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Background Historically, the incidence of cardiovascular disease and mortality in persons with Type I diabetes (TID) has been increased compared to the general population. Contemporary studies on time trends of mortality and cardiovascular disease are sparse. Methods In this observational study, TID persons were identified in the Swedish National Diabetes Registry (n=45,575) and compared with matched controls from the general population (n=220,141). Incidence rates from 2002 to 2019 were estimated with respect to mortality and cardiovascular disease in persons with TID overall and when stratified for prevalent cardiovascular and renal disease relative to controls. Findings Mean age in persons with TID was 32.4 years and 44.9% (20,446/45,575) were women. Age- and sex-adjusted mortality rates declined over time in both groups but remained significantly higher in those with TID compared to controls during 2017-2019, 7.62 (95% CI 7.16; 8.08) vs. 2.23 (95% CI 2.13; 2.33) deaths per 1,000 person years. Myocardial infarction, heart failure and stroke decreased over time in both groups, with persistent excess risks in the range of 3.4 -5.0 times from 2017 to 2019 in those with TID. TID persons >= 45 years without previous renal or cardiovascular complications had standardized mortality rates similar or even lower than controls 5.55 (4.51; 6.60) vs.7.08 (6.75; 7.40) respectively in the last time period. Interpretation Excess mortality persisted over time in persons with TID, largely in patients with cardiorenal complications. Improved secondary prevention with a focus on individualized treatment is needed to dose the gap in mortality for individuals with TID. Copyright (C) 2022 The Authors. Published by Elsevier Ltd. Funding Agencies|ALF-agreement; Novo Nordisk Foundation; Swedish Heart and Lung Foundation

ObjectiveThe aim of the study was to investigate all-cause and disease-specific mortality in a large population-based cohort of oral glucocorticoid (GC) users.MethodsThis was a retrospective, matched cohort study. Information on dispensed prescriptions was obtained from the Swedish Prescribed Drug Register. The cause of death was obtained from the Swedish Cause-of-Death Registry. Patients receiving prednisolone ≥5 mg/day (or equivalent dose of other GC) for ≥21 days between 2007-2014 were included. For each patient, one control subject matched for age and sex was included. The study period was divided into 3-month periods and patients were divided into groups according to a defined daily dose (DDD) of GC used per day. The groups were: Non-users (0 DDD per day), low-dose users (>0 but 1.5 DDD per day). Hazard ratios (HRs), unadjusted and adjusted for age, sex and comorbidities, were calculated using a time-dependent Cox proportional hazard model.ResultsCases (n=223 211) had significantly higher all-cause mortality compared to controls (HR adjusted for age, sex and comorbidities 2.08, 95% confidence interval 2.04 to 2.13). After dividing the cases into subgroups, adjusted HR was 1.31 (1.28 to 1.34) in non-users, 3.64 (3.51 to 3.77) in low-dose users, 5.43 (5.27 to 5.60) in medium-dose users and, 5.12 (4.84 to 5.42) in high-dose users. The highest adjusted hazard ratio was observed in high-dose users for deaths from sepsis 6.71 (5.12 to 8.81) and pulmonary embolism 7.83 (5.71 to 10.74).ConclusionOral GC users have an increased mortality rate compared to the background population, even after adjustment for comorbidities. High-dose users have an increased risk of dying from sepsis, and pulmonary embolism compared to controls. Whether the relationship between GC exposure and the excess mortality is causal remains to be elucidated.

