The effect of coronal plane angulation on patient reported outcome measures of operatively treated distal femur fractures: A multi-center prospective evaluation.

OBJECTIVES: The goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures. DESIGN: Multicenter, randomized controlled trial SETTING: 20 academic trauma centers PATIENTS/PARTICIPANTS: 156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing MAIN OUTCOME MEASUREMENTS: Radiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs. RESULTS: At 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point. With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time. CONCLUSIONS: Valgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury.

Radiological criteria for atypical features of femur fractures: what we can learn when applied in a clinical study setting.

The paper focuses on the identification of atypical fractures (AFFs). This paper examines the concordance between objective classification and expert subjective review. We believe the paper adds critical information about how to apply the American Society of Bone and Mineral Research (ASBMR) criteria to diagnose AFFs and is of high interest to the field. INTRODUCTION: Assess American Society of Bone and Mineral Research (ASBMR) criteria for identifying atypical femoral fractures (AFFs). METHODS: Two orthopedic surgeons independently evaluated radiographs of 372 fractures, applying ASBMR criteria. We assessed ease of applying ASBMR criteria and whether criteria-based assessment matched qualitative expert assessment. RESULTS: There was up to 27% uncertainty about how to classify specific features. 84% of films were classified similarly for the presence of AFF according to ASBMR criteria; agreement increased to 94% after consensus meeting. Of 37 fractures categorized as AFFs based on ASBMR criteria, 23 (62.2%) were considered AFFs according to expert assessment (not relying on criteria). Only one (0.5%) femoral shaft fracture that did not meet ASBMR criteria was considered an AFF per expert assessment. The number of major ASBMR features present (four vs five) and whether there was periosteal or endosteal thickening ("beaking" or "flaring") played major roles in the discrepancies between ASBMR criteria-based and expert-based determinations. CONCLUSIONS: ASBMR AFF criteria were useful for reviewers but several features were difficult to interpret. Expert assessments did not agree with the ASBMR classification in almost one-third of cases, but rarely identified an AFF when a femoral shaft fracture did not meet ASBMR AFF criteria. Experts identified lateral cortical transverse fracture line and associated new-bone formation along with no or minimal comminution as crucial features necessary for the definition of atypical femoral fractures.

Risk factors for fracture among current, persistent users of bisphosphonates.

SUMMARY: Bisphosphonate therapy reduces fracture risk but does not eliminate fracture occurrence. We determined the fracture incidence and risk factors for fractures among 14,674 bisphosphonate users in a community setting. Bisphosphonate users remained at risk of fracture, and additional measures to prevent fractures in these patients would be beneficial. INTRODUCTION: Bisphosphonate therapy reduces but does not eliminate fracture occurrence. The incidence of fracture and risk factors for fractures among persistent, current users of bisphosphonates in a community setting have not been well studied. METHODS: We conducted a retrospective cohort study of 14,674 bisphosphonate users in a health maintenance organization. Patients were followed until a 3-month gap in therapy, creating a pool of highly compliant [mean medication possession ratio (MPR) of 94%] current users. We used Cox proportional hazards models to identify risk factors for fractures among these persistent, current users. RESULTS: There were 867 fractures over the period of observation or 3.7 fractures per 100 users per year. Older patients who take multiple medications, have lower bone mineral density, have a history of prior fracture, and suffer from particular comorbidities (i.e., dementia, chronic kidney disease, and rheumatoid arthritis) are at higher risk of fracture while taking bisphosphonates. CONCLUSION: Persistent, current bisphosphonate users remain at risk of fracture, and additional measures to prevent fractures in these patients would be of benefit.

Fracture of the proximal humerus with injury to the axillary artery in a boy aged 13 years.

Fractures of the proximal humerus with concomitant vascular injury are rare in children. We describe the presentation, diagnosis, and treatment of a fracture of the proximal humerus in association with an axillary artery injury in a child.

Menorrhagia caused by severe hereditary factor VII deficiency. Case 1.

This report describes the clinical history and laboratory findings of three sisters with severe inherited factor VII deficiency. We present current knowledge about factor VII structure and function, and discuss clinical presentation as well as management options for patients affected by factor VII deficiency.

Qualitative platelet defect and thrombohaemorrhagic complications in a patient with polycythaemia vera. Case 10.

We describe a 67-year-old patient with polycythaemia vera and pathological functional platelet studies. He not only suffered a transient ischaemic attack despite taking of antiplatelet agents, but also showed bleeding diathesis with cerebral bleeding and spontaneous suffusions. Platelet function studies and clinical findings improved after phlebotomy and cytoreductive treatment with hydroxyurea. Thrombosis and haemorrhage account predominantly for morbidity and mortality in patients with polycythaemia vera. The pathophysiological mechanisms to explain thrombosis and bleeding in patients with myeloproliferative disorders including polycythaemia vera were intensively studied. However, up to now no clear correlation of laboratory findings in relation to clinical history of thrombosis and bleeding was demonstrated. In this report the most important pathophysiological mechanisms and therapy with antiplatelet agents are discussed.

