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Table 3

Prevelance and mean age by source of low back pain after fusion

CI = confidence interval; SD = standard deviation; LBP = low back pain; IDD = internal disc disruption; ZJA = zygapohyseal joint arthropathy; SIJ = sacroiliac joint.

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Table 3

Prevelance and mean age by source of low back pain after fusion

CI = confidence interval; SD = standard deviation; LBP = low back pain; IDD = internal disc disruption; ZJA = zygapohyseal joint arthropathy; SIJ = sacroiliac joint.

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Table 4

Symptomatic IDD levels in seven cases after fusion

IDD = internal disc disruption.

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Table 4

Symptomatic IDD levels in seven cases after fusion

IDD = internal disc disruption.

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Table 5

Symptomatic ZJA levels in five cases after fusion

ZJA = zygapohyseal joint arthropathy.

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Table 5

Symptomatic ZJA levels in five cases after fusion

ZJA = zygapohyseal joint arthropathy.

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IDD occurred as a source of LBP with significantly greater frequency in patients without fusion history than with a history (45.4% vs 25.0%; P = 0.0406). Cases of SIJ pain were more common for subjects with a fusion history than without (42.9% vs 12.8%; P = 0.0005); there were not significant differences in ZJA sources of LBP between subjects with and without fusion history (33.3% vs 17.9%; P = 0.0911). Mean ages of LBP patients were similar between cases with and without fusion history for LBP cases diagnosed as IDD (46.1 vs 43.4 years), ZJA (57.6 vs 59.9 years), and SIJ pain (61.0 vs 62.7 years).

Our findings suggest that the specific etiology of chronic LBP after a lumbar fusion can be identified. However, our results do not allow us to support or discard the notion that multiple painful structures can coexist after lumbar fusion. Each patient whose LBP was diagnosed as discogenic after positive provocation discography did not necessarily undergo negative joint blockade. Nonetheless, we can assert that patients complaining of LBP after lumbar fusion typically do suffer such symptoms due to involvement of a spinal structure within or adjacent to the index fusion segment. The most common source of which is the SIJ followed, respectively, by the intervertebral disc(s), ZJ(s), and soft tissue irritation by fusion hardware.

LBP symptoms emanating from intra-articular SIJ pathology should be recognized as a diagnostic group separate from iliac donor site mediated LBP. The prevalence of SIJ pain in our cohort was 43%, yet, may be as high as 61%. It is likely that SIJ pain after lumbar fusion represents a third to over half of chronic LBP cases having undergone previous fusion. Greater than 80% of our subjects having a history of both a fusion and a subsequent SIJ pain, had fusion to the sacrum ( P = 0.0032). A risk factor for development of SIJ pain after fusion is inclusion of the sacrum into the surgical construct. Our finding corroborates earlier reports of the correlation between SIJ pain and fusion to the sacrum [21,40] . Computed sacrum angular motions and average stress on SIJ articular surfaces increase after lumbar fusion, especially fusion to the sacrum [41] . It is logical that increased motion and stress across the SIJ instigates intra-articular derangement leading to persistent LBP.

After exposure to HIV, HIV RNA is detectable in plasma by 10–12 days, followed by appearance of HIV p24 antigen in serum or plasma at 15–17 days. Depending on the sensitivity of the serologic assays used, HIV-specific antibodies are detectable in serum or plasma at the earliest at 21 days after exposure. Performing an HIV RNA test after a negative initial antibody and/or antigen test in persons suspected of acute infection may therefore be helpful. Due to the time course of test positivity and the possibility of seronegativity, laboratory diagnosis of primary (acute) HIV-1 infection is usually based on a high quantitative HIV-1 RNA (viral load) result (typically >10 5 copies/mL) or qualitative detection of HIV-1 RNA and/or proviral DNA ( Table 48 ) [ 266 ]. However, in the setting of nonacute HIV infection, HIV viral load assays should be used with caution for diagnosis of HIV infection because of the possibility of false-positive results. Since false-positive results are generally of low copy number (<1000 copies/mL), low copy number results should prompt retesting of a second specimen. Notably, because there is a 10- to 12-day period after infection when serologic markers are not detectable, testing another specimen 2–4 weeks later should be considered if initial antibody, antigen, or RNA tests are negative. NAAT is not 100% sensitive in individuals with established HIV infection due to viral suppression, either naturally or therapeutically, or improper specimen collection/handling. If NAAT is used to make a diagnosis of acute HIV-1 infection, subsequent HIV-1 seroconversion by conventional serologic testing is recommended.

