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With more moderate temperatures and less snowfall than the park interior cholesterol levels order 10 mg ezetimibe otc, this area can support large numbers of wintering elk cholesterol in an eggs purchase ezetimibe discount. The herd winters in the area of the Lamar and Yellowstone river valleys from Soda Butte to Gardiner cholesterol deposits buy discount ezetimibe on-line, Montana cholesterol food chart diet order ezetimibe online pills. It also migrates outside of the park into the Gallatin National Forest and onto private lands. The winter count, which was approximately 17,000 when wolf reintroduction began in 1995, fell below 10,000 in 2003. The Madison­Firehole elk herd (less than 100 animals) has been the focus of a research study since November 1991. Researchers are examining how environmental variability effects ungulate reproduction and survival. Prior to wolf restoration, the population was naturally regulated by severe winter conditions to a degree not found in other, human-hunted elk herds. The elk are also affected by high fluoride and silica levels in the water and plants they eat, which affect enamel formation and wear out teeth quickly-thus shortening their lives. The typical life span is 13 years; elk on the northern range regularly live to about 18 years. Information gained in this study will be useful in comparing non-hunted and hunted elk populations. Elk in the Greater Yellowstone Ecosystem the Greater Yellowstone Ecosystem is home to approximately 30,000­40,000 elk. For most of the last two decades, the Jackson herd, which currently numbers about 12,000, has been larger than the northern Yellowstone herd. Some ranges and migratory routes overlap, and some interchange occurs among the herds. Summer range in the southern part of Yellowstone National Park is used by part of the Jackson herd as well as by elk from the North Fork Shoshone and northern Yellowstone herds. Disease in Greater Yellowstone Brucellosis Many elk and bison in the Greater Yellowstone Ecosystem have been exposed to the bacterium that causes brucellosis. Brucellosis is a contagious bacterial disease that originated in livestock and often causes infected cows to abort their first calves. It is transmitted primarily when susceptible animals directly contact infected birth material. Elk are commonly observed within 100 yards of bison during late winter and spring when brucellosis-induced abortion or calving occurs in Yellowstone. Because of their high densities, elk that are fed in winter have sustained high levels of brucellosis; winter feeding on the northern range stopped more than 50 years ago. Elk are fed during the winter at the National Elk Refuge in Jackson, Wyoming, in addition to 22 Wyoming-run feed grounds. Transmission of brucellosis from feed ground elk, where an average of 30% have tested positive for exposure to the bacteria, was the apparent source of infection in Wyoming cattle in 2004. This fatal infection, transmitted by animal contact or through the environment, has spread to within 130 miles of the park. National Park Service staff and partners will continue surveillance and, if necessary, take action to minimize both transmission of the disease and the effects of intervention on the elk population and other park resources. Jackson W Y O M I N G Species tested positive for chronic wasting disease 2009­2013 Elk Mule deer White-tail deer! Individual cases of chronic wasting disease, by species, recorded in Wyoming from 2009­2013. Yellowstone elk calf mortality following wolf restoration: Bears remain top summer predators. Ecology of ungulates and their winter range in northern Yellowstone National Park, Research and Synthesis 1962­1970. Behavioral responses of bison and elk in Yellowstone to snowmobiles and snow coaches. The Ecology of Large Mammals in Central Yellowstone: Sixteen Years of Integrated Field Studies In Terrestrial Ecology Series.