Synergistic effect between iron and gadolinium in MRI.

Different combinations of iron glycerophosphate (Fe) and gadolinium-diethylene triamine pentaacetic acid (DTPA) (Gd) were imaged with a three-dimensional (3D) gradient-recalled echo (GRE), a 2D GRE, and a HASTE sequence on a 1.5-T MR scanner. A combination of Fe and Gd results in a synergistic effect, which improves the signal gain for selective 3D imaging of the colon and simultaneously decreases the endoluminal signal on the HASTE and 2D GRE images for better visualization of water and Gd-enhanced structures in the gut wall.

Peritonitis in childhood: aspects of pathogenesis and therapy.

The pathogenesis of peritonitis due to hollow-viscus perforation is currently accepted as being mainly based on the local and systemic release of pro- and anti-inflammatory mediators triggered by the presence of bacteria and bacterial products in the abdominal cavity. Therefore, treatment consists in focal restoration, intraoperative debridement and lavage, and postoperative measures such as drainage, continuous peritoneal lavage, or scheduled reoperation aiming at the removal of infectious agents from the peritoneal cavity to prevent persisting peritonitis and sepsis. In order to evaluate the pathophysiologic relevance of the bacterial and endotoxin load of the peritoneal exudate, we examined the peritoneal fluid of 20 children with perforated appendicitis for qualitative and quantitative analysis of bacteria, antibiotic concentrations, and endotoxin content. The time period ranged in 12-h intervals from intraoperatively to day 5. Eighteen of 20 fluid specimens (90%) showed endotoxin levels above 1.5 endotoxin units EU/ml (standard <0.1 EU/ml). The most common bacterial species isolated was Escherichia coli, mostly in high concentrations. Despite persisting high endotoxin concentrations and bacterial loads in the peritoneal cavity during the 5 postoperative days, the children recovered uneventfully and the systemic signs of infection disappeared rapidly. In conclusion, neither the bacterial nor the endotoxin load of the peritoneal cavity proved to be associated with the clinical course. Therefore, we hypothesize that during peritonitis compartmentalization of the focus of infection prevents further systemic reactions and ultimately leads to removal of the infectious agents by endogenous mechanisms. At least in peritonitis due to perforated appendicitis in children, adjuvant surgical measures in addition to appendectomy and intraoperative debridement are not necessary.

Plasma concentrations of different local anesthetics after facial nerve block.

BACKGROUND AND OBJECTIVE: The authors studied the plasma concentrations of several anesthetics to determine the relative safety of facial blocks as reflected by each anesthetic's kinetics. PATIENTS AND METHODS: Seventy-five patients undergoing cataract extraction received a proximal block of a facial nerve using prilocaine, lidocaine, mepivacaine, bupivacaine, or etidocaine. RESULTS: Mean plasma concentrations were significantly lower after the administration of prilocaine than they were after the administration of lidocaine and mepivacaine (P < .0008; multivariate analysis of variance, Roy's max root). Plasma concentrations of lidocaine and mepivacaine or bupivacaine and etidocaine did not differ from each other. Mean plasma concentrations of prilocaine, lidocaine, and mepivacaine increased continuously for 15 to 22 minutes, whereas mean plasma concentrations of bupivacaine and etidocaine peaked after 10 and 9 minutes, respectively. Peak plasma concentrations of anesthetics were well below toxic levels in all patients. CONCLUSIONS: Although systemic toxicity resulting from the rapid absorption of local anesthetics after facial nerve block seems unlikely, prilocaine may be the anesthetic most preferred for such a block because of its high level of safety.

Plasma concentrations of lidocaine after proximal and peripheral facial nerve block.

We compared plasma levels of lidocaine after the administration of proximal and peripheral blocks of the facial nerve in 30 cataract patients to evaluate the risk of systemic toxicity after both procedures. We performed the two block techniques with 5 ml 1% lidocaine solution plus (1:20,000) naphazoline nitrate as follows: the proximal block, at the dorsal rim of the mandible and the peripheral block, by subcutaneous infiltration of the lids. After the administration of the proximal block, mean plasma concentrations of lidocaine increased continuously for 15 min, whereas after the peripheral block they peaked within 12 min. Mean plasma concentrations were significantly lower following the proximal facial block than after the peripheral block of the facial nerve's terminal branches (P = 0.008-0.039, Wilcoxon test). In all patients, plasma concentration of lidocaine were below toxic levels.