Background: Historically, life expectancy in persons with type 1 diabetes (T1D) has been shorter than the general population, but earlier studies did not stratify patients according to cardiorenal complications. Methods: T1D persons were identified in the Swedish National Diabetes Registry (n=45,575) and compared with matched controls from the general population (n=220,141) . Mortality rates from 2002 to 20were estimated in persons with T1D overall and after stratification for prevalent cardiovascular and renal disease. Results: In persons with T1D, mean age was 32.4 years and 44.9% were women. Age- and sex- adjusted mortality rates decreased over time in both groups but remained significantly higher in those with T1D during 2017 to 2019. In T1D persons ≥45 years without previous renal or cardiovascular complications (approximately 50% of persons in this age group) similar standardized mortality rates were observed, over time compared with controls, with slightly lower mortality in T1D persons during the last period, 5.55 (95% CI 4.51-6.60) vs. 7. (95% CI 6.75-7.40) deaths per 1,000 person years (Figure) . Conclusion: Excess mortality persisted over time in persons with T1D, largely in patients with cardiorenal complications. Improved secondary prevention with a focus on differentiated treatment is needed to close the gap in mortality for persons with T1D. Disclosure S. Hallström: None. M.O. Wijkman: None. J. Ludvigsson: Advisory Panel; Dompé. Research Support; Diamyd Medical. M.A. Pfeffer: Consultant; AstraZeneca, Boehringer Ingelheim and Eli Lilly Alliance, Corvidia Therapeutics, GlaxoSmithKline plc., Lexicon Pharmaceuticals, Inc., Novartis Pharmaceuticals Corporation, Novo Nordisk, Peerbridge, Sanofi. Research Support; Novartis Pharmaceuticals Corporation. Other Relationship; DalCor Pharmaceuticals, National Heart, Lung, and Blood Institute. A. Rosengren: None. M. Lind: Consultant; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk. Research Support; Eli Lilly and Company, Novo Nordisk. Funding ALF [ALFGBG-717211] and [ALFGBG-966173], grants from the Novo Nordisk foundation, Swedish Heart and Lung Foundation [20180589], [20210679], Swedish Research Council [2018-02527] [VRREG 2019-00193], and the Gothenburg Society of Medicine.

Trauma and Collective Memories in Georgia’s Foreign PolicyGeorgia’s foreign policy since the mid-1990s would appear to be a regional anomaly. While Georgia’s neighbors have either accommodated to Russia’s geopolitical interests or sought to navigate between Russia and the West, Georgian governments have pursued a comparatively stable pro-Western foreign policy orientation. Thus, structural arguments like geographic proximity, or Russia’s assertive foreign policy, cannot account for the variation in foreign-policy orientation among post-Soviet states. Moreover, although alternative explanations, like Georgia’s European identity and commitment to democracy, or explanations related to qualities of the Mikheil Saakashvili government, are not without merits, they cannot fully account for the continuity in Georgia’s pro-Western foreign policy over time. This article argues that the collective memory of the traumatic years 1989–1994 is a key factor for understanding Georgia’s foreign policy continuity. The collective memory and trauma related to loss of territory, together with a weak state and Russia’s negative involvement, have shaped the strategic thinking of Georgia’s foreign policy elites. This trauma explains Georgia’s shift to a pro-Western foreign policy in the mid-1990s and the continuity of this policy up until today. This argument is supported by the author’s interviews with key Georgian decision-makers responsible for foreign policy decisions.

Aims Chronic low back pain due to degenerative disc disease is sometimes treated with fusion. We compared the outcome of three different fusion techniques in the Swedish Spine Register: noninstrumented posterolateral fusion (PLF), instrumented posterolateral fusion (IPLF), and interbody fusion (IBF). Patients and Methods A total of 2874 patients who were operated on at one or two lumbar levels were followed for a mean of 9.2 years (3.6 to 19.1) for any additional lumbar spine surgery. Patient-reported outcome data were available preoperatively (n = 2874) and at one year (n = 2274), two years (n = 1958), and a mean of 6.9 years (n = 1518) postoperatively and consisted of global assessment and visual analogue scales of leg and back pain, Oswestry Disability Index, EuroQol five-dimensional index, 36-Item Short-Form Health Survey, and satisfaction with treatment. Statistical analyses were performed with competing-risks proportional hazards regression or analysis of covariance, adjusted for baseline variables. Results The number of patients with additional surgery were 32/183 (17%) in the PLF group, 229/1256 (18%) in the IPLF group, and 439/1435 (31%) in the IBF group. With the PLF group as a reference, the hazard ratio for additional lumbar surgery was 1.16 (95% confidence interval (CI) 0.78 to 1.72) for the IPLF group and 2.13 (95% CI 1.45 to 3.12) for the IBF group. All patient-reported outcomes improved after surgery (p < 0.001) but were without statistically significant differences between the groups at the one-, two- and 6.9-year follow-ups (all p ≥ 0.12). Conclusion The addition of interbody fusion to posterolateral fusion was associated with a higher risk for additional surgery and showed no advantages in patient-reported outcome Cite this article: Bone Joint J 2019;101-B:1526–1533