Despite such strong data cholesterol test pin prick order cheap ezetimibe, adherence to recommended practices remains suboptimal cholesterol test monitor generic ezetimibe 10 mg visa, often due to misconceptions of the dialysis staff cholesterol levels and exercise order 10 mg ezetimibe visa. On the basis of their observational results cholesterol ratio definition 10mg ezetimibe with mastercard, which included high compliance with glove use (93%) in contrast to poor hand hygiene compliance (36%), Arenas et al. These data support the need for improved training and education to address knowledge gaps, as well as other initiatives focused on optimizing adherence to recommended infection control practices (Table 7). As mentioned above, implementation is more likely when guidelines are accompanied by changes in regulations. Research recommendations Further observation studies should be conducted to ascertain features of facilities that do not have incident cases. These studies should ideally evaluate costs, patient perceptions, and complications associated with isolation. These studies should ensure the physical separation of either the center or room, or separation by treatment shift; these programs should have strict isolation strategies in place that include staff. In particular, we need innovative, effective strategies to improve infection control, and it is still important to overcome barriers to identification and treatment of all infected patients. Future research should devise innovative approaches that accurately measure infection control processes at a reasonable cost. In addition, measurement of hepaticvein wedge-pressure gradient is useful when deciding whether single kidney transplantation or simultaneous liver-kidney transplantation should be proposed. Absence of varices on endoscopy and portal pressure gradient < 10 mm Hg suggests that cirrhosis is compensated. In patients with compensated cirrhosis without portal hypertension, isolated kidney transplantation is recommended. Other factors such as candidate sensitization and patient preference can be also considered for choosing the timing of treatment. The scarcity of donor organs for transplantation results in long waiting times for kidney transplantation. Longer time on hemodialysis and on wait-list may be an independent risk factor for graft loss and mortality after transplantation. For these reasons kidney transplantation with expanded criteria donors has become a necessity. Indeed, cyclosporine, tacrolimus, sirolimus, and everolimus are metabolized in the liver by the cytochrome P450. As such, the Work Group suggests that the Hepatitis Drug Interactions website from the University of Liverpool. The most common presentation is proteinuria with or without microhematuria, or nephrotic syndrome. In the case of urine protein-to-creatinine ratio > 1 g/g or 24-hour urine protein (protein excretion rate) greater than 1 g on 2 or more occasions, a graft biopsy is indicated. Pathological examination should include immunofluorescence and electron microscopy. In the absence of an identified etiology (currently <10% of mixed cryoglobulinemia), cryoglobulinemic vasculitis is defined as essential or idiopathic. Thus, some patients might be spared from immunosuppression in the presence of severe chronic lesions when there is no extrarenal indication for immunosuppression. Glomeruli may show prominent hypercellularity as a result of infiltration of glomerular capillaries by mononuclear and polymorphonuclear leucocytes. Glomeruli frequently show accentuation of lobulation of the tuft architecture with a combination of increased matrix and mesangial cells, capillary endothelial swelling, splitting of capillary basement membrane, and accumulation of eosinophilic material representing precipitated immune complexes or cryoglobulins. The glomerular basement membrane often shows double contours, which are caused by the interposition of monocytes