Presence Of Spinal Deformity Research Articles

Anesthetic management in orthopaedic surgery for rheumatic patients

Patients with rheumatic diseases frequently require orthopaedic surgeries due to progressive joint damage and deformities. These patients pose unique challenges for anesthesiologists due to systemic involvement, altered anatomy, and chronic pain management needs. This review explores optimal anesthetic strategies to improve surgical outcomes and enhance patient safety in this vulnerable population. Preoperative assessment is crucial for identifying systemic manifestations of rheumatic diseases, including cardiovascular, respiratory, and renal involvement, which can significantly impact anesthetic management. A thorough evaluation helps tailor the anesthetic plan to individual patient needs, ensuring better perioperative care.Regional anesthesia, particularly neuraxial blocks and peripheral nerve blocks, offers significant benefits over general anesthesia in this population. These techniques can reduce postoperative pain, enhance recovery times, and decrease opioid consumption. However, the presence of spinal deformities and anticoagulation therapy in these patients requires careful consideration and meticulous planning. Multimodal analgesia, combining regional techniques with systemic medications, is recommended to manage chronic pain and minimize opioid use postoperatively. Effective pain management strategies are essential for improving postoperative outcomes and patient satisfaction.

Effects of Spinal Deformities on Hiatal Hernia Occurrence and Recurrence

BackgroundSpinal deformities such as kyphosis, lordosis, and scoliosis have demonstrated a possible association between these deformities. Our hypothesis is that the presence of spinal deformities will increase the risk of hiatal hernia recurrence after repair. MethodsThe following data was retrospectively gleaned for patients undergoing hiatal hernia repair (1997–2022): age, sex, date of hiatal hernia repair, presence and type of spinal deformity, Cobb angle, type of hiatal hernia and size, type of hiatal hernia repair, recurrence and size, time to recurrence, reoperation, type of reoperation, and time to reoperation. ResultsSpinal deformities were present in 15.8% of 546 patients undergoing hiatal hernia repair, with a distribution of 21.8% kyphosis, 2.3% lordosis, 58.6% scoliosis, and 17.2% multiple. There was no difference in sex or age between groups. Spinal deformity patients were more likely to have types III and IV hiatal hernias (52.3% vs. 38.9%, p = 0.02) and larger hernias (median 5 [3-8] vs. 4 [2-6], p = 0.01). There was no difference in access, fundoplication use, or mesh use between groups. However, these patients had a higher recurrence rate (47.7% vs 30.0%, p = 0.001) and a shorter time to recurrence (months) (10.3 [5.6-25.1] vs 19.2 [9.8-51.0], p = 0.02). Cobb angle did not affect recurrence. ConclusionsSpinal deformity patients were more likely to have more complex and larger hiatal hernias. They were at higher risk of hiatal hernia recurrence after repair with shorter times to recurrence. This is a group that requires special attention with additional preoperative counseling and possibly use of surgical adjuncts in repair.

Mismatch between school furniture dimensions and anthropometric parameters is a risk for spinal deformities in secondary school students in Lagos, Nigeria: a cross-sectional study

BackgroundA mismatch between school furniture dimensions and anthropometric parameters has been well documented in adolescents, but there is a paucity of data on the impact of these mismatches on the students’ spinal health in Nigeria. This study therefore investigated the relationship of spinal deformities with selected anthropometric parameters and furniture dimensions of adolescents in secondary schools.MethodsThis study involved 540 apparently healthy students between the ages of 10 and 19 years from 9 public and private secondary schools in Lagos state, Nigeria. The furniture dimensions, anthropometric parameters, and spinal curvature disorders were evaluated using standard protocol. Data was analyzed using SPSS version 20.0 with a level of significance set at p < 0.05.ResultsTwo hundred two (37%) of the participants had abnormal spinal curvatures in varying types and degrees. There was a significant association at p ≤ 0.05 between the presence of spinal deformities and popliteal height to seat height mismatch (X2 = 175.67, p = 0.001), hip breadth to seat width mismatch (X2 = 293.14, p = 0.00), and shoulder height to backrest height mismatch (X2 = 788.16, p = 0.001).ConclusionAnthropometric parameters to furniture dimensions mismatch are significantly associated with the presence of spinal deformities among the students. The main cause of mismatch is using a homogeneous size of furniture for all students in addition to non-consideration of the students’ dimensions during furniture manufacturing.