BACKGROUND CONTEXT Data on the long-term outcome after fusion for isthmic spondylolisthesis are scarce. PURPOSE To study patient-reported outcomes and adjacent segment degeneration (ASD) after fusion for isthmic spondylolisthesis and to compare patient-reported outcomes with a control group. STUDY DESIGN/SETTING A prospective study including a cross-sectional control group. PATIENT SAMPLE Patients with isthmic spondylolisthesis underwent posterior lumbar interbody fusion (PLIF) (n=86) or posterolateral fusion (PLF) (n=77). Patient-reported outcome data were available for 73 patients in the PLIF group and 71 in the PLF group at a mean of 11 (range 5–16) years after baseline. Seventy-seven patients in the PLIF group and 54 in the PLF group had radiographs at a mean of 14 (range 9–19) years after baseline. One hundred thirty-six randomly selected persons from the population served as controls for the patient-reported outcomes. OUTCOME MEASURES Patient-reported outcomes include the following: global outcome, Oswestry Disability Index, Disability Rating Index, and Short Form 36. The ASD was determined from radiographs using the University of California Los Angeles (UCLA) grading scale. METHODS : The chi-square test or analysis of covariance (ANCOVA) was used for group comparisons. The ANCOVA was adjusted for follow-up time, smoking, Meyerding slippage grade, teetotaler (yes/no) and, if available, the baseline level of the dependent variable. RESULTS There were no significant patient-reported outcome differences between the PLIF group and the PLF group. The prevalence of ASD was 42% (32/77) in the PLIF group and 26% (14/54) in the PLF group (p=.98). The patient-reported outcome data indicated lower physical function and more pain in individuals with surgically treated isthmic spondylolisthesis compared to the controls. CONCLUSIONS PLIF and PLF groups had similar long-term patient-reported and radiological outcomes. Individuals with isthmic spondylolisthesis have lower physical function and more pain several years after surgery when compared to the general population.

Objective. Long-term oral glucocorticoid (GC) use is associated with increased mortality in patients with rheumatoid arthritis and inflammatory bowel disease. The aim of the study was to investigate whether there is excess mortality among oral GC users, regardless of the underlying disease. Methods. This was a retrospective case-control study. Information on dispensed prescriptions was obtained from the Swedish Prescribed Drug Register. Patients receiving ≥5 mg prednisolone (or equivalent dose of other GC) daily for ≥21 days between 2007-2014 were included. For each patient, a control person, matched for age and sex, was included. The cause of death was obtained from the Swedish Cause-of-Death Registry. Hazard ratio (HR) for mortality was calculated by using Cox proportional hazard model and by the log-rank test. The GC users were divided into four groups according to the length of GC treatment: 1) single-occasion users 2) occasional users ( 300 tablets/year for ≤ 2 consecutive years); and 4) long-term users (>300 tablets/year for > 2 consecutive years). Results. Of 1,585,335 inhabitants in Western Sweden, 223,211 GC users (women 55.6%) were identified for the analysis. The mean age was 48 ± 24 years. Median follow-up time was 3.6 years for GC users and 3.9 years for matched controls. The overall HR for death in oral GC users was 2.26 (95% CI 2.21-2.31). After exclusion of patients with malignant neoplasm, the HR for death was 1.41 (95% CI 1.38-1.45); 1.33 (95% CI 1.27-1.38) in single-occasion GC users (n=112,196), 1.36 (95% CI 1.30-1.42) in occasional users (n=63,862), 1.89 (95% CI 1.79-1.99) in medium-term users (n=19,129) and 1.67 (95% CI 1.51-1.84) in long-term users (n=7,191). The highest HRs were observed for deaths from heart failure (HR 1.71, 95% CI 1.63-1.80), sepsis (HR 1.71, 95% CI 1.51-1.94), and pulmonary embolism (HR 1.87, 95% CI 1.58-2.21). Conclusion. GC users have excess mortality compared to the background population. This illustrates the importance of surveillance for patients on oral GC treatment where adverse effects should be monitored and, when indicated, appropriately treated.

