Suprapatellar versus infrapatellar nailing for tibial shaft fractures: A comparison of surgical and clinical outcomes between two approaches.

BACKGROUND: Tibial shaft fractures are a relatively common injury and contemporary treatment includes on-axis fixation with a locked intramedullary nail in the majority of cases. The conventional technique is via an infrapatellar approach but currently there is a trend towards the use of a suprapatellar approach. We compared key variables including operative time, radiation exposure and early patient reported outcomes when adopting a suprapatellar approach to tibial nailing in our unit versus our previous experience of infrapatellar tibial nailing. METHOD: Twenty-eight consecutive patients with tibial fracture underwent tibial nailing via the suprapatellar (SPN) approach. Six patients in the study group were excluded due polytrauma and need for dual orthopaedic and plastic surgery management. We compared outcomes with our most recent 20 consecutive patients who had undergone tibial nailing via an infrapatellar (IPN) approach. Primary surgical outcomes were: operative time, radiation exposure and accuracy of entry point of the nail on both anteroposterior and lateral radiographs. Clinical outcomes included time to weightbearing, time to radiographic union and patient-reported outcome score (Lysholm score). RESULTS: Forty-eight consecutive patients underwent intramedullary nail fixation for tibial shaft fractures and 42 were eligible for inclusion in our study (22 SPN vs 20 IPN). There were no significant differences in patient demographics or injury patterns between the two groups. Operative time and radiation exposure were significantly lower in the SPN group when compared to the IPN group (115 min vs 139 min ± 12.5) (36 cGY/cm2 vs 76.33 cGY/cm2 +/- 20.1). Furthermore, patients in the SPN group reported superior outcome scores at a mean follow up of 3 months (8-24 weeks) There were no observed differences in complication rate between groups and time of final clinical follow up at a minimum of 6 months. CONCLUSION: Our study shows that adoption of the SPN approach requires minimal learning curve, and has the potential benefits of reduced operative time, radiation exposure and superior patient reported outcomes when compared to the conventional infrapatellar approach.

Abdominal wall reconstruction with large polypropylene mesh: is bigger better?

PURPOSE: Hernia repair for large and complex hernias presents challenges related to the availability of larger mesh sizes. When sizes beyond those manufactured are required, multiple meshes (MM) may be sutured to create a larger graft. With the availability of large polypropylene mesh up to 50 × 50 cm (LM), abdominal wall reconstruction (AWR) may be accomplished with a single mesh. This study evaluates clinical and economic outcomes following AWR with component separation utilizing MM and LM. METHODS: A retrospective study was performed with review of health records and cost accounting data. Patients that underwent AWR with LM were case matched 1:1 with patients undergoing MM repair based upon comorbidities, defect size and wound class. RESULTS: Twenty-four patients underwent AWR with LM. Twenty patients (10F, 10 M) who underwent AWR with LM were matched with 20 MM AWR (11F, 9 M). Age, BMI, ASA 3 + , never smoker, diabetes, and hernia characteristics were similar between LM and MM. Operative cost ($4295 vs $3669, p = 0.127), operative time (259 min vs 243 min, p = 0.817), length of stay (5.5 vs 6.2, p = 0.484), wound complication (30% vs 20%, p = 0.716), infected seroma (5% vs 5%, p = 1), and readmission (5% vs 15%, p = 0.605) were similar between LM and MM, respectively. CONCLUSIONS: This is the first report of patients undergoing AWR with a large 50 × 50 cm prolene mesh. In this small cohort, clinical outcomes were similar between those undergoing repair with multiple sutured mesh sheets and a single large mesh.

Associations between anxiolytic medications and ventral hernia repair.