Endoscopic Rhizotomy in Management of Facetogenic Chronic Lumbar Pain

Background Facet Arthritis causing Chronic Low Back Pain (CLBP) is an increasingly controversial field. The diagnosis of Facetogenic pain is still deemed difficult by many physicians, and its pathophysiology, as well as its management are still not quite understood. From the available literature, we can conclude that Lumbo-sacral Facet Arthritis is attributed to a degenerative process affecting the facet joint, which is described as the articulation between the superior articular process of one vertebrae and the inferior articular process of a vertebrae above. This degenerative process is commonly attributed to the „wear-and-tear' theory coming with age, highly comparative to the same degenerative process affecting any other joint. Aim of the Work to evaluate its effectiveness in controlling short term and long term pain caused by lumbar facet arthritis resulting in Chronic Low Back Pain (CLBP), and its effectiveness in decreasing disabilities caused by the debilitating symptoms of progressive arthritis in the lumbar facet joints. Patients and Methods was done to evaluate a novel technique, the Endoscopic Rhizotomy, as one of the minimally invasive procedures that is implemented in the management of Lumbar Facet Arthritis. All the available papers in literature describing this intervention from May 2000 to December 2020 were included. Results The initial search resulted in 468 articles from five databases including PubMed, Science Direct, Cochrane Library, Scopus, and Google Scholar. 16 studies are retrieved from additional databases. The total number before duplicates removal is 484 records. Conclusion that Endoscopic Rhizotomy is a very safe procedure, with a very low complication rate. We also concluded that Endoscopic Rhizotomy significantly relieves Facetogenic CLBP, with up to 3 years of pain relief. The procedure improved the subjective and objective quality of the patients. With comparison to the traditional Radiofrequency Ablation (RFA), Endoscopic Rhizotomy does not use radiation and allows direct visualization, in addition to being superior to RFA considering improving both pain and disability post-operative. It is considered a single day procedure, and the patient can return to work the 2nd day, fully-functioning. Without doubt, several factors, however, have to be taken into account when offering the patient such a procedure, as the presence of spinal deformities, instabilities, hypermobility, and the overall assessment of the patient‟s condition.

Association between spinal muscular atrophy type and delayed diagnosis and the risk of spinal deformity in Indonesian patients

BackgroundSpinal muscular atrophy (SMA) is a genetic disease that causes muscle weakness and atrophy. Delayed diagnosis can lead to loss of motoric functions, which may then progress to deformities such as thoracolumbar scoliosis, pelvic obliquity, and hip subluxation/dislocation. The lack of information or limited experience among healthcare providers and costly genetic tests can cause delayed diagnosis. The current study aimed to assess the characteristics of patients with SMA. Moreover, the association between SMA type and delayed diagnosis and the risk of spinal deformity in the Indonesian SMA Community was evaluated. MethodsThis was a cross-sectional study performed on 53 patients diagnosed with SMA. Data about patients’ characteristics were obtained from the Indonesian SMA Community using a questionnaire in August 2019. The information included age, sex, SMA type, age at suspicion and definite diagnosis of SMA, and presence of spinal deformities. Then, descriptive analysis and logistic regression analysis were performed, and the Kruskal–Wallis test and the Chi-square test were utilized.ResultsThe median age of patients suspected of SMA was 24 months. A definitive diagnosis of SMA was obtained at 36 months. Further, 43% of patients presented with SMA type 2 and 58% with spinal deformities. Results showed a positive correlation between time interval between suspicion and definite diagnosis of SMA and the risk of spinal deformities (B = 0,07; p > 0.05). Delayed diagnosis was more common in SMA type 3 than in SMA types 1 and 2, and SMA type 2 was correlated with a twofold risk of spinal deformities (p = 0.03; prevalence ratio = 2.09). ConclusionsSMA type 2 is associated with a twofold risk of spinal deformities. Delayed diagnosis is more common in SMA type 3 than in SMA types 1 and 2. Moreover, there was an association between the time interval between suspicion and definite diagnosis of SMA and the risk of spinal deformities in patients with SMA.

Treatment of spinal deformity with diastematomyelia type I: one-stage, two-stage surgery and new technique (vertebral column resection through wide bony septum).

