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Adjuvant radiotherapy versus combined sequential chemotherapy followed by radiotherapy in the treatment of resected nonsmall cell lung carcinoma. A randomized trial of 267 patients. GETCB (Groupe d'Etude et de Traitement des Cancers Bronchiques)
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Reconstruction After Skin Cancer
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METHODSFrom October, 1982, to November, 1986, 267 patients with resected NSCLC were included in a randomized trial. The adjuvant allocated treatments were either postoperative radiotherapy, 60 Gy in 6 weeks (radiotherapy group = 129 patients), or three courses of postoperative COPAC (cyclophosphamide, doxorubicin, cisplatin, vincristine, lomustine) chemotherapy followed by a similar radiotherapy schedule (chemotherapy/radiotherapy group = 138 patients).RESULTSThe sex ratio (M:F) was 19/1; mean age was 57 +/- 9 years. According to postoperative staging, 8 patients were Stage I, 70 were Stage II, and 189 were Stage III. The histologic type was squamous cell carcinoma in 175 patients, adenocarcinoma in 57, and large cell carcinoma in 35. The minimum follow-up was 6 years. Four patients were lost to follow-up. Death was recorded in 233 patients. No significant difference was observed in terms of disease free interval (P = 0.47, log-rank test), or overall survival (P = 0.68, log-rank test). With respect to the first site of relapse, distant metastasis occurred more frequently in the radiotherapy group (P = 0.09, log-rank test) whereas local relapse occurred similarly in both groups (P = 0.27). An interaction was observed between lymph node involvement and treatment in terms of overall survival.CONCLUSIONSThe COPAC chemotherapy as postoperative treatment failed to improve overall survival in patients with resected NSCLC receiving postoperative radiotherapy but decreased the pattern of metastatic progression, mainly in the N2 patients.BACKGROUNDThe effect of adjuvant chemotherapy after resection of nonsmall cell lung cancer (NSCLC) remains an unresolved question.
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Recent approaches to periodontal therapy
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Periodontal diseases encompass a variety of disease classifications, all involving inflammation of the supporting tissues of the teeth. When progressive, these diseases ultimately lead to the destruction of attachment apparatus including bone and periodontal ligament, culminating in eventual tooth loss. Inflammation extends from superficial gingival structures, effecting adjacent submerged bone and periodontal ligament. Progression modifies an initially highly favourable, reversible diagnosis of gingivitis to a less favourable, somewhat irreversible situation: periodontitis. Periodontal diseases manifest variable and sometimes unpredictable prognoses, are generally somewhat complicated and costly to treat and often require long-term follow-up for maintenance and monitoring. Treatment aims at restoration of health and control of future disease within a functional, albeit reduced, periodontium. In the strictest sense, periodontal diseases are not 'cured'. The conventional, usually successful, approach to the treatment of patients with gingivitis or chronic periodontitis has involved non-surgical mechanical periodontal therapy [1,2]. Some patients manifest localised or generalised continuous attachment loss and periodontal destruction. These sites are prime candidates for alternative therapeutic regimens. This review highlights some of the recent advances in periodontal therapy and evokes some questions that should be addressed during future studies
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Hereditary amyloidosis: evidence against early amyloid deposition
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Twelve members of the Indiana hereditary amyloidosis type II kindred were tested for the presence of amyloid deposits. All were young adults (age 26-37), with no evidence of disease and with 1 affected parent. Six were found to be carriers of the variant gene, by DNA testing and/or reduced serum retinol-binding protein levels. Nevertheless, no amyloid could be found in any skin, rectal, or carpal tunnel biopsy specimens. Our results suggest that hereditary amyloidosis type II is a true late-onset disease, in which accumulation of amyloid does not start until late in life--perhaps only a short time before symptoms appear
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Chemokine receptor CCR6 as a prognostic factor after hepatic resection for hepatocellular carcinoma
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MSTS 2018 - Femur Mets and MM
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BACKGROUND AND AIMS: Chemokines and their receptors have recently been shown to have major roles in cancer metastasis. The aim of this study was to determine whether the interaction between chemokine receptor 6 (CCR6) and its ligand, macrophage inflammatory protein-3 alpha (MIP-3alpha), correlates with metastasis of hepatocellular carcinoma (HCC).
METHODS: To observe the reaction of CCR6 expressed cancer cells to MIP-3alpha stimulation, chemotactic and actin polymerization assays for both CCR6 high cells (HepG2) and CCR6 low cells (MCF-7) were performed. CCR6 mRNA levels in tumor specimens from 30 HCC patients were quantified by real-time polymerase chain reaction. Patients were classified into two groups, high (>or= 20 copies; n=10) CCR6 and low (<20 copies; n=20) CCR6 on the basis of CCR6 expression, and the groups were compared with respect to clinicopathological features.
RESULTS: When HepG2 cells (CCR6 high) were stimulated with MIP-3alpha, they migrated in a dose-dependent manner, and formation of pseudopodia was observed. These phenomena were not observed in the CCR6 low cells. The incidence of intrahepatic metastasis was higher in the high CCR6 expression group than in the low CCR6 expression group (P<0.05). Disease-free survival was significantly poorer in the high CCR6 expression group than in the low CCR6 expression group (P<0.05).
CONCLUSIONS: It was indicated that CCR6 might be associated with intrahepatic metastasis of HCC and might be able to become one of the prognostic factor after hepatic resection for HCC.
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Microbiology of the infected total joint arthroplasty
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Infection associated with arthroplasty is a relatively rare event, but when it does occur, it is of major consequence for the patient. Many organisms can cause these infections, but most are the results of gram-positive bacteria, with the genus Staphylococcus accounting for at least 50%. Streptococcus and aerobic gram-negative bacilli are responsible for another significant percentage. The ability of the organism to produce a slime or glycocalix extracellular layer seems to be a contributing virulence factor for prosthesis-associated infections. Growth, identification, and susceptibility testing of the etiologic agent are performed by the microbiology laboratory, but antimicrobial treatment is usually only successful after removal of the prosthesis
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Open pelvic fracture: an injury for trauma centers
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DoD LSA (Limb Salvage vs Amputation)
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Twenty-seven blunt trauma patients with open pelvic fracture who were seen in a trauma center over a 10-year period were characterized for treatment and resource consumption. Age, injury severity score, mortality, mechanism of injury, associated injuries, blood requirement, length of stay (LOS), surgical procedures, and complications were analyzed. There was a mean of 26 units of blood transfused, 9 operative procedures, and LOS of 43 days. Associated injuries were common. Aggressive hemorrhage and sepsis control, including 2 hemipelvectomies, resulted in an overall survival rate of 85%, with no mortality occurring in the last 20 patients. The reduced mortality obtained in the treatment of this highly resource consumptive injury suggests that open pelvic fracture should be managed at a trauma center, where these resources are immediately available.
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Subtrochanteric femoral fractures: A comparative study of the long proximal femoral nail and the long trochanteric fixation nail
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Management of Hip Fractures in the Elderly
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Subtrochanteric femoral fractures are expected to increase in the coming years. Despite the improvement of implants and surgical techniques, failures due to complications are still considerable. This article reports a retrospective review of patients who showed a subtrochanteric femoral fracture and who were treated consecutively with the Long Proximal Femoral Nail (LPFN) from January 2001 to August 2004, or with the Long Trochanteric Femoral Nail (LTFN) from January 2005 to January 2008. A total of 43 patients with 44 subtrochanteric femoral fractures were included in the study: 23 were treated with the LPFN and 21 with the LTFN. The number of complications related to the LPFN was eight (two re-interventions) against only one related to the LTFN (no re-interventions). haemoglobin decrease was on average higher in the group treated with the LPFN (35.5 g/L) than with the LTFN (30.4 g/L), and so was the number of patients needing for red blood cell concentrates transfusion (15 and 9, respectively). Mortality at the sixth-month follow up was higher in the group treated with the LTFN. The average surgery time was similar in both groups. The percentage of patients capable of walking within the first postoperative week was similar in both groups as well as time to discharge and the consolidation time. Both the LPFN and the LTFN are reliable implants for the treatment of subtrochanteric fractures of the femur. New features related to the LTFN might decrease the number of complications as well as the need for red blood cell concentrates transfusion. (copyright) Springer-Verlag 2010
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Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post COVID-19 World
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Coronavirus Disease 2019 (COVID-19)
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OBJECTIVES: 1. To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. 2. To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 level 1 trauma centers, 1 university-based tertiary-care referral hospital, and 1 orthopedic specialty hospital. PATIENTS/PARTICIPANTS: 1278 patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The STTGMAORIGINAL score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared to STTGMAORIGINAL where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% of deaths in the minimal and low risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 day mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 day mortality. COVID-19 patients who are symptomatic on presentation to the ED and undergo surgical fixation have a 30% inpatient mortality rate compared to 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk-assessment models. These patients should be considered high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
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Oblique Lateral Closing-Wedge Osteotomy for Cubitus Varus in Skeletally Immature Patients
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: We perform an oblique lateral closing-wedge osteotomy of the distal end of the humerus to correct cubitus varus deformity in children. This deformity is often the consequence of undertreatment, malreduction, or malunion of supracondylar humeral fractures(1). Although standard arcs of motion may be altered, cosmesis was traditionally considered a primary surgical indication. However, uncorrected cubitus varus leads to posterolateral rotatory instability of the elbow (PLRI)(2), lateral condylar fractures(3), snapping medial triceps, and ulnar nerve instability(4). A contemporary understanding of these delayed sequelae has expanded our current indications. Detailed parameters predictive of late sequelae are needed to further specify surgical indications. DESCRIPTION: We remove an oblique lateral closing wedge from the distal end of the humerus via a standard lateral approach. The osteotomy is angled away from the varus joint line such that lateral cortices after reduction lack prominence. Kirschner wires provide adequate fixation in young patients. In older children, extension is simultaneously corrected, and fragments are stabilized via plate osteosynthesis. ALTERNATIVES: Patients who decline surgery are counseled regarding risks of delaying treatment until symptoms are present. PLRI manifests as lateral elbow pain or instability while rising from a chair. Once symptomatic, the lateral ulnar collateral ligament (LUCL) is irreversibly attenuated and morphologic changes in the ulnohumeral joint necessitate more extensive surgery to include distal humeral osteotomy, LUCL reconstruction, and possibly ulnar nerve transposition(5). Alternative osteotomy techniques are described and categorized as simple lateral closing wedge, step-cut(6-9), dome, 3-dimensional(10), or distraction osteogenesis. Simple closing-wedge osteotomies include a distal cut parallel to the joint line and retain a problematic lateral prominence (if the medial cortex is intact or the distal end of the humerus is not translated medially)(11,12). Step-cut osteotomies theoretically minimize this lateral prominence while enhancing inherent stability. However, these additional cuts mandate wide surgical exposure despite similar outcomes(13). Three-dimensional planning employs computed tomography to create expensive anatomic cutting guides that address varus, extension, and internal rotation. However, residual internal rotation is generally well tolerated, derotation is associated with loss of fixation, and the extension deformity will successfully remodel in patients who are <10 years old(14). We employ 3-dimensional planning in skeletally mature patients with complex deformity and no remodeling potential. RATIONALE: The oblique lateral closing wedge is ideal for skeletally immature patients because it is simple, reproducible, and efficient. It avoids the lateral prominence without increasing complexity or complications.
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Neuromuscular complications of acromegaly
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Seventeen consecutive acromegalic patients were evaluated for evidence of neuromuscular dysfunction and followed for 1 year after hypophysectomy. Before treatment, four patients had both a myopathy and the carpal tunnel syndrome, five had myopathy alone, four had carpal tunnel syndrome alone, and four had neither. The myopathy was characterized by mild, strictly proximal weakness and flabbiness of muscles; electromyography revealed typical myopathic abnormalities, but serum enzymes and muscle biopsy usually were normal. The presence of myopathy or the carpal tunnel syndrome could not be correlated with the magnitude of growth hormone elevation or any secondary endocrine derangement, but myopathy was associated with a longer duration of acromegaly. Carpal tunnel symptoms usually improved in the first 6 weeks after hypophysectomy, while myopathy improved more slowly and sometimes was detectable 1 year later
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New developments in post-transplant maintenance treatment of multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Treatment of multiple myeloma (MM) has evolved significantly over the past two decades with high-dose chemotherapy and autologous stem cell transplant (ASCT), incorporating novel therapies such as proteasome inhibitors (PIs) and immunomodulatory drugs (IMiDs) during induction and post-transplant maintenance therapies. We reviewed the evolution of maintenance therapy from traditional chemotherapy, interferon (IFN), and prednisone to the current use of thalidomide, lenalidomide, and bortezomib in the post-transplant maintenance setting. Based on existing literature, either thalidomide or lenalidomide can be recommended for maintenance therapy post-transplant resulting in improved progression- free survival (PFS) and overall survival (OS). Thalidomide is less tolerated than lenalidomide and does not improve survival in patient subgroups who had achieved at least a very good partial response (VGPR) or who had chromosome 13 deletion. Thalidomide maintenance may be even detrimental in patients with high-risk cytogenetics. Alternatively, lenalidomide maintenance improves PFS in all subgroups of patients including those achieving at least a VGPR and those with high-risk cytogenetics, and improves OS in one other study. Bortezomib maintenance improves PFS and OS as part of induction and maintenance when compared to thalidomide maintenance and it is uncertain as to whether this improvement was due to bortezomib used during induction. The future research in maintenance therapy may include incorporation of current novel agents and testing new oral agents such as pomalidomide, or ixazomib or antibody therapy with elotuzumab. © 2013 Elsevier Inc.
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The excess risk of major osteoporotic fractures in hypothyroidism is driven by cumulative hyperthyroid as opposed to hypothyroid time: An observational register-based time-resolved cohort analysis
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AAHKS (2) Corticosteroids
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The long-term relationship between hypothyroidism and fracture risk is challenging to dissect because of the modifying influence of subsequent thyroxine replacement with the potential for excessive replacement doses. We studied changes in serum thyrotropin concentration (TSH) over time and association with fracture risk in real-world patients presenting with elevated TSH. All TSH determinations were done in the same laboratory, which served all hospitals and general practices. The study population consisted of all adults with a first measurement of TSH >4.0 mIU/L (n = 8414) or normal TSH (n = 222,138; comparator). We used a Cox proportional hazards analysis incorporating additional time-dependent covariates to represent initiation of thyroxine replacement and cumulative number of periods with high versus low TSH after index date with a mean follow-up of 7.2 years. Elevated baseline TSH was not associated with an increased risk of hip fracture (HR 0.90; 95% CI, 0.80 to 1.02) or major osteoporotic fractures (HR 0.97; 95% CI, 0.90 to 1.05), nor was subsequent thyroxine prescription predictive of increased risk of fractures. The number of subsequent 6-month periods with low TSH - suggesting excessive thyroxine dosing - was significantly associated with increased risk of both hip fracture (HR 1.09; 95% CI, 1.04 to 1.15) and major osteoporotic fracture (HR 1.10; 95% CI, 1.06 to 1.14). When gender- and age-stratified analyses for major osteoporotic fractures were undertaken, hyperthyroid time was identified as a predictor of fracture risk in postmenopausal women whereas hypothyroid time predicted increased fracture risk in men below age 75 years. In conclusion, among patients who present with an elevated TSH, the long-term risk of hip and other osteoporotic fractures is strongly related to the cumulative duration of periods with low TSH - likely from excessive replacement. An independent effect of elevated TSH could only be observed in young and middle-aged men, suggesting gender-discrepant consequences on risk.
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Treatment of Colles' fracture. A prospective comparison of three different positions of immobilization
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Distal Radius Fractures
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The usual treatment of Colles' fracture, i.e. fracture of the distal radius with dorsal angulation of the distal fragment, is closed reduction and immobilization in a plaster cast. The position of the forearm in the cast varies, according to the reports of various authors. Forty-two extra-articular-fractures of the distal radius have been randomly divided into three groups. All were reduced, and the forearms were then immobilized in three different positions of rotation according to the grouping. The study indicates that the position of the forearm during immobilization is of importance as regards redislocation. After application of a plaster cast with the forearm in pronation there seems to be less likelihood of redislocation occurring than when the forearm is immobilized in supination (P less than 0.05).