PURPOSE: This study examines the relationship between anxiolytic medications (AXM) on outcomes following ventral hernia repair. METHODS: A single-center review of prospectively obtained perioperative and 30-day outcome data, including AXM use at admission, as part of the National Surgery Quality Improvement Program. RESULTS: Sixty-three of the 393 patients who presented for ventral hernia repair were taking an AXM (15.6%). AXM users were more likely to have a higher ASA class, dyspnea, and treated hypertension (p < 0.05). AXM use was associated with increased operative duration, hernia size, increased estimated blood loss, and need for component separation. After adjusting for medical comorbidities, AXM users were not found to have greater 30-day morbidity or mortality. Patients taking AXM were found to have greater length of stay and increased hospital readmissions. CONCLUSIONS: Patients taking anxiolytic medications undergoing ventral hernia repairs have higher ASA scores, more complex hernia characteristics, and require more concurrent procedures. They were found to have longer operative times, increased blood loss, greater duration of hospital stay, and increased readmissions that were associated with the increased perioperative risk factors. Further studies are required to determine causal links.

Two-year cortical and trabecular bone loss in CKD-5D: biochemical and clinical predictors.

This prospective two-year study of patients on chronic dialysis measured changes in bone mineral density (BMD). Patients with higher baseline BMD and shorter dialysis vintage lost more bone. Treatment with anti-hypertensives acting on the central nervous system was protective against bone loss. Baseline serum levels of sclerostin and bone-specific alkaline phosphatase predicted bone loss. INTRODUCTION: This prospective 2-year study of chronic kidney disease on dialysis (CKD-5D) patients assessed trabecular and cortical bone loss at the hip and spine and examined potential demographic, clinical, and serum biochemical predictors of bone loss. METHODS: Eighty-nine CKD-5D patients had baseline, year 1, and year 2 bone mineral density (BMD) measurements using dual X-ray absorptiometry (DXA) and quantitative computed tomography (QCT); concurrent blood samples were drawn and clinical variables recorded. No study treatments occurred. RESULTS: The 2-year total hip BMD change was - 5.9% by QCT and - 3.1% by DXA (p < 0.001). Spinal BMD was unchanged. QCT total hip cortical mass and volume decreased (- 7.3 and - 10.0%); trabecular volume increased by 5.9% (ps < 0.001). BMD changes did not vary with age, BMI, race, diabetes, smoking, or exercise. Patients with higher baseline BMD and shorter dialysis vintage lost more bone (p < 0.05). Vitamin D analogs and phosphate binders were not protective against bone loss; cinacalcet was protective by univariate but not by multivariable analysis. CNS-affecting antihypertensives were protective against loss of BMD, cortical mass, cortical volume (ps < 0.05) and trabecular mass (p = 0.007). These effects remained after adjustment. BSAP correlated with changes in BMD, cortical mass, and volume (p < 0.01) as did sclerostin (inversely). CONCLUSIONS: There was severe cortical bone loss at the hip best recognized by QCT. Patients with shorter dialysis vintage and less pre-existing bone loss lost more bone, while treatment with CNS-acting antihypertensives was protective. BSAP and sclerostin were useful markers of bone loss.

Outcome of kidney transplant in primary, repeat, and kidney-after-nonrenal solid-organ transplantation: 15-year analysis of recent UNOS database.

The number of nonrenal solid-organ transplants increased substantially in the last few decades. Many of these patients develop renal failure and receive kidney transplantation. The aim of this study was to evaluate patient and kidney allograft survival in primary, repeat, and kidney-after-nonrenal organ transplantation using national data reported to United Network for Organ Sharing (UNOS) from January 2000 through December 2014. Survival time for each patient was stratified into the following: Group A (comparison group)-recipients of primary kidney transplant (178 947 patients), Group B-recipients of repeat kidney transplant (17 819 patients), and Group C-recipients of kidney transplant performed after either a liver, heart, or lung transplant (2365 patients). We compared survivals using log-rank test. Compared to primary or repeat kidney transplant, patient and renal allograft survival was significantly lower in those with previous nonrenal organ transplant. Renal allograft and patient survival after liver, heart, or lung transplants are comparable. Death was the main cause of graft loss in patients who had prior nonrenal organ transplant.

