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Chymopapain
Abstract
To the Editor.—
A Diagnostic and Therapeutic Technology Assessment (DATTA) report, published in JAMA, August 18, 1989,1 concluded that chemonucleolysis was neither safe nor effective. This conclusion was based on certain inaccuracies and significant omissions.The DATTA statement notes that, "Chemonucleolysis is not safe if there is nuclear material extruding from the disk." However, animal studies have demonstrated that epidural chymopapain is not harmful at doses of up to 100 times the therapeutic level. Experience in humans verifies this fact.2-5Though the DATTA statement maintains that "current imaging techniques are not infallible and cannot differentiate a protrusion from an extrusion," I believe that the newer magnetic resonance imaging equipment is able to differentiate these diagnoses, as are discograms.The DATTA report states, "Even small intrathecal leaks of chymopapain have a potential for damage to the central nervous system." Chymopapain will cause bleeding from the capillaries of the pia-arachnoid
Percutaneous, minimally invasive, transforaminal endoscopic spine surgery can address various pathologies, including degenerative disc disease, while incurring the least amount of damage to soft tissues and bony structures that contribute to biomechanical stability of the spine. Patients undergoing this procedure require only conscious sedation and are able to provide the surgeon with accurate and instantaneous feedback regarding their radicular symptoms. They are able to ambulate immediately postoperatively and do not require hospitalization. The development of techniques and advances in equipment design has allowed surgeons to apply this procedure to multiple indications.
Eleven children with acute encephalopathy associated with an influenza virus infection were treated during the 1997–1998 influenza season. Reverse transcription-polymerase chain reaction (RT-PCR) assay was used to detect the viral genome in peripheral blood and cerebrospinal fluid (CSF) samples. The results were compared with those of control influenza patients without neurological complications. Viral RNA was detected only in the peripheral blood mononuclear cells of one patient with influenza-virus-associated encephalopathy (1 of 9; 11%) and in the CSF of another patient (1 of 11; 9%). RT-PCR was negative in the blood of all the controls, but the percentage of RT-PCR-positive samples in the two groups was not significantly different. Cytokines and soluble cytokine receptors in plasma and CSF were then quantified using an enzyme-linked immunosorbent assay. The CSF concentrations of soluble tumor necrosis factor receptor-1 were elevated in two patients and interleukin-6 (IL-6) was elevated in one patient with influenza-virus-associated encephalopathy. On the other hand, the plasma concentrations of IL-6 were elevated in four of nine patients. The number of encephalopathy patients who had elevated plasma concentrations of IL-6 100 pg/ml was significantly higher than that of controls (P = .01). In conclusion, the infrequent detection of the viral genome in the CSF and blood showed that direct invasion of the virus into the central nervous system was an uncommon event. Proinflammatory cytokines and soluble cytokine receptors may mediate the disease. The high plasma concentration of IL-6 could be an indicator of the progression to encephalopathy. J. Med. Virol. 58:420–425, 1999. © 1999 Wiley-Liss, Inc.
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