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Imaging in early posttraumatic complex regional pain syndrome: a comparison of diagnostic methods
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Distal Radius Fractures
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OBJECTIVES: The complex regional pain syndrome type I (CRPS I) still is difficult to diagnose in posttraumatic patients. As CRPS I is a clinical diagnosis the characteristic symptoms have to be differentiated from normal posttraumatic states. Several diagnostic procedures are applied to facilitate an early diagnosis, although their value for diagnosing posttraumatic CRPS I is unclear.
METHODS: One hundred fifty-eight consecutive patients with distal radial fracture were followed up for 16 weeks after trauma. To assess the diagnostic value of the commonly applied methods a detailed clinical examination was carried out 2, 8, and 16 weeks after trauma in conjunction with bilateral thermography, plain radiographs of the hand skeleton, three phase bone scans (TPBSs), and contrast-enhanced magnetic resonance imaging (MRI). All imaging procedures were assessed blinded.
RESULTS: At the end of the observation period 18 patients (11%) were clinically identified as having CRPS I and 13 patients (8%) revealed an incomplete clinical picture which were defined as CRPS borderline cases. The sensitivity of all diagnostic procedures used was poor and decreased between the first and the last examinations (thermography: 45% to 29%; TPBS: 19% to 14%; MRI: 43% to 13%; bilateral radiographs: 36%). In contrast a high specificity was observed in the TPBS and MRI at the eighth and sixteenth-week examinations (TPBS: 96%, 100%; MRI: 78%, 98%) and for bilateral radiographs 8 weeks after trauma (94%). The thermography presented a fair specificity that improved from the second to the sixteenth week (50% to 89%).
DISCUSSION: The poor sensitivity of all tested procedures combined with a reasonable specificity produced a low positive predictive value (17% to 60%) and a moderate negative predictive value (79% to 86%). These results suggest, that those procedures cannot be used as screening tests. Imaging methods are not able to reliably differentiate between normal posttraumatic changes and changes due to CRPS I. Clinical findings remain the gold standard for the diagnosis of CRPS I and the procedures described above may serve as additional tools to establish the diagnosis in doubtful cases.
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Second-Look Arthroscopic Evaluation of Cartilage Lesions After Mesenchymal Stem Cell Implantation in Osteoarthritic Knees
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Cartilage regenerative procedures have been receiving increased interest because of their potential to alter the progression of osteoarthritis (OA). The application of mesenchymal stem cells (MSCs) has been proposed as a new treatment option for OA based on the ability of these cells to differentiate into chondrocytes.
PURPOSE: To investigate the clinical and second-look arthroscopic outcomes of MSC implantation and to identify prognostic factors associated with this treatment.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: This study retrospectively evaluated 37 knees examined using second-look arthroscopic surgery after MSC implantation for cartilage lesions in OA knees. Clinical outcomes were evaluated according to the International Knee Documentation Committee (IKDC) score and Tegner activity scale, and cartilage repair was assessed using International Cartilage Repair Society (ICRS) grading. Statistical analyses were performed to identify various prognostic factors associated with the clinical and second-look arthroscopic outcomes.
RESULTS: The mean patient age was 57.4 years (range, 48-69 years), the mean follow-up period was 26.5 months (range, 24-34 months), the mean body mass index (BMI) was 26.3 kg/m2 (range, 19.8-31.2 kg/m2), and the mean lesion size was 5.4 +/- 2.9 cm2 (range, 2.3-8.9 cm2). The mean IKDC and Tegner activity scale scores were significantly improved from 38.0 +/- 7.8 to 61.0 +/- 11.0 and from 2.5 +/- 0.5 to 3.6 +/- 0.7, respectively (P < .001 for both). According to the ICRS overall repair grades at second-look arthroscopic surgery, 2 of the 37 lesions (5%) were grade I (normal), 7 (19%) were grade II (near normal), 20 (54%) were grade III (abnormal), and 8 (22%) were grade IV (severely abnormal). In terms of overall patient satisfaction with the operation, 33 (94%) patients reported good to excellent satisfaction. High BMI (>=27.5 kg/m2) and large lesion size (>=5.4 cm2) were found to be significant predictors of poor clinical and arthroscopic outcomes (P < .05 for both). Other prognostic factors, including patient age, sex, cartilage lesion location, and presence of subchondral cysts, did not significantly influence the outcomes (P > .05).
CONCLUSION: The outcomes of MSC implantation for cartilage repair in OA knees seem encouraging; high BMI and large lesion size are important factors affecting outcomes. Although still in the early stages of application, MSC implantation for cartilage repair may have great potential for the treatment of OA knees. However, second-look arthroscopic findings revealed that 76% had the repair rated as abnormal or severely abnormal by ICRS standards. The development of an advanced surgical procedure with tissue-engineered scaffolds may be needed to treat patients with large cartilage lesions.
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Early perioperative complication rates and subsidence with the Tribute® short cementless, tapered stem in primary total hip arthroplasty
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Hip Fx in the Elderly 2019
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This study examined early perioperative complications and subsidence following total hip arthroplasty (THA) with a short femoral stem. A retrospective review of 207 consecutive patients (247 hips) having undergone THA via the direct anterior approach produced only six perioperative complications: two intraoperative fractures, three perioperative femur fractures and one dislocation. Subsidence greater than 5 mm was observed in four hips but subsidence did not progress greater than 3 mm at the latest follow-up. Based on these results, cementless THA though the direct anterior approach with a short femoral stem provides a clinical and radiographic advantage while maintaining low complication rates.
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Managing bone loss in men with locally advanced prostate cancer receiving androgen deprivation therapy
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MSTS 2018 - Femur Mets and MM
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Purpose: We reviewed the pathogenesis, diagnosis, prevalence, prevention and treatment of bone loss in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy. Materials and Methods: Using PubMed® we performed a comprehensive literature search to identify articles on bone mineral density loss in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy. Pertinent articles were reviewed and evaluated. Results: Bone mineral density loss and related fractures were recently established as significant adverse events associated with androgen deprivation therapy. Patients with nonmetastatic prostate cancer receiving androgen deprivation therapy experience annual bone mineral density losses of 0.6% to 4.6% with the most significant loss within year 1 of therapy. In addition to calcium and vitamin D supplements, current treatment options for androgen deprivation therapy induced bone loss include synthetic estrogens, selective estrogen receptor modulators and bisphosphonates. Recent safety concerns have been identified, including renal dysfunction with intravenous bisphosphonates and osteonecrosis of the jaw with oral and intravenous bisphosphonates. However, minimal renal dysfunction and no cases of osteonecrosis of the jaw have been reported in this setting. Conclusions: Because the most significant bone mineral density loss occurs within year 1 of androgen deprivation therapy and most fractures in healthy men occur in those without osteoporosis, early intervention is warranted to prevent skeletal morbidity in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy. Although the majority of and the most compelling evidence supports the use of bisphosphonates for preventing and treating androgen deprivation therapy induced bone loss, further study is needed to define the optimal regimen, timing of initiation and duration of therapy as well as long-term efficacy and safety. Copyright © 2008 by American Urological Association.
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Wheels-in-line roller skating injuries
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Distal Radius Fractures
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Injuries sustained by patients using wheels-in-line roller skates were reviewed in a survey of 57 cases collected by the Roosevelt Hospital Hand Service and 444 cases compiled by the Consumer Product Safety Commission. Most patients were novice skaters in the second and third decades of life. Severe distal radius fractures and upper extremity soft-tissue trauma were the most common injuries in both groups. The distal radius (44.9%), scaphoid (13.9%), and radial head (10.4%) were the three most common fracture sites in the Roosevelt survey. Most (80%) skaters in this group did not wear protective equipment. In-line roller skating can and does produce disabling injuries. Also, several deaths were reported among skaters traveling in heavy traffic. To reduce the number of injuries, all skaters should wear protective gear, especially wrist and elbow pads. Splints reduce but do not eliminate the potential for trauma. In our study most injured skaters had not mastered controlled skating and stopping techniques. This new recreational sport is increasing in popularity and more injuries are expected if skaters fail to protect themselves properly.
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Upper cervical spine injuries: age-specific clinical features
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Management of Hip Fractures in the Elderly
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BACKGROUND: There are few reports on the age-specific clinical features of upper cervical spine injury. To identify these age-specific changes, we reviewed 103 patients with upper cervical spine injury. METHODS: We subdivided the patients into four groups according to age: 12 patients were classified as old elderly (> or = 75 years), 18 patients as young elderly (65-74 years), 67 patients as young adults (18-64 years), and 6 patients as adolescents (< or = 17 years). Data were collected on injury etiology, mortality, neurological deficit, distribution and pattern of injury, degenerative changes of each joint in the upper cervical spine and disc in the cervical spine, and osteoporosis of the axis. RESULTS: The proportion of patients with a simple fall as the etiology of their injury showed a statistically significant trend to increase with aging. Although no specific distribution or pattern of injury was statistically elucidated, we were able to detect some common features. A high proportion of the old elderly group (5/12) had a type II odontoid fracture. Body fracture of the axis tends to be frequent in the young elderly and traumatic spondylolisthesis and hyperextension teardrop fracture to be frequent in the young adults. In adolescents, a traffic accident as an unbelted rear seat passenger was the most frequent etiology. Among the 103 patients, 16 died during the initial hospitalization. The mortality rate for upper cervical spine injury was similar in all groups. CONCLUSIONS: In the old elderly, stiffness of the lower cervical spine, caused by degenerative changes and osteopenia, might contribute to upper cervical spine injury in response to low-energy trauma. The disproportion of degenerative change in joints of the upper cervical spine might also contribute to the high frequency of type II odontoid fracture. In young adults, high-energy and hyperextension injury was the most frequent cause of upper cervical spine injury
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Comparison of oral versus sublingual piroxicam during postoperative pain management after lower third molar extraction
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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In this study, 53 patients received piroxicam, administered orally or sublingually, after undergoing removal of symmetrically positioned lower third molars, during two separate appointments. This study used a randomized, blind, cross-over protocol. Objective and subjective parameters were recorded for comparison of postoperative results for 7 days after surgery. Patients treated with oral or sublingual piroxicam reported low postoperative pain scores. The patients who received piroxicam orally took a similar average amount of analgesic rescue medication compared with patients who received piroxicam sublingually (p > 0.05). Patients exhibited similar values for mouth opening measured just before surgery and immediately following suture removal 7 days later (p > 0.05), and showed no significant differences between routes of piroxicam administration for swelling control during the second or seventh postoperative days (p > 0.05). In summary, pain, trismus and swelling after lower third molar extraction, independent of surgical difficulty, could be controlled by piroxicam 20 mg administered orally or sublingually and no significant differences were observed between the route of delivery used in this study. (copyright) 2010 International Association of Oral and Maxillofacial Surgeons
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Lymphedema and lipedema - an overview of conservative treatment
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Panniculectomy & Abdominoplasty CPG
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Lymphedema and lipedema are chronic progressive disorders for which no causal therapy exists so far. Many general practitioners will rarely see these disorders with the consequence that diagnosis is often delayed. The pathophysiological basis is edematization of the tissues. Lymphedema involves an impairment of lymph drainage with resultant fluid build-up. Lipedema arises from an orthostatic predisposition to edema in pathologically increased subcutaneous tissue. Treatment includes complex physical decongestion by manual lymph drainage and absolutely uncompromising compression therapy whether it is by bandage in the intensive phase to reduce edema or with a flat knit compression stocking to maintain volume.
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Relationship between aerobic capacity, injury risk and tenure for new-hire delivery drivers
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DoD PRF (Psychosocial RF)
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Over a 2-year study period, aerobic capacity was measured at time of hire for 1419 delivery drivers. Injury experience and tenure were then monitored for these new-hires during that same period. Number of strain injuries, time to first strain and time to termination were regressed on aerobic capacity adjusting for tenure. Statistically significant, monotonically changing relationships were found for all three outcome variables. A unit increase in aerobic capacity was predicted to result in a 3.7% decrease in injury rate and a 1.1% decrease in risk of termination. When age was included in the model for time to termination, aerobic capacity was no longer a significant predictor. The findings regarding injury experience and aerobic capacity support National Institute for Occupational Safety and Health recommendations that individuals should work at no more than 21â??30% of their aerobic capacity. Statement of Relevance: Knowledge of the nature of the relationship between aerobic capacity, injury experience and retention allows the ergonomist to determine whether there is a point of diminishing returns in intervention effectiveness for higher levels of aerobic capacity. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Is the prevalence of the medication-related osteonecrosis of the jaws underestimated, evaluation in oncological and non-oncological disease
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MSTS 2018 - Femur Mets and MM
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OBJECTIVES: The purpose of this study was to evaluate the prevalence of medication-related osteonecrosis of the jaw in Slovak population and compare the literature findings, whether the prevalence of MRONJ is underestimated.
BACKGROUND: Antiresorptive drugs significantly increase quality of life, although during therapy, or in post-treatment period, osteonecrosis of the jaws might occur as a severe adverse effect. Medication-related osteonecrosis of the jaws (MRONJ) is a severe problem that has been observed in the past few years.
METHODS: This multi-centric study evaluates the prevalence in Slovak population, assesses the values from 4 largest centres of maxillofacial surgery in Slovakia (1166 patients with MRONJ) and provides the comparison of literature review.
RESULTS: Between 2010-2015, there was increasing number of newly diagnosed patients with MRONJ (1166 overall MRONJ patients) annually, except 2012 (mean growth of 123.88 %). This finding was supported by a statistical analysis of the rising tendency of prevalence in literature, where there was a significant difference in prevalence of non-oncologic patients before and after 2010 t(15) = 2.725, p = 0.016. The 6-year prevalence was 1.34 % in population with antiresorptive drugs intake, for osteoporosis 0.47 %, for breast cancer 4.10 %, prostate cancer 3.99 % and multiple myeloma 21.26 %.
CONCLUSION: This study considers that there is a significant rising tendency of MRONJ in non-oncological patients, what could be caused by underestimation of the risk for development MRONJ in these patients. There should be a better cooperation and information among dentists and doctors indicating the antiresorptive treatment and strong emphasis on primary prevention before the initial treatment even in non-oncological patients (Tab. 5, Fig. 7, Ref. 69).
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0 |
Osteochondritis dissecans of the lateral femoral condyle following total resection of the discoid lateral meniscus
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AMP (Acute Meniscal Pathology)
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PURPOSE: The purpose of this study was to describe the clinical presentation of 6 athletically active children with symptomatic osteochondritis dissecans (OCD) of the lateral femoral condyle following total resection for a torn discoid lateral meniscus and to discuss its cause.
TYPE OF STUDY: Case series.
METHODS: Six patients in whom OCD affecting the lateral femoral condyle developed after total resection of the discoid lateral meniscus participated in a detailed clinical, radiologic, and arthroscopic review. The average age at the time of meniscectomy was 9 years (range, 6 to 12 years). At a mean of 50 months (range, 36 to 65 months) after surgery they developed recurrent pain in the treated knee; all had radiologic abnormalities at the lateral femoral condyle consistent with OCD. Before the recurrence of pain, all patients had been continuously engaged in sports activity. Radiologic and arthroscopic findings of the OCD lesions were assessed. Clinical outcomes of surgical treatment for OCD were also documented.
RESULTS: The radiographic evaluation showed all lesions to be in the central portion of the lateral femoral condyle on the anteroposterior views and posteriorly next to a line extending distally from the posterior femoral cortex on the lateral views. Arthroscopic evaluation revealed softening in 2 knees, a separated fragment in 2 knees, and a completely loose fragment in 2 knees. All lesions were treated surgically, including 2 drillings of the lesion, 2 fixations of separated fragment, and 2 excisions of loose bodies with drilling. At an average follow-up period of 51 months (range, 22 to 77 months), all patients but 1 were asymptomatic.
CONCLUSIONS: Repeated impaction in sports activities on the immature osteochondral structures under altered mechanical force transmission after total resection of the discoid meniscus might be a predisposing factor in the development of OCD in the lateral femoral condyle.
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0 |
Compartment syndrome after pressurized infusion
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DOD - Acute Comp Syndrome CPG
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We report two cases of compartment syndrome caused by extravasation of infused fluids and suggest a rationale for management and treatment based upon slit catheter monitoring of pressure in the compromised compartments.