Comparison of EBT and EBT3 RadioChromic Film Usage in Parotid Cancer Radiotherapy.

BACKGROUND: EBT and EBT3 radioChromic films have been used in radiotherapy dosimetry for years. OBJECTIVE: The aim of the current study is to compare EBT and EBT3 radioChromic films in dosimetry of radiotherapy fields for treatment of parotid cancer. METHODS: Calibrations of EBT and EBT3 films were performed with identical setups using a 6 MV photon beam of a Siemens Primus linac. Skin dose was measured at different points in the right anterior oblique (RAO) and right posterior oblique (RPO) fields by EBT and EBT3 films on a RANDO phantom. RESULTS: While dosimetry was performed with the same conditions for the two film types for calibration and in phantom in parotid cancer radiotherapy, the measured net optical density (NOD) in EBT film was found to be higher than that from EBT3 film. The minimum difference between these two films under calibration conditions was about 2.9% (for 0.2 Gy) with a maximum difference of 35.5% (for 0.5 Gy). In the therapeutic fields of parotid cancer radiotherapy at different points, the measured dose from EBT film was higher than the EBT3 film. In these fields the minimum and maximum measured dose differences were 16.0% and 25.5%, respectively. CONCLUSION: EBT film demonstrates higher NOD than EBT3 film. This effect may be related to the higher sensitivity of EBT film over EBT3 film. However, the obtained dose differences between these two films in low dose range can be due to the differences in fitting functions applied following the calibration process.

A discriminated conditioned punishment model of phobia.

Traditionally, the signaled avoidance (SA) paradigm has been used in an attempt to better understand human phobia. Animal models of this type have been criticized for ineffectively representing phobia. The SA model characterizes phobia as an avoidance behavior by presenting environmental cues, which act as warning signals to an aversive stimulus (ie, shock). Discriminated conditioned punishment (DCP) is an alternative paradigm that characterizes phobia as a choice behavior in which fear serves to punish an otherwise adaptive behavior. The present study quantifies the differences between the paradigms and suggests that DCP offers an alternative paradigm for phobia. Rats trained on either SA or DCP were compared on a number of behavioral variables relevant to human phobia. Results indicate that rats in the DCP paradigm responded significantly earlier to warning signals and were more effective at preventing shocks than rats in the SA paradigm. Implications of this alternative paradigm are discussed.

Behavioral assessment of visual deficits in the taiep mutant.

Taiep (tremor, ataxia, immobility, epilepsy, paralysis) mutants show a significant increase in myelin thickness from 10 to 30 days of age but then demonstrate a decrease in myelin thickness from 1 to 6 months. The severity of the demyelination in the optic nerve suggests that visual deficits may exist in the taiep mutants. Animals were trained on a discrimination task, in which responses to a light stimulus (the SD period) were reinforced on a fixed ratio (FR)-1 schedule, and responses in the absence of the light stimulus (the SΔ period) were not reinforced. Following training, the light intensity presented during the SD period was gradually reduced between sessions until -6.0 candela/m2 was reached. Both groups of animals - taiep mutants and control Sprague Dawley rats - successfully recognized and responded in the presence of the stimulus near perfectly by the final day of training, suggesting that taiep mutants demonstrated normal learning, at least under this paradigm. Despite the severe demyelination of the taiep optic nerve, no visual deficits were detected as both groups of animals performed similarly as the light intensity decreased. Though the myelin loss of the optic nerve may have negatively affected signal transduction, this did not result in an increase in visual threshold.

The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique.