Table 48.

Laboratory Diagnosis of Human Immunodeficiency Virus Infection

Abbreviations: EDTA, ethylenediaminetetraacetic acid; HIV-1, human immunodeficiency virus type 1; HIV-2, human immunodeficiency virus type 2; NAAT, nucleic acid amplification test; PPT, plasma preparation tube; RT, room temperature; SST, serum separator tube.

For viral load testing, blood collected in PPT should be processed within 6 hours of collection to separate plasma from cells prior to transport. Since polymerase chain reaction does not differentiate between such proviral DNA and cell-free viral RNA, leakage of proviral DNA from cells during storage in PPT may cause falsely elevated plasma HIV RNA level results.

Nucleic acid amplification tests are commercially available to detect non-integrated HIV DNA present in cell-free plasma.

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Table 48.

Laboratory Diagnosis of Human Immunodeficiency Virus Infection

Abbreviations: EDTA, ethylenediaminetetraacetic acid; HIV-1, human immunodeficiency virus type 1; HIV-2, human immunodeficiency virus type 2; NAAT, nucleic acid amplification test; PPT, plasma preparation tube; RT, room temperature; SST, serum separator tube.

For viral load testing, blood collected in PPT should be processed within 6 hours of collection to separate plasma from cells prior to transport. Since polymerase chain reaction does not differentiate between such proviral DNA and cell-free viral RNA, leakage of proviral DNA from cells during storage in PPT may cause falsely elevated plasma HIV RNA level results.

Nucleic acid amplification tests are commercially available to detect non-integrated HIV DNA present in cell-free plasma.

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In the neonate, serologic testing is unreliable due to persistence of maternal antibodies; quantitative HIV-1 RNA testing is as sensitive as qualitative HIV-1 RNA and/or proviral DNA testing for the diagnosis of HIV-1 infection [ 267 ]. NAAT is recommended at 14–21 days, 1–2 months, and 4–6 months after birth, in infants born to HIV-1–infected mothers. Since the availability of HIV serologic assays in the 1980s, HIV screening tests have evolved to the current fourth- and fifth-generation assays in which recombinant and synthetic HIV peptide antigens are used in the detection of HIV p24 antigen and specific IgM and IgG antibodies. Such assays generally yield positive results by 4–6 days after positive NAAT results. Fifth-generation screening assays have the advantage over fourth-generation assays in their ability to discriminate among HIV-1 p24 antigen, HIV-1 antibodies, and HIV-2 antibodies.

Note that on both OS X and iOS that the Foundation framework provides a convenience macro NS_REQUIRES_SUPER that provides syntactic sugar for this attribute:

This macro is conditionally defined depending on the compiler’s support for this attribute. If the compiler does not support the attribute the macro expands to nothing.

Operationally, when a method has this annotation the compiler will warn if the implementation of an override in a subclass does not call super. For example:

By default, the Objective-C interface or protocol identifier is used in the metadata name for that object. The objc_runtime_name attribute allows annotated interfaces or protocols to use the specified string argument in the object’s metadata name instead of the default name.

Usage : __attribute__((objc_runtime_name("MyLocalName"))) . This attribute can only be placed before an @protocol or @interface declaration:

objc_runtime_visible (clang::objc_runtime_visible, clang::objc_runtime_visible)

This attribute specifies that the Objective-C class to which it applies is visible to the Objective-C runtime but not to the linker. Classes annotated with this attribute cannot be subclassed and cannot have categories defined for them.

optnone (clang::optnone, clang::optnone)

The attribute suppresses essentially all optimizations on a function or method, regardless of the optimization level applied to the compilation unit as a whole. This is particularly useful when you need to debug a particular function, but it is infeasible to build the entire application without optimization. Avoiding optimization on the specified function can improve the quality of the debugging information for that function.

This attribute is incompatible with the and attributes.

Clang provides support for C++ function overloading in C. Function overloading in C is introduced using the overloadable attribute. For example, one might provide several overloaded versions of a tgsin function that invokes the appropriate standard function computing the sine of a value with float , double , or long double precision:

Given these declarations, one can call tgsin with a float value to receive a float result, with a double to receive a double result, etc. Function overloading in C follows the rules of C++ function overloading to pick the best overload given the call arguments, with a few C-specific semantics:

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