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0 |
Mid-term results of large diameter heads on cross-linked polyethylene liners in total hip replacement
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PJI DX Updated Search
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BACKGROUND: Highly cross-linked polyethylene liners in total hip replacement (THR) have allowed the use of larger diameter femoral heads. Larger heads allow for increased range of motion, decreased implant impingement, and protection against dislocation. The purpose of this study is to assess the clinical and radiographic outcomes of patients with large femoral heads THR at 4 years postop. MATERIALS AND METHODS: Study includes 28 patients who had a primary THR with a 36 mm larger femoral head were retrospectively for minimum 4 years follow-up. All patients received a cementless acetabular shell and a highly cross-linked polyethylene liner with an inner diameter of 36 mm. The median radiographic follow-up was 4 years (range 2.0-6.0), and patients were assessed clinically by Harris hip score. RESULTS: The mean follow-up is minimum 4 years (range 2-6 years) results in all operated patients showed marked improvement in Harris hip score from preoperative mean 49.1 to 89.9 at 4 years or more follow-up. The complications include superficial infection (n = 2). No dislocation, or no osteolysis was seen in the pelvis or proximal femur, and no components failed due to aseptic loosening. There was no evidence of cup migration, screw breakage, or eccentric wear on the liner. CONCLUSION: The mid-term results in this series of patients with LDH using 36 mm femoral head articulating with highly cross linked polyethylene showed excellent clinical, and radiological results, in terms of, joint restoration that replicates the natural anatomy, optimized range of motion without impingement & reduced opportunity for postoperative dislocation
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1 |
Clinical Management in Early OA
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PRP (Platelet-Rich Plasma)
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Knee osteoarthritis affects an important percentage of the population throughout their life. Several factors seem to be related to the development of knee osteoarthritis including genetic predisposition, gender, age, meniscal deficiency, lower limb malalignments, joint instability, cartilage defects, and increasing sports participation. The latter has contributed to a higher prevalence of early onset of knee osteoarthritis at younger ages with this active population demanding more consistent and durable outcomes. The diagnosis is complex and the common signs and symptoms are often cloaked at these early stages. Classification systems have been developed and are based on the presence of knee pain and radiographic findings coupled with magnetic resonance or arthroscopic evidence of early joint degeneration. Nonsurgical treatment is often the first-line option and is mainly based on daily life adaptations, weight loss, and exercise, with pharmacological agents having only a symptomatic role. Surgical treatment shows positive results in relieving the joint symptomatology, increasing the knee function and delaying the development to further degenerative stages. Biologic therapies are an emerging field showing early promising results; however, further high-level research is required.
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0 |
Could the bone mineral density (T-score) be correlated with the Raman spectral features of keratin from women's nails and be used to predict osteoporosis?
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Hip Fx in the Elderly 2019
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Osteoporosis is a disease with great importance in current public health due to the associated risk of fracture; therefore, a rapid and accurate diagnosis becomes increasingly important. Recent literature has described a possible relationship between the changes in the organic phase of bone and the changes in nail keratin measured through Raman spectroscopy, aiming at the development of a standard for measuring bone quality and fracture risk both rapid and accurately. This work evaluated the correlation between the bone mineral density (BMD) scores of women with and without osteoporotic disease with the changes in the Raman spectra of the nail keratin, by assessing the intensity of the peak at 510 cm(-1) (S-S bridge) and the scores of principal component analysis (PCA), correlated with the values of BMD measured at the lumbar and hip. Raman spectra of ex vivo fingernails of 213 women were obtained by means of a dispersive Raman spectrometer (830 nm, 300 mW, in the spectral range between 400 and 1,800 cm(-1)). Peak intensities at ~510 cm(-1) (assigned to the keratin S-S bridge) were measured, and the scores of first principal component loading vectors were calculated. Results showed no differences in the mean Raman spectra of nails of groups with and without osteoporosis. No correlation was found between the BMD scores and both the intensities of the 510 cm(-1) peak and the scores of the first four principal component vectors. Results suggest that BMD and fracture risk could not be assessed by the nail keratin features.
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1 |
Comparison of the Clinical Effectiveness of Single Versus Multiple Injections of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-analysis
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PRP (Platelet-Rich Plasma)
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Background: Reports have concluded that platelet-rich plasma (PRP) is an effective and safe biological approach in the treatment of knee osteoarthritis (OA). However, no consensus has been established regarding the number of injections required to observe a therapeutic effect.
Purpose: To compare the clinical effectiveness reported in randomized controlled trials (RCTs) of single versus multiple PRP injections in the treatment of knee OA.
Study Design: Systematic review; Level of evidence, 1.
Methods: A comprehensive search was conducted for RCTs published between 1970 and 2019 that compared the effect of single versus multiple PRP injections on pain and functionality in patients with knee OA. Searched databases included MEDLINE, Scopus, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. A data extraction form was designed to obtain bibliographic information of the study as well as patient, intervention, comparison, and outcomes of interest data. A random-effects model was used to pool quantitative data from the primary outcomes.
Results: We included 5 clinical trials with a low-moderate risk of bias that reported data for 301 patients. Meta-analysis showed that, at 6 months after the intervention, single and multiple (double or triple) injections had similar pain improvement, with no significant differences (standardized mean difference [SMD], 0.61 [95% CI, -1.09 to 2.31]; I <sup>2</sup> = 97%; P = .48). A significant improvement in knee functionality was observed in favor of multiple injections (SMD, 2.29 [95% CI, 0.45-4.12]; I <sup>2</sup> = 97%; P = .01). Subanalysis showed that the significant improvement was only evident for the results of single versus triple injections (SMD, 3.12 [95% CI, 0.64-5.60]; I <sup>2</sup> = 97%; P = .01).
Conclusion: According to our results, a single injection was as effective as multiple PRP injections in pain improvement; however, multiple injections seemed more effective in joint functionality than a single injection at 6 months. We consider that the available evidence is still insufficient, and future research on this specific topic is needed to confirm our results.
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0 |
Complications related to sedation and anesthesia for interventional pain therapies
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Aim. The use of sedation with invasive pain management procedures is increasingly prevalent. This paper discusses the inherent risks associated with sedation that is too deep as well as general anesthesia for these procedures. Methods. This article provides numerous illustrations of the risks associated with sedation for invasive procedures and explains other disadvantages of sedation and general anesthesia in this context. Conclusion. Sedation for invasive procedures cannot be considered benign and the risks of sedation should be discussed with the patient along with the risks of the procedure itself. (copyright) 2008 by American Academy of Pain Medicine
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0 |
Implementation of locking compression plate together with intramedullary fibular graft in atrophic type humeral nonunions
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DoD SSI (Surgical Site Infections)
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Objective: This study aims to report the results of locking compression plate along with intramedullary fibular graft that was implemented in patients with the diagnosis of nonunion of humerus diaphysis. Materials and methods: Five patients, operated between 2000 and 2009 for atrophic type nonunion of humeral diaphysis, were included in this study. Two patients were women (40%) and three were men (60%). The mean age was 49.2 years. Nonunion was found to be on the right humerus of 3 patients and on the left side of 2 patients. Causes of fractures were traffic accident in 2 cases, simple fall in 2 cases, and fall from height in 1 case. Mean duration after the elementary fracture was 70 months. Nonunion was diagnosed at 1/3 proximal humeral diaphysis in 2 patients, 1/3 distal humeral diaphysis in 2 patients, and 1/3 middle humeral diaphysis in one patient. Initially, conservative treatment was chosen for 3 cases and plate-screw osteosynthesis for 2 cases. Results: Complete union was obtained in all cases radiologically. Mean union time was 20.1 weeks. With a mean of 1.78 cm, shortening was detected in comparative radiographies of both humeri. Mean range of motion at the elbow was 118° in flexion-extension arch of patients. The mean Constant-Murley score was 88 points. There was no complication regarding the operation and graft donor sites. Conclusion: The management of atrophic type humeral nonunions is difficult. The method that we practice in such patients is a reliable treatment option with its stabile fixation and high union rates. © Springer-Verlag 2011.
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1 |
Time to peak torque and acceleration time are altered in male patients following traumatic shoulder instability
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Trial Systematic Review Project
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Background: Numerous authors have evaluated the strength of the rotator cuff muscles in patients with shoulder instability. However, only limited data are available with regard to neuromuscular control in patients with traumatic anterior shoulder instability, in particular at 90° of abduction. This study was designed to assess muscle strength and neuromuscular control ability using time to peak torque and acceleration time in nonathletic patients with traumatic anterior shoulder instability. Methods: Isokinetic muscle performance testing was performed in 20 male nonathletic anterior shoulder instability patients compared with 20 side-matched asymptomatic volunteers. Isokinetic muscle performance testing was performed at an angular velocity of 180°/s with 90° of shoulder abduction. Muscle strength and neuromuscular control (time to peak torque and acceleration time) of the internal rotators (IRs) and external rotators (ERs) were measured. Results: There were no significant differences in muscle strength of the IRs and ERs between the 2 groups. The injured shoulder showed delayed neuromuscular control in both the IRs and ERs in the instability patients compared with the normal control subjects (time to peak torque, P =.023 for IRs and P =.020 for ERs; acceleration time, P =.035 for IRs and P =.021 for ERs). Conclusion: The neuromuscular control of both the IRs and ERs was decreased in male nonathletic patients with traumatic anterior shoulder instability even though muscle strength was not altered. Therefore, clinicians and therapists should implement exercises that aim to restore neuromuscular control in the rehabilitation of nonathletic patients with anterior shoulder instability.
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0 |
Knee Joint Distraction Compared with High Tibial Osteotomy and Total Knee Arthroplasty: Two-Year Clinical, Radiographic, and Biochemical Marker Outcomes of Two Randomized Controlled Trials
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Both, knee joint distraction (KJD) and high tibial osteotomy (HTO) are joint-preserving surgeries that postpone total knee arthroplasty (TKA) in younger osteoarthritis (OA) patients. Here we evaluate the 2-year follow-up of KJD versus TKA and KJD versus HTO in 2 noninferiority studies.
DESIGN: Knee OA patients indicated for TKA were randomized to KJD ( n = 20; KJD<sub>TKA</sub>) or TKA ( n = 40). Medial compartmental knee OA patients considered for HTO were randomized to KJD ( n = 23; KJD<sub>HTO</sub>) or HTO ( n = 46). Patient-reported outcome measures were assessed over 2 years of follow-up. The radiographic joint space width (JSW) was measured yearly. In the KJD groups, serum-PIIANP and urinary-CTXII levels were measured as collagen type-II synthesis and breakdown markers. It was hypothesized that there was no clinically important difference in the primary outcome, the total WOMAC, when comparing KJD with HTO and with TKA.
RESULTS: Both trials were completed, with 114 patients (19 KJD<sub>TKA</sub>; 34 TKA; 20 KJD<sub>HTO</sub>; 41 HTO) available for 2-year analyses. At 2 years, the total WOMAC score (KJDTKA: +38.9 [95%CI 28.8-48.9] points; TKA: +42.1 [34.5-49.7]; KJDHTO: +26.8 [17.1-36.6]; HTO: +34.4 [28.0-40.7]; all: P < 0.05) and radiographic minimum JSW (KJDTKA: +0.9 [0.2-1.6] mm; KJDHTO: +0.9 [0.5-1.4]; HTO: +0.6 [0.3-0.9]; all: P < 0.05) were still increased for all groups. The net collagen type-II synthesis 2 years after KJD was increased ( P < 0.05). Half of KJD patients experienced pin tract infections, successfully treated with oral antibiotics.
CONCLUSIONS: Sustained improvement of clinical benefit and (hyaline) cartilage thickness increase after KJD is demonstrated. KJD was clinically noninferior to HTO and TKA in the primary outcome.
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0 |
Case report of bone mastocytosis: Total hip arthroplasty for osteoarthritis and open reduction for condylar fracture of the knee
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Surgical Management of Osteoarthritis of the Knee CPG
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A 72-year-old woman was admitted in 1984 for painful protrusive osteoarthritis of the left hip diagnosed as systemic mastocytosis with bone lesions and clinical features of intestinal malabsorption but no clinical skin lesion. The total hip replacement, refused in a first step because of the bone pathology, was carried out two years later. Signs of loosening appeared after one year. In 1990, following a traumatic bicondylar fracture of the left knee, an osteosynthesis was carried out. Ten days later, a shaft pathologic fracture of the femur above the osteosynthesis plate implied another open reduction. Two and a half years later, the patient is able to walk short distances, using walking sticks, and lives at home receiving social assistance
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0 |
Patellofemoral arthroplasty: the third compartment
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Surgical Management of Osteoarthritis of the Knee CPG
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Isolated arthritis on the patellofemoral articulation has received minimal attention in the past. It is now recognized to be relatively common, especially in women. Treatment alternatives such as patellectomy, unloading osteotomies, debridement, and cartilage transplant have not offered long-term sustainable benefits. Therefore, there is a need for a reliable patellofemoral arthroplasty. The current indications for surgery include middle-aged patients with isolated patellofemoral arthritis without severe maltracking, inflammatory arthritis, crystalline arthropathy, femorotibial arthritis, or high demands. Reports show 60% to 80% good-to-excellent results in the short term and midterm. The main problems with patellofemoral arthroplasty have been patellar instability and patellar edge loading on the condylar cartilage in flexion. Newer designs are addressing both issues and are leading to improved results
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0 |
Intentional nonadherence due to adverse symptoms associated with antiretroviral therapy
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Reduction Mammoplasty for Female Breast Hypertrophy
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Objective: To estimate the frequency and possible predictors of patient-mediated intentional alterations in antiretroviral medication regimens in direct response to symptoms associated with antiretroviral therapy use. Design: Cross-sectional survey of a population-based dynamic cohort of antiretroviral recipients in a province-wide HIV drug treatment program, the only source of free-of-charge antiretroviral medications in the province of British Columbia. Methods: Program participants voluntarily complete program surveys on an annual basis. Study subjects were those who responded to the annual treatment program survey between January 1 and November 1, 2001. Patients reported on the occurrence and severity of symptoms of 42 side effects of antiretroviral agents. Symptoms were classified into four subgroups based on whether they were considered subjective or objective and whether they would or would not prompt clinical action. For each of the four symptom categories, patients reported what their physician recommended in response to symptoms in that group and what the patient actually did in response to these same symptoms. Intentional nonadherence was defined as reporting either skipping or altering dosages of selective regimen components or temporary cessation of therapy that was not recommended by the physician in response to adverse drug effects in the past year. Results: Of 638 study subjects, 70 (11%) reported intentional nonadherence with between 4% and 7.4% reporting this activity over the preceding year depending on the symptom group. Multivariate analysis revealed that a plasma viral load of <400 copies/mL (adjusted odds ratio [AOR], 0.35; 95% CI, 0.21-0.61) and completion of high school (AOR, 0.43; 95% CI, 0.24-0.78) were both inversely associated with intentional nonadherence. Those subjects reporting at least one severe symptom were more than twice as likely to report intentional nonadherence (AOR, 2.24; 95% CI, 1.16-4.33). Similarly, each additional symptom considered to be objective and to require clinical action was associated with a 25% increase in the risk of intentional nonadherence (AOR, 1.25; 95% CI, 1.10-1.43). Conclusion: Intentional nonadherence to antiretroviral therapy is common among persons experiencing therapy-related side effects. Although the type and severity of adverse effects impact intentional nonadherence, this activity occurs in relation to symptoms regardless of their strict clinical relevance.
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0 |
Heparin-induced thrombocytopenia: a complication of thromboprophylaxis
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Management of Hip Fractures in the Elderly
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Heparin is a drug widely used for thromboprophylaxis or treatment in many clinical situations. However, it can cause serious adverse effects, including thrombocytopenia, which is a potentially life-threatening condition. Unfortunately, heparin-induced thrombocytopenia is generally under-recognised and under-diagnosed. A case of heparin-induced thrombocytopenia occurring in a post-operative orthopaedic patient in association with prophylactic low-molecular-weight heparin is described
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0 |
Acute Compartment Syndrome: Update on Diagnosis and Treatment
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DOD - Acute Comp Syndrome CPG
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Acute compartment syndrome can have disastrous consequences. Because unusual pain may be the only symptom of an impending problem, a high index of suspicion, accurate evaluation, and prophylactic treatment will allow the physician to intervene in a timely manner and prevent irreversible damage. Muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible. Ischemic injury begins when tissue pressure is 10 to 20 mm Hg below diastolic pressure. Therefore, fasciotomy generally should be done when tissue pressure rises past 20 mm Hg below diastolic pressure.