PURPOSE: The component separation technique for hernia repair results in significant wound morbidity due to the need for large undermining skin flaps. The endoscopic component separation technique allows for advancement of the abdominal wall while preserving the blood supply originating from the epigastric vessels. This study compares the outcomes following hernia repair utilizing these techniques. METHODS: A retrospective review of patients undergoing component separation or endoscopic component separation hernia repair from 2008 to 2010. Patients underwent open component separation or endoscopic component separation with closure of the linea alba and reinforcement with mesh. RESULTS: Thirty-five patients that underwent a component separation [14 open component separation (CST) and 21 that underwent endoscopic component separation (ECST)] were identified. There was no difference in hospital length of stay (CST 5.0 ± 3.0 days vs ECST 6.3 ± 3.6 days, P = 0.28) or operating room times (CST; 268 ± 62 min vs ECST; 229 ± 57 min, P = 0.07). Wound complications occurred in 57% of CST and 19% of ECST, P = 0.03. One recurrent hernia was identified in the ECST group with a mean follow up of 8 months (range 1-21 months). No recurrences were seen in the CST group. CONCLUSIONS: ECST is associated with comparable hospital length of stay and operative times and reduced wound complications compared to CST.

Successful treatment of Staphylococcus aureus bacterial endocarditis in a renal transplant recipient.

We report the successful treatment of Staphylococcus aureus endocarditis in a renal transplant recipient with preservation of his renal allograft. A 44-year-old man presented to the emergency room with sudden onset of fevers and rigors 7 weeks after renal transplantation. Infective endocarditis was diagnosed by Duke's Criteria (Durack et al. New criteria for the diagnosis of infective endocarditis. Am J Med 1994: 96: 200-209) with multiple positive blood cultures for S. aureus and a mitral valve vegetation on transesophageal echocardiogram. He was treated with intravenous antibiotics for 6 weeks with continuation of his immunosuppression. He has remained clinically stable for over 5 years. Although the treatment of S. aureus endocarditis in immunosuppressed transplant patients has traditionally resulted in loss of their allograft, prompt diagnosis and appropriate antibiotics with continued immunosuppressive therapy resulted in a successful outcome and allograft preservation in this case.

Effects of enamel matrix protein application on the viability, proliferation, and attachment of human periodontal ligament fibroblasts to diseased root surfaces in vitro.

OBJECTIVES: The purpose of this research was to examine the influence of enamel matrix proteins (EMP) on the viability, proliferation, and attachment of periodontal ligament fibroblasts (PDLF) to diseased root surfaces. MATERIALS AND METHODS: Primary cell cultures of PDFL were obtained from clinically healthy third molars or premolar teeth. Viability and proliferation rates were carried out over a 10-day period. A total of 80,000 cells were plated in 24-well plates followed by EMEM with 10% FBS (positive control) and EMEM plus EMP at 25, 50, 75, and 100 micro g/ml. Cells were harvested on days 1, 3, 5, 7, and 10 and viability was performed utilizing an MTS assay. PDLF proliferation rates were assessed by a CyQUANT GR dye assay. SEM analysis was used to examine the qualitative effects of cellular attachment to diseased root surfaces following EMP compared to nontreated controls. RESULTS: The results indicated that viability was negatively affected for higher doses over time while lower doses displayed viability effects similar to control. Proliferation, however, appeared to be ameliorated following exposure to EMP. The SEM analysis suggests that cellular attachment to diseased dentin was enhanced following EMP application. CONCLUSION: These in vitro studies support the concept that EMP may act as a suitable matrix for PDLF.

Atypical rumen acidosis in a dairy herd from whiskey distillery by-products.

Decreased milk and reproductive performance, high incidence of gastrointestinal surgeries, and acute deaths were investigated in a herd of Holstein cows. The health problems were due to abnormally low rumen pH's from ingestion of 30 gal/hd/d of a 3.4 pH liquid feed ingredient. A combination of acid neutralizing agents (calcium hydroxide plus sodium carbonate) alleviated the toxic effects of the feed ingredient.

Disseminated Dactylaria constricta infection in a renal transplant recipient.

We report the case of a 32-year-old renal transplant recipient who developed disseminated Dactylaria constricta infection. The patient died despite treatment with amphotericin B, itraconazole, and fluconazole.

Effective models for medical and health response coordination: summary and action plan.

