached peanut leaflets at soil temperatures ranging from 18 to 30°C at ψM of -100, -10, and -7.2 kPa. In addition, detached pegs, leaves, main stems, and lateral branches from three peanut lines varying in field resistance were examined for resistance to infection by S. minor. Sclerotial germination was greatest at 30°C and ψM of -7.2 kPa. Final mycelial diameters decreased with decreasing ψM, whereas soil matric potential did not affect lesion development. Mycelial growth and leaflet lesion expansion were maximal at 18 or 22°C. Soil ψM did not affect leaflet infection and lesion expansion. Lesions were not observed on leaves incubated at temperatures of 29°C or above, but developed when temperatures were reduced to 18 or 22°C 2 days after inoculation. Pegs and leaflets were equally susceptible to infection and were more susceptible than either main stems or lateral branches. Results of this work, particularly the effects of temperature on S. minor, and knowledge of peanut part susceptibility has application in improving Sclerotinia blight prediction models for recommending protective fungicide applications.

First Report of Sclerotinia minor on Allium vineale in North Carolina.

Allium vineale L. (wild garlic) is a bulbous perennial that emerges in early spring in many agricultural fields. The soilborne fungus Sclerotinia minor Jagger is a major pathogen found in many peanut (Arachis hypogaea L.) production areas of northeastern North Carolina. During September 2002, symptoms of bleached, water-soaked foliage and wilting were observed on several wild garlic plants growing in a 0.8-ha (2-acre) peanut research plot in Perquimans County, NC. We had previously observed similar symptoms on wild garlic at another location. Two symptomatic wild garlic plants were collected from the field. In the laboratory, symptomatic tissues were excised into 1- to 2-cm sections, rinsed in tap water, towel dried, and placed on potato dextrose agar (PDA) for fungal isolation and identification. Pure cultures with small, black, irregular-shaped sclerotia (<2 mm) scattered abundantly over the culture surface were distinctive of S. minor. Pathogenicity of isolates was tested by inoculating leaf blades near the leaf axils of two symptom-free wild garlic plants (vegetative stage, 4 cm high) with fungal mycelium from 2-day-old cultures. Mycelial agar plugs (4 mm in diameter) were held in place with self-sticking bandaging gauze. Plants were misted, enclosed in plastic bags, and incubated at an ambient temperature (24°C) on the laboratory countertop. Fluffy mycelium developed on leaves within 2 days. Plants wilted and bleached water-soaked lesions formed within 6 days after inoculation. Sclerotia were produced on leaf blades after approximately 14 days. Following the incubation period, S. minor was reisolated from the inoculated plants. Two plants treated similarly with plugs of pure PDA remained healthy over the incubation period. The performance of Koch's postulates confirmed that wild garlic is a host of S. minor. Although few monocots have been reported as hosts of S. minor, the fungus has been reported on two other species of Allium (A. cepa and A. satium), Gladiolus spp., and Cyperus esculentus (1,2). Weed hosts may support populations of S. minor during rotations to nonhosts, serve as reservoirs of inoculum, or act as infection bridges in peanut fields. References: (1) D. F. Farr et al. Fungal Databases. Systematic Botany and Mycology Laboratory. On-line publication. ARS, USDA, 2005. (2) M. S. Melzer et al. Can. J. Plant Pathol. 19:272, 1997.

First Report of Sclerotinia minor on Sida spinosa in North Carolina.