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0 |
Glenohumeral relationships: subchondral mineralization patterns, thickness of cartilage, and radii of curvature
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Glenohumeral Joint OA
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Subchondral mineralization represents the loading history of a joint and can be measured in vivo using computed tomography osteoabsorptiometry. Different mineralization patterns in the glenohumeral joint have been explained by the principle of physiologic incongruence. We sought to support this explanation by measurement of mineralization, radii, and cartilage thickness in 18 fresh shoulder specimens. We found three mineralization patterns: bicentric, monocentric anterior, and monocentric central. Mean radii of the glenoids were 27.4 mm for bicentric glenoids, 27.3 mm for monocentric anterior, and 24.8 mm for monocentric central glenoids. Cartilage thickness measurement revealed the highest values in anterior parts; the thinnest cartilage was found centrally. Our findings support the principle of a physiologic incongruence in the glenohumeral joint. Bicentric mineralization patterns exist in joints consisting of more flat glenoids compared to the corresponding humeral head. Monocentric distribution with a central maximum was found in specimens with glenoids being more curved, indicating higher degrees of congruence, which might represent an early stage of degenerative disease. The obtained information might also be important for implant fixation in resurfacing procedures or to achieve the best possible fit of an osteochondral allograft in the repair of cartilage defects.
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0 |
Pattern noise (PANO): a new automated functional glaucoma test
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Upper Eyelid and Brow Surgery
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PURPOSE: To present a newly developed visual field device (pattern noise: PANO) designed to be sensitive to glaucoma defects, cost-effective, material-practical and easy to repair and therefore particularly suited for low-income countries, where glaucoma can be highly prevalent (e.g. sub-Saharan Africa). METHODS: This is primarily a descriptive paper, but it also includes a prospective matched case-control pilot study. Hardware, stimulus, target configuration, testing strategy and result sheet are described. The main outcome measure is the contrast level (range 2-64). Targets are composed of bright/dark pixels flickering with 18 Hz and have a size of 5 degrees . Pixel size is approximated to the hill of vision. Average luminance of targets is constant and equals background luminance.The study was performed in the West Region in Cameroon. Twenty eyes of 20 newly presenting patients with glaucomatous optic disc cupping on funduscopy were compared with 20 eyes of 20 normal patients matched in age and laterality of eye. RESULTS: Mean age was 32.9 +/- 18.8 years for glaucoma patients and 32.2 +/- 15.6 years for healthy subjects. Mean contrast threshold was significantly higher in eyes with abnormal disc (16.2 +/- 14.3 vs. 4.4 +/- 0.8, P = 0.002). Correlation of mean contrast thresholds and cup-to-disc ratio was significant (r = 0.59; P = 0.006). Average examination time was significantly longer for glaucoma eyes compared to healthy eyes (8.2 vs. 6.1 min, P < 0.001), whereas error rate did not differ (4.8 +/- 2.5% vs. 4.1 +/- 1.8%, P = 0.33). CONCLUSION: PANO demonstrated visual field defects in patients with glaucomatous optic disc. Defects correlated significantly with glaucomatous optic nerve head morphological alterations. Healthy eyes obtained normal results. More studies are needed to establish PANO.
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1 |
The salvage of open grade IIIB ankle and talus fractures
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DoD LSA (Limb Salvage vs Amputation)
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Between 1983 and 1989, 11 open grade IIIB ankle or talus fractures were treated according to protocol including debridement, temporary placement of antibiotic beads, soft tissue coverage (including seven free vascular tissue transfers), intravenous antibiotics and fusion using an anterior plate, and bone graft. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2/patient (range: 5-12). The total in-patient hospital stay averaged 61.6 days (20-107 days) and in patient costs averaged $62,174.43/patient (range: $33,535.06-$143,847.45). Overall hospital cost averaged $1,009.32/day. Follow-up averaged 47.8 months (range 32-85 months), with an average time to union of 4.4 months. Fusion rate and muscle flap success was 100%. Although fusion and eradication of infection in this specific group of patients was possible, significant functional and psychosocial disability remained. Eight of eleven patients had significant pain, difficulty with stairs, and limited ambulation. All changed jobs or were unemployed. Patients with open grade IIIB tibiotalar injuries with significant bone loss may therefore benefit from early amputation. A multicenter randomized clinical outcome study is needed.
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0 |
Compressive neuropathy in the upper limb
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Entrampment neuropathy or compression neuropathy is a fairly common problem in the upper limb. Carpal tunnel syndrome is the commonest, followed by Cubital tunnel compression or Ulnar Neuropathy at Elbow. There are rarer entities like supinator syndrome and pronator syndrome affecting the Radial and Median nerves respectively. This article seeks to review comprehensively the pathophysiology, Anatomy and treatment of these conditions in a way that is intended for the practicing Hand Surgeon as well as postgraduates in training. It is generally a rewarding exercise to treat these conditions because they generally do well after corrective surgery. Diagnostic guidelines, treatment protocols and surgical technique has been discussed
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0 |
Cost analysis of dental services needed before hematopoietic cell transplantation
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVE: Streptococcal bacteremia occurs during hematopoietic cell transplantation (HCT), and treatment of active oral disease may reduce this risk. The objective of this study was to determine the type, number, and costs of pre-transplantation dental procedures in this population. STUDY DESIGN: Data were collected retrospectively from the records of patients who were to undergo HCT. The type, number, and costs of dental procedures were determined based on median charges of MassHealth (the Medicaid program in Massachusetts) and also on the median "usual and customary" fees charged by dentists in Massachusetts. RESULTS: A total of 405 patients were evaluated. There were 243 men (60%) and 162 women, with a median age of 53 years. The median and average costs (in US dollars) of dental treatment before HCT were $275 and $384, respectively, for patients covered by MassHealth and $368 and $522, respectively, for those with private insurance, adjusted to 2012 levels. CONCLUSIONS: Dental evaluation before HCT is an economical way for patients to minimize the risk of localized infection and possibly reduce the risk of bacteremia that may prolong the length of hospitalization
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0 |
Wrist position in closed reduction of fractured carpal scaphoid. An experimental observation
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Distal Radius Fractures
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Experimental observation on the relation between the apposition of scaphoid fracture surfaces and wrist position showed that fracture reduction could be achieved when the wrist was placed in a position from 15 degrees radial deviation to 15 degrees ulnar deviation provided that the wrist assumed certain amount of extension. The principle was that the more the wrist was radially deviated, the more the extension was needed. Fracture displacement occurred regularly and could be classified into three types, which were related to different loading patterns on the distal scaphoid.
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0 |
Results of open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable pelvic ring injuries: retrospective study of 36 patients
|
DoD SSI (Surgical Site Infections)
|
Introduction: Surgical stabilization of posterior pelvic ring fractures can be achieved by closed reduction and percutaneous fixation (CRPF) or by open reduction and internal fixation (ORIF). The aim of the present study is to compare the clinical results of both methods. Material and methods: Medical records of 36 patients consecutively operated for unstable pelvic ring injuries were retrospectively reviewed. We compared 22 patients treated with CRPF versus 14 patients stabilized by using ORIF between 2007 and 2017. The Majeed and Pohlemann scores were used to evaluate postoperative functional outcomes. Complications like blood loss, infection rate, Neurological injury, the operative time and the length of hospital stay were analyzed. Results: The median Majeed pelvic score was 87 points for the CRPF technique compared with 69 points for the ORIF technique. The median Pohlemann score, operative time and length of hospitalization were similar between the two groups. The median blood loss for the CRPF technique was 300 ml compared to 500 ml for the ORIF technique. CRPF and ORIF procedure had each one neurological lesion. There was one case of infection in the ORIF group and none in the CRPF group. No measurements except for the blood loss have reached the significance threshold. Conclusion: The CRPF technique shows a clear decrease in blood loss. There was no statistically significant difference in the functional results, infection rate, neurological injury, operative time and hospital stay between both techniques.
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0 |
Are continuous femoral nerve catheters beneficial for pain management after operative fixation of tibial plateau fractures? A randomized trial
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AAHKS (9/10) Regional Nerve Blocks
|
Purpose: Continuous femoral and sciatic nerve blocks diminish pain and narcotic requirements after total knee arthroplasty. While sciatic block is contraindicated after plateau fractures in order to allow clinical evaluation of compartment syndrome, femoral nerve blocks may help in pain management as this block affects the anterior part of the knee. The purpose of this study was to determine whether a continuous femoral nerve block after open reduction and internal fixation of tibial plateau fractures would diminish visual analog scale (VAS) scores and/or systemic narcotic intake. Methods: Adult patients with operatively treated tibial plateau fractures were randomized to either a control group (standard of care using an IV morphine patientâ?controlled analgesia [PCA]) or to the experimental group (a continuous infusion femoral nerve block [bupivacaine] in addition to the same PCA pump). The primary outcomes were pain and narcotic use. VAS pain scores were obtained at 4, 8, 12, 24, 36, 48, and 72 hours postoperatively and narcotic use was evaluated as morphine equivalents. Statistical analysis included Fisherâ??s exact test for categorical variables and t tests for continuous variables. Results: 42 patients were enrolled in this study. There were 21 women and 21 men aged 21â?70 years (average, 49) with operatively treated tibial plateau fractures. 21 patients were randomized to receive a femoral nerve block with 5 crossovers for technical reasons. Accordingly, we analyzed 16 patients with femoral nerve blocks and 26 with standard care. There were no significant differences between the study groups regarding age, gender, or fracture type. There was no significant difference in VAS scores between the control and experimental group at any time point (Fig. 1). The total systemic morphine equivalent for the femoral block group and the control group was 375 and 397, respectively (P = 0.76, Fig. 2). Across groups, patients with bicondylar fractures tended to have higher VAS scores than those with unicondylar fractures and to use more narcotics although neither was statistically significant. Conclusion: Femoral nerve blocks for postoperative pain management in tibial plateau fractures did not demonstrate an improvement in pain relief or narcotic use.
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0 |
Antibiotic prophylaxis of infective endocarditis in dentistry: clinical approach and controversies
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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PURPOSE: Infective endocarditis (IE) in high-risk patients is a potentially severe complication which justifies the administration of antibiotics before invasive dental treatment. This literature review presents the current guidelines for antibiotic prophylaxis and discusses the controversial aspects related to the antibiotic administration for prevention of IE. RESULTS: According to the guidelines of the American Heart Association, individuals who are at risk to develop IE following an invasive dental procedure still benefit from antibiotic prophylaxis. In contrast, the guidelines of the National Institute for Health and Clinical Excellence in England and Wales have recommended that prophylactic antibiotic treatment should no longer be performed in any at-risk patient. Bacteraemia following daily routines such as eating and toothbrushing may be a greater risk factor for the development of IE than the transient bacteraemia that follows an invasive dental procedure. However, a single administration of a penicillin derivate 30 to 60 minutes pre-operatively still represents the main prophylactic strategy to prevent bacteraemia. CONCLUSIONS: Presently, there is not enough evidence that supports and defines the administration of antibiotics to prevent IE. The authors suggest performing a risk-benefit evaluation in light of the available guidelines before a decision is made about administration
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0 |
Epidermal growth factor receptor is associated with the onset of skeletal related events in non-small cell lung cancer
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DoD PRF (Psychosocial RF)
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Background: Bone metastasis and skeletal related events (SREs) are common in non-small cell lung cancer (NSCLC). Patients with mutant epidermal growth factor receptor (EGFR) could benefit from tyrosine kinase inhibitors (TKIs). However, it is unclear whether SRE is influenced by EGFR status. We aimed to evaluate the correlation of EGFR status and TKIs with the incidence of SREs. Methods: We conducted a retrospective study of stage IV NSCLC patients with bone metastasis. Incidence rate of SREs was collected and was compared using chi-square test. Logistic-regression analysis was used to identify the risk factors predicting the incidence of SREs. Results :410 eligible patients were enrolled in the study. 49.0% were detected with EGFR mutation. 49.8% of patients received EGFR-TKIs therapy prior to the onset of SREs. 42.7% experienced at least one SRE. Patients who were treated with TKIs held lower incidence of SREs than patients who were not treated with TKIs (23.5% vs 61.7%, p < 0.001). Multivariate analysis showed that poor performance status (OR 5.550, 95%CI 2.290-13.450; p < 0.001) and mutant EGFR (OR 3.050, 95%CI 1.608- 5.787, p=0.001) were independent risk factors predicting the onset of SREs, while the usage of TKIs (OR 0.102, 95%CI 0.054-0.193, p < 0.001) was a protective factor of SREs in NSCLC patients with bone metastasis. Conclusions: This study indicates that the incidence of SREs is common in both patients with and without EGFR mutation. Poor performance ability and mutant EGFR imply higher risks of SREs, while the usage of TKIs may be a protective factor of SREs. Copyright: Huang et al.
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0 |
Falls in the elderly
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Management of Hip Fractures in the Elderly
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Most falls in older people can be prevented or reduced in frequency if clinicians first begin to view the fall as symptomatic of an underlying problem and, second, perform comprehensive assessments to uncover a multitude of medical, psychological, and environmental factors that may cause falling
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0 |
Variability in the disposition of ibuprofen enantiomers in osteoarthritis patients
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Management of Hip Fractures in the Elderly
|
The pharmacokinetics of the enantiomers of ibuprofen have been investigated following oral administration of 300 or 600 mg of racemic ibuprofen four times daily to 45 patients with osteoarthritis. Fifteen of these patients also received single doses of 300 or 600 mg of racemic ibuprofen. Serum concentrations of R- and S-ibuprofen and urine concentrations of the stereoisomers of ibuprofen and its metabolites were measured by high-performance liquid chromatography. The fraction inverted (F(inv)) of the inactive R- to active S-ibuprofen was estimated by a urinary metabolite method. For the 15 patients in both the chronic and single dose studies, there were no significant differences in the clearance of R-ibuprofen or F(inv). The elimination half-lives of R- and S-ibuprofen were comparable for the single and chronic dosing studies. The area under the curve (AUC) values, 6-h trough concentrations, and average steady state concentrations of the R- and S-enantiomers were statistically different after chronic dosing. Despite considerable variability in the clearances in these patients, e.g., clearance (CL) of R-ibuprofen showed 28-49% CV, much less variability was seen in F(inv) (range 9-19% CV), implying that patients would receive similar effective doses of active S-ibuprofen in spite of large differences in kinetics
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0 |
Correlates of psychological distress following armed robbery
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DoD PRF (Psychosocial RF)
|
Although mental health professionals have long been aware of the impact of traumatic events, it was not until 1980 that the term posttraumatic stress disorder (PTSD) was introduced into the DSM-III. Since then, one major goal of research has been to identify factors associated with distress following trauma; as yet, few reliable indicators have emerged. Within the population of armed robbery victims, this is particularly true. The purpose of this study was to investigate possible correlates of posttrauma distress in armed robbery victims, and to assess the overall level of distress within this group. A questionnaire was mailed out of 57 robbery victims, aged 15 to 65, who were recruited as study volunteers via community outreach. Severity of the trauma, vulnerability attributions, and avoidant coping were significantly related to distress level, and victims exhibited a high level of distress.
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0 |
BIS and Entropy in the elderly
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Management of Hip Fractures in the Elderly
|
The interaction of many poorly defined, physiological, pharmacological, and pathological factors make titration of general anaesthesia in the elderly difficult. There may be a potential clinical benefit using the processed electroencephalogram (EEG) to monitor hypnotic level in this population. We prospectively studied 16 patients aged over 65 years having hip fractures repaired under general anaesthesia by experienced anaesthetists blinded to Bispectral Index (BIS(XP)) and Entropy values. Pre-induction EEG indices did not correlate with age or mini-mental state examination (MMSE). During maintenance of anaesthesia, BIS(XP) and Response Entropy (RE) values were within the recommended range of 40-60, 45% and 32% of the total time, respectively. BIS(XP) and Response Entropy (RE) values were above 60 for 11% and 13% of the total time, respectively, and below 40 for 44% and 55% of the total time, respectively. BIS(XP) correlated well with RE in 12 patients, but in the other four patients there was a difference of more than 20 points between BIS(XP) and RE
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1 |
A comparison of sartorius versus quadriceps stimulation for femoral nerve block: a prospective randomized double-blind controlled trial
|
AAHKS (9/10) Regional Nerve Blocks
|
BACKGROUND: Femoral nerve block is widely used for regional anesthesia and analgesia in many lower limb operations. Peripheral nerve stimulation of the femoral nerve may elicit 1 of 2 responses: contraction of the sartorius muscle through stimulation of its muscular branch or contraction of the quadriceps muscle through stimulation of its respective muscular branches. Historically, a quadriceps response has been preferred. We hypothesized that the success of femoral nerve block using a sartorius muscle evoked motor response is equivalent to that using quadriceps muscle twitch response. This prospective randomized double-blind controlled trial compared sartorius or quadriceps muscle evoked motor response as the end point for stimulation for femoral nerve block.