BACKGROUND Various methods for the treatment of isthmic spondylolisthesis are available. The aim of this study was to compare outcomes after posterolateral fusion without instrumentation, posterolateral fusion with instrumentation, and interbody fusion. METHODS The Swedish Spine Register was used to identify 765 patients who had been operated on for isthmic spondylolisthesis and had at least preoperative and 2-year outcome data; 586 of them had longer follow-up (a mean of 6.9 years). The outcome measures were a global assessment of leg and back pain, the Oswestry Disability Index (ODI), the EuroQol-5 Dimensions (EQ-5D) Questionnaire, the Short Form-36 (SF-36), a visual analog scale (VAS) for back and leg pain, and satisfaction with treatment. Data on additional lumbar spine surgery was searched for in the register, with the mean duration of follow-up for this variable being 10.6 years after the index procedure. Statistical analyses were performed with analysis of covariance or competing-risks proportional hazards regression, adjusted for baseline differences in the studied variables, smoking, employment status, and level of fusion. RESULTS Posterolateral fusion without instrumentation was performed in 102 patients; posterolateral fusion with instrumentation, in 452; and interbody fusion, in 211. At 1 year, improvement was reported in the global assessment for back pain by 54% of the patients who had posterolateral fusion without instrumentation, 68% of those treated with posterolateral fusion with instrumentation, and 70% of those treated with interbody fusion (p = 0.009). The VAS for back pain and reported satisfaction with treatment showed similar patterns (p = 0.003 and p = 0.017, respectively), whereas other outcomes did not differ among the treatment groups at 1 year. At 2 years, the global assessment for back pain indicated improvement in 57% of the patients who had undergone posterolateral fusion without instrumentation, 70% of those who had posterolateral fusion with instrumentation, and 71% of those treated with interbody fusion (p = 0.022). There were no significant outcome differences at the mean 6.9-year follow-up interval. There was an increased hazard ratio for additional lumbar spine surgery after interbody fusion (4.34; 95% confidence interval [CI] = 1.71 to 11.03) and posterolateral fusion with instrumentation (2.56; 95% CI = 1.02 to 6.42) compared with after posterolateral fusion without instrumentation (1.00; reference). CONCLUSIONS Fusion with instrumentation, with or without interbody fusion, was associated with more improvement in back pain scores and higher satisfaction with treatment compared with fusion without instrumentation at 1 year, but the difference was attenuated with longer follow-up. Fusion with instrumentation was associated with a significantly higher risk of additional spine surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND CONTEXT Whiplash-associated disorder is a common cause of chronic neck pain. Several radiological cervical angular variables are suggested to have constitutional characteristics, that is, them being minimally influenced by body positioning. However, the association between these variables and pain conditions remains poorly understood. To our knowledge, no previous studies have investigated the association between constitutional angular variables and the outcome after whiplash trauma. PURPOSE Our objectives were (1) to study the inter-rater agreement of sagittal radiologic variables between 2 raters and (2) to investigate any association between these variables and self-perceived nonrecovery after whiplash injury. STUDY DESIGN Prospective cohort study. PATIENT SAMPLE Forty-six patients aged 16 to 70 years, attending an emergency department after a motor vehicle accident resulting in neck pain were recruited. OUTCOME MEASURES Self-perceived nonrecovery (yes/no) was the primary outcome measure. The secondary outcome measure was pain level on a numeric rating scale. METHODS The participants underwent computed tomography scans in a supine position. Sagittal alignment variables (T1 slope, neck tilt, thoracic inlet angle [TIA], and C2–C7 angle) on the computed tomography scans were measured by 2 independent raters. Inter-rater agreement was tested with a paired sample t test and Bland-Altman plots for each variable. The patients were followed up after 6 months. RESULTS No systematic differences for the assessed variables were found between the 2 raters. The overall nonrecovery rate was 28%. For the group with low neck tilt, the nonrecovery rate was 50% (95% CI: 36%–78%) and for the group with high neck tilt, 8% (95% CI: 3%–25%). The nonrecovery rate for the group low TIA was 50% (95% CI 29%–72%) and for those with high TIA 14% (95% CI 4%–26%). The associations remained significant after adjustments for possible confounders. The inter-rater analysis shows satisfactory agreement without proportional bias. CONCLUSIONS This study indicates the existence of an association between the constitutional sagittal alignment of the cervical spine and the outcome after whiplash injuries.