The soilborne fungus Sclerotinia minor Jagger is a major pathogen of peanut (Arachis hypogaea L.) in North Carolina, Virginia, Oklahoma, and Texas. The pathogen attacks several winter annual weed species (1). Economic crops that are hosts to S. minor are seldom grown in rotation with peanut; therefore, its pathogenicity on weed species is of importance in understanding how inoculum densities are maintained between peanut crops. During September 2004, signs of fluffy, white mycelium, small, black sclerotia, and symptoms of bleached leaves and stems were observed on prickly sida (Sida spinosa L.) in a peanut field in Bertie County, NC. Plants of prickly sida with similar signs and symptoms were observed previously in a Chowan County, NC peanut field. Prickly sida is one of several weed species commonly found in peanut fields and rotational crops in agricultural areas of northeastern North Carolina. Cultivation and herbicides usually keep prickly sida under control in the early part of the growing season, but as the summer progresses into early fall, it can become prevalent, as was true in the two fields reported here. Symptomatic tissues were excised into 1- to 2-cm sections, rinsed in tap water, blotted dry, and placed on potato dextrose agar (PDA). The pure cultures with small, black irregular-shaped sclerotia (<2 mm) scattered abundantly over the culture surface were distinctive of S. minor. Pathogenicity was determined by inoculating stems of two symptom-free prickly sida plants with 2-day-old fungal mycelium. Mycelial agar plugs, 4 mm in diameter, were held in place with self-sticking bandaging gauze. Plants were misted, enclosed in plastic bags, and incubated at ambient temperature (24°C) on the laboratory countertop. Fluffy mycelium developed on the stems in 2 days and water-soaked leaves and bleached lesions formed within 6 days after inoculation. Following the incubation period, S. minor was reisolated from the inoculated plants. Two plants treated similarly with plugs of pure PDA remained healthy over the incubation period. The performance of Koch's postulates confirmed that prickly sida is a host of S. minor. To our knowledge, this report of S. minor on prickly sida is also the first report of a plant in the family Malvaceae as a host of S. minor (2). Reference: (1) J. E. Hollowell et al. Plant Dis. 87:197, 2003. (2) M. S. Melzer et al. Can. J. Plant Pathol. 19:272, 1997.

Reliability of stimulated and spontaneous growth hormone (GH) levels for identifying the child with low GH secretion.

The reliability of stimulated and spontaneous GH levels for identifying the child with low GH secretion has been the subject of debate. We compared the ability of GH concentrations after pharmacological stimulation with levodopa and clonidine and of spontaneous peak and 12-h pooled GH concentrations during sleep on a single night to estimate the maximum spontaneous GH secretion from 2 nights in 55 children, aged 5-16 yr, with heights below the 3rd percentile and/or height velocities below the 25th percentile for age, who had two consecutive overnight GH secretory profiles. Maximum stimulated GH concentrations correctly categorized 80% of children who had maximum spontaneous GH concentrations above and below 4 micrograms/L using a double monoclonal immunoradiometric assay for GH (Tandem-R HGH, Hybritech). The remaining 20% of children had stimulated GH concentrations below but spontaneous GH concentrations above 4 micrograms/L. Using this cut-off, the maximum GH concentrations from the first and second nights correctly categorized 98% and 95% of the children, respectively. Night to night variation in GH secretion was low in children who had low spontaneous GH secretion (maximum spontaneous peak and pool GH concentrations, less than 4 and less than or equal to 0.7 micrograms/L, respectively), and pooled GH concentrations from the 2 nights were concordant in 98% of the cases. We conclude that it is not uncommon for stimulated GH concentrations to underestimate spontaneous GH secretion. Even without acclimatization to the hospital setting, measurement of spontaneous GH secretion on a single night was more reliable for identifying the child with low endogenous GH secretion than was GH stimulation testing alone.

Iodine nutrition in the United States. Trends and public health implications: iodine excretion data from National Health and Nutrition Examination Surveys I and III (1971-1974 and 1988-1994)

Iodine deficiency in a population causes increased prevalence of goiter and, more importantly, may increase the risk for intellectual deficiency in that population. The National Health and Nutrition Examination Surveys [NHANES I (1971-1974) and (NHANES III (1988-1994)] measured urinary iodine (UI) concentrations. UI concentrations are an indicator of the adequacy of iodine intake for a population. The median UI concentrations in iodine-sufficient populations should be greater than 10 microg/dL, and no more than 20% of the population should have UI concentrations less than 5 microg/dL. Median UI concentrations from both NHANES I and NHANES III indicate adequate iodine intake for the overall U.S. population, but the median concentration decreased more than 50% between 1971-1974 (32.0+/-0.6 microg/dL) and 1988-1994 (14.5+/-0.3 microg/dL). Low UI concentrations (<5 microg/dL) were found in 11.7% of the 1988-1994 population, a 4.5-fold increase over the proportion in the 1971-1974 population. The percentage of people excreting low concentrations of iodine (UI, <5 microg/dL) increased in all age groups. In pregnant women, 6.7%, and in women of child-bearing age, 14.9% had UI concentrations below 5 microg/dL. The findings in 1988-1994, although not indicative of iodine deficiency in the overall U.S. population, define a trend that must be monitored.