METHODS: Seventy-two patients scheduled for primary unilateral total knee arthroplasty were randomly assigned to undergo femoral nerve block using either the sartorius or the quadriceps evoked muscle response as an end point of stimulation. Motor block of the femoral and sensory block of the femoral, saphenous, and lateral femoral cutaneous nerves were assessed. The primary outcome was the quality of motor and sensory block of the femoral nerve 30 minutes after injection of 20 mL of 0.5% ropivacaine. Secondary outcomes were duration of femoral nerve block, time required to perform the nerve block, total dose of hydromorphone patient-controlled analgesia, and postoperative pain by visual analog score 24 hours after block insertion. In addition, the spread of local anesthetic and the position of the needle in relation to the femoral nerve were assessed by means of ultrasonography.
RESULTS: There were no statistically significant differences in the proportion of patients with either complete alone or complete and partial block combined between quadriceps and sartorius groups 30 minutes after block insertion; femoral nerve (P = 0.49; P = 0.13), the saphenous nerve (P = 0.64; P = 0.21), or the lateral femoral cutaneous nerves (P = 0.2; P = 0.35). Patient-controlled analgesia hydromorphone consumption was significantly higher in the group that underwent sartorius muscle stimulation ([mean +/- SD] 4.9 +/- 3.6 mg [range, 0-13.2 mg] vs 3.1 +/- 2.7 mg [range, 0-10.0 mg]; P = 0.024).
CONCLUSION: Our study demonstrated that using sartorius or quadriceps evoked muscle twitch as an end point of stimulation was associated with an equivalent degree of femoral nerve block.
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1 |
The Effect of Drains and Compressive Garments Versus Progressive Tensioning Sutures on Seroma Formation in Abdominoplasty
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Panniculectomy & Abdominoplasty CPG
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Seroma is a common problem following abdominoplasty surgery. Both compressive garments with drains and progressive tension sutures have their advocates to minimise seroma formation. This is a retrospective study in which patients underwent an identical surgical procedure, except for use of drains and garments in comparison to progressive tension sutures between 2005 and 2020. Two hundred thirty-two patients were included in the study 61 in the drains and garment group (DG group), and 171 with progressive tension sutures (PTS group) alone. There was a lower incidence of seroma formation in the PTS group (X(2) (1, N?=?232) = 6.35, P = .012). The weight of tissue excised in the PTS group was greater than the DG group (P?<?.001). There was there a significantly higher tissue excision weights for patients who developed a seroma, compared with those who did not (P=.02). Patients, who developed a seroma in the PTS group, had significantly greater excision weights than the DG group. Liposuction did not change the incidence of seroma in each group (X(2) (4, N = 232) = 6.701, P = .08 n/s). This study demonstrates the effectiveness of progressive tension sutures in reducing the incidence of seroma formation following abdominoplasty, particularly when large excision weights are involved. The addition of small volume liposuction distant to the abdominal flap does not increase the incidence of seroma formation.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Solvent-free fabrication of micro-porous polyurethane amide and polyurethane-urea scaffolds for repair and replacement of the knee-joint meniscus
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AMP (Acute Meniscal Pathology)
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New porous polyurethane urea and polyurethane amide scaffolds for meniscal reconstruction have been developed in a solvent-free process. As soft segments, copolymers of 50/50 L-lactide/epsilon-caprolactone have been used. After terminating the soft segment with diisocyanates, chain extension was performed with adipic acid and water. Reaction between the isocyanate groups and adipic acid or water provides carbon dioxide and results in a porous polymer. Extra hydroxyl-terminated prepolymer was added in order to regulate the amount of carbon dioxide formed in the foaming reaction. Furthermore, salt crystals ranging in size from 150 to 355 microm were added in order to induce macroporosity. The pore size was regulated by addition of surfactant and by the use of ultrasonic waves. The resulting porous polymer scaffolds exhibit good mechanical properties like a high-compression modulus of 150 kPa. Chain extension with adipic acid results in better mechanical properties due to better defined hard segments. This results from the lower nucleophilicity of carboxylic acids compared to water and alcohols. By adjusting the reaction conditions, materials in which macropores are interconnected by micropores can be obtained. On degradation only non-toxic products will be released; importantly, the materials were obtained by a simple, reproducible and solvent-free procedure.
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1 |
Comparison between eyelid indices of ptotic eye and normal fellow eye in patients with unilateral congenital ptosis
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Upper Eyelid and Brow Surgery
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PURPOSE: To evaluate the relationship between levator muscle function (LMF) and other eyelid parameters in the normal and affected eyes of patients with unilateral congenital ptosis. METHODS: This study includes subjects with unilateral congenital upper lid ptosis who were referred for operation over a 2-year period. Patients with other eyelid abnormalities and previous eyelid surgery were excluded. Eyelid parameters including LMF, lid fissure height (LFH) and margin reflex distance (MRD) were measured in both eyes and analyzed. RESULTS: A total of 77 patients with mean age of 26.4 +/- 16.4 years were enrolled in the study. Mean LMF was 8.3 +/- 4.6 mm in the ptotic and 13.1 +/- 3.6 mm in the normal fellow eyes. Each millimeter of difference in LMF was associated with 0.30 mm of difference in LFH (95% CI: 0.25-0.35, P < 0.001) and 0.11 mm of difference in MRD of the ptotic eyes (95% CI: 0.08-0.12, P < 0.001) in the same direction. In addition, each millimeter of difference in LMF of ptotic eyes was associated with 0.48 mm of difference (95% CI: 0.33-0.62, P < 0.001) in LMF of non-ptotic eyes in the same direction. CONCLUSION: A direct correlation was observed between LMF, and LFH and MRD in ptotic eyes which confirms the role of levator muscle dysfunction in the development of congenital ptosis and its severity. Furthermore, a direct correlation was also present between LMF of ptotic and non-ptotic eyes suggesting possible bilateral involvement in apparently unilateral congenital ptosis.
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0 |
Effects of 8-bromoadenosine 3':5'-cyclic monophosphate on proteolytic enzymes, adhesiveness and lung-colonizing ability of cloned low-metastatic Lewis lung carcinoma cells
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MSTS 2018 - Femur Mets and MM
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Treatment of cloned low-metastatic Lewis lung carcinoma cells (P-29) with dimethylsulfoxide or butyric acid resulted in enhancement of their lung-colonizing ability. This was accompanied with increases in cathepsin B activity, the production of plasminogen activator, and adhesiveness, mainly heterotypic adhesion (adhesion to monolayers of endothelial cells) of dimethylsulfoxide-treated cells and homotypic aggregation of butyric acid-treated cells. Treatment of P-29 cells with 8-bromoadenosine 3':5'-cyclic monophosphate (8-bromo-cyclic AMP) also resulted in increases in cathepsin B activity and the production of plasminogen activator. However, it did not enhance either heterotypic adhesion or homotypic aggregation of the cells. The lung-colonizing ability of 8-bromo-cyclic AMP-treated P-29 cells was examined after their intravenous injection into male C57BL/6 mice. It was found that these cells did not have enhanced lung-colonizing ability. These results suggest that high activities of proteolytic enzymes such as cathepsin B and plasminogen activator in tumor cells are not sufficient alone for completing the metastatic process, but that other properties of tumor cells such as adhesiveness are also necessary.
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0 |
Thumb reconstruction by micro-vascular techniques
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DoD LSA (Limb Salvage vs Amputation)
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Sixty-three patients with thumb reconstruction by total or partial toe transfer have been reviewed. Mean age was 25 years. Males (84%) and manual workers (76%) dominated the series. The rate of failure was 3%. Second toe transfer gave a functionally acceptable thumb with 10 mm two point discrimination, 59% of strength in pinching (compared to normal side), 30 degrees of range of flexion but with a flessum deformity (average 27 degrees) and a poor cosmesis score (1.5 on a 5 point scale). Partial toe transfers were useful in amputations at metacarpophalangeal (MP) level and distal to this area. Around MP level, three techniques were available: wrap around, Twisted Two Toes and "bipolar" lengthening. More distally a "custom made" transfer allows to match exactly the defect. All of these techniques save the great toe length. When a pulp was incorporated in the transfer, two point discrimination averaged 9 mm and in the entire series the mean pinch strength was 93% normal and the mean cosmetic score was 3.5 points. Partial toe transfers are preferable in cases with any otherwise normal hand, providing good function and better cosmesis.
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1 |
Effects of a diabetes-specific care model for hip fractured older patients with diabetes: A randomized controlled trial
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Hip Fx in the Elderly 2019
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OBJECTIVES: To examine the effects of a diabetes-specific care model for hip fractured elderly with diabetes mellitus (DM).
METHODS: A randomized controlled trial was implemented in a 3000-bed medical center in northern Taiwan. Older adults (age>=60) with DM who had hip-fracture surgery (N=176) were recruited and randomly assigned to diabetes-specific care (n=88) and usual care (n=88). Usual care entailed one or two in-hospital rehabilitation sessions. Diabetes-specific care comprised an interdisciplinary care (including geriatric consultation, discharge planning, and in-home rehabilitation) and diabetes-specific care (including dietary and diabetes education, blood pressure control, dyslipidemia management, a glycemic treatment regimen, and rehabilitation exercises). Outcomes including heart rate variability; rehabilitation outcomes; activities of daily living and instrumental activities of daily living were assessed before discharge and 1, 3, 6, 12, 18, 24months afterwards.
RESULTS: Patients who received diabetes-specific care had significantly higher hip-flexion range of motion (b=5.24, p<.01), peak-force quadriceps strength of the affected limb (b=2.13, p<.05), higher total heart rate variability in terms of the time-domain parameter for the mean squared difference between two adjacent normal R-R intervals (b=11.35, p<.05), and frequency-domain parameters, such as low frequency (b=42.17, p<.05), and the high frequency-to-low frequency ratio (b=0.11, p<.01).
CONCLUSIONS: Our diabetes-specific care model enhanced hip-flexion range of motion, peak quadriceps strength of the affected limb, and overall heart rate variability, indicating dynamic responses to environmental changes during the 24months following hospital discharge, above and beyond the effects of usual care.
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1 |
The role of blood cultures in the acute evaluation of postoperative fever in arthroplasty patients
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The use of blood cultures to work up fever in postarthroplasty patients was studied retrospectively. Four hundred fifty-three patients done consecutively with a diagnosis-related group 209 discharge diagnosis were studied. One hundred patients (22%) had blood cultures drawn for fever greater than 101 degrees F. Specifically, there were 240 total knee arthroplasty patients with 40 blood cultures drawn. There were 124 total hip arthroplasty patients with 31 blood cultures drawn. One patient with a total knee arthroplasty had positive cultures as did one patient with a total hip arthroplasty. Both were thought to be contaminants, and neither had any sequelae. Blood cultures are expensive and do not add relevant information in the care of postarthroplasty patients
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0 |
Acellular Dermal Matrix Reduces Myofibroblast Presence in the Breast Capsule
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Acellular Dermal Matrix
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BACKGROUND: Capsular contracture remains a common complication after implant-based breast reconstruction. Previous work has suggested that the use of acellular dermal matrix (ADM) reduces the rate of capsular contracture, though little is understood about the underlying mechanism. As myofibroblasts are believed to be the key cells implicated in contracture formation, we hypothesized that ADM would result in a reduction in periprosthetic myofibroblast concentration. METHODS: Five patients who underwent immediate prepectoral tissue expander placement with anterior ADM coverage and an inferior cuff were included. At the second stage, tissue samples were obtained of both ADM and capsule from each reconstructed breast. Samples were then prepared for hematoxylin and eosin staining and immunohistochemistry for myofibroblast identification (alpha smooth muscle actin and vimentin positive and desmin negative) and analysis. Experimental values are presented as mean ± SD unless otherwise stated. Statistical significance was determined using unpaired t test. RESULTS: Successful incorporation of ADM was noted in all cases. A significant reduction in myofibroblast concentration was noted in the ADM versus the capsule (P = 0.0018). This was paralleled by significantly thicker periprosthetic capsule formation overlying the formerly raw pectoralis major muscle, that is, not covered by ADM (P < 0.0001). CONCLUSIONS: In the presence of ADM, there are significantly fewer myofibroblasts in breast capsules and thinner capsules on histology. Given the central role of myofibroblasts in the development of clinically significant capsular contracture, this study unmasks a possible mechanism for the protective effect of ADM with respect to capsular contracture development.
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Family, socioeconomic status and health services: Clues to health care in diabetic patients with lower limb amputations in Andalusia. A qualitative study
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DoD LSA (Limb Salvage vs Amputation)
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Aim: To examine the experience of diabetic care in patients undergoing lower limb amputation. Design: A qualitative study using the phenomenological approach. Setting: Cadiz Health District. Participants: A total of 16 patients (11 men and 5 women) diagnosed with diabetes mellitus type 2 and with non-traumatic lower limb amputation. Methods: Semi-structured interviews were performed, followed by a content analysis according Graneheim and Lundman. Results: Four categories were identified: 1. The family is the cornerstone for diabetic care. 2. The socio-economic and working conditions determine the quality of self-care. 3. The patient-health professional interaction facilitates patient care. 4. Limitations in the provision of health services. Conclusion: Family, economic and working conditions, along with health system-related factors are the most important elements in the care of patients with diabetes and amputations. Social, economic and working conditions determine diabetic complications. In order to enhance health care impact on the prevention of diabetes mellitus complications, health system policy makers must take these facts seriously into consideration and in a more personalised manner.
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Association of low birth weight and preterm birth with the incidence of knee and hip arthroplasty for osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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Objectives: Low birth weight (LBW) and preterm birth have been associated with adverse adult outcomes including hypertension, insulin resistance, cardiovascular disease and reduced bone mass. It is unknown whether LBW and preterm birth affect the risk of osteoarthritis (OA). This study aims to examine whether LBW and preterm birth were associated with the incidence of knee and hip arthroplasty for OA. Methods: 3,604 participants of the Australian Diabetes, Obesity and Lifestyle Study who reported their birth weight and history of preterm birth and were aged more than 40 years at the commencement of arthroplasty data collection. The incidence of knee and hip replacement for osteoarthritis during 2002-2011 was determined by linking cohort records to the Australian Orthopaedic Association National Joint Replacement Registry. Results: One hundred and sixteen participants underwent knee arthroplasty and 75 underwent hip arthroplasty for OA. Low birth weight (yes vs. no, HR 2.04, 95% CI 1.11-3.75, p=0.02) and preterm birth (yes vs. no, HR 2.50, 95% CI 1.29-4.87, p=0.007) were associated with increased incidence of hip arthroplasty independent of age, sex, BMI, education level, hypertension, diabetes, smoking and physical activity. No significant association was observed for knee arthroplasty. Conclusions: Although these findings will need to be confirmed, they suggest that individuals born with LBW or preterm are at increased risk of hip arthroplasty for OA in adult life. The underlying mechanisms warrant further investigation. (c) 2014 American College of Rheumatology
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Metabolomic and Lipidomic Profiling of Preoperative CSF in Elderly Hip Fracture Patients With Postoperative Delirium
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Hip Fx in the Elderly 2019
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Objective: To investigate dysregulated molecules in preoperative cerebrospinal fluid (CSF) of elderly hip fracture patients with postoperative delirium (POD), in order to identify potential pathological mechanisms and biomarkers for pre-stage POD.
Materials and Methods: This nested case control study used untargeted metabolomic and lipidomic analysis to profile the preoperative CSF of patients (n = 40) who developed POD undergone hip fracture surgery (n = 10) and those who did not (n = 30). Thirty Non-POD patients were matched to 10 POD patients by age (+/- 2 years) and Mini Mental State Examination score (+/- 2 points). CSF was collected after successful spinal anesthesia and banked for subsequent analysis. On the first two postoperative days, patients were assessed twice daily using the Confusion Assessment Method-Chinese Revision. CSF samples from the two groups were analyzed to investigate possible relevant pathological mechanisms and identify candidate biomarkers.