Case series, literature review, and technical note. To compare two different approaches to treat the spinal deformity with split cord malformation type I (SCM I). To present a new method of one-stage surgical treatment of congenital spinal deformity with wide bony septum (SCM I). Analysis of the literature on the different types of combined surgical treatment of spinal deformities with SCM I was performed. We have provided our own data on 27 patients treated for congenital spinal deformity and SCM I, one of which underwent Schwab IV type osteotomy at the apex of the deformity through the bony septum and pedicles. Inclusion criteria were presence of spinal deformity in combination with SCM 1, performed surgery to correct spinal deformity, and follow-up period of at least 2years. The result of the literature review was controversial and requires additional research. The average age of patients was 8.8 ± 6.6years old. One-stage treatment of SCM I and spinal deformity was performed in 10 patients (group I) and two-stage in 14 patients (group II). Three patients with severe myelodysplasia, SCM I, and congenital kyphoscoliosis underwent correction of spinal deformity without SCM I removing (group III). The group I had the longest surgery duration (mean 289 ± 75min) and largest blood loss (mean 560 ± 386ml), a high percentage of deformity correction (mean 69.6%), and the highest rate of complications (60%). The most optimal was the two-stage treatment with the mean surgery duration 191 ± 137min, mean blood loss 339 ± 436ml, mean correction rate 63%, and frequency of complications 21%. The average follow-up time was 6.0 ± 2.6years. One stage surgery associated with a large surgical invasion and a large number of complications. It can be used in some cases, for example when the wide bony septum (SCM I) is localized at the apex of the congenital scoliosis or kyphosis. In all other cases, it is worth adhering to a two-stage treatment. Many new works demonstrate the relative safety and effectiveness of deformity correction without removing the SCM. In our opinion, indications for treatment of spinal deformity without SCM I removing can be the need to perform a shortening ostetomy outside the SCM zone. The remaining cases require a thorough assessment and a balanced decision.

Risk factors for worsening sexual function after lumbar spine surgery and characteristics of non-responders to the questionnaire of sex life.

To precisely assess the Oswestry Disability Questionnaire (ODQ) and its total score (Oswestry Disability Index: ODI) and reveal characteristics of non-responders of the 8th item of ODQ (ODI-8) relating to sexual function. Furthermore, we evaluated risk factors for aggravation of postoperative sexual function. We enrolled patients undergoing lumbar spine surgery at eight hospitals between April 2017 and November 2018. Patients' background data and operative factors were collected. We also assessed pain or dysesthesia (lower back, buttock, leg, and plantar area) on a numerical rating scale, EuroQol 5 Dimension, core outcome measures index back, and ODI before and 1year after surgery. Factor analysis was conducted for the ODQ. Non-responders of the ODI-8 were compared with full-responders using propensity score matching. Risk factors for worsening ODI-8 were evaluated by multivariate logistic regression analysis. Of the 2,610 patients enrolled, 601 (23.0%) answered all but the ODI-8 item; these patients were likely to show better preoperative clinical symptoms than full-responders, even after adjusting for age and gender using propensity scores. Age, spinal deformity, and the American Society of Anesthesiologists physical status (ASA-PS) 3/4 were significant risk factors for postoperative aggravation of the ODI-8. Factor analysis revealed that the ODQ was composed of dynamic and static activities; the ODI-8 was considered a dynamic activity. Almost a fourth of the patients skipped the ODI-8. Age, the presence of spinal deformity, and worse ASA-PS were found to be risk factors for postoperative aggravation of sexual function. Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

PROMIS is superior to established outcome measures in capturing disability resulting from sagittal malalignment in patients with back pain.