Use of iodine for water disinfection: iodine toxicity and maximum recommended dose.

Iodine is an effective, simple, and cost-efficient means of water disinfection for people who vacation, travel, or work in areas where municipal water treatment is not reliable. However, there is considerable controversy about the maximum safe iodine dose and duration of use when iodine is ingested in excess of the recommended daily dietary amount. The major health effect of concern with excess iodine ingestion is thyroid disorders, primarily hypothyroidism with or without iodine-induced goiter. A review of the human trials on the safety of iodine ingestion indicates that neither the maximum recommended dietary dose (2 mg/day) nor the maximum recommended duration of use (3 weeks) has a firm basis. Rather than a clear threshold response level or a linear and temporal dose-response relationship between iodine intake and thyroid function, there appears to be marked individual sensitivity, often resulting from unmasking of underlying thyroid disease. The use of iodine for water disinfection requires a risk-benefit decision based on iodine's benefit as a disinfectant and the changes it induces in thyroid physiology. By using appropriate disinfection techniques and monitoring thyroid function, most people can use iodine for water treatment over a prolonged period of time.

Growth hormone therapy in achondroplasia.

A pilot study was carried out to examine the safety and efficacy of recombinant human growth hormone for growth-promoting therapy of achondroplasia. The data suggest that the agent in doses used to treat non-GH-deficient forms of short stature (0.3 mg/kg/wk) modestly increases overall height velocity in some children with achondroplasia. The effect was seen mainly in children with the lowest growth velocities prior to treatment. No untoward effects were noted. Several questions were raised that require further study.

Revision of the International Classification of Impairments, Disabilities, and Handicaps: developmental issues.

Variability in approaches to define and classify disability has constituted persistent problems in documenting the epidemiology of disability and providing appropriate services. The major institutions of health care, mental health, and welfare often have separate systems of classification and terminology related to defining eligibility for programs and funding for services. In 1980, the International Classification of Impairments, Disabilities and Handicaps-ICIDH was published by the World Health Organization as a companion document of the International Classification of Disease to document the consequences of illness or injury. Current problems concerning the classification of childhood disability in health, education, and related services have resulted in growing interest in the revision of the ICIDH as a classification tool. The strengths and limitations of the ICIDH are examined in general, as well as with specific reference to its ability to document the nature and epidemiology of childhood disability. This paper (1) describes the ICIDH taxonomy and representative contributions; (2) reviews issues and concerns contributing to its revision; (3) summarizes changes in the revised ICIDH2 draft document, and (4) identifies issues of particular relevance to children and public health applications.

The General Practice Research Database. Scientific and Ethical Advisory Group.

We describe a powerful new information resource for pharmacovigilance, pharmaco-economic studies, clinical epidemiology and health service research, which involves automated linkage of demographic, diagnostic and prescription information on some 3.4 million patients enrolled in over 500 separate general practices. Information is subject to regular validation checks. Access to this resource is available for bona fide research workers, subject to appropriate safeguards for patient anonymity and for scientific and ethical standards of the proposed studies. This database has depended upon the participating general practitioners and has already resulted in a substantial output of studies in peer-reviewed literature. It has great potential for further work of major relevance to public health, and its increasing use is to be actively encouraged.

Radiologic technique to mark ureteral calculi for extracorporeal shock-wave lithotripsy.

A technique is described to bypass ureteral calculi with a catheter and radiologically mark the exact position of the calculus on the horizontal and vertical planes to perform extracorporeal shock-wave lithotripsy.

Trimester-specific changes in maternal thyroid hormone, thyrotropin, and thyroglobulin concentrations during gestation: trends and associations across trimesters in iodine sufficiency.