Results: Demographic characteristics of the groups were matched. Eighteen metabolites and thirty-three lipids were dysregulated in the preoperative CSF of POD patients. Pathway enrichment analysis revealed perturbations in D-glutamine and D-glutamate metabolism; glycerophospholipid metabolism; alanine, aspartate and glutamate metabolism; sphingolipid metabolism; histidine metabolism; and arginine biosynthesis at the pre-delirium stage. Receiver operating characteristic curve analysis indicated that phosphatidylethanolamine (PE, 40:7e), with an area under the curve value of 0.92, is a potential biomarker for POD.
Conclusion: Multiple pathological mechanisms in the POD group were involved before surgery, including neuroinflammation, oxidative stress, and energy metabolism disorders induced by hypoxia, as well as neurotransmitter imbalances such as increased dopamine and glutamate, and decreased glutamine. These metabolic abnormalities potentially increase the fragility of the brain, thus contributing to POD. PE (40:7e) might be a potential biomarker for POD. Not only do our results provide potential biomarkers for POD, but also provide information for deep pathological research.
Clinical Trial Registration: www.ClinicalTrials.gov, identifier ChiCTR1900021533.
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0 |
Computed tomography of knee injuries
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AMP (Acute Meniscal Pathology)
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The knee is the largest and most complex joint in the body and a wide variety of bone and soft tissue injuries are seen in the knee. Trauma to the knee can result in injury to the bone, articular cartilage, meniscus and ligaments. Fractures of the proximal tibia, particularly those that extend into the knee joint, are serious injuries that frequently result in functional impairment. Recent advances in cross-sectional imaging, particularly in computed tomography (CT), have given this modality a prominent role in the detection and classification of fractures in and around the knee. With the advent of high-performance multi-detector CT, isotropic data sets can be generated with subsecond gantry rotation times and submillimetre slice thickness. CT arthrography can clearly demonstrate many lesions in the plethora of internal derangement of the knee. CT arthrography also deserves its advantage as it may be used to evaluate knee injuries in patients where magnetic resonance imaging is contraindicated. In this article we discuss the indications for imaging of knee injuries by CT, present the advantages of multi-detector CT and CT arthrography, and provide examples that highlight the utility of CT in the evaluation of the knee injuries.
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Medial epicondyle fractures of the humerus: how to evaluate and when to operate
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The fundamental principles of fracture care apply to medial epicondyle fractures in that the goals of treatment are to obtain fracture healing and to promote a return of appropriate motion, strength, and stability. Recent studies have revealed limitations of some classically described evaluation methods and have revealed more precise methods of measuring displacement. The authors of this manuscript describe established principles of care and incorporate recent evidence-based articles to help the clinician study the issues relative to the clinical evaluation and the operative and nonoperative treatment of medial epicondyle fractures
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Associations of cardiovascular risk factors, carotid intima-media thickness and manifest atherosclerotic vascular disease with carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: The role of atherosclerosis in carpal tunnel syndrome (CTS) has not previously been addressed in population studies. The aim of this study was to investigate the associations of cardiovascular risk factors, carotid artery intima-media thickness (IMT), and clinical atherosclerotic diseases with CTS. METHODS: In this cross sectional study, the target population consisted of subjects aged 30 or over who had participated in the national Finnish Health Survey in 2000-2001. Of the 7977 eligible subjects, 6254 (78.4%) were included in our study. Carotid IMT was measured in a sub-sample of subjects aged 45 to 74 (N=1353). RESULTS: Obesity (adjusted odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1-5.4), high LDL cholesterol (OR 3.8, 95% CI 1.6-9.1 for >190 vs. <129 mg/dL), high triglycerides (OR 2.7, 95% CI 1.2-6.1 for >200 vs. <150 mg/dL), hypertension (OR 3.4, 95% CI 1.6-7.4) and cardiac arrhythmia (OR 10.2, 95% CI 2.7-38.4) were associated with CTS in subjects aged 30-44. In the age group of 60 years or over, coronary artery disease (OR 1.9, 95% CI 1.1-3.5), valvular heart disease (OR 2.3, 95% CI 1.0-5.0) and carotid IMT (1.4, 95% CI 0.9-2.1 for each 0.23 mm increase) were associated with CTS. Carotid IMT was associated with CTS only in subjects with hypertension or clinical atherosclerotic vascular disease, or in those who were exposed to physical workload factors. CONCLUSIONS: Our findings suggest an association between CTS and cardiovascular risk factors in young people, and carotid IMT and clinical atherosclerotic vascular disease in older people. CTS may either be a manifestation of atherosclerosis, or both conditions may share similar risk factors
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0 |
Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The treatment of entrapment neuropathy in the upper extremity with surgical decompression has generally provided good results. Recurrence of symptoms, however, is not uncommon and its management is both challenging and difficult. Nineteen patients with recurrent carpal tunnel and cubital tunnel syndrome were treated with the vein wrapping technique using the autogenous saphenous vein. The average number of surgeries before vein wrapping was 3.3. The mean patient age was 53 years (range, 28-75 years) and the mean follow-up period was 43 months (range, 24-78 months). All patients reported reduction in pain and the sensory disturbances secondary to the compression of the median or ulnar nerve. Two-point discrimination and electrodiagnostic findings also improved
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1 |
Double contrast arthrography of the knee
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AMP (Acute Meniscal Pathology)
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The author's experience with 280 double contrast knee arthrograms is presented. The accuracy of the procedure in 101 operated cases was 100 percent for normal menisci and 88 percent for abnormal. It is suggested that arthrography can be regarded as an integral part of the investigation of any knee in which a serious meniscal abnormality is suspected.
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0 |
Midfoot crush injuries
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DOD - Acute Comp Syndrome CPG
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Treatment of midfoot injuries is surgical or nonsurgical, depending on the injury, the location, and the extent of the injury. Minor injuries usually heal with casting or bracing, whereas more unstable injuries typically need surgery for stability. Whether the injury is in a weight-bearing portion of the foot is also a consideration for surgery. The importance of treating midfoot injuries adequately is shown in how the midfoot is needed for function with weight bearing and its relationship between the front and the back of the foot. It is also important to ensure that the patient is able to ambulate with a reasonably normal gait.
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0 |
Integrity of the first metatarsophalangeal joint: A biomechanical analysis
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DoD LSA (Limb Salvage vs Amputation)
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Five fresh-frozen cadaver feet obtained from traumatic amputations were tested during hyperdorsiflexion stress of the first metatarsophalangeal joint. Three different types of injury were observed: (1) rupture of the capsule proximal to the sesamoids, (2) rupture of the plantar plate distal to the sesamoids, and (3) rupture of the capsular structures medially, allowing a lateral swing of the sesamoids around the metatarsal head. Incomplete dislocation can be associated with significant damage to the plantar plate and other soft tissues of the foot.
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0 |
Analysis of Bony and Internal Organ Injuries Associated With 26,357 Adult Femoral Shaft Fractures and Their Impact on Mortality
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Pediatric Diaphyseal Femur Fractures 2020 Review
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The spectrum of injuries associated with femoral shaft fractures and those injuries' association with mortality have not been well delineated previously. Patients in the National Trauma Data Bank who presented with femoral shaft fractures from 2011 to 2012 were analyzed in 3 age groups (18-39, 40-64, and 65+ years). For each group, modified Charlson Comorbidity Index (CCI), mechanism of injury (MOI), injury severity score (ISS), and associated injuries were reported. Multivariate logistic regression was used to identify predictors of mortality. Among the 26,357 patients with femoral shaft fractures, modified CCIs gradually increased with increasing age category and ISS decreased. Motor vehicle accidents were the most common MOI in the younger 2 age groups, whereas falls were the most common MOI in the 65 years and older age group. The top 3 associated bony injuries for the study cohort as a whole were tibia/fibula (20.5%), ribs/sternum (19.1%), and non-shaft femur (18.9%, of which 5.8% of the total cohort were femoral neck) fractures. The top 3 associated internal organ injuries were lung (18.9%), intracranial (13.5%), and liver (6.2%), injuries. A multivariate mortality analysis showed that increasing age, increasing comorbidity burden, and associated injuries all had independent associations with mortality. The injuries most associated with mortality were thoracic organ injuries (adjusted odds ratio [AOR]=3.53), head injuries (AOR=2.93), abdominal organ injuries (AOR=2.78), and pelvic fractures (AOR=1.80). This study used a large, nationwide sample of trauma patients to profile injuries associated with femoral shaft fractures. Associations between injuries and mortality underscore the importance of these findings. [Orthopedics. 2017; 40(3):e506-e512.].
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Does Chronic Corticosteroid Use Increase Risks of Readmission, Thromboembolism, and Revision After THA?
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AAHKS (2) Corticosteroids
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BACKGROUND: Systemic corticosteroids are commonly used to treat autoimmune and inflammatory diseases, but they can be associated with various musculoskeletal problems and disorders. There currently is a limited amount of data describing the postoperative complications of THA associated specifically with chronic corticosteroid use.
QUESTIONS/PURPOSES: For chronic corticosteroid users undergoing THA, we asked: (1) What is the risk of hospital readmission at 30 and 90 days after surgery? (2) What is the risk of venous thromboembolism at 30 and 90 days after surgery? (3) What is the risk of revision hip arthroplasty at 12 and 24 months after surgery?
METHODS: We identified patients in the Statewide Planning and Research Cooperative System who underwent primary THA between January 2003 and December 2010. This database provides hospital discharge abstracts for all admissions in the state of New York each year. We used propensity scores to three-to-one match the 402 chronic corticosteroid users with a comparison cohort of 1206 patients according to age, sex, race, comorbidity score, year of surgery, and hip osteonecrosis. The risk of each outcome was compared between chronic corticosteroid users and the matched cohort. Because multiple comparisons were made, we considered p less than 0.008 as statistically significant.
RESULTS: Readmission was more common for corticosteroid users at 30 days (odds ratio [OR], 1.45; 95% CI, 1.14-1.85; p = 0.003) and 90 days (OR, 1.37; 95% CI, 1.09-1.73; p = 0.007). Venous thromboembolism was not more frequent in corticosteroid users at 30 days (OR, 2.39; 95% CI, 1.08-5.26; p = 0.031) or 90 days (OR, 1.91; 95% CI, 1.03-3.53; p = 0.039). Revision arthroplasty was more common in corticosteroid users at 12 months (OR, 2.49; 95% CI, 1.35-4.59; p = 0.004), but not 24 months (OR, 2.04; 95% CI, 1.19-3.50; p = 0.010).
CONCLUSIONS: After THA, chronic corticosteroid use is associated with an increased risk of readmission at 30 and 90 days and revision hip arthroplasty at 12 months in corticosteroid users. Patients and providers should discuss these risks before surgery. Insurers should consider incorporating chronic corticosteroid use as a comorbidity in bundled payments for THA, since this patient population is more likely to return to their provider for care during the postoperative period.
LEVEL OF EVIDENCE: Level III, therapeutic study.
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1 |
Animation Deformity in Postmastectomy Implant-Based Reconstruction
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Acellular Dermal Matrix
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Despite increasing interest in prepectoral implant-based reconstruction to avoid animation deformity (AD), the prevalence of this deformity and patient attitudes toward it have not been extensively studied. The purpose of this study was to report on AD in the breast reconstruction population and identify those at highest risk. METHODS: A retrospective chart review was completed for patients at least 6 months postoperative from subpectoral, implant-based breast reconstruction using acellular dermal matrix in the lower pole. Patient age, BMI, and implant size were collected. A questionnaire was distributed to the patients. Returned questionnaires were compiled and data were analyzed. RESULTS: Eighty-four of 108 patients (77.8%) returned the questionnaire with 62 (75.6%) reporting AD; 75.6% of patients were aware of AD, 14.6% considered it moderate, and 11% considered it severe. No statistically significant differences in age, body mass index, implant size, or athleticism were found between those who noted AD versus those who did not. Forty-one of 79 patients (51.9%) would have been interested in an initial surgical procedure without AD; interest dropped significantly if the alternative surgery involved increased risk, cost, or additional stages of reconstruction. CONCLUSION: The prevalence of AD in subpectoral implant-based breast reconstruction is significantly higher than in subpectoral augmentation. The majority of patients expressed interest in an alternative procedure to avoid AD unless it involved increased risk, cost, or additional surgeries. We found insignificant differences in age, athleticism, BMI, and implant size between patients who note AD and those who do not. Further study is necessary to better define patients at risk for AD to guide patient-centered breast reconstruction.
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0 |
Long-term followup of the bone-ingrowth Ortholoc knee system without a metal-backed patella
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Surgical Management of Osteoarthritis of the Knee CPG
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Between June 1981 and January 1984, 265 Ortholoc-I femoral and tibial components were implanted using bone-ingrowth technique in 202 patients. Five knees (five patients) were lost to followup and 66 knees were excluded because the patients died, leaving 184 knees (165 patients) with 15 to 18 years followup. One knee loosened during the 15- to 18-year followup period and was revised, and five knees were revised for infection. Survival rate at 18 years considering loosening was 98.6%. At 15 years after surgery, 79.9% of patients did not have pain, 10.1% had mild pain, 8% had moderate pain, and 2% had severe pain. At 18 years after surgery, 77.6% did not have pain, 7.2% had mild pain, 5.2% had moderate pain, and 1% had severe pain. Knee flexion was 110 degrees preoperatively and increased to a mean of 115 degrees at 2 years postoperative, then remained unchanged for the rest of the followup. Intramedullary alignment proved to be highly effective, and has become the standard for total knee arthroplasty instrumentation systems. Total knee replacement with bone-ingrowth technique was a reliable and effective means of treating the end-stage arthritic knee. In patients who required revision surgery, excellent bone stock remained and revision with bone-ingrowth technique was accomplished easily
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1 |
Usefulness of prophylactic antibiotics in preventing infection after internal fixation of closed hand fractures
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DoD SSI (Surgical Site Infections)
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Prophylactic antibiotics (PA) have been shown to be ineffective in reducing the incidence of surgical site infection (SSI) in clean wounds associated with elective surgery of the hand. Routine administration of PA for internal fixation of hand fractures is a subject that has been scarcely studied. We hypothesized that PA do not reduce SSI incidence in fixation of closed hand fractures. We did a retrospective comparative study in patients who underwent open or closed reduction and internal fixation of a hand and carpus fracture. Patient demographics, past medical history, fracture characteristics and the type of internal fixation used were extracted from our electronic archives. Follow-up period lasted for 1 year, during which any form of clinically evident SSI, such as pus formation, wound dehiscence and positive bacterial culture was documented. A total of 107 patients met the inclusion criteria, 63 in the control group and 44 in the test group. The overall infection rate was 6.5%. All infections (3 in the control group and 4 in the test group) were pin-tract infections that resolved completely after pin extraction. Our study did not find significant differences between groups (P = 0.442). No specific fracture pattern was associated with increased total infection rate (p = 0.898). In this study, we found no support for routine administration of PA prior to internal fixation of closed fractures of the hand and carpus. PA should still be administered in selected patients, such as those with decreased immunity or open fractures. Further large-scale research is needed to establish proper guidelines, to reduce the adverse effects of antibiotic treatment.