Patient reported outcomes measurement information system (PROMIS) is a quality of life metric that has gained increased popularity due to computer adaptive testing. Previous studies have shown that PROMIS correlates with Oswestry Disability Index (ODI) in patients with back pain and takes significantly less time to complete. However, the ability of PROMIS to capture disability from spinal malalignment relative to established metrics is unknown. The aim of the present study is to validate the correlation between ODI and PROMIS in patients with back pain, analyze correlations of PROMIS and legacy metrics to sagittal alignment, and identify major drivers of PROMIS scores and ODI in patients with back pain. A retrospective review was conducted of a prospectively collected outcome measures database (PROMIS, ODI, VAS Back, VAS Leg, VAS Neck, and VAS Arm) of spine patients > 18years. Inclusion criteria for the present study was a chief complaint of back pain and full length weight bearing X-rays within 30days of health related quality of life (HRQL) completion. Demographic information, radiographic alignment, psychiatric diagnoses, and comorbidities were recorded. PROMIS metrics were correlated to legacy metrics (ODI and VAS). Next, outcome metrics were correlated with sagittal alignment variables T1 Pelvic Angle (TPA), SVA, PT, and PI-LL. Patients were grouped based on the presence of spinal deformity (defined radiographically as any one of SVA > 4cm, PI-LL > 10°, PT > 20°) and mean HRQL scores were investigated for the adult spinal deformity (ASD) and non-ASD groups. Finally, drivers of PROMIS PF scores and ODI scores were determined using multiple stepwise regression. 150 patients met inclusion criteria including 60 patients with ASD and 90 patients without. For the whole cohort, PROMIS PF correlated with ODI (r = -0.651, p < 0.001), VAS Back (r = -0.260, p = 0.014) and Charleson Comorbidity Index (r = -0.336, p < 0.001). PROMIS PF had higher correlations than ODI for each sagittal alignment parameter tested, including TPA, SVA, PT, and PI-LL. When patients with ASD were compared to non-ASD patients, the PROMIS score was different between the groups but the ODI and VAS scores were not. Finally, stepwise linear regression showed that SVA, PI-LL, and VAS Leg were significant drivers of PROMIS PF (r2 = 0.406, p < 0.001). VAS Leg and VAS Back were significant contributors to ODI (r2 = 0.376, p < 0.001). In a cohort of 150 patients with back pain, PROMIS correlated strongly with legacy outcome metrics, including VAS and ODI. PROMIS PF correlated more strongly with sagittal malalignment than ODI. Additionally, patients with spinal deformity had significantly worse PROMIS PF scores but similar ODI scores as patients without ASD. Finally, sagittal alignment was found to be a significant driver of PROMIS PF scores but not ODI scores. PROMIS PF should be utilized as a disability assessment tool in patients with spinal deformity due to ease of use, strong correlations with legacy metrics, and ability to capture disability resulting from sagittal alignment.

In Patients with Early-Onset Scoliosis, Can Growing Rods Be Removed Without Further Instrumentation? An Evidenced-Based Review.

Early-onset scoliosis (EOS) is defined by the presence of spinal deformity in children 10years of age or younger. Left untreated, patients with EOS are at high risk for thoracic insufficiency and early demise. This article provides a critical review of a recent prospective cohort study of children with EOS: "Graduation Protocol After Growing-Rod Treatment: Removal of Implants without New Instrumentation Is Not a Realistic Approach," by Kocyigit and colleagues (J Bone Joint Surg Am. 2017;99(18):1554-1564). Treatment for EOS requires deformity correction while accommodating the growing spine. Dual growing rod implantation is a well-described technique that consists of the placement of two telescoping rods anchored to vertebrae proximal and distal to the apex of the curve. Multiple lengthening procedures are then performed as the child grows. Management of the endpoint of growing rod treatment remains controversial, with high complication rates associated with final fusion. As an alternative to final fusion or implant retention, Kocyigit and colleagues examined the removal of growing rods without spinal fusion and found that this procedure resulted in substantial worsening of the deformity in nine out of ten patients. This treatment group was terminated on ethical grounds. We believe this important result demonstrates that the removal of implants without fusion is an unacceptable treatment strategy that leads to poor outcomes.

A Preoperative Workup of a “Hip-Spine” Total Hip Arthroplasty Patient: A Simplified Approach to a Complex Problem

BackgroundA large body of evidence has confirmed that patients with spinal deformity, lumbar fusion, and abnormal spinopelvic mobility are at significantly increased risk for instability, dislocation, and revision after total hip arthroplasty (THA). MethodsAchieving a stable construct in patients with pre-existing spine disease requires an understanding of basic spinopelvic parameters and the compensatory mechanisms associated with abnormal spinopelvic motion. Indicated patients with concomitant hip-spine pathology should be assessed for (1) the presence of spinal deformity and (2) the presence of spinal stiffness before undergoing THA. Preoperative imaging should include a standing anteroposterior pelvis x-ray, as well as two lateral spinopelvic radiographs in the standing and seated position. ResultsBased on the presence of spinal deformity and/or spinal stiffness, patients may be categorized as one of the four groups of the “Hip-Spine Classification in THA.” A series of illustrative case examples is provided. ConclusionA simple three-step assessment with minimal measurements will effectively identify the complex “hip-spine” THA patient at high risk for postoperative instability. Adhering to group-specific recommendations for acetabular cup position can help to further reduce the burden of instability and related revisions in this challenging population.

