Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9 × 109 per liter, an erythrocyte sedimentation rate of 52mm/hour, and 10.88mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.
Complication; infection; injection; facet joint
Viral infection is the most common aggravating factor for childhood asthma. Asthma may be a risk factor for severe respiratory symptoms in children with lower respiratory tract infections of viral etiology. Influenza A infection enhances Th2-polarization to house dust mites during the acute phase and leads to lung dysfunction in a mouse model. However, there are no data on the relationship between atopic sensitization and H1N1 (Influenza A) infection in humans. To investigate whether atopic sensitization is associated with the severity of H1N1 pneumonia, we compared clinical features and the atopic sensitization rate between children with and without H1N1 infection.
Using reverse transcription-polymerase chain reactions, we investigated H1N1 virus infection in 214 children who were hospitalized with high fever and respiratory symptoms from September 2009 to February 2010. We also performed immunoassays for total and specific IgEs to six common aeroallergens. Atopy was defined as positivity for more than one specific IgE. The clinical severity of pneumonia was evaluated based on intensive care unit admission, oxygen therapy, steroid therapy, and atelectasis.
There were 70 H1N1-positive children, 42.9% of whom had pneumonia. Children with H1N1 infection were older and had a higher prevalence of atopic sensitization and pneumonia compared with H1N1-negative children. The rate of atelectasis was higher in children with H1N1 pneumonia than in children with non-H1N1 pneumonia. Among children with H1N1 viral infection, those with atopic sensitization had a higher prevalence of intensive care unit admission and oxygen therapy, and a longer duration of hospitalization than non-atopic children. There were no differences between atopic and non-atopic children without H1N1 viral infection.
The prevalence of H1N1-induced severe lower respiratory tract diseases is higher in children with atopic sensitization.
H1N1 virus; atopy; pneumonia; severity; children
Dramatic improvement of hemangioma to propranolol has been recently reported; however, details on dose and duration of treatment, potential risks, and monitoring have not been determined. The objective of this study is to describe and analyze the use of propranolol as a first-line treatment or as a single therapy in management of complicated hemangioma.
A retrospective chart review of eight patients diagnosed with hemangioma and treated with propranolol in Kangbuk Samsung Hospital from February 2010 to April 2011 was performed.
Eight patients with hemangioma with functional impairment, cosmetic disfigurement, or rapid growth were treated with propranolol. Five patients had solitary facial hemangioma. The mean age of symptoms at onset was 5 weeks. The median age for starting propranolol treatment was 5.5 months. Propranolol at 2 mg/kg/day was finally administered in divided doses with a gradual increase. Significant regression was observed in seven patients, and shrinkage in size, softening in consistency, and decrease in redness were evident within 4 weeks. Among them, six patients were still taking propranolol, and one patient had stopped after 12 months. Other one patient did not show significant improvement with satisfactory result after 3 months of propranolol use. Treatment with propranolol was well tolerated and had few side effects. No rebound growth was observed in any of the patients.
We observed that use of propranolol was very effective in treatment of hemangioma without obvious adverse effects or relapse.
Hemangioma; Propranolol; Treatment
Obesity is a risk factor for asthma and type II diabetes. Peroxisome proliferator-activated receptor (PPAR)-γ has been suggested to regulate inflammatory responses in diabetes and asthma. We investigated whether PPAR-α, PPAR-γ, adiponectin receptors (AdipoR1, AdipoR2), leptin, and tumor necrosis factor (TNF)-α are expressed in rat lung tissues and whether the expression differs between obese Otsuka Long-Evans Tokushima Fatty (OLETF) and lean Long Evans Tokushima Otsuka (LETO) rats.
Materials and Methods
Obese and lean rats were given with a high fat diet or a 30% restricted diet for 32 weeks, and their blood glucose levels and weights were monitored. After 32 weeks, mRNA levels of PPAR-α, PPAR-γ, AdipoR1, AdipoR2, leptin, and TNF-α in lung tissues were measured using real time PCR.