Objective Glucocorticoids (GCs) are a cornerstone in treating various common and uncommon diseases. The aim of this study was to estimate the prevalence of GC use in terms of doses associated with risk of tertiary adrenal insufficiency in adults and children, and treatment indications. Methods This was a retrospective cohort study. Information on dispensed prescriptions was obtained from the Swedish Prescribed Drug Register. Patients with prescriptions of prednisolone (or equivalent dose of other GCs) ≥5 mg daily for ≥21 days between 2007 and 2014 were included. Information on concurrent diseases was obtained from the Swedish National Patient Register and the Vastra Gotaland Regional Healthcare Database. Results Of 1 585 335 inhabitants in Vastra Gotaland County, 223 211 were included in the study (women 55.6%). Mean age was 48 ± 24 years. Period prevalence of oral GC use during the 8-year study period was 14.1%. The highest prevalence (27.4%) was in men aged 80-89 years and lowest (7.5%) in men 10-19 years of age. The period prevalence in children 0-9 years of age was 10.6%. COPD and asthma were the most common indications for treatment (17.2%) followed by allergy (12.5%) and malignant neoplasms (11.5%). Allergy was the most frequent indication (20.5%) in children and adolescents. Conclusion Between 2007 and 2014, every seventh inhabitant in western Sweden received a GC prescription at doses associated with risk of developing tertiary adrenal insufficiency. These findings illustrate the importance of awareness of the potential development of tertiary adrenal insufficiency in both paediatric and adult patients.

Loss to follow-up in observational studies may skew results and hamper study reliability. We evaluated the importance of loss to follow-up in the Swedish spine register. Patients operated in the lumbar spine and scheduled for a postal questionnaire follow-up during part of 2016 were identified. Out of the 351 patients, 203 had responded. After multiple attempts, 115 of the 148 non-responders were reached; 68 returned the complete questionnaire; and 47 answered a brief questionnaire by phone. Analyses were made with the Chi-square test, analysis of covariance or logistic regression. Some analyses were adjusted. At baseline, the non-responders were younger than the responders (55 vs 61 years, p

Background: Low back pain (LBP) with or without lumbar disc herniation (LDH) is one of the most commonly found symptoms worldwide. The etiology is often unclear, but a low-grade infection caused by the anaerobic skin bacterium Cutibacterium acnes (formerly Propionibacterium acnes), sometimes found on culture during LDH surgery, has been suggested as a cause. Given worldwide concern over multidrug resistant bacteria, further investigation is highly warranted. Our study aimed to compare findings regarding bacterial presence in painful lumbar degenerative disc disease (DDD) in adults having LDH with findings in young patients with scoliosis, but without DDD or relevant lumbar pain. Methods: Between 2015 and 2017, 40 adults with LDH (median age 43, IQR 33-49) and 20 patients with scoliosis (median age 17, IQR 15-20) underwent surgery at seven Swedish hospitals. Samples were collected and cultured from skin, surgical wound, discs and vertebrae. Genetic relatedness of C. acnes isolates was investigated using single nucleotide polymorphism (SNP) analysis. DNA samples collected from discs/vertebrae were analysed using 16S rRNA-based PCR sequencing. Preoperative MRI findings were assessed for inflammatory Modic changes. Findings: No bacterial growth was found in 6/40 (15%) LDH patients, compared with 3/20 (15%) scoliosis patients. A single species, C. acnes, was found exclusively in the disc/vertebra from one patient in each group; in the LDH group, 29/40 (72%) patients had at least one sample with growth of C. acnes, while the corresponding figure in the scoliosis group was 14/20 (70%). There was no association between bacterial findings and Modic changes. Interpretations: The results suggest that finding bacteria like C. acnes in discs and vertebrae during surgery is likely due to contamination. Antibiotic use to treat LBP/LDH without signs of clinical discitis/spondylitis should be seriously questioned. Funding Statement: The study was funded by FORSS, a Swedish regional research foundation Declaration of Interests: The authors state: " no conflicts of interest to declare." Ethics Approval Statement: The study was approved by the ethical committee in Linkoping (EPN, Ref. no. 2015/152-31). All patients gave their written informed consent.