OBJECTIVES: To describe the interrelationships of thyroid functions based on trimester-specific concentrations in healthy, iodine-sufficient pregnant women across trimesters, and postpartum. METHODS: Circulating total 3,5,3'- triidothyronine (T(3)) and thyroxine (T(4)) concentrations were determined simultaneously using liquid chromatography tandem mass-spectrometry (LC/MS/MS). Free thyroxine (FT(4)), thyroid-stimulating hormone (TSH), and thyroglobulin (Tg) were measured using immunoassay techniques. Linear mixed effects models and correlations were calculated to determine trends and associations, respectively, in concentrations. RESULTS AND CONCLUSIONS: Trimester-specific T(3), FT(4), TSH, and Tg concentrations were significantly different between the first and third trimesters (all p < 0.05); second and third trimester values were not significantly different for FT(4), TSH, and Tg (all p > 0.25) although T3 was significantly higher in the third, relative to the second trimester. T(4) was not significantly different at any trimester (all p > 0.80). With two exceptions, analyte concentrations tended not to be correlated at each trimester and at 1-year postpartum. One exception was that T(3) and T(4) tended to be associated (all p < 0.05) at all time points except the third trimester (rho = 0.239, p > 0.05). T(4) and FT(4) concentrations tended to correlate positively during pregnancy (rho 0.361-0.382, all p < 0.05) but not postpartum (rho = 0.179, p > 0.05). Trends suggest that trimester-specific measurements of T(3), FT(4), Tg, and possibly TSH are warranted.

Rosai-Dorman disease causing cervical myelopathy.

STUDY DESIGN: A case report of a rare disease entity and review of the literature. OBJECTIVES: To illustrate the occurrence of an unusual disease affecting the spine and spinal canal. SUMMARY OF BACKGROUND DATA: Rosai-Dorman disease is considered an idiopathic benign lymphoproliferative disease that typically occurs in the earlier decades of life. The usual manifestation is painless massive cervical lymphadenopathy, although involvement of many extra nodal sites is common. This case illustrates Rosai-Dorman disease occurring in an elderly man with myelopathy and mass lesions of the cervical, thoracic, and lumbar spinal canal without typical lymphadenopathy.- METHODS: Case report illustrating clinical presentation as well as radiographic and pathologic findings, including comparisons to cases previously reported. RESULTS: Surgical decompression with incomplete resection of the lesion was performed, providing diagnosis and treatment guidance. The patient experienced significant neurologic improvement of myelopathy. CONCLUSIONS: Recognizing clinical and laboratory features of this disease may permit earlier diagnosis and limit or avoid surgical intervention in some cases.

Biomechanical analysis of thoracolumbar interbody constructs. How important is the endplate?

STUDY DESIGN: A biomechanical study of human cadaveric thoracic vertebral bodies was conducted using several anterior fusion options subjected to axial loads. This study emphasized the contribution of the endplate to resistance of graft subsidence. OBJECTIVES: To determine the importance of the vertebral endplate in resisting subsidence of various constructs into the vertebral body; the relative efficacy of potential alternative graft constructs such as iliac crest, ribs, humerus, and titanium mesh cage; and the importance of bone mineral content, vertebral level, and cross-sectional graft area on construct subsidence. SUMMARY OF BACKGROUND DATA: As the fixation length of anterior and posterior spinal constructs is reduced, load sharing of the anterior column has become more important to reduce failure of the shorter devices. Several alternative graft constructs and surgical techniques have been used for reconstruction of the anterior column. There exist little comparative data as to whether any of these constructs are superior and whether the vertebral endplate contributes significantly to the integrity of the construct. METHODS: Sixty-three isolated human cadaveric vertebral bodies from T3 to T12 were used to test seven different constructs in direct axial load onto prepared endplates with an electrohydraulic testing device. These constructs were: 1) titanium mesh cage (17 x 22 mm) on intact endplate, 2) C-shaped humerus on intact endplate, 3) tricorticated iliac graft in "tee configuration" on intact endplate, 4) tricorticated iliac graft in cancellous trough, 5) triple rib strut graft, 6) single rib on endplate, and 7) single rib on cancellous body. Dual X-ray absorptiometry assessment of bone mineral content was performed. A uniaxial load was applied with force and displacement data collected to determine maximal load to "failure" of the vertebral body. RESULTS: Preservation of vertebral endplate did not significantly increase the resistance to graft subsidence. The titanium cage construct provided the greatest resistance to axial load. CONCLUSIONS: Preservation of the vertebral endplate may not offer a significant biomechanical advantage in reconstructing the anterior column. Several alternative constructs are mechanically equivalent.