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The development of risk assessment models for carpal tunnel syndrome: a case-referent study
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The present study developed risk assessment models for carpal tunnel syndrome (CTS) which can provide information of the likelihood of developing CTS for an individual having certain personal characteristics and occupational risks. A case-referent study was conducted consisting of two case groups and one referent group: (1) 22 work-related CTS patients (W-CTS), (2) 25 non-work related CTS patients (NW-CTS), and (3) 50 healthy workers (HEALTHY) having had no CTS history. The classification of CTS patients into one of the case groups was determined according to the type of insurance covering their medical costs. Personal characteristics, psychosocial stresses at work, and physical work conditions were surveyed by using a questionnaire tailor-designed to CTS (reliability of each scale > or = 0.7). By contrasting the risk information of each case group to that of the referent group, three logistic regression models were developed: W-CTS/HEALTHY, NW-CTS/HEALTHY, and C-CTS/HEALTHY (C-CTS, the combined group of W-CTS and NW-CTS). ROC analysis indicated that the models have satisfactory discriminability (d' = 1.91 to 2.51) and high classification accuracy (overall accuracy = 83-89%). Both W-CTS/HEALTHY and C-CTS/HEALTHY include personal and physical factors, while NW-CTS/HEALTHY involves only personal factors. This suggests that the injury causation of NW-CTS patients should be attributable mainly to their 'high' personal susceptibility to the disorder rather than exposure to adverse work conditions, while that of W-CTS patients be attributable to improper work conditions and CTS-prone personal characteristics in combination
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Vascular access for hemodialysis: Current practice in Vietnam
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Panniculectomy & Abdominoplasty CPG
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A well-functioning vascular access is a mainstay to perform an efficient hemodialysis procedure, which directly affects the quality of life in hemodialysis patients. We use three main types of access: native arteriovenous fistula, arteriovenous graft, and central venous catheter. Arteriovenous fistula remains the first and best choice for chronic hemodialysis. It is the best access for longevity, the lowest related complications, and for this reason, arteriovenous fistula use is strongly recommended by guidelines from different countries, including Vietnam. In practice, well-functioning arteriovenous fistula creation is not always simple. In this case, arteriovenous fistula creation with vein transposition or translocation is certainly useful. When native vein options have been exhausted, prosthetic can be used as the second option of maintenance hemodialysis access alternatives. Central venous catheters are very common and have become an important adjunct in maintaining patients on hemodialysis. In Bach Mai hospital, we certainly create about 1000 new arteriovenous fistulas every year (among these, about 84.98% new hemodialysis patients start hemodialysis without permanent accesses and depend on temporary central venous catheters) and successfully matured arteriovenous fistula rate is 92.6%. Among hemodialysis population in Bach Mai, 2.29% have arteriovenous grafts and 2.81% of patients still depend on cuffed tunneled catheters. The preferable locations for catheter insertions are the internal jugular and femoral veins. Proper vascular access maintenance requires integration of different professionals to create a vascular access team. Percutaneous transluminal angioplasty is not available. In our circumstance, we have achieved some advantages for hemodialysis patients but still a big gap to an advanced country.
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0 |
Translation and validation of the Oxford-12 Item Knee Score for use in Sweden
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Surgical Management of Osteoarthritis of the Knee CPG
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The Oxford-12 Item Knee Score is a recently developed and validated patient-completed outcome measure designed specifically for use with knee arthroplasty in the United Kingdom. We have translated this questionnaire into Swedish and tested the validity and reliability of the translated version in a cross-sectional study by a postal survey to 1200 randomly selected patients from the Swedish Knee Arthroplasty Register. Swedish versions of the WOMAC, Nottingham Health Profile, SF-36, SF-12, and the Sickness Impact Profile were employed in the validation process. We also tested feasibility and patient-burden parameters. The translated version appeared to be linguistically and culturally equivalent to the original version with good validity and reliability. Indirect measures of responsiveness indicated that it is at least as responsive to relevant knee arthroplasty patient states as the previously validated Swedish version of the WOMAC. Application of the translated questionnaire to this population is feasible with minimal imposed patient-burden. The Swedish translation of the Oxford-12 Item Knee Score is a valid and reliable tool for outcome studies on knee arthroplasty patients
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Penicillin compared with other advanced broad spectrum antibiotics regarding antibacterial activity against oral pathogens isolated from odontogenic abscesses
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Objectives: We examined the spectrum of oral pathogens found in odontogenic abscesses and their susceptibility to penicillin as well as to amoxicillin with clavulanic acid, doxycycline, clindamycin and moxifloxacin. The in vitro results were compared with clinical observations. Patients and methods: One hundred and eighty eight swabs were obtained from 94 patients with odontogenic abscesses. Bacterial strains were isolated for susceptibility tests. The same patients were investigated for their clinical outcome after standard therapy. Results: A total of 517 bacterial strains were isolated from 94 patients. Ninety eight per cent of abscesses were polymicrobial. The most prevalent bacteria were Viridans streptococci representing 54% of the aerobic/facultative anaerobic bacteria. Prevotella spp. comprised 53% of the anaerobes. No multiresistant strains were detected. Susceptibility testing revealed a sensitivity of over 99% of aerobes/facultative aerobes and 96% of anaerobes sensitivity for moxifloxacin. The corresponding values for penicillin were lowest at 61% and 79%, respectively. In the clinical collective, patients with minor abscesses and no risk of further progression received surgical treatment without antibiotics (36%). Penicillin was administered additionally in 30%. Amoxicillin with clavulanic acid was given in 18% and clindamycin in 15%. Ninety two of the 94 patients showed significant recovery with the described treatment. Only in two cases was a change to the latest broader spectrum antibiotics necessary. Conclusion: In contrast to the moderate in vitro results, penicillin successfully treated the pathogens derived from odontogenic abscess sufficiently when adequate surgical treatment was provided. One third of the patients was treated successfully with incision and drainage only. We suggest that one good reason for its clinical efficacy is the susceptibility of the dominant aerobe/facultative aerobe and anaerobe strains to penicillin. (copyright) 2008 European Association for Cranio-Maxillofacial Surgery
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0 |
Update on the treatment of granulomatosis with polyangiitis (Wegener's)
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Reconstruction After Skin Cancer
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Granulomatosis with polyangiitis (Wegener's) (GPA), formerly known as Wegener's granulomatosis, is a systemic vasculitis characterized by involvement of the upper airways, lungs, and kidneys. GPA shares many features with microscopic polyangiitis (MPA), so much so that recent trials have included both vasculitides. This article focuses on GPA only, as complete management includes modalities that are unique to this disease. The current treatment of GPA is stratified based on severity. For those patients who have active but non-severe GPA and do not have contraindications, methotrexate and glucocorticoids can induce and maintain remission. For patients with severe disease, options include glucocorticoids combined with either cyclophosphamide or rituximab. When cyclophosphamide is used, it is given for 3 to 6 months, after which time it is stopped and switched to methotrexate or azathioprine for remission maintenance. In randomized trials, rituximab was found to be as effective as cyclophosphamide to induce remission of severe active GPA. Given the recency of experience with rituximab, there remain a number of questions regarding relapse rate, use of repeat courses, long-term toxicity, and combination with maintenance agents. Until these questions are answered, the choice of whether to use cyclophosphamide or rituximab must be decided between the patient and physician. For patients with relapsing disease who have had prior cyclophosphamide exposure, rituximab is an excellent option. In newly diagnosed patients, the extensive experience with cyclophosphamide and its side effect profile must be weighed against these factors with rituximab. There has been limited experience with rituximab in patients with alveolar hemorrhage requiring mechanical ventilation or rapidly progressive glomerulonephritis requiring dialysis, as these patients were excluded from the largest randomized trial. Until such data become available, cyclophosphamide remains the agent with which there has been the greatest experience for efficacy in these settings. © Springer Science+Business Media, LLC 2012.
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The critical role of the bone microenvironment in cancer metastases
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MSTS 2018 - Femur Mets and MM
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Bone metastatic disease is a late-stage event of many common cancers, such as those of prostate and breast. It is incurable and causes severe morbidity. Tumor and bone interact in a vicious cycle, where tumor-secreted factors stimulate bone cells, which in turn release growth factors and cytokines that act back on the tumor cells. Within the vicious cycle are many potential therapeutic targets for novel treatment of bone metastatic disease. Therapeutic strategies can be oriented to inhibit bone cells (osteoclasts and osteoblasts) or tumor responses to factors enriched in the bone microenvironment. Many publications, especially from pre-clinical animal models, show that this approach, especially combination treatments, can reduce tumor burden and tumor-derived bone lesions. This supports a novel paradigm: tumor growth can be effectively inhibited by targeting the bone and its microenvironment rather than the tumor itself alone. © 2009 Elsevier Ireland Ltd. All rights reserved.
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Differences in risk factors for neurophysiologically confirmed carpal tunnel syndrome and illness with similar symptoms but normal median nerve function
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objectives To explore whether neurophysiologically confirmed carpal tunnel syndrome (CTS) has different risk factors from sensory symptoms in the hand that occur in the absence of impaired median nerve conduction. Methods We compared 475 patients with neurophysiologically confirmed (NP+ve) CTS, 409 patients investigated for CTS but negative on neurophysiological testing (NP-ve), and 799 controls. Exposures to risk factors were ascertained by self-administered questionnaire. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated by logistic regression. Results NP+ve CTS was associated with obesity, use of vibratory tools, repetitive movement of the wrist or fingers, poor mental health and workplace psychosocial stressors. NP-ve illness was also related to poor mental health and occupational psychosocial stressors, but differed from NP+ve disease in showing associations also with prolonged use of computer keyboards and tendency to somatise, and no relation to obesity. In direct comparison of NP+ve relative to NP-ve cases, the most notable differences were for obesity (OR 2.7, 95% CI 1.9-3.9), somatising tendency (OR 0.6, 95% CI 0.4-0.9), diabetes (OR 1.6, 95% CI 0.9-3.1) and work with vibratory tools (OR 1.4, 95% CI 0.9-2.2). Conclusions When viewed in the context of earlier research, our findings suggest that obesity, diabetes, use of hand-held vibratory tools, and repeated forceful movements of the wrist and hand are causes of impaired median nerve function. In addition, sensory symptoms in the hand, whether from identifiable pathology or non-specific in origin, may be rendered more prominent and distressing by hand activity, low mood, tendency to somatise, and psychosocial stressors at work
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C-reactive protein, metabolic syndrome and incidence of severe hip and knee osteoarthritis. A population-based cohort study
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: To explore the relationships between C-reactive protein (CRP), metabolic syndrome (MetS) and incidence of severe knee or hip osteoarthritis (OA) in a prospective study. METHODS: A population-based cohort (n=5171, mean age 57.5+/-5.9 years) was examined between 1991 and 1994. Data was collected on lifestyle habits, measures of overweight, blood pressure as well as high-density lipoprotein (HDL) cholesterol, triglycerides, glucose and CRP measured with high-sensitive methods. Incidence of severe OA, defined as arthroplasty due to knee or hip OA, was monitored over 12 years of follow-up, in relation to CRP levels and presence of the MetS according to the adult treatment panel III-national cholesterol education program (ATPIII-NCEP) definition. RESULTS: A total of 120 participants had severe hip OA and 89 had knee OA during the follow-up. After adjustment for age, sex, smoking, physical activity and CRP, presence of MetS was associated with significantly increased risk of knee OA (relative risk [RR]: 2.1, 95% confidence interval [CI]: 1.3-3.3). However, this relationship was attenuated and non-significant after adjustment for body mass index (BMI) (RR: 1.1, 95% CI: 0.7-1.8). MetS was not significantly associated with incidence of hip OA. In women, CRP was associated with knee OA in the age-adjusted analysis. However, there was no significant relationship between CRP and incidence of knee or hip OA after risk factor adjustments. CONCLUSION: The increased incidence of knee OA in participants with the MetS was largely explained by increased BMI. CRP was not associated with incidence of knee or hip OA when possible confounding factors were taken into account
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Medial mini-open versus percutaneous pin fixation for type III supracondylar fractures in children
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DoD SSI (Surgical Site Infections)
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BACKGROUND: The present objective was to compare medial mini-open and percutaneous treatment of pediatric supracondylar fractures according to fluoroscopy time, duration of surgery, and iatrogenic ulnar nerve injury. METHODS: A total of 104 Gartland type III supracondylar humerus fractures were prospectively evaluated between 2011 and 2013. Patients were divided into 2 groups according to type of fixation. In Group A (41 patients), medial pin was inserted with mini-open incision with 2 lateral pins inserted percutaneously. In Group B (63 patients), all pins were inserted percutaneously. Mean follow-up time was 14.1±1.2 months in Group A, and 14.6±2.1 months in Group B. All patients were postoperatively evaluated for nerve injury with both motor and sensory function assessment. Length of surgery, total fluoroscopy time, fluoroscopy time for medial pin insertion, Baumann’s angle, humeral capitellum angle, final carrying angle, and range of motion were recorded. RESULTS: Sensorial evaluation showed that Group A had 3 poor, and 1 fair results, and Group B had 2 poor, and 1 fair results. No statistically significant differences were observed, including no differences in either surgery or total fluoroscopy times between groups. However, fluoroscopy time during medial pin placement was significantly lower in the mini-open group. CONCLUSION: In conclusion, similar results of both techniques were observed, and both carry risk of iatrogenic ulnar nerve injury. Medial pin placement is easier and less demanding when used with mini-open technique.
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Health care professionals' readiness for an interprofessional orthogeriatric unit: A cross-sectional survey
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Hip Fx in the Elderly 2019
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An assessment of readiness for change can set the stage for the implementation by providing information regarding staff members' beliefs and attitudes prior to an organizational change. We conducted a cross-sectional survey to assess readiness for change (N = 113 employees) in a hospital on the verge of implementing an interprofessional, co-managed orthogeriatric unit. Staff members from three departments with roles related to orthogeriatric patients were invited to answer a web-based questionnaire. Our survey demonstrates that health care professionals are confident that interprofessional collaboration will be promoted by the implementation of orthogeriatric care. We found they were knowledgeable about the proposed orthogeriatric collaboration model and ready to engage in its implementation. Their concerns pertained to various practical aspects; those voiced by the nursing staff related to work strain and the work-related interests of their professional group whereas the physicians' reservations concentrated on the planning of the change. The exploration of readiness for organizational change among health care professionals offers managers an understanding of their motivations and concerns and provides a useful tool for the planning and implementation of a new interprofessional collaboration model.
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0 |
Multiple myeloma and chronic lymphocytic leukemia
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MSTS 2018 - Femur Mets and MM
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Much progress has been made in delineating the pathogenesis of multiple myeloma and chronic lymphocytic leukemia. The cell of origin in both diseases has been better defined, which has led to important clinical treatments. For myeloma, reduction of tumor burden in autografts has been accomplished and been associated with favorable outcome. The importance of interleukin-6 in maintaining this tumor and causing skeletal disease has been more clearly defined and has led to treatment with antibodies that block this cytokine's action. The bisphosphonate pamidronate decreases skeletal complications and improves quality of life for these patients. For chronic lymphocytic leukemia, further definition of common cytogenetic and gene abnormalities have been made and associated with patient outcome. The nucleoside analogues continue to produce excellent responses and the use of myeloablative chemotherapy with hematopoietic support shows promise in early studies. [References: 124]
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0 |
Bacterial infections associated with allogenic bone transplantation
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DoD SSI (Surgical Site Infections)
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Background/Aim. Bone allografts are frequently used in or-thopedic reconstructive procedures carrying a high risk for re-cipients. To assess the nature and frequency of allograft con-tamination and associated surgical infection the case records from our institutional bone bank were reviewed. Methods. We retrospectively analyzed the microbiology of discarded bone al-lografts and the surgical site of the recipients. A case series of patients who acquired surgical site infection after allogenic bone transplantation was presented. Swab culturing was con-ducted on 309 femoral heads from living donors who under-went partial and total hip arthroplasty between January 2007 and December 2013. To prevent potential bone allograft con-tamination we used saline solution of 2.0 mg/ml of amikacin during thawing. The overall infection rate was analyzed in 197 recipients. Results. Of the 309 donated femoral heads, 37 were discarded due to bacterial contamination, giving the overall contamination rate of 11.97%. The postoperative survey of 213 bone allotransplantations among 197 recipients showed the in-fection rate of 2.03%. The coagulase-negative Staphylococcus was the most commonly identified contaminant of bone allografts and recipient surgical sites. Conclusion. The allograft con-tamination rate and the infection rate among recipients in our institution are in accordance with the international standards. The coagulase-negative Staphylococcus was the most commonly identified contaminant of bone allografts and recipient surgical sites. There is no strong evidence that surgical site infections were associated with bone allograft utilization. We plan further improvements in allograft handling and decontamination with highly concentrated antibiotic solutions in order to reduce in-fection risk for recipients.
