University Times

Monitoring method can make certain delicate operations safer

Spine surgeons at the UPMC Health System reported in September's Journal of Neurosurgery that a unique monitoring system used during certain delicate spine surgeries can be an added safeguard against bone and nerve injury.

Some patients with lumbar spinal instability undergo a surgical procedure called lumbar spinal fusion, in which vertebrae in the lower back are fused together with bone screws. The bony structure projecting around each vertebra is called the pedicle and in between are delicate nerves. The proximity of this delicate nerve tissue allows little room for surgical error during the fusion and pedicle bone screw insertion.

"It is not surprising that nerve root injury occurs in as many as 15 percent of these types of operations," said William C. Welch, Pitt assistant professor of neurosurgery, co-director of the UPMC Health System's Comprehensive Spine Center, and study investigator.

"We evaluated a technique that uses continuous stimulation through an electrified pedicle probe and feeler designed to provide immediate sound feedback of nerve activity during preparation of the pedicle entry site and insertion of the implant screws," Welch said. "This serves as an early warning system, alerting the surgeon if re-direction of the pedicle probe or screw is necessary to avoid nerve root irritation or injury." The current, commonly used monitoring techniques detect nerve and bone injury after the pedicle screws have already been placed in the bone. "This monitoring is helpful," Welch said, "but it may not detect subtle compromises in nerve root function and it does not preclude the possibility of creating nerve root damage during probing or tapping of the pedicle or placement of the screw."

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Education, exercise, low-fat diet can reduce excessive weight gain in pregnant women

Women who are of normal weight before pregnancy can significantly reduce their chances of gaining too much weight during pregnancy through a program of education, moderate exercise and low-fat eating, say researchers at the Western Psychiatric Institute and Clinic (WPIC).

Pregnancy increases a woman's risk of becoming overweight by 60 percent. Women who gain more than the recommended amount of weight during their pregnancies retain twice as much weight after pregnancy as women who gain within the guidelines.

According to the Institute of Medicine, women of normal weight should gain 25 to 35 pounds during pregnancy, and overweight women should gain no more than 15 to 25 pounds. Yet, one-third to one-half of normal-weight women and nearly two-thirds of overweight women gain more than the institute recommends.

"The strongest predictor of postpartum weight retention is the amount of weight gained during pregnancy," said Betsy A. Polley of WPIC's Behavioral Weight Loss Program. "In fact, weight gain at 12 weeks gestation can closely predict total weight gain. Because of this, we can identify women who are on their way to gaining too much weight and counsel them about proper diet and exercise." The WPIC researchers are the first to test whether a program of education, exercise and low-fat eating works to reduce excessive weight gain in healthy pregnant women. Previous research has focused on women who don't gain enough weight. According to Polley, many women aren't given guidelines for proper weight gain during their pregnancies. "Many times, doctors tell women that they'll naturally gain the right amount of weight," she said. "This could be one of the reasons why so many women gain more weight during pregnancy than they should." Even moderate obesity is associated with hypertension, diabetes, stroke and heart disease, Polley noted. "In the United States, 35 percent of women are overweight. Since long-term weight loss is difficult to achieve, we need to focus more on ways to prevent obesity," she said.

During the WPIC study, a program developed by Polley, psychiatry professor Rena Wing and Cynthia Sims of Magee-Womens Hospital helped two-thirds of normal-weight women stay within Institute of Medicine boundaries. In the group where there was no intervention, 58 percent of the normal-weight women gained too much.

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Uninsured kids more likely to be referred to public vaccine clinics

In the health care marketplace, it is no surprise that economics plays a major role in a physician's decision whether to refer a child.

A study by Pitt researchers published in the Sept. 24 Journal of the American Medical Association has found that primary care providers are more likely to refer uninsured children to low- or no-cost clinics, also called public vaccine clinics, for necessary immunizations.

"However, we found that providing free vaccines to physicians may encourage them to vaccinate children in their practice as opposed to referring these children to public vaccine clinics," said Richard Kent Zimmerman, lead author and assistant professor of family medicine and epidemiology in Pitt's School of Medicine.

"This is an important finding because if we eliminate the economic impediments of vaccinating an uninsured child by offering free vaccines to physicians, the patient's continuum of care is preserved.

"Typically, referrals are made by primary care providers for complicated procedures that require the skill and knowledge of a specialist. Any practitioner is capable of giving a shot or giving a pill. We have shown that economics is a primary factor in referring a child to a public vaccine clinic," Zimmerman said.

More than half of the 1,236 physicians interviewed by Pitt researchers reported they would refer a child to a low- or no-cost clinic to receive necessary vaccinations if the child did not have insurance or had an insurance plan that did not cover vaccination costs. "When physicians refer a child to a public vaccine clinic they are helping children receive the necessary medical care while realistically addressing cost issues for the patients and their families," Zimmerman said. "But when a child is referred to a low- or no-cost clinic, often the medical records are not transferred and the clinician administering the vaccine is not aware of the child's entire medical history." Referrals also place an added burden on the children's parents and probably prevent or delay many from scheduling appointments, Zimmerman cautioned. More than 30,000 adults and children in the United States die each year from diseases that are preventable by vaccines.