PPAR-α, PPAR-γ, AdipoR1, AdipoR2, leptin, and TNF-α were expressed in both obese and lean rat lung tissues. Increased serum glucose levels on intraperitoneal glucose tolerance testing and a higher weight gain at 32 weeks were observed in OLETF control rats compared to OLETF diet restricted rats. PPAR-γ expression was markedly elevated in obese control and diet restricted rats compared to lean rats, although PPAR-γ expression in obese rats was not affected by diet restriction. Leptin was highly expressed in OLETF rats compared to LETO rats. TNF-α expression was enhanced in OLETF control rats compared LETO diet restricted rats, and decreased by diet restriction. PPAR-α, AdipoR1, and AdipoR2 expression were not significantly different between obese and lean rats.
PPAR-γ was highly expressed in the lung tissues of obese rats and may be a novel treatment target for regulating lung inflammation associated with obesity.
Obesity; peroxisome proliferator activated receptor; adiponectin receptor; lung; leptin; TNF-alpha
The object of this study is to compare radiographic outcomes of anterior cervical decompression and fusion (ACDF) versus cervical disc replacement using the Bryan Cervical Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN) in terms of range of motion (ROM), Functional spinal unit (FSU), overall sagittal alignment (C2–C7), anterior intervertebral height (AIH), posterior intervertebral height (PIH) and radiographic changes at the implanted and adjacent levels. The study consisted of 105 patients. A total of 63 Bryan disc were placed in 51 patients. A single level procedure was performed in 39 patients and a two-level procedure in the other 12. Fifty-four patients underwent ACDF, 26 single level cases and 28 double level cases. The Bryan group had a mean follow-up 19 months (12–38). Mean follow-up for the ACDF group was 20 months (12–40 months). All patients were evaluated using static and dynamic cervical spine radiographs as well as MR imaging. All patients underwent anterior cervical discectomy followed by autogenous bone graft with plate (or implantation of a cage) or the Bryan artificial disc prosthesis. Clinical evaluation included the visual analogue scale (VAS), and neck disability index (NDI). Radiographic evaluation included static and dynamic flexion-extension radiographs using the computer software (Infinitt PiviewSTAR 5051) program. ROM, disc space angle, intervertebral height were measured at the operative site and adjacent levels. FSU and overall sagittal alignment (C2–C7) were also measured pre-operatively, postoperatively and at final follow-up. Radiological change was analyzed using χ2 test (95% confidence interval). Other data were analyzed using the mixed model (SAS enterprises guide 4.1 versions). There was clinical improvement within each group in terms of VAS and NDI scores from pre-op to final follow-up but not significantly between the two groups for both single (VAS p = 0.8371, NDI p = 0.2872) and double (VAS p = 0.2938, NDI p = 0.6753) level surgeries. Overall, ROM and intervertebral height was relatively well maintained during the follow-up in the Bryan group compared to ACDF. Regardless of the number of levels operated on, significant differences were noted for overall ROM of the cervical spine (p < 0.0001) and all other levels except at the upper adjacent level for single level surgeries (p = 0.2872). Statistically significant (p < 0.0001 and p = 0.0172) differences in the trend of intervertebral height measurements between the two groups were noted at all levels except for the AIH of single level surgeries at the upper (p = 0.1264) and lower (p = 0.7598) adjacent levels as well as PIH for double level surgeries at the upper (p = 0.8363) adjacent level. Radiological change was 3.5 times more observed for the ACDF group. Clinical status of both groups, regardless of the number of levels, showed improvement. Although clinical outcomes between the two groups were not significantly different at final follow-up, radiographic parameters, namely ROM and intervertebral heights at the operated site, some adjacent levels as well as FSU and overall sagittal alignment of the cervical spine were relatively well maintained in Bryan group compared to ACDF group. We surmise that to a certain degree, the maintenance of these parameters could contribute to reduce development of adjacent level change. Noteworthy is that radiographic change was 3.5 times more observed for ACDF surgeries. A longer period of evaluation is needed, to see if all these radiographic changes will translate to symptomatic adjacent level disease.