INTRODUCTION: To effectively respond to this relatively new, complex mandate, it is essential to find effective models of coordination to ensure that medical and health services can meet the standards now expected in a disaster situation. This theme explored various models, noting both the strengths that can be built on and the weaknesses that still need to be overcome. METHODS: Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Since the findings from the Theme 1 and Theme 4 groups were similar, the chairs of both groups presided over one workshop that resulted in the generation of a set of Action Plans that then were reported to the collective group of all delegates. RESULTS: The main points developed during the presentations and discussion included: (1) preplanning (predisaster goals), (2) information collection (assessment), (3) communication (materials and methods); and (4) response centres and personnel. There exists a need for institutionalization of processes for learning from experiences obtained from disasters. DISCUSSION: Action plans presented include: (1) creation of an information and data clearinghouse on disaster management, (2) identification of incentives and disincentives for readiness and develop strategies and interventions, and (3) action on lessons learned from evidence-based research and practical experience. CONCLUSIONS: There is an urgent need to proactively establish coordination and management procedures in advance of any crisis. A number of important insights for improvement in coordination and management during disasters emerged.

Effect of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus.

OBJECTIVE: To evaluate effects of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. DESIGN: Randomized controlled crossover trial. ANIMALS: 16 cats with naturally acquired diabetes mellitus. PROCEDURE: Cats were fed a diet high in insoluble fiber (HF) containing 12% cellulose (dry-matter basis) or a diet low in insoluble fiber (LF) for 24 weeks; they were fed the other diet for the subsequent 24 weeks. Caloric intake and insulin treatment were adjusted to maintain stable body weight and control of glycemia, respectively. Cats were allowed an adaptation period of 6 weeks after initiation of a diet, after which control of glycemia was evaluated at 6-week intervals for 18 weeks. Variables assessed included serum glucose concentration measured during the preprandial state, blood glycated hemoglobin concentration, serum glucose concentration measured at 2-hour intervals for 12 hours beginning at the time of the morning insulin injection, 12-hour mean serum glucose concentration, and mean fluctuation in serum glucose concentration from the 12-hour mean serum glucose concentration. RESULTS: Mean daily caloric intake, body weight, or daily insulin dosage did not differ significantly between cats when fed HF and LF diets. Mean preprandial serum glucose concentration, most post-prandial serum glucose concentrations, and the 12-hour mean serum glucose concentration were significantly lower when cats consumed the HF diet, compared with values when cats consumed the LF diet. CONCLUSIONS AND CLINICAL RELEVANCE: These results support feeding a commercially available diet containing approximately 12% insoluble fiber (dry-matter basis) to cats with naturally acquired diabetes mellitus.

Effect of fish oil, arginine, and doxorubicin chemotherapy on remission and survival time for dogs with lymphoma: a double-blind, randomized placebo-controlled study.

BACKGROUND: Polyunsaturated n-3 fatty acids have been shown to inhibit the growth and metastasis of tumors. This double-blind, randomized study was designed to evaluate the hypothesis that polyunsaturated n-3 fatty acids can improve metabolic parameters, decrease chemical indices of inflammation, enhance quality of life, and extend disease free interval and survival time for dogs treated for lymphoblastic lymphoma with doxorubicin chemotherapy. METHODS: Thirty-two dogs with lymphoma were randomized to receive one of two diets supplemented with menhaden fish oil and arginine (experimental diet) or an otherwise identical diet supplemented with soybean oil (control diet). Diets were fed before and after remission was attained with up to five dosages of doxorubicin. Parameters examined included blood concentrations of glucose, lactic acid, and insulin in response to glucose and diet tolerance tests; alpha-1 acid glycoprotein; tumor necrosis factor; interleukin-6; body weight; amino acid profiles; resting energy expenditure; disease free interval (DFI); survival time (ST); and clinical performance scores. RESULTS: Dogs fed the experimental diet had significantly (P < 0.05) higher mean serum levels of the n-3 fatty acids docosahexaenoic acid (C22:6) and eicosapentaenoic acid (C20:5) compared with controls. Higher serum levels of C22:6 and C20:5 were associated with lesser (P < 0.05) plasma lactic acid responses to intravenous glucose and diet tolerance testing. Increasing C22:6 levels were significantly (P < 0.05) associated with longer DFI and ST for dogs with Stage III lymphoma fed the experimental diet. CONCLUSIONS: Fatty acids of the n-3 series normalize elevated blood lactic acid in a dose-dependent manner, resulting in an increase in DFI and ST for dogs with lymphoma.