between the basement membrane and the endothelium. Both subendothelial and mesangial immune complexes can be identified by electron microscopy 138 typically without a distinctive substructure. On light microscopy, the characteristic finding is a diffuse and uniform thickening of the glomerular basement membrane without mesangial or endothelial proliferation. Diffuse subepithelial immune deposits can be identified by electron microscopy, and immunofluorescence shows diffuse and granular deposits of IgG, IgA, and C3. At the end of antiviral therapy, the summary estimate of the mean decrease in proteinuria was 2. Serum creatinine was not significantly decreased with antiviral treatment; however, stabilization of serum creatinine was achieved.

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See a lso A r tif a c ts M ed icin e cholesterol levels chart in south africa order 10 mg ezetimibe with mastercard, 82 cholesterol maladie definition discount ezetimibe uk, 274 cholesterol statins order cheapest ezetimibe and ezetimibe, 315 cholesterol lowering foods youtube buy ezetimibe 10 mg mastercard, 805, 823, 2652; c o n the m p o ra ry, 283, 1083, 2215, 2216; e v a lu a tio n o f, 726, 2316; and h e ia u s, 829, 1502; the rm in o lo g y, 12, 1316, 1317. See a lso D e n ta l H e alth; D iseases; E th n o b o ta n y; K ahuna-M edical; L eprosy; M e n tal H e alth; M o rta lity M ele (p o e try), 82, 955, 1356, 1764; a n aly sis of, 94, 635, 1951, 1952, 2005; c o lle c tio n s o f, 2013, 2706; c o m p a ra tiv e stu d ie s o f, 425, 924, 1702, 2254; of a fa m ily, 2439; and im a g e ry, 1124; fo r K aah u m an u, 1624; fo r K u alii, 1623; and p ro b lem s in tr a n s la tio n, 1178, 1360; ro le o f, 2277; and sym bolism in, 485, 603, 1634. S ee a lso A g ric u ltu re; E th n o b o ta n y P o e p o e, A ndrew (le g isla to r), 2163, 2296 P o e try. See a lso A g ric u ltu re; Food; K alo P o lic e, 956, 1074, 1692, 1782, 2343 P o litic a l a c tiv is m, 2107, 2318; Ad Hoc c o m m itte e fo r a H aw aiian tr u s the e, 1946; A loha A s so c ia tio n, In c. See a lso K ah o o law e, K aona In su rre c tio n; P o litic a l a c tiv is ts; W ilcox, R o b e rt P o litic a l a c tiv is ts, 2704; e a rly, 1451, 1663, 1800; H elm, G e o rg e, 755, 770, 885, 1090, 2159; o th e rs, 361, 563, 1715, 1889, 2203; R itte, W aiter, J r. See a lso K aona in s u rre c tio n; P o litic a l A c tiv ism; W ilcox, R o b e rt P o litic ia n s, 723, 2135; d e le g a the to C o n g re ss, 1981; g o v e rn o r, 205; H onolulu C ity C o u n c il, 1407; le g is la to rs, c o n the m p o ra ry, 2162, 2163, 2292-2297; le g is la to rs, e a rly, 408, 1445; m ay o rs, 684, 1174, 1727. See a lso A kaka, D aniel; Brow n, K e n n eth; C a m p b e ll, A lic e; K a la n ia n a o le, Jonah; P o e p o e, A ndrew; W ilcox, R o b e rt P o ly n e sian Voyaging S o c ie ty. See also D ep o p u latio n; M o rta lity P ra y e rs; fo r c ro p s, 861, 1357; to gods, 626, 1358, 1362; of k ah u n as, 622, 628, 1355, 1359. See also K ahunas; R eligion P ro v e rb s and rid d le s, 82; a n aly sis o f, 180,182, 1211, 1369, 1603; lis ts o f, 1123, 1208 P u a a ik i, B a rtim e u s (c le rg y m a n), 91, 221, 477, 584, 1210. See O p u k a h aia, H enry O ffic e of H aw aiian A ffa irs, 2654, 2655; p u b lic a tio n s o f, 2661-2665 O h a n a (e x the n d e d fa m ily), 380, 841, 863, 1095, 1713, 2011; a n aly sis o f, 862; and c h ild re n, 359, 1516, 2365; c o n the m p o ra ry, 366, 704, 734, 1092, 1177, 2685. See a lso C u ltu re; S o c iety O p u k a h aia, H enry (C h ristia n c o n v e rt), 581, 1210, 1390, 2447, 2616; l e t t e r s o f, 488. See also H aw a iia n s a b ro a d -New E ngland O ra l h isto rie s; c a ta lo g o f, 2656; tra n s c r ip ts o f, 1541, 2043, 2473, 2494 O rg a n iz a tio n s, 2119; c a n o e ra c in g, 1293; D a u g h the rs and Sons of H aw aiian W arrio rs, 1243; D a u g h the rs of H aw aii, 300, 301, 1073; H ale N a