Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection

Item does not contain fulltextBACKGROUND CONTEXT: Spinal fusion is a common but controversial treatment for chronic low back pain (LBP) with outcomes similar to those of programmed conservative care. To improve the results of fusion, tests for patient selection are used in clinical practice. PURPOSE: To determine the prognostic accuracy of tests for patient selection that are currently used in clinical practice to identify those patients with chronic LBP who will benefit from spinal fusion. STUDY DESIGN: Systematic review of the literature. SAMPLE: Studies that compared the results of magnetic resonance imaging (MRI), provocative discography, facet joint blocks, orthosis immobilization, and temporary external fixation with the clinical outcome of patients who underwent spinal fusion for chronic LBP. OUTCOME MEASURES: To determine the prognostic accuracy of tests to predict the clinical outcome of spinal fusion in terms of sensitivity, specificity, and likelihood ratios (LRs). METHODS: Data sources PubMed (1966 to November 2010), EMBASE (1974 to November 2010), and reference lists were searched without restriction by language or publication status. Two reviewers independently selected studies for inclusion, extracted data for analysis, and assessed the risk of bias with the Quality Assessment of Diagnostic Accuracy Studies checklist, modified for prognostic studies. Discrepancies were resolved by consensus. RESULTS: Ten studies met the eligibility criteria. Immobilization by an orthosis (median [range] positive LR, 1.10 [0.94-1.13] and negative LR, 0.92 [0.39-1.12]), provocative discography (median [range] positive LR, 1.18 [0.70-1.71] and negative LR, 0.74 [0.24-1.40]), and temporary external fixation (median [range] positive LR, 1.22 [1.02-1.74] and negative LR, 0.58 [0.15-0.94]) failed to show clinically useful prognostic accuracy. Statistical pooling was not feasible because of different test protocols, variability in outcome assessment, and heterogeneous patient populations. No studies reporting on facet joint blocks or MRI could satisfy the inclusion criteria. Obscure patient selection, high risk of verification bias, and outcome assessment with poorly validated instruments precluded strong conclusions for all tests. CONCLUSIONS: No subset of patients with chronic LBP could be identified for whom spinal fusion is a predictable and effective treatment. Best evidence does not support the use of current tests for patient selection in clinical practice

Random effect modelling of patient-related risk factors in orthopaedic procedures: results from the Dutch nosocomial infection surveillance network 'PREZIES'.

Item does not contain fulltextIn the Dutch surveillance for surgical site infections (SSIs), data from 70277 orthopaedic procedures with 1895 SSIs were collected between 1996 and 2003. The aims of this study were: (1) to analyse the trends in SSIs associated with Gram-positive and Gram-negative bacteria; (2) to estimate patient-related risk factors for deep and superficial SSIs after all orthopaedic procedures, with special attention to primary total hip arthroplasty (THA); and (3) to analyse inherent differences in infection risk between hospitals. A random effect model was used to estimate the odds ratios of patient-related risk factors for developing an SSI, and to describe the distribution of the most widespread bacterial species responsible for SSIs among hospitals. Gram-positive organisms, mainly staphylococci, were the main cause of both deep (84.0%) and superficial SSIs (69.1%) after orthopaedic procedures. The percentage of SSIs after THA caused by coagulase-negative staphylococci decreased over the surveillance period, while the contribution of Staphylococcus aureus increased. Temporary elevations in the incidence of the most widespread pathogen species were observed within hospitals. Patient-related factors such as the National Nosocomial Infections Surveillance System risk index or age had little effect on the predictive power of the random effect models. This study underlines the usefulness of a random effect model, which adjusts risk estimates for random variation between hospitals, in a multicentre study on risk factors for SSIs

A comparison of hallux valgus angles assessed with computerised plantar pressure measurements, clinical examination and radiography in patients with diabetes

Background Hallux valgus deformity is a common musculoskeletal foot disorder with a prevalence of 3.5% in adolescents to 35.7% in adults aged over 65 years. Radiographic measurements of hallux valgus angles (HVA) are considered to be the most reproducible and accurate assessment of HVA. However, in European countries, many podiatrists do not have direct access to radiographic facilities. Therefore, alternative measurements are desired. Such measurements are computerised plantar pressure measurement and clinical goniometry. The purpose of this study was to establish the agreement of these techniques and radiographic assessments. Methods HVA was determined in one hundred and eighty six participants suffering from diabetes. Radiographic measurements of HVA were performed with standardised static weight bearing dorsoplantar foot radiographs. The clinical goniometry for HVA was measured with a universal goniometer. Computerised plantar pressure measurement for HVA was executed with the EMED SF-4® pressure platform and Novel-Ortho-Geometry software. The intra-class correlation coefficients (ICC) and levels of agreement were analysed using Bland & Altman plots. Results Comparison of radiographic measurements to clinical goniometry for HVA showed an intraclass correlation coefficient (ICC) of 0.81 (95% confidence interval, 0.76 to 0.86; p<0.001). Radiographic measurement versus computerised plantar pressure measurement showed an ICC of 0.59 (95% confidence interval, 0.49 to 0.68; p<0.001). In addition, clinical goniometry versus computerised plantar pressure measurement showed an ICC of 0.77 (95% confidence interval, 0.70 to 0.82; p<0.001). The systematic difference of the computerised plantar pressure measurement compared with radiographic measurement and clinical goniometry was 7.0 degrees (SD 6.8) and 5.2 degrees (SD 5.0), respectively. The systemic difference of radiographic measurements compared with clinical goniometry was 1.8 degrees (SD 5.0). Conclusions The agreement of computerised plantar pressure measurement and clinical goniometry for HVA compared to radiographic measurement of HVA is unsatisfactory. Radiographic measurements of HVA and clinical goniometry for HVA yield better agreement compared to radiographic measurements and computerised plantar pressure measurement. The traditional radiographic measurement techniques are strongly recommended for the assessment of HVAMan-machine InteractionElectrical Engineering, Mathematics and Computer Scienc

The role of chemokines in lymphocyte infiltration in ovarian cancer: from MRNA microarray to tissue microarray

Introduction: High numbers of CD8+ cytotoxic T lymphocytes (CTL) are associated with a survival advantage in ovarian cancer. Chemokines may play a role in T lymphocyte recruitment to the tumor, but they are also linked to metastasis and angiogenesis. Aim: To determine to what extent chemokines are involved in lymphocyte infiltration of ovarian cancer. Methods: We used microarray technology to rank chemokines based on their differential expression levels between tumors with many and few tumor infiltrating CTL. Next, we further investigated these results using immunohistochemistry and cytokine bead arrays. Results: Six chemokines and chemokine receptors were differentially expressed between 24 CTL high and 35 CTL low tumors. Based on these data and previous literature, we selected CXCL9, CXCL10, CXCL6 and CXCR6 for further validation. Stainings for these chemokines were performed on 254 tumor samples using tissue microarrays. There were no associations between chemokine (receptor) staining intensity and CTL infiltration. However, for CXCL10, high expression was associated with high stage, serous tumors, and >2 cm residual tumor after surgery. In univariate survival analysis, CXCL10 was associated with a worse prognosis. Next, we analyzed soluble CXCL10 at the serum level. For 98 patients, both tissue and serum were available. There were no associations between CXCL10 staining and serum concentrations. However, we found a positive correlation between CXCL10 in serum and CTL infiltration in the tumor. Conclusion: After validation of microarray results, we found a very limited role for chemokines in lymphocyte migration. However, CXCL10 is implicated in more aggressive tumor behavior