[Amphotericin B--bioavailability in the cornea. Studies with local administration of liposome incorporated amphotericin B]. / Amphotericin B--Wirkspiegel in der Kornea. Untersuchungen zur lokalen Anwendung von liposomal-inkorporiertem Amphotericin B.

Amphotericin B remains an important antifungal agent in the treatment of ocular mycosis. Since topical ocular application is limited because of ocular irritation and poor penetration, we studied the pharmacokinetics of amphotericin B encapsulated in unilamellar liposomes (AmBisome). One drop (20 microliters) of AmBisome or an equivalent concentration of amphotericin B was applied to rabbit eyes. Drug concentrations were measured 15, 60, 120 and 240 min following administration of the agents by HPLC in cornea and aqueous humor. The effect of intact (group A) and debrided corneal epithelium (group B) was also studied. Corneal amphotericin B levels were significantly higher (P < 0.01) after 15 min in animals receiving amphotericin B as compared to AmBisome in group A. At later time points no differences in the corneal drug levels were found, and the drug levels following AmBisome application were remarkably stable. Epithelial removal resulted in increased corneal drug levels following application of both amphotericin B preparations. Significantly higher drug levels were observed after free amphotericin B treatment at 15-60 min (P < 0.01). Drug levels in the aqueous humor did not differ between the two amphotericin B preparations and remained below therapeutically effective concentrations. These results suggest that topically delivered AmBisome provides stable corneal drug levels, but has the potential benefit of lowered ocular toxicity.

Perioperative antibiotic prophylaxis with cefuroxime in oral-maxillofacial surgical procedures.

A study was carried out to investigate the suitability of cefuroxime for perioperative antibiotic prophylaxis in maxillofacial surgical procedures. Serum and tissue samples were taken, to determine the intraoperative cefuroxime concentration, from 40 patients who had been given 1.5 g cefuroxime (Zinacef) i.v. during maxillofacial surgery. The time between i.v. administration and taking the blood and tissue samples varied between 10 and 260 min. The serum tissue kinetics were determined using an HPLC method in the jaw area, particular emphasis being given to the concentrations measured in bone. It was demonstrated that concentrations of cefuroxime were reached which are above the MIC values for many of the pathogens in the maxillofacial area and therefore adequate protection during intraoperative bacterial contamination is guaranteed. Maximum serum levels averaging 80 mg/l were measured within 30 min of administration. An average of 15 mg/l could still be demonstrated after 4 h. The bone samples gave maximum levels of 8-9 mg/kg 90 min after administration. Average levels of 1-3 mg/kg were still measurable after 4 h. It is only possible to describe trends due to the wide variation in the values, particularly of the bone samples. No postoperative wound infection was seen under prophylaxis with cefuroxime. Cefuroxime is suitable for perioperative prophylaxis during maxillofacial surgery procedures because of its favourable kinetics and broad spectrum of action.

Orointestinal yeast colonization of paediatric oncologic patients during antifungal prophylaxis: results of quantitative culture and Candida serology and comparison of three polyenes.

The orointestinal yeast colonization of 46 children with newly diagnosed malignancies was studied prospectively and longitudinally with quantitative cultures during remission induction chemotherapy. The initial colonization rate was 24%; only 28% of the patients remained free of yeasts during their entire treatment although all of them continuously received oral polyenes as antifungal prophylaxis. A randomized comparison of natamycin (suspension, lozenges), nystatin (suspension) and amphotericin B (suspension, lozenges) failed due to serious problems with patient compliance. Natamycin was best accepted by the patients and natamycin lozenges were the most efficacious drug in the oral cavity. The effectivity of the suspensions of nystatin and amphotericin B was similar; both were equally efficacious in the oral cavity and the gut. Assessment of faecal polyene concentrations by HPLC showed the highest results for amphotericin B (mean 6808 microgram(-1)). Regularly performed Candida serology (indirect haemagglutination, indirect immunofluorescence and immunodiffusion precipitation) revealed significant titre increases in 63% of the patients. In six cases, the synopsis of clinical picture, culture and serology strongly suggested systemic yeast invasion.

[Peridural anesthesia with mepivacaine-CO2]. / Periduralanaesthesie mit Mepivacain-CO2.

After favourable experience with bupivacaine-CO2 for peridural anaesthesia we studied, whether carbonated Meaverine would have a shortened latency period also. In one hundred patients we found that the latency period of Meaverine-CO2 was shortened by about four minutes on average compared with mepivacaine hydrochloride. There were no significant differences in spread or in effect on circulation, heart rate or compatibility. Blood concentration estimations showed a rapid dose-related increase of the level within five to ten minutes.