Purpose To compare bacterial findings in pain-generating degenerated discs in adults operated on for lumbar disc herniation (LDH), and mostly also suffering from low back pain (LBP), with findings in adolescent patients with non-degenerated non-pain-generating discs operated on for scoliosis, and to evaluate associations with Modic signs on magnetic resonance imaging (MRI). Cutibacterium acnes (Propionibacterium acnes) has been found in painful degenerated discs, why it has been suggested treating patients with LDH/LBP with antibiotics. As multidrug-resistant bacteria are a worldwide concern, new indications for using antibiotics should be based on solid scientific evidence. Methods Between 2015 and 2017, 40 adults with LDH/LBP (median age 43, IQR 33–49) and 20 control patients with scoliosis (median age 17, IQR 15–20) underwent surgery at seven Swedish hospitals. Samples were cultured from skin, surgical wound, discs and vertebrae. Genetic relatedness of C. acnes isolates was investigated using single-nucleotide polymorphism analysis. DNA samples collected from discs/vertebrae were analysed using 16S rRNA-based PCR sequencing. MRI findings were assessed for Modic changes. Results No bacterial growth was found in 6/40 (15%) LDH patients, compared with 3/20 (15%) scoliosis patients. Most positive samples in both groups were isolated from the skin and then from subcutis or deep within the wound. Of the four disc and vertebral samples from each of the 60 patients, 235/240 (98%) were DNA negative by bacterial PCR. A single species, C. acnes, was found exclusively in the disc/vertebra from one patient in each group. In the LDH group, 29/40 (72%) patients had at least one sample with growth of C. acnes, compared to 14/20 (70%) in the scoliosis group. Bacterial findings and Modic changes were not associated. Conclusions Cutibacterium acnes found in discs and vertebrae during surgery for disc herniation in adults with degenerated discs may be caused by contamination, as findings in this group were similar to findings in a control group of young patients with scoliosis and non-degenerated discs. Furthermore, such findings were almost always combined with bacterial findings on the skin and/or in the wound. There was no association between preoperative Modic changes and bacterial findings. Antibiotic treatment of lumbar disc herniation with sciatica and/or low back pain, without signs of clinical discitis/spondylitis, should be seriously questioned. Graphic abstract These slides can be retrieved under Electronic Supplementary Material.

Unfortunately, the 5th author name was incorrectly published in the original paper. The complete correct name is given below.

PurposeThe use of brand ambassadors is a quite recent phenomenon, even in the business world. This paper aims to explore the employment of ambassador networks as a place marketing and place development tool. This is done by identifying various kinds of networks, understanding how networks are governed, and pinning down the motivations and expectations of network members.Design/methodology/approachThe study used interviews and a survey to collect empirical material. The research process employed an approach with many inductive elements, deemed appropriate given that research into the topic is scant.FindingsThe study identified four main dimensions of networks and, on this basis, we outline a typology with four main categories of networks. One major finding is that ambassador networks are seen not only as a communication channel, but also as a development resource. That means they are seen as enhancing the general competitiveness of the place involved. The networks are also seen as a resource for mobilising local citizen pride. Another finding was that ambassadors value getting access to first‐hand information about the place much more than the opportunity of taking part in meetings and events and forming new relationships.Research limitations/implicationsThe findings are in line with the perspective of the place brand as a “relational brand network”, extending place branding beyond a matter of just one‐way communication. It is somewhat surprising that ambassadors value getting access to information more than interaction, given that other research puts such a high value on interaction and dialogue as value‐creating factors.Practical implicationsBased on the observations in the study, it is argued that ambassador networks have the potential to constitute an integral component of place brand management.Originality/valueResearch on the application of ambassador networks in place marketing seems to be scant, not to say non‐existent. The present study relates to the implementation of place branding, and can hopefully contribute to a more efficient practice as well as a better theoretical understanding.