Comparison of Structural Disease Burden to Health-related Quality of Life Scores in 264 Adult Spinal Deformity Patients With 2-Year Follow-up: Novel Insights into Drivers of Disability.

This is a review of a prospective multicenter database. To investigate the relationship between preoperative disability and sagittal deformity in patients with high Oswestry Disability Index (ODI) and no sagittal malalignment, or low ODI and high sagittal malalignment. The relationship between ODI and sagittal malalignment varies between each adult spinal deformity (ASD) patient. A prospective multicenter database of 365 patients with ASD undergoing surgical reconstruction was analyzed. Inclusion criteria entailed: age 18 years or above and the presence of spinal deformity as defined by a coronal Cobb angle≥20 degrees, sagittal vertical axis (SVA)≥5 cm, pelvic tilt (PT) angle≥25 degrees, or thoracic kyphosis≥60 degrees. Radiographic and health-related quality of life (HRQOL) variables were examined and compared, preoperatively and at 2-year postoperative follow-up. Group 1 (low disability high sagittal-LDHS) consisted of ODI<40 and SVA≥5 cm or PT≥25 degrees or pelvic incidence-lumbar lordosis≥11 degrees and group 2 (high disability low sagittal-HDLS) consisted of ODI>40 and SVA<5 cm and PT<25 degrees and pelvic incidence-lumbar lordosis<11 degrees. Of 264 patients with follow-up, 58 (22.0%) patients were included in LDHS and 30 (11.4%) were included in HDLS. Both groups had similar demographics and preoperative coronal angles. HDLS had worse baseline HRQOL for all measures (P<0.05) except leg and back pain. HDLS had a higher rate of self-reported leg weakness, arthritis, depression and neurological disorder. Both groups had similar 2-year improvements in HRQOL (P>0.05), except only HDLS had a significant Scoliosis Research Society Mental improvement and a significantly higher rate of reaching minimal clinically important differences in Scoliosis Research Society Mental scores (P<0.05). There is an association of worse baseline HRQOL measures, weakness, arthritis, and mental disease in HDLS. Furthermore, HDLS patients demonstrated similar improvements to LDHS. However, HDLS had greater improvements in the mental domains, perhaps indicating the responsiveness of the mental disability to surgical treatment. Level III.

Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction.

OBJECT Back and leg pain are the primary outcomes of adult spinal deformity (ASD) and predict patients' seeking of surgical management. The authors sought to characterize changes in back and leg pain after operative or nonoperative management of ASD. Outcomes were assessed according to pain severity, type of surgical procedure, Scoliosis Research Society (SRS)-Schwab spine deformity class, and patient satisfaction. METHODS This study retrospectively reviewed data in a prospective multicenter database of ASD patients. Inclusion criteria were the following: age > 18 years and presence of spinal deformity as defined by a scoliosis Cobb angle ≥ 20°, sagittal vertical axis length ≥ 5 cm, pelvic tilt angle ≥ 25°, or thoracic kyphosis angle ≥ 60°. Patients were grouped into nonoperated and operated subcohorts and by the type of surgical procedure, spine SRS-Schwab deformity class, preoperative pain severity, and patient satisfaction. Numerical rating scale (NRS) scores of back and leg pain, Oswestry Disability Index (ODI) scores, physical component summary (PCS) scores of the 36-Item Short Form Health Survey, minimum clinically important differences (MCIDs), and substantial clinical benefits (SCBs) were assessed. RESULTS Patients in whom ASD had been operatively managed were 6 times more likely to have an improvement in back pain and 3 times more likely to have an improvement in leg pain than patients in whom ASD had been nonoperatively managed. Patients whose ASD had been managed nonoperatively were more likely to have their back or leg pain remain the same or worsen. The incidence of postoperative leg pain was 37.0% at 6 weeks postoperatively and 33.3% at the 2-year follow-up (FU). At the 2-year FU, among patients with any preoperative back or leg pain, 24.3% and 37.8% were free of back and leg pain, respectively, and among patients with severe (NRS scores of 7-10) preoperative back or leg pain, 21.0% and 32.8% were free of back and leg pain, respectively. Decompression resulted in more patients having an improvement in leg pain and their pain scores reaching MCID. Although osteotomies improved back pain, they were associated with a higher incidence of leg pain. Patients whose spine had an SRS-Schwab coronal curve Type N deformity (sagittal malalignment only) were least likely to report improvements in back pain. Patients with a Type L deformity were most likely to report improved back or leg pain and to have reductions in pain severity scores reaching MCID and SCB. Patients with a Type D deformity were least likely to report improved leg pain and were more likely to experience a worsening of leg pain. Preoperative pain severity affected pain improvement over 2 years because patients who had higher preoperative pain severity experienced larger improvements, and their changes in pain severity were more likely to reach MCID/SCB than for those reporting lower preoperative pain. Reductions in back pain contributed to improvements in ODI and PCS scores and to patient satisfaction more than reductions in leg pain did. CONCLUSIONS The authors' results provide a valuable reference for counseling patients preoperatively about what improvements or worsening in back or leg pain they may experience after surgical intervention for ASD.