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Nerve entrapments associated with postmastectomy lymphedema
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Ninety females underwent mastectomy for breast cancer and were thereafter investigated to determine whether nerve entrapments were responsible for some of the disabling symptoms in their arms. The majority of these patients suffered from fullness (edema), numbness, paraesthesia, weakness and pain of the arm on the mastecotmized side. Lymphedema of varying degrees found in 50% of these patients was associated with brachial plexus entrapment and carpal tunnel syndrome (CTS). 28% of the patients has CTS, and 28% suffered from brachial plexus entrapment of the arm on the mastecotmized side, as compared with 8% and 5%, respectively, on the nonoperated side. 12% of the patients suffered from both types of entrapment. Thus we consider that brachial plexus entrapment and carpal tunnel syndrome should be added to the list of complications following mastectomy, with lymphedema playing an active part in their development
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Effects of chlorhexidine-fluoride mouthrinses on viability, acidogenic potential, and glycolytic profile of established dental plaque
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Inhibition of dental plaque acidogenicity by chlorhexidine (CHX) mouthrinses has been ascribed to a long-lasting bacteriostatic effect due to binding of CHX to oral surface structures combined with a slow release rate from the binding sites. The present aims were to study the effects of CHX-containing mouthrinses on the viability and glycolytic activity of established plaque in order to assess the bactericidal versus the bacteriostatic effects. Following 2 days of plaque accumulation, three groups of 10 students rinsed with either 12.0 mM NaF, 0.55 mM CHX plus NaF, or with 2.2 mM CHX plus NaF. Plaque samples were collected before and 90 min after mouthrinsing. The pH in pooled pre- and post-rinse plaque samples was recorded before and up to 10 min after the addition of D-[U-14C]glucose. Total colony-forming units in each sample were determined. High-performance liquid chromatography analyses showed lactate to be the major extracellular glycolytic metabolite in all samples. CHX-NaF markedly reduced the colony-forming units, the pH fall from fermentation of glucose, as well as glucose consumption and lactate formation, whereas NaF alone exhibited no such effects. The reduction of glucose consumption by the CHX-NaF mouthrinses corresponded to the reduction of colony-forming units, indicating no bacteriostatic effect. The plaque pH in vivo was monitored in each student 90 min after mouthrinsing with the test solutions prior to and up to 1 h after a sucrose mouthrinse using touch microelectrodes. The CHX-NaF mouthrinses reduced the fall in pH significantly (p < 0.05) as compared with the NaF mouthrinse.(ABSTRACT TRUNCATED AT 250 WORDS)
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Technical protocol for infiltration of the humeral joint in a rat animal model
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Glenohumeral Joint OA
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Studies exist which confirm that the rat is the most appropriate model for assessing the glenohumeral (shoulder) joint and its pathologies, such as osteoarthritis and disease of the tendons of the rotator muscles in the joint. However there are no recorded studies of osteoarthritis induced in the Glenohumeral Joint (GJ) in rat models, nor is there a technical protocol for the correct approach to the joint. The object of this work was to establish a technical protocol, identifying anatomical reference points which would allow correct location of the penetration site for the articular cavity of the GJ followed by simulated infiltration. Four Sprague-Dawley rats were re-used for this protocol, respecting the animal ethics principles of refinement, reduction and replacement. The anatomical reference points were established and the joint was subsequently infiltrated with Indian ink. The success of the approach was corroborated by dissection of the joint, when the Indian ink could be sighted in the articular cavity. The rat's humerus was positioned in lateral rotation, using the sternoclavicular joint as a reference and following the lower margin of the clavicle until the coracoid process and the head of the humerus were reached. The mid-line of the humerus was calculated and the ink was injected below the intersection of the inferior margin of the clavicle and the mid-line of the humerus. Successful infiltration of the joint cavity requires knowledge of the morphology of the rat's GJ and the lateral rotation movement of the humerus, following the anatomical reference points identified. This technique can be applied for induction and treatment of osteoarthritis in models.
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Trabecular bone modeling and subcapital femoral fracture
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Management of Hip Fractures in the Elderly
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Fragility fractures, including neck of femur fractures, result from reductions in the amount, quality and architecture of bone. The aim of this study was to compare the cancellous bone structure, and static indices of bone turnover, in female patients who had sustained fragility fracture at the femoral neck, with age-matched females without fragility fracture. Bone samples were taken from the intertrochanteric region of the proximal femur of female patients undergoing hip arthroplasty surgery for a subcapital fragility fracture of the femoral neck (#NOF) or from age-matched female control individuals at routine autopsy. The histomorphometric data, which were normally distributed, indicated no difference between the mean values for any of the structural parameters in control and fracture samples. In particular, the BV/TV values were not different and did not change significantly with age in these cohorts of individuals aged >65 years. The static indices of bone turnover, eroded surface (ES/BS) and osteoid surface (OS/BS), were positively correlated with age in the >65-year-old control group (p<0.05 and p<0.03, respectively). The median values for these indices were not different between the fracture and control groups. However, both the median and the range of OS/BS values were increased for >65-year-old controls compared with a group of younger females aged <65 years, suggesting an increase in bone formation in older females in the proximal femur after 65 years of age. When the data were further interrogated, a reduction in the percentage osteoid surface to eroded surface quotient (OS/ES) was found for the fracture group compared with the age-matched control group. These data indicate that perturbations in bone formation and/or resorption surface are potentially important in producing bone in the proximal femur with increased propensity to fracture. These data also support the concept that trabecular bone modeling may be a factor influencing bone strength in addition to bone mass
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Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone
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Management of Hip Fractures in the Elderly
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To study the complications of renal osteodystrophy in patients with end-stage renal disease, we reviewed the incidence of hip fractures in our outpatient dialysis population from 1988 to 1998. One thousand two hundred seventy-two patients were treated for a total of 4,039 patient-years; 56 hip fractures were documented during this period. The incidence of hip fractures was many times greater in the dialysis patients than in the general population in each of the age-, race-, and sex-matched subgroups. The 1-year mortality rate from the hip fracture event was nearly two and a half times greater in the dialysis patients compared with the general population. The incidence of hip fractures in the first half of the decade was similar to that observed in the second half. When parathyroid hormone (PTH) levels were evaluated, we determined that patients with lower serum PTH levels were more likely to sustain a hip fracture than patients with higher PTH levels (P: < 0.006). In addition, we determined that patients with lower PTH levels had an earlier mortality than patients with higher PTH levels (P: < 0.03). We conclude that despite more aggressive therapy directed toward bone health in our dialysis patients in recent years, the incidence of hip fractures and their devastating morbidity and mortality remained unchanged over the past decade. Lower PTH levels may predispose to earlier mortality
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Hip protectors for preventing hip fractures in older people
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Management of Hip Fractures in the Elderly
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BACKGROUND: Hip fracture in older people usually results from a fall on the hip. Hip protectors have been advocated as a means to reduce the risk of sustaining a hip fracture. OBJECTIVES: To determine if external hip protectors reduce the incidence of hip fractures in older people following a fall. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register (January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to January Week 2, 2005), EMBASE (1988 to 2005 Week 02), CINAHL (1982 to December Week 2 2004), other databases and reference lists of relevant articles. We also contacted trialists. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing the use of hip protectors with a control group. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We sought additional information from trialists. Pooling of uncorrected data from cluster-randomised trials was only done on an exploratory basis. MAIN RESULTS: Fifteen included trials contributed data to this updated review. One trial, which was a study of compliance (adherence) lasting 12 weeks, contributed no fracture outcome data. Pooling of data from eleven trials conducted in nursing or residential care settings, including six cluster-randomised studies, showed evidence of a marginally statistically significant reduction in hip fracture incidence (relative risk (RR) 0.77, 95% confidence interval (CI) 0.62 to 0.97). This analysis showed significant statistical heterogeneity. Pooling of data from three individually randomised trials involving 5135 community dwelling participants, showed no reduction in hip fracture incidence from the provision of hip protectors (RR 1.16, 95% CI 0.85 to 1.59). There was no evidence of any significant effect of hip protectors on incidence of pelvic or other fractures. No important adverse effects of the hip protectors were reported but compliance, particularly in the long term, was poor. AUTHORS' CONCLUSIONS: Accumulating evidence casts some doubt on the effectiveness of the provision of hip protectors in reducing the incidence of hip in older people. Acceptance and adherence by users of the protectors remain poor due to discomfort and practicality
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Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands
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Hip Fx in the Elderly 2019
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Background: The treatment of acute pain in the emergency department is not always optimal. Peripheral nerve blocks using â??blindâ? or nerve stimulator techniques have substantial disadvantages. Ultrasound-guided regional anesthesia may provide quick, safe, and effective pain relief in patients with proximal femoral fractures with severe pain. However, no evidence exists on emergency physician-performed ultrasound-guided regional anesthesia in these patients in Dutch emergency departments. We hypothesized that emergency physicians can be effectively trained to safely perform and implement ultrasound-guided femoral nerve blocks, resulting in effective pain relief in patients with proximal femoral fractures. Methods: In this prospective observational study, emergency physicians were trained by expert anesthesiologists to perform ultrasound-guided femoral nerve blocks during a single-day course. Femoral nerve blocks were performed on patients with proximal femoral fractures. A system of direct supervision by skilled anesthesiologists and residents was put in place. Results: A total of 64 femoral nerve blocks were performed. After 30 min, blocks were effective in 69% of patients, and after 60 min, in 83.3%. The mean reduction in pain scores after 30 and 60 min was 3.84 and 4.77, respectively (both p OpenSPiltSPi 0.001). Patients reported a mean satisfaction of 8.42 (1 to 10 scale). No adverse events occurred. Conclusions: Ultrasound-guided femoral nerve block is an effective, safe, and easy to learn (single-day course) procedure for emergency physicians to implement and perform in the emergency department. Patient satisfaction was high.
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Recent advances in the surgical management of necrotizing pancreatitis
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DoD - ACS - Interrater Reliability
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PURPOSE OF REVIEW: To summarize advances and new concepts in the surgical management of necrotizing pancreatitis published within the past year with emphasis on the evolving importance of the recognition of abdominal compartment syndrome as a significant contributor to early development of organ failure.
RECENT FINDINGS: Underdiagnosed and untreated, abdominal compartment syndrome is a potential contributing factor to the development of early organ failure in patients with severe acute pancreatitis and warrants routine measurement of intra-abdominal pressure in patients treated for severe pancreatitis. The current estimate of the prevalence of intra-abdominal hypertension in severe acute pancreatitis is about 40%, with about 10% overall developing abdominal compartment syndrome, associated with increased hospital mortality rates. Early surgical decompression without exploring the pancreas further seems to be the most effective treatment. Primary fascial closure of the abdominal wall following abdominal decompression can be attempted, but in most cases the prolonged inflammatory process in the abdomen and the risk of recurrent abdominal compartment syndrome favors use of gradual closure or delayed reconstruction of the abdominal wall.
SUMMARY: Recent studies confirm the overall validity of the established surgical principles for necrotizing pancreatitis: delayed necrosectomy in patients with infected peripancreatic necrosis, mostly nonoperative management of sterile necrosis, and delayed cholecystectomy in severe gallstone-associated pancreatitis. The role of abdominal compartment syndrome as an important contributing factor to early development of multiple organ failure and the potential benefit of surgical decompression are gaining support from recent reports and should be carefully assessed in future studies. [References: 16]
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Acellular dermal matrices in breast surgery: tips and pearls
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Acellular Dermal Matrix
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Acellular dermal matrices (ADMs) have been used for postmastectomy breast reconstruction, primary and secondary breast augmentation, and reduction mammaplasty. In postmastectomy breast reconstruction, ADMs can be used to either create an implant pocket in single-stage reconstruction or to create the inferolateral portion of the tissue expander pocket in two-stage reconstruction. Specific deformities after cosmetic breast augmentation such as contour irregularities and implant malposition can be addressed with ADMs. The use of ADMs is a safe alternative for the correction of breast deformities after reconstructive and aesthetic breast surgery.
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Salter-harris type III fracture-dislocation of the proximal humerus
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Salter-Harris type III fractures of the proximal humerus are rare injuries. We report a Salter-Harris type III anterior fracture-dislocation of the proximal humerus in a 10-year-old boy that was open reduced and internally stabilized. A hone scan performed during the initial hospitalization and at 2-year follow-up revealed devascularizatiou and subsequent revascularization of the humeral head. At 2-year follow-up, the patient had full motion of the shoulder, no pain, and arm strength equal to that of the contralateral side. Four cases of Salter-Harris type III fracturse of the proximal humerus have been previously reported; good early clinical outcomes were obtained in all. Despite devascularization of the epiphyseal fragment, excellent clinical outcomes may result
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Limited diagnostic accuracy of magnetic resonance imaging and clinical tests for detecting partial-thickness tears of the rotator cuff
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Trial Systematic Review Project
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INTRODUCTION: The reliable diagnosis of partial-thickness tears of the rotator cuff is still elusive in clinical practise. Therefore, the purpose of the study was to determine the diagnostic accuracy of MR imaging and clinical tests for detecting partial-thickness tears of the rotator cuff as well as the combination of these parameters.
MATERIALS AND METHODS: 334 consecutive shoulder arthroscopies for rotator cuff pathologies performed during the time period between 2010 and 2012 were analyzed retrospectively for the findings of common clinical signs for rotator cuff lesions and preoperative MR imaging. These were compared with the intraoperative arthroscopic findings as "gold standard". The reports of the MR imaging were evaluated with regard to the integrity of the rotator cuff. The Ellman Classification was used to define partial-thickness tears of the rotator cuff in accordance with the arthroscopic findings. Descriptive statistics, sensitivity, specificity, positive and negative predictive value were calculated.
RESULTS: MR imaging showed 80 partial-thickness and 70 full-thickness tears of the rotator cuff. The arthroscopic examination confirmed 64 partial-thickness tears of which 52 needed debridement or refixation of the rotator cuff. Sensitivity for MR imaging to identify partial-thickness tears was 51.6%, specificity 77.2%, positive predictive value 41.3% and negative predictive value 83.7%. For the Jobe-test, sensitivity was 64.1%, specificity 43.2%, positive predictive value 25.9% and negative predictive value 79.5%. Sensitivity for the Impingement-sign was 76.7%, specificity 46.6%, positive predictive value 30.8% and negative predictive value 86.5%. For the combination of MR imaging, Jobe-test and Impingement-sign sensitivity was 46.9%, specificity 85.4%, positive predictive value 50% and negative predictive value 83.8%.
CONCLUSIONS: The diagnostic accuracy of MR imaging and clinical tests (Jobe-test and Impingement-sign) alone is limited for detecting partial-thickness tears of the rotator cuff. Additionally, the combination of MR imaging and clinical tests does not improve diagnostic accuracy.
LEVEL OF EVIDENCE: Level II, Diagnostic study.
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NF-KB activity is reduced by inosderived no in human chondrocytes: Contribution to sustained low grade inflammation in osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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NF-kB mediates important chondrocyte inflammatory and catabolic responses that ultimately lead to cartilage destruction, the hallmark of osteoarthritis (OA). This work aimed at identifying the role of the neuronal and inducible Nitric Oxide Synthases (nNOS and iNOS, respectively) as sources of NO in normal and OA human chondrocytes and at elucidating the role of endogenous iNOS-derived NO on the regulation of NF-kB activity. For this, we compared nNOS and iNOS protein levels by western blot and NF-kB activity by ELISA in normal and OA human chondrocytes and measured spontaneous NO production. Then, we evaluated the effect of inhibiting iNOS on the ability of interleukin-1b (IL-1) to induce NF-kB. Chondrocytes were isolated from human knee cartilage obtained from normal multi-organ donors or OA patients undergoing total knee replacement surgery. The results showed that nNOS was expressed in 83% of the normal and 65% theOA chondrocytes, whereas the opposite was found for iNOS (33 vs. 65%). The average nitrite concentration in the supernatants from normal or OAchondrocyte cultures that did not express iNOS was 3.6 (plus or minus) 1.0 mM, whereas in cells expressing iNOS it was 9.4 (plus or minus) 2.9 mM (P<0.01). Although IkB-a was present in all the normal samples and in the majority (88.5%) of the OA samples, NF-kB activity in OA chondrocytes (1.82 (plus or minus) 0.23) was approximately twofold higher than in normal ones (0.91 (plus or minus) 0.05). Treatment with a general NOS inhibitor, after induction of iNOS expression, was sufficient to induce IkB-a degradation and NF-kB-DNA binding and also potenciated IL-1- induced NF-kB activation. These findings favor an inhibitory role of iNOS-derived NO on the regulation of NF-kB activity in human chondrocytes. This seems to contribute to sustain a moderate level of NF-kB activity and NF-kB-dependent gene expression over time, thus perpetuating inflammation and cartilage destruction
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