Background Today there is some evidence-based medicine support for a positive short-term treatment effect of fusion in chronic low back pain in spondylolisthesis and in nonspecific degenerative lumbar spine disorders. The long-term effect is, however, unknown. Purpose To determine the long-term outcome of lumbar fusion in adult isthmic spondylolisthesis. Study design Prospective, randomized controlled study comparing a 1-year exercise program with instrumented and non-instrumented posterolateral fusion with average long-term follow-up of 9 years (range, 5–13). Patient sample 111 patients aged 18 to 55 years with adult lumbar isthmic spondylolisthesis at L5 or L4 level of all degrees, and at least 1-year's duration of severe lumbar pain with or without sciatica. Outcome measures Pain and functional disability was quantified by pain (VAS), the Disability Rating Index (DRI), the Oswestry Disability Index (ODI) work status, and global assessment of outcome by the patient into much better, better, unchanged or worse. Quality of life was assessed by the SF-36. Methods The patients were randomly allocated to treatment with 1) a 1-year exercise program (n=34), 2) posterolateral fusion without pedicle screw instrumentation (n=37), or 3) posterolateral fusion with pedicle screw instrumentation (n=40). Long-term follow-up was obtained in 101 (91%) patients. Nine patients in the exercise group were eventually operated on. Results Longitudinal analysis: At long-term follow-up pain and functional disability were significantly better than before treatment in both surgical groups. No significant differences were observed between instrumented and non-instrumented patients in any variable studied. In the exercise group the pain was significantly reduced but not the functional disability. Compared with the 2-year follow-up a significant increase in functional disability was observed, as measured by the DRI, but not the ODI, in the surgical group at long term. In the exercise group no significant changes were observed between the 2-year and the long-term follow-up. Cross-sectional analysis: Between the surgical and conservative group no significant differences were observed in any outcome measurement at long-term follow-up except for global assessment, which was significantly better for surgical patients. Of surgical patients 76% classified the overall outcome as much better or better compared with 50% of conservatively treated patients (p=0.015). Quality of life as estimated by the SF-36 at long term was not different between treatment groups in any of the eight domains studied but was considerably lower than for the normal population. Conclusions Posterolateral fusion in adult lumbar isthmic spondylolisthesis results ina modestly improved long-term outcome compared with a 1-year exercise program. Although the results show that some of the previously reported short-term improvement is lost at long term, patients with fusion still classify their global outcome as clearly better than conservatively treated patients. Furthermore, because the long-term outcome of the patients conservatively treated most likely reflects the natural course, one can also conclude that no considerable spontaneous improvement should be expected over time in adult patients with symptomatic isthmic spondylolisthesis. Substantial pain, functional disability and a reduced quality of life will in most patients most likely remain unaltered over many years.

A prospective study on predictive factors for the outcome of 164 patients with adult isthmic spondylolisthesis operated on with fusion. In view of the need to better select patients for fusion, we investigated the use of the pain drawing (PD) and other potential factors for predicting the outcome of fusion. Results on predictive factors of outcome after spinal fusion have been contradictory and large, well-defined, patient samples with adequate observation times are lacking. Questionnaires including possible predictive factors and PDs were obtained before surgery. Degree and level of slip were documented. Outcome was quantified by measurement of pain (VAS), Disability Rating Index, the Oswestry Disability Index, and global assessment by the patient into "much better," "better," "unchanged," or "worse." The 2-year follow-up rate was 160 of 164 (98%). In the total sample 49% of patients were much better, 25% better, 14% unchanged, and 12% worse. The following preoperative factors correlated to a worse outcome in the univariate analysis: not working, no regular exercise, female gender, shortness in stature, and a nonorganic PD. The multivariate regression analysis showed that work status was the main determinant of outcome. Gender and exercise had less but significant impact (P = 0.004 and 0.02, respectively). In the multivariate regression analysis the PD was not a significant predictor (P = 0.06). The present study shows that patients working before surgery have a more favorable outcome. Also male gender and regular exercise are indicators of a better outcome after fusion. Female patients not working, not exercising or, if these factors are not known, with nonorganic PDs, should be informed about their suboptimal chances of an excellent outcome after fusion.

The existence and importance of an accelerated adjacent segment disc degeneration (ASD) after lumbar fusion have previously not been demonstrated by RCTs. The objectives of this study were, to determine whether lumbar fusion in the long term accelerates degenerative changes in the adjacent disc and whether this affects the outcome, by using a prospective randomised design. A total of 111 patients, aged 18-55, with isthmic spondylolisthesis were randomised to exercise (EX, n = 34) or posterolateral fusion (PLF, n = 77), with (n = 37) or without pedicle screw instrumentation (n = 40). The minimum 10 years FU rate was 72%, with a mean FU time of 12.6 years (range 10-17 years). Three radiographic methods of ASD quantification were used, i.e. two digital radiographic measurement methods and the semi quantitative UCLA grading scale. One digital measurement method showed a mean disc height reduction by 2% in the EX group and by 15% in the PLF group (p = 0.0016), and the other showed 0.5 mm more disc height reduction in the PLF compared to the Ex group (ns). The UCLA grading scale showed normal discs in 100% of patients in the EX group, compared to 62% in the PLF group (p = 0.026). There were no significant differences between instrumented and non-instrumented patients. In patients with laminectomy we found a significantly higher incidence of ASD compared to non laminectomised patients (22/47 vs. 2/16 respectively, p = 0.015). In the longitudinal analysis, the posterior and anterior disc heights were significantly reduced in the PLF group, whereas in the EX group only the posterior disc height was significantly reduced. Except for global outcome, which was significantly better for patients without ASD, the clinical outcome was not statistically different in patients with and without ASD. In conclusion, the long-term RCT shows that fusion accelerates degenerative changes at the adjacent level compared with natural history. The study suggests that not only fusion, but also laminectomy may be of pathogenetic importance. The clinical importance of ASD seems limited, with only the more severe forms affecting the outcome.