au a, 8 38, 1563; H aw aiian C iv ic C lub, 1119, 2428; H ula, 1056; K aah u m an u S o c ie ty, 266; p o litic a l a c tiv is ts, 972, 1895, 1946; Sons of H aw aii, 551. See also P o litic a l a c tiv is m O rig in s, 125, 320, 323, 661, 978, 2557; and c h ie fs, 371; c o m p a ra tiv e stu d ie s o f, 59, 132, 319, 594, 969; and fishhooks, 2173; and H aw aii L oa, 369, 731; in New Z ea la n d, 2208; and o ral tra d itio n s, 732, 1163; in R a ro to n g a, 2209; re s o u rc e u n its on, 1764; in T a h iti, 1185; th e o rie s a b o u t, 655, 807, 1091, 2344, 2709. See also S e ttle m e n t, e arly; V oyages, e a rly P aao (leg en d ary high p rie s t), 552, 1914, 2265, 2286. See also H eiaus; R eligion P a h in u i, G abby (m u sician), 247, 248, 669; o b itu a rie s fo r, 253, 1912; re m in isc e n c e s a b o u t, 32, 249, 1923, 2369 P e le (goddess), 184, 2563, 2615; a n e c d o the s a b o u t, 207, 1523, 1601, 2197 P e rso n a l t r a i t s, 1145, 1146, 1199, 1440, 1893, 2081; c o m p a ra tiv e stu d ie s o f, 2106; c o n the m p o ra ry, 380, 1287, 1288, 1300, 1695, 2640; and dim in ish ed m o ra le, 1549; e a rly, 128, 237, 434, 435, 929, 1835; of p a rt-H a w a iia n s, 2284; p e rso n a l view s o f, 1027, 1217, 1373; r e fle c tio n s on, 359, 1209, 1220; t e s ts on, 117, 701, 712, 713 P e tro g ly p h s, 466, 1707, 2314; a n aly sis o f, 197, 390, 1200; on H aw aii Island, 136, 138, 140, 150, 429, 654, 2553; on K au ai, 202, 692; on O ahu, 652, 1 149, 1189, 1556. See also A rt Q u ilts, 157, 267, 717; m aking o f, 874, 958, 1 197, 2363, 2646 R a d io, 886; on K au ai, 1774; K C C N, 882, 883, 1052, 1458, 1459, 1941, 2619 R e lig io n, c o n the m p o ra ry, 1930, 2142; and a n c ie n t re lig io n, 51, 1290, 1839, 2023, 2086; and in tro d u c e d re lig io n s, 7 57; and M orm onism, 1729; and re v o lu tio n of 1893, 2228; and y o u th, 1323. See also C h u rc h es; C lerg y R e lig io n, e a rly, 82, 125, 493, 1314, 1602; c o m p a ra tiv e stu d y o f, 1741; fe s tiv a ls, 1378; and c u lt of Io, 859, 2355; and m an a, 1789; o u tlin e o f, 1764, 2004; and P o ly n e sia, 317, 853, 858, 1028; p ra c tic e s o f, 675, 1264. S ee a lso G ods; H eiaus; K ahuna; K apu S y stem; M akahiki R e p a ra tio n s, 2647; and A laskan p r e c e d e n t, 1195; a lte r n a tiv e s, 745; c o n g re ssio n a l h e arin g s a b o u t, 2470-2472; fic tio n a l a c c o u n t o f, 1881; and lan d, 1536; leg a l a s p e c ts o f, 255; and O H A, 276, 1760, 2321, 2689; p rin c ip le s o f, 2664 R id d le s. S ee P ro v e rb s and rid d le s R itte, W alter (p o litic a l a c tiv is t), 755, 2072, 2574, 2687 R oyal H aw aiian Band, 204, 949, 1573, 2098, 2099; and 1895 m ain lan d trip, 1872, 2602 R o y a lty, 243, 1026, 1739, 1742, 2567, 2569; a n aly sis of, 925, 957, 1705, 2110, 2111, 2268; c h ie fe s s e s, 387; c h ie fs, 599, 714, 950, 1522, 1644, 2446; d e the r io r a tio n o f, 988; and e d u c a tio n, 2692, 2693; fic tio n a b o u t, 419, 1856; g e n ea lo g y o f, 2103; ind iv id u als of (A launiuohua, 2565; B eckley fa m ily, 1487; K a h ah a n a, 728; K a ia n a, 942; K a n ain a, 512; K aoleioku, 2270; K a u m u alii, 1616; K a w a ile p o le p o, 802; K a w a n an a k o a, A bigail, 1089, 2515; K aw a n an a k o a, D avid, 516; K a w a n an a k o a, E dw ard, 1584; K a w a n an a k o a, K a p io la n i, 1734; K a w a n an a k o a, L ydia, 1735; K e k au lik e, 991; K e o p u o lan i, 1479; K eouanui, 1986; K uakini, 1161; K u alii, 2547; L aan u i, G ideon, 2044; L eleio h u k u, 508; L ik e lik e, 428; P ak i, 515; T olm an, 2042; U m i, 43; Y oung, John); in the rv ie w s w ith, 2234; and lan d, 2226; q u e en of K au ai, 2585; w edding o f, 681; and W estern goods, 2062. See K e elik o lan i, R u th (P rin c ess) to W estern so c ie ty, 2111; s t r a ti f i c a ti o n o f, 957, 2109, 2218. K ing, 1281; by Q ueen L iliu o k alan i, 558, 1780, 2184; n a m e, 2589; n a tio n a l a n