Bryan; Arthroplasty; Arthrodesis; Radiologic degenerative change; Adjacent level
The object of this study is to review the early clinical results and radiographic outcomes following insertion of the Bryan Cervical Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN), together with its effect on maintaining sagittal alignment of the functional spinal unit (FSU) and overall sagittal balance of the cervical spine for the treatment of single-level or two-level symptomatic disc disease. Forty-seven patients with symptomatic single or two-level cervical disc disease who received the Bryan Cervical Artificial Disc were reviewed prospectively. A total of 55 Bryan disc were placed in 47 patients. A single-level procedure was performed in 39 patients and a two-level procedure in the other eight. Radiographic and clinical assessments were made preoperatively and at 1.5, 3, 6, 9, 12, and 18 and up to 33 months postoperatively. Mean follow-up duration was 24 months, ranging from 13 to 33 months. Periods were categorized as early follow up (1.5–3 months) and late follow up (6–33 months). The visual analogue scale (VAS), neck disability index(NDI), Odom’s criteria were used to assess pain and clinical outcomes. Static and dynamic radiographs were measured by hand and computer to determine the range of motion (ROM), the angle of the functional segmental unit (FSU), and the overall cervical alignment (C2–7 Cobb angle). With all of these data, we evaluated the change of the preoperative lordosis (or kyphosis) of the FSU and Overall sagittal balance of the cervical spine during the follow-up period. There was a statistically significant improvement in the VAS score from 7.0 ± 2.6 to 2.0 ± 1.5 (paired-t test, P = 0.000), and in the NDI from 21.5 ± 5.5 to 4.5 ± 3.9 (paired-t test P = 0.000). All of the patients were satisfied with the surgical results by Odom’s criteria. The postoperative ROM of the implanted level was preserved without significant difference from preoperative ROM of the operated level. Only 36% of patients with a preoperative lordotic sagittal orientation of the FSU were able to maintain lordosis following surgery. However, the overall sagittal alignment of the cervical spine was preserved in 86% of cases at the final follow up. Interestingly, preoperatively kyphotic FSU resulted in lordotic FSU in 13% of patients during the late follow-up, and preoperatively kyphotic overall cervical alignment resulted in lordosis in 33% of the patients postoperatively. Clinical results are encouraging, with significant improvement seen in the Bryan Cervical Artificial disc. The Bryan disc preserves motion of the FSU. Although the preoperative lordosis (or kyphosis) of the FSU could not always be maintained during the follow-up period, the overall sagittal balance of the cervical spine was usually preserved.
Cervical arthroplasty; Artificial disc; Sagittal alignment; Kyphosis; Cervical spine
Airway smooth muscle (ASM) hyperplasia and angiogenesis are important features associated with airway remodeling. We investigated the effect of IL-4 and amphiregulin, an epidermal growth factor family member, on the proliferation of human ASM cells and on the release of vascular endothelial growth factor (VEGF) and monocyte chemotactic protein (MCP)-1 from human ASM cells. Human ASM cells were growth-arrested for 48 hr and incubated with platelet-derived growth factor (PDGF)-BB, interleukin (IL)-4, amphiregulin, and VEGF to evaluate cell proliferation. The cells were treated with PDGF, IL-4 and amphiregulin to evaluate the release of VEGF, MCP-1. IL-4 suppressed unstimulated and PDGF-stimulated ASM cell proliferation. Amphiregulin stimulated ASM cell proliferation in a dose-dependent manner. VEGF did not have any influence on ASM cell proliferation. IL-4 stimulated VEGF secretion by the ASM cells in a dose-dependent manner and showed added stimulatory effects when co-incubated with PDGF. Amphiregulin did not promote VEGF secretion. IL-4 and amphiregulin showed no stimulatory effects on MCP-1 secretion. The results of this study showed that IL-4 had bifunctional effects on airway remodeling, one was the suppression of the proliferation of the ASM cells and the other was the promotion of VEGF release by the ASM cells, and amphiregulin can promote human ASM cell proliferation.
Interleukin-4; Remodeling; Humans, Bronchi; Myocytes, Smooth Muscle; Cell Proliferation; Vascular Endothelial Growth Factor; Amphiregulin
Herniated nucleus pulposus fragments are recognized by the immune system as a foreign-body, which results in an autoimmune reaction. Human activation-inducible tumor necrosis factor receptor (AITR) and its ligand, AITRL, are important costimulatory molecules in the pathogenesis of autoimmune diseases. Despite the importance of these costimulatory molecules in autoimmune disease, their role in the autoimmune reaction to herniated disc fragments has yet to be explored. The purpose of the present study is to investigate whether the overexpression of AITR and AITRL might be associated with lumbar disc herniation.