STUDY DESIGN: A prospective study with historical controls. OBJECTIVE: To compare the outcome of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in adult isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: On theoretical grounds, PLIF has been suggested to result in an improved outcome compared with PLF. Data to support this view, however, are lacking. METHODS: A total of 86 patients (age range, 18-55 years) with adult isthmic spondylolisthesis were operated on with PLIF. The comparison group consisted of 77 patients operated on with PLF with iliac bone autograft, 40 with and 37 without pedicle fixation. The 2 groups had similar socioeconomic, age and sex distribution, level of pain, and disability. Inclusion criteria and outcome measurements were identical in both groups. The PLIF group was operated on with autograft and carbon fiber ramps with pedicle fixation. Before surgery and at the 2-year follow-up, pain (VAS) and functional disability were quantified by the Disability Rating Index (DRI, 0-100) and the Oswestry Disability Index (ODI). The global outcome was assessed by the patient as much better, better, unchanged, or worse. RESULTS: The follow-up rate was 98% in the PLIF group and 97% in the PLF group. In PLIF patients, pain index improved from 66 to 35 (P < 0.0001) and the DRI from 47 to 30 (P < 0.01). The levels of pain and DRI were similar to that of the PLF group (pain 37, DRI 29, not significant), and the ODI was identical in both groups (25); 74% of the patients in both groups classified the results as much better or better. CONCLUSION: Type of fusion, PLIF or PLF, does not affect the 2-year outcome of surgical treatment of adult isthmic spondylolisthesis. Despite the theoretical advantages of PLIF, no improvement on patient outcome compared with posterolateral fusion could be demonstrated, questioning the need of anterior support in short lumbar fusions.

We present PerfMiner, a system for the transparent collection, storage and presentation of thread-level hardware performance data across an entire cluster. Every sub-process/thread spawned by the user through the batch system is measured with near zero overhead and no dilation of run-time. Performance metrics are collected at the thread level using tool built on top of the Performance Application Programming Interface (PAPI). As the hardware counters are virtualized by the OS, the resulting counts are largely unaffected by other kernel or user processes. PerfMiner correlates this performance data with metadata from the batch system and places it in a database. Through a command line and web interface, the user can make queries to the database to report information on everything from overall workload characterization and system utilization to the performance of a single thread in a specific application. This is in contrast to other monitoring systems that report aggregate system-wide metrics sampled over a period of time. In this paper, we describe our implementation of PerfMiner as well as present some results from the test deployment of PerfMiner across three different clusters at the Center for Parallel Computers at The Royal Institute of Technology in Stockholm, Sweden.

Publisher Summary This chapter discusses the performance of the Itanium 2 processor on a number of benchmarks from computational electromagnetic. The chapter explains how the hardware performance counters of the Itanium 2 can be used to analyze the behavior of a kernel code, Yee bench, for the finite-difference time-domain (FDTD) method. A performance result for a parallel FDTD code on a cluster of HP rx2600 Intel Itanium 2 based workstations is presented. Finally, results from a benchmark suite of an industrial time-domain code based on the FDTD method are given. All these results show that the Itanium 2/rx2600 is very well suited to the FDTD method, due to its high main memory bandwidth. The Itanium 2 has the same peak performance as the AMD Opteron. The Itanium 2 is about 30% faster than the AMD Opteron on this benchmark— that is, it is more efficient. On the other hand, it is also more expensive.

When the Scandinavian inland ice left the Erken basin about 10000 years ago the moraine (till) was covered by more than 100 metres of water. Sedimentation started, at first mainly of clay, and has continued up to the present day. Continual land upheaval has decreased the depth of the water and altered the character of the sedimentation. A core was taken through the sediments down to the moraine at a depth of 11 metres. Analyses of total N and easily soluble Ca, K and Na were carried out on samples from the core. The concentration of N should give a good indication of the organic sedimentation which becomes larger at higher levels in the core. This is particularly noticeable in the sediment deposited during the recent 2000 years, after the Erken basin became isolated from, the Baltic and turned into a fresh water lake. The sediment mainly consists of soap clay with a varying gyttja content. The mobility of water and salts in these clays is very restricted and especially, as in the case here, when ...