th e m s, 2190; of n in e the e n th c e n tu ry, 2194; p o p u la rity o f, 1226, 2372; by ro y a lty, 2186; of tw e n tie th c e n tu ry, 2195. See a lso M usic Speech; am ong c h ild re n, 262, 263, 1180; c o m p a ra tiv e stu d ie s o f, 2509; e a rly, 177, 178, 1951; by p o litic ia n s, 408, 1977; and p ro n u n c ia tio n, 1179; and s tu tte r in g, 1530. S ee also L anguage; S to ry the llin g S p o rts, 82, 1389, 1372, 1425, 1764, 1765; b ib lio g rap h y o f, 1766; and bodybuilding, 1389; c o c k fig h tin g, 439; d e c lin e o f, 629, 743; e a rly b a llg a m e s, 1382; e a rly c o m m e n ts a b o u t, 1367, 1370; holua slid in g, 847, 1321, 1660, 2221; h o rse b ac k rid in g, 953; and J a p a n e s e s p o rts, 1374; and K a m e h a m e h a I, 1375; in th e M akahiki, 1768, 1841, 1866; and n a tu re, 1392; w ag erin g on, 1382. S ee also A th le the s; C a n o e ra c in g, G am es; M akahiki; Surfing; Sw im m ing S to ry the llin g, 444, 1277, 1369; a n a ly sis o f, 263, 1180, 2521. S ee a ls o, L egends; S peech S tru c tu re s, 831, 1221 S um ner, N ancy (C hiefess), 2437, 2442 S u p e rn a tu ra l, 985, 2086, 2615; bib lio g rap h y of, 2158;and fire b a ll, 1411; and h itc h h ik e r, 1601; and N ig h t M a rc h e rs, 114, 1101; re m in isc e n c e s o f, 1320, 1324; visions o f, 1659. See a lso K ahunas S u rfin g, 711, 1460, 1588, 1966, 2374; e a rly a c c o u n ts o f, 245, 246, 532, 706, 2311; m e e ts, 1558; the c h n iq u e s o f, 1239. See also A th le the s; K ah an am o k u, D uke; S ports; Surfing S alt m aking, 961, 1476, 1792 S c u lp tu re. See A rt S e ttle m e n t, e a rly, 130, 320, 323, 661, 732; e s tim a the s o f, 655; exp an sio n o f, 1033; on H aw aii, 1434; and H aw aii L oa, 731; im p a c t on e c o s y s the m, 2683; on K au ai, 656; on M olokai, 1431, 1432, 1435; on O ahu, 667; re c o n s tru c tio n o f, 186, 1943; re v ie w o f, 1091; se q u e n c e o f, 452, 658. See a lso O rigins; Voyages S e x u a lity, 1499, 1980, 2490; a n aly sis o f, 2012; and ra p e, 2104 S m a rt, R ic h a rd (ra n c h e r), 683, 1968 S o c ie ty, c o n the m p o ra ry, 261, 790, 1547; and a d ju s tm e n t to W estern so c ie ty, 1063; as a c o n s tru c tiv e fo rc e, 1119; and food e x c h a n g e, 1954; group c h a r a c the r is tic s of, 2617, 2640; on H aw aii Island, 192, 2694; and housing, 2328; on M aui, 443, 734, 735, 2635, 2685; and so c ial c o n d itio n s, 115. See a lso C u ltu re -c o n the m p o ra ry; H aw aiian H om e Lands; H ealth; P o litic a l a c tiv is m S o c ie ty, e a rly, 82, 670, 1167, 2084, 2672; c o m p a ra tiv e stu d ie s of, 570, 782, 1115, 1878; e a rly a c c o u n ts of, 102, 784, 927, 1160; e v o lu tio n of, 783, 21 10, 2148, 2702; p rin c ip le s o f, 1387; re a c tio n T apa. See a lso A stronom y; N a v ig atio n; O rigins W este rn c o n ta c t, 374, 754, 1948; a c c u ltu ra tio n, on H aw aii Island, 578, 1022, on K a u ai, 742, on M aui, 733-735, 2635, in R u ssia, 2611; a d a p ta tio n to , 640, 1196, 1368, 1569; a n aly sis o f, 1156, 2040; c o m p a ra tiv e stu d ie s o f, 969, 1115, 1897, 2660; c o n tin u in g e f f e c ts fro m, 168, 1063, 1898, 2107; e a rly re a c tio n to , 399, 613, 1269, 1737, 2111, 2702; and e co n o m ic c h a n g e, 1781; and e d u c a tio n, 1445, 2322, 2692, 2693; and e f f e c t on W est, 1145, 1466, 1467; fo re the llin g o f, 756, 2244, 2514; and in flu e n c e on d e c o ra tiv e a r ts, 2062; and land a lie n a tio n, 1339, 1342, 1536, 2580; and m issio n arie s, 220, 414, 1496; and s tr e s s re su ltin g fro m, 341, 555, 592, 1118, 1549, 1550; and tra n s fo rm a tio n, 2461, 2477. See also C u ltu re; D ep o p u latio n; D iseases; H a w a iia n s O v e rse as; K apu sy s the m; M ental h e a lth; M o rality; S ociety W ilcox, R o b e rt (D e le g a the to C o n g re ss), 1663, 1879, 2048, 2469; as a n e w sp a p erm a n, 1778; o b itu a ry o f, 2074; as a the a c h e r, 1445.