Lumbar pedicle screw placement: Using only AP plane imaging

Background:Variations in the pedicle morphology and presence of spinal deformities can make pedicle screw placement challenging. Recently, computerized tomography (CT) guided screw placement has reportedly improved the surgical accuracy of pedicle screw insertion. However, it is time consuming and expensive. We combined single-plane fluoroscopy in AP projection alone with tactile guidance for placing pedicle screws more efficiently and accurately. This report presents our results with this technique.Materials and Methods:An Institutional Review Board (IRB) approved retrospective study was carried out on 308 patients who underwent lumbar spinal fusion with 1806 pedicle screws placed using fluoroscopy only in the AP plane. There were 182 patients with two-level fusion, 79 with single-level fusion, 26 with three-level fusion, and 21 with more than three-level fusions. The indications of surgery included spondylolisthesis, adult scoliosis, revision surgery, lumbar canal stenosis, and discogenic pain. Pedicle screws were inserted under fluoroscopic guidance in the AP plane alone with a final lateral image after completion of implant placement. Radiographs were performed postoperatively in all patients and CT scans were obtained on 78 patients with 588 screws.Results:Twenty nine (5%) cortical wall perforations were noted amongst the 588 screws that were evaluated with a CT scan and did not result in postoperative vascular or neural complications. Anterior cortical vertebral violation was noted in 14 patients, while in 9 patients the screws penetrated the lateral wall of the pedicle. The medial wall of the pedicle was encroached in six patients with no frank perforations.Conclusion:Placement of pedicle screws under fluoroscopic guidance using AP plane imaging alone with tactile guidance is safe, fast, and reliable. However, a good understanding of the radiographic landmarks is a prerequisite.

Improved field trial methodology for quantifying vaccination side-effects in farmed Atlantic salmon ( Salmo salar L.)

A controlled field trial was conducted on a commercial Atlantic salmon farm employing an improved field trial methodology for quantifying the effects of vaccination on harvest weight. Vaccinated and unvaccinated passive integrated transponder (PIT) tagged fish were hosted in a commercial production from vaccination till harvest for individual fish data recording. A standardized harvest weight (SHW), based on the thermal growth coefficient (TGC) was utilised in order to handle sorting and differences in growth periods. Visual analog scales (VAS) were used to score vaccine-induced adhesions, melanin on abdominal organs and melanin on abdominal wall. Weight at vaccination, sex and presence of spinal deformity were recorded in order to control for potential biasing effects. The results were analyzed using a multiple linear regression model, with the individual fish as the statistical unit. It was shown that vaccination caused a 506 g (95% CI: 243, 768) reduction in SHW, male fish were 1211 g (95% CI: 950, 1473) heavier than females, each gram in vaccination weight gave 36.2 g (95% CI: 11.1, 61.2) extra at harvest and deformed fish were 1177 g (95% CI: 465, 1889) smaller than normal fish. None of the scoring variables for vaccine-induced lesions contributed with additional explanation of SHW when added to the final model, nor was weight at vaccination associated with the adhesion score. The biological cost of vaccination even in fish with mild abdominal lesions was the most striking finding of the study. The improved field trial methodology used, controlling for confounding and the use of individual fish data in multivariable models, will give both more accurate and valid estimates in quantifying the adverse effects of vaccination.