Materials and Methods
The study population consisted of 20 symptomatic lumbar disc herniation patients. Ten macroscopically normal control discs were obtained from patients with spinal fractures managed with anterior procedures that involved a discectomy. Peripheral blood samples from both the study patients and controls were collected. The expression levels of AITR and AITRL were investigated by flow cytometric analysis, confocal laser scanning microscopy, immunohistochemistry and by reverse transcriptase-polymerase chain reaction (RT-PCR). The soluble AITR and AITRL serum levels were measured by an enzyme-linked immunosorbent assay.
Flow cytometric analysis revealed significantly higher levels of both AITR and AITRL in the lumbar disc herniation patients than in the controls. The AITRL expression levels were also increased in patients with lumbar disc herniation, shown by using confocal laser scanning microscopy, immunohistochemistry and RT-PCR. Finally, soluble AITR and AITRL were elevated in the patients with lumbar disc herniations.
The AITR and AITRL are increased in both the herniated disc tissue and the peripheral blood of patients with lumbar disc herniation.
Lumbar disc herniation; costimulatory molecule
Autologous transfusion has been used to overcome adverse effects of homologous transfusion. Clinical studies evaluating general orthopaedic postoperative results have been designed to compare these transfusion methods. However, few studies have evaluated postoperative results in spinal fusion surgeries, which have larger blood loss volumes. The purpose of this study is to determine if there are differences in postoperative infection and clinical results of spinal fusion with autologous, as compared to homologous, blood transfusion. A total of 62 patients who underwent instrumented spinal fusion and received autologous (n = 30) or homologous (n = 32) transfusions were reviewed. Information on gender, age, preoperative and 3-day postoperative hematologic features, total transfused units, segmental estimated blood loss, transfused units, and surgery time were collected. In addition, postoperative infection data on wound infection, pneumonia, urinary tract infection, cellulitis, and viral disease, incidence and duration of fever, as well as clinical results, fusion rates, and patient feedback were collected. No differences in postoperative infection and clinical results were found between the two types of transfusions; however, homologous transfusion was associated with an increased number of total units transfused, longer duration of fever, and decreased patient satisfaction regarding the transfusion.
Spinal fusion; autologous transfusion
This study investigated the serum vascular endothelial growth factor (VEGF) levels in children with community-acquired pneumonia. Serum VEGF levels were measured in patients with pneumonia (n=29) and in control subjects (n=27) by a sandwich enzyme-linked immunosorbent assay. The pneumonia group was classified into bronchopneumonia with pleural effusion (n=1), bronchopneumonia without pleural effusion (n=15), lobar pneumonia with pleural effusion (n=4), and lobar pneumonia without pleural effusion (n=9) groups based on the findings of chest radiographs. We also measured serum IL-6 levels and the other acute inflammatory parameters. Serum levels of VEGF in children with pneumonia were significantly higher than those in control subjects (p<0.01). Children with lobar pneumonia with or without effusion showed significantly higher levels of serum VEGF than children with bronchopneumonia. For lobar pneumonia, children with pleural effusion showed higher levels of VEGF than those without pleural effusion. Children with a positive urinary S. pneumonia antigen test also showed higher levels of VEGF than those with a negative result. Serum IL-6 levels did not show significant differences between children with pneumonia and control subjects. Serum levels of VEGF showed a positive correlation with the erythrocyte sedimentation rate in the children with pneumonia. In conclusion, VEGF may be one of the key mediators that lead to lobar pneumonia and parapneumonic effusion.