Food hypersensitivity reactions in Soft Coated Wheaten Terriers with protein-losing enteropathy or protein-losing nephropathy or both: gastroscopic food sensitivity testing, dietary provocation, and fecal immunoglobulin E.

The purpose of this study was to evaluate Soft Coated Wheaten Terriers (SCWTs) affected with protein-losing enteropathy (PLE) or protein-losing nephropathy (PLN) or both for allergy to food. We performed gastroscopic food-sensitivity testing, a provocative dietary trial, and measurement of fecal immunoglobulin E (IgE) in 6 SCWTs affected with PLE or PLN or both. Positive gastroscopic food-sensitivity test reactions were noted in 5 of 6 dogs. Positive reactions were found to milk in 4 dogs, to lamb in 2 dogs, and to wheat and chicken each in 1 dog. Adverse reactions to food (diarrhea, vomiting, or pruritus) were detected in all 6 dogs during the provocative dietary trial. Adverse reactions were found to corn in 5 dogs, to tofu in 3 dogs, to cottage cheese in 2 dogs, to milk in 2 dogs, to farina cream of wheat in 2 dogs, and to lamb in 2 dogs. Serum albumin concentrations significantly decreased and fecal alpha1-protease inhibitor concentration significantly increased 4 days after the provocative trial when compared with baseline values. Antigen-specific fecal IgE varied throughout the provocative trial, with peak levels following ingestion of test meals. We conclude that food hypersensitivities are present in SCWTs affected with the syndrome of PLE/PLN. Mild inflammatory bowel disease was already established in the 6 SCWTs of this report at the time of study, making it impossible to determine if food allergies were the cause or result of the enteric disease.

Addition of casein or whey protein to colostrum or a colostrum supplement product on absorption of IgG in neonatal calves.

The effects of the addition of nonimmunoglobulin protein on absorption of immunoglobulin G (IgG) from colostrum or colostrum supplement products were determined in two experiments. In experiment 1, 48 Holstein calves were fed 4 L of pooled maternal colostrum or 4 L of reconstituted colostrum supplement with 0, 200, or 400 g of added whey protein concentrate or casein. In experiment 2, 38 Jersey calves were fed 2 L of pooled maternal colostrum with 100 or 200 g of whey protein concentrate or casein added immediately before feeding. Blood was collected at 24 h of age and plasma IgG concentration, total protein, hematocrit (experiment 1 only), and plasma urea N were determined. In experiment 1, blood samples were also collected at 4, 8, 12, 16, and 20 h to evaluate absorption of IgG and protein and urea N concentrations. The addition of 400 g of casein to colostrum supplement in experiment 1 reduced plasma IgG from 5.66 g/L (0 g of casein addition) to 3.88 g/L, increased plasma urea N at 24 h, and reduced the change in plasma total protein from 0 to 24 h. Hourly plasma IgG concentrations increased with the consumption of colostrum or supplements but increased more rapidly in calves fed whey protein concentrate and more slowly in calves fed casein. The addition of 200 g of casein or whey protein concentrate to colostrum supplements had no effect on plasma IgG concentration at 24 h of age. The addition of 100 or 200 g of casein or whey protein concentrate to maternal colostrum had no effect on plasma urea N, total protein, or plasma IgG in experiment 2. The addition of nonimmunoglobulin protein to colostrum supplements or maternal colostrum did not affect IgG absorption from the intestine of newborn calves unless the amount of total protein exceeded 500 g of protein.