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Of the 114 patients included in the study cholesterol uptake by cells cheap generic ezetimibe canada, 63 were treated with microdiscectomies and 51 received macrodiscectomies cholesterol definition medical ezetimibe 10 mg with amex. Patients treated with microdiscectomy had smaller incisions and showed a statistically significantly greater improvement in muscle power content of cholesterol in shrimp order 10 mg ezetimibe visa, lower nar- There is insufficient evidence to make a recommendation for or against the performance of aggressive discectomy or sequestrectomy for the avoidance of chronic low back pain in patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery cholesterol grams chart order ezetimibe 10mg with mastercard. Grade of Recommendation: I (Insufficient Evidence) Barth et al1,2 reported results of a prospective study comparing microdiscectomy with sequestrectomy in patients with lumbar disc herniation and radiculopathy. Self-rated assessment deteriorated over two years in discectomy patients but improved in sequestrectomy patients. The authors concluded that reherniation rates were similar two years after microdiscectomy or sequestrectomy. The authors concluded that microdiscectomy allows more return to work and function with less narcotic use than open surgery. There is insufficient evidence to make a recommendation for or against the use of medial facetectomy to improve the outcomes for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. Grade of Recommendation: I (Insufficient Evidence) Abramovitz et al6 performed a prospective comparative study evaluating the indications for and efficacy of lumbar discectomy with or without facetectomy, stratified by preoperative risk factors. Outcomes were assessed at 12 months for the 740 patients included in the study, with three-month data available and presented for 533 patients. Use of the operating microscope improved outcome in patients with one to two predictors of favorable outcome but worsened outcome in patients with five to six predictors. The meaning of these findings relative to the use of the operating microscope is speculative. Epstein et al7 performed a retrospective comparative study to determine and compare indications and benefits of varying surgical approaches to far lateral lumbar disc herniation. Of the 174 patients included in the study, 73 were treated with complete facetectomy, 39 with laminotomy with medial facetectomy and 58 with intertransverse discectomy. No difference in outcomes, defined as the percentage of patients with good or excellent results, was seen between the surgical treatment subgroups. The authors concluded that the three surgical procedures yielded near comparable outcomes in patients with far lateral disc herniations. Ryang et al8 described a retrospective comparative study comparing the efficacy of lateral transmuscular and combined interlaminar/paraisthmic approach to treat lateral lumbar disc herniation. Of the 48 patients included in the study, 28 were treated with a combined interlaminar/paraisthmic approach and 20 with a lateral transmuscular approach. Outcomes were assessed between 18 and 37 months using Ebling criteria and assessing pain in the lower back, along with consideration of radicular, sensory or motor deficits. There was a statistically significant improvement in overall excellent outcomes in the lateral transmuscular group. Even though 100% of back pain resolved in both groups, the patients treated with the combined approach had a 21% incidence of new back pain. The authors concluded that a lateral transmuscular approach leads to overall better outcomes and is the preferred choice at their institution. There is insufficient evidence to make a recommendation for or against the specific surgical approach for far lateral disc herniations in patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. Grade of Recommendation: I (Insufficient Evidence) There is insufficient evidence to make a recommendation for or against the use of tubular discectomy compared with open discectomy to improve the outcomes for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. Grade of Recommendation: I (Insufficient Evidence) Note: For purposes of this guideline, the work group defined tubular discectomy as a discectomy procedure in which a tubular retractor is used to access the herniation. This usually involves making a smaller incision than with a traditional open microdiscectomy procedure and involves direct visualization of the disc and or nerve roots by naked eye and or microscope/loupe magnification. Of the 328 patients included in the study, 167 were treated with tubular discectomy and 161 with conventional discectomy. During the entire follow-up period, no statistical difference was found in the Roland Morris Disability scores between the two surgical treatment groups. The authors concluded that the expected treatment benefit of faster recovery after tubular discectomy could not be demonstrated in this study. Pain and recovery rates were superior in the patients treated with conventional discectomy. This study provides Level I therapeutic evidence that conventional discectomy produces similar results to tubular discectomy in functional outcome as assessed by the Roland Morris Disability score. Recovery rate and improvement in back and leg pain are superior in patients treated with conventional discectomy with no differences in hospital stay or blood loss. There were no differences between patient groups with regard to functional outcome measures in medium and long term outcomes although there were some trends for improved pain control in the first few days after surgery in the group in the steroid group.