Vascular Endothelial Growth Factor A; Interleukin-6; Pleural Effusion; Community-Acquired Infections; Pneumonia
The mutation of the PKD1 gene causes autosomal dominant polycystic kidney disease (ADPKD), and the PKD1 gene encodes polycystin-1 (PC-1). PC-1 is thought to be a cell-cell/matrix adhesion receptor molecule at the cell surface that is widely expressed in the kidney. However, there are controversies about the role of PC-1 protein and its expression when using different antibodies to detect it. We used two PC-1 antibodies; C-20 (Santa Cruz, sc-10372) as the C-terminal antibody, and P-15 (Santa Cruz, sc-10307) as the N-terminal antibody. We evaluated the PC-1 expression by performing immunoblotting on the human embryonic kidney (HEK) 293 cells and the renal proximal tubular epithelial cell (RPTEC) lysates. We characterized the expression of PC-1 in the fetal, adult and polycystic kidneys tissues by performing immunohistochemistry. We confirmed the PC-1 expression in the HEK 293 cells and the RPTEC lysates, but the expression was very low. The PC-1 proteins were diffusely expressed in the tubular epithelial cells cytoplasm in the fetal and adult kidneys, and the PC-1 expression was more prominent in the proximal tubules of the fetal kidney. In the ADPKD kidney, the PC-1 proteins were heterogenously and weakly expressed in the tubular or cyst lining epithelial cells. Our data suggests that the development of the kidney may regulate the expression of PC-1, and an altered PC-1 expression may contribute to cyst formation in ADPKD.
Polycystic Kidney Diseases; Polycystin-1; Polycystic kidney disease 1 protein
Chronic lower back pain is one of the most common musculoskeletal problems; it is also the most expensive industrial injury. Not surprisingly, many treatments have been developed to combat this expensive and debilitating condition. One of these, intradiscal electrothermal treatment (IDET), was developed for patients with chronic discogenic lower back pain who failed to improve with any of the wide variety of non-surgical treatments. The present study sought to evaluate the efficacy of IDET for patients with chronic lower back pain. Twenty-five patients were enrolled in this prospective study; the patients received IDET between June 2001 and June 2003. MRI was used to confirm the diagnosis of internal disc disruption in all patients. The patients then underwent a pre-operative provocative test and discography. The follow-up duration was at least 1 year in all cases, and the visual analogue scale, recovery rate, and satisfaction of each patient were evaluated. The average age of the patients was 32 years (age range 18 to 49 years), and the patient group was 33% male and 67% female. Of the 25 patients, 5 underwent lumbar fusion surgery within 1 year of IDET. After IDET, 8 patients (32%) reported more pain than before, 14 patients (56%) reported less pain, and 3 patients (12%) experienced no change. Twelve patients (48%) were satisfied with IDET, 11 (44%) were dissatisfied, and 2 (8%) were undecided about the treatment. At least 1 year after IDET, nearly half the study patients were dissatisfied with their medical outcome. Consequently, 5 patients (20%) underwent fusion surgery at 1 year after IDET. Although other studies have shown good results with IDET for at least 2 years, this investigation suggests the IDET may be somewhat less effective. In order to firmly establish the efficacy of IDET for treating chronic discogenic lower back pain, additional studies with larger numbers of patients evaluated over longer time periods are recommended.
Intradiscal electrothermal treatment (IDET); internal disc disruption; back pain
Lumbar spinal fusions have been performed for spinal stability, pain relief and improved function in spinal stenosis, scoliosis, spinal fractures, infectious conditions and other lumbar spinal problems. The success of lumbar spinal fusion depends on multifactors, such as types of bone graft materials, levels and numbers of fusion, spinal instrumentation, electrical stimulation, smoking and some drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2001, 88 consecutive patients, who were diagnosed with spinal stenosis or spondylolisthesis, were retrospectively enrolled in this study. One surgeon performed all 88 posterolateral spinal fusions with instrumentation and autoiliac bone graft. The patients were divided into two groups. The first group (n=30) was infused with ketorolac and fentanyl intravenously via patient controlled analgesia (PCA) postoperatively and the second group (n=58) was infused only with fentanyl. The spinal fusion rates and clinical outcomes of the two groups were compared. The incidence of incomplete union or nonunion was much higher in the ketorolac group, and the relative risk was approximately 6 times higher than control group (odds ratio: 5.64). The clinical outcomes, which were checked at least 1 year after surgery, showed strong correlations with the spinal fusion status. The control group (93.1%) showed significantly better clinical results than the ketorolac group (77.6%). Smoking had no effect on the spinal fusion outcome in this study. Even though the use of ketorolac after spinal fusion can reduce the need for morphine, thereby decreasing morphine related complications, ketorolac used via PCA at the immediate postoperative state inhibits spinal fusion resulting in a poorer clinical outcome. Therefore, NSAIDs such as ketorolac, should be avoided after posterolateral spinal fusion.
Lumbar spine; spinal fusion; ketorolac