The Effect of Trunk-Flexed Postures on Balance and Metabolic Energy Expenditure During Standing

This study analyzed force plate, kinematic, and metabolic energy data of 14 able-bodied subjects standing statically with upright and trunk-flexed postures. To explore the effect of trunk-flexed postures on balance and metabolic energy expenditure during standing. Abnormal trunk posture often occurs in the presence of spinal deformities, such as lumbar flatback. It is unclear whether alterations in trunk posture affect energy expenditure and the location of the body's center of mass in the transverse plane (BCOMtrans) during standing. Kinematic, kinetic, and energy expenditure data were collected with upright trunk alignment and with 25 degrees +/- 7 degrees and 50 degrees +/- 7 degrees of trunk flexion from the vertical. The mean location of the BCOMtrans was estimated from the net center of pressure (COP), which is a weighted average of the COP beneath both feet. The fore-aft position of the net COP under the base of support was not significantly different between postures (P < 0.08). At each posture, the net COP was located 16% of the foot length anterior to the ankle joint centers. However, with increasing trunk flexion, there was a significant increase in oxygen consumption rate (P < 0.001 for all postures). Compensatory actions, such as ankle plantarflexion and hip flexion, allowed the mean position of the net COP to remain within a narrowly defined region irrespective of trunk posture. Changes in muscle activity associated with a trunk-flexed posture and the associated compensations likely contributed to the increased energy expenditure.

Prognostic factors in pediatric spinal cord astrocytoma.

Factors that could optimize the management of pediatric spinal cord astrocytoma remain unclear and controversial. To determine the factors that influence the prognosis of pediatric patients with spinal cord astrocytomas, a series of 73 consecutive patients at 13 French treatment centers with histologically proven spinal cord astrocytomas was retrospectively reviewed. Hospital records, operative records, and results of radiologic investigations were available in all cases. Follow-up was achieved in 94% of cases. Seventy percent of the patients had low grade (1 or 2) tumors. Total or subtotal surgical resection was achieved in 43%. Thirty-six patients were irradiated following surgery. Fifty-one patients were alive at a median follow-up of 54 months. Twenty-three patients relapsed. Univariate analysis showed that good outcome was correlated with male gender, age younger than 7 years, duration of presenting symptoms longer than 2 months, the presence of spinal deformities, and low grade histology, whereas sensory loss was associated with decreased survival. Multivariate analysis using the Cox proportional hazards model confirmed that histology (relative risk [RR] = 7.69) and the interval between first symptoms and diagnosis (RR = 4.93) were significant independent prognostic factors. The extent of surgery or radiotherapy had no clear influence on survival. This review sheds light on the prognoses of pediatric patients with spinal cord astrocytomas and may help to determine therapeutic strategies based on patients' clinical, radiologic, and pathologic features.

Duchenne pseudohypertrophic muscular dystrophy: a clinical and electrocardiographic study of patients and female carriers.

Summary: Clinical and electrocardiographic examinations were performed on 29 individuals with X-linked (Duchenne) pseudohypertrophic muscular dystrophy, three girls and one boy with “Duchennetype” muscular dystrophy and 19 female relatives of the X-linked Duchenne patients. These female relatives were divided into seven definite, two probable and 10 possible heterozygous carriers of the dystrophic gene. Myocardial dystrophic involvement was manifested by the presence of significant abnormalities in 69% of the electrocardiograms in the Duchenne dystrophic group of patients. There was, however, no correlation between the electrocardiographic appearances and the patient's degree of activity, age or severity of the disease process or the presence of spinal deformities. An abnormal electrocardiogram in this group did not appear to have any prognostic significance. The electrocardiograms in the four children with “Duchenne-type” muscular dystrophy were normal as were also all but one in the female carrier group, the only significant abnormality being minor non-specific S-T and T wave changes in the lateral precordial leads of one recording. None of the carriers demonstrated any muscle weakness. The significance of these findings is discussed especially in regard to potential dystrophic involvement in the heterozygous female carrier.