Does Open Reduction and Internal Fixation Yield Better Outcomes Over Closed Reduction of Mandibular Condylar Fractures?

PURPOSE: Despite decades of study, a consensus on therapeutic approaches to condylar fractures remains elusive, and the vexing question of invasive or noninvasive therapy remains to be definitively answered. This randomized clinical study aimed to compare the outcomes of mandibular condylar fractures (MCFs) treated by closed reduction (CR) with those treated by open reduction and internal fixation (ORIF). METHODS: The investigators designed and implemented a randomized controlled trial composed of patients with unilateral or bilateral MCFs. Patients were randomly allocated into the ORIF and CR groups. The primary predictor variable was treatment, either CR or ORIF. The primary outcome variable was temporomandibular joint function (pain and range of motion) assessed at 1 and 6 weeks and at 3, 6, and 12 months. The secondary outcomes included occlusion and complications (deviation, facial nerve injury, and scarring). Perioperative covariates included fracture displacement, ramus height loss, and associated mandibular fractures. The effect of treatment group on each of the 12-month outcomes was assessed using the χ2 test or the independent samples t test. A 5% significance level was used. RESULTS: A total of 116 patients with MCFs were included in the study. Sixty-eight (59%) and 48 (41%) patients were treated by CR and ORIF, respectively. No statistically significant differences were observed between the 2 groups for mouth opening (P = .073, protrusion (P = .71), laterotrusive movements toward fractured side (0.080), and nonfractured side (P = .28). The median pain scores decreased from 4 (interquartile range [IQR] 3 to 4) at 6 weeks to 0 (IQR 0 to 0) at 52 weeks and 6 (IQR 5 to 6) at 6 weeks to 0 (IQR 0 to 0) at 52 weeks in the CR and ORIF groups, respectively. Statistically significant differences between the groups were observed for the outcome of malocclusion (P = .040) and deviation (P < .0001). Ramal height loss (P = .013) and angle of displacement (P = .0084) were significantly associated with the presence of complications in the CR group. CONCLUSIONS: The results of the present study have shown that both treatment options for MCFs yield acceptable results. However, CR yielded more complications, especially in patients with bilateral MCFs, ramus height loss greater than 5 mm, and angle of displacement greater than 15°.

Pain modulation by audiovisual distraction during cystoscopy.

INTRODUCTION: Cystoscopy is one of the most common urological procedures used for either diagnostics, therapeutics, or for surveillance. It may be performed under local or general anesthesia. The procedure is associated with pain and discomfort. AIMS: The aim of the study was to compare the levels of perceived pain during local cystoscopy with and without audiovisual distraction (AVD). METHODOLOGY: A randomized control study was performed at our academic hospital local cystoscopy theater of the urology division. Approximately half the patients already booked for the local rigid cystoscopy procedure were exposed to a distracting musical video during the procedure (study group), while the control group was not. STATISTICAL ANALYSIS: Descriptive statistics were used to determine percentage, mean, and standard deviation (SD) for categorical data. The Mann-Whitney U-test for nonparametric data was used for comparing pain levels. RESULTS: A total of 91 patients participated in the study with 48 patients in the study group and 43 patients in the control group. The visual analog scale (VAS) ranged between 1 and 5/10 in the study group and 1-8/10 in the control group, while the mean VAS was 2.52 ± 1.2 SD in the study group and 4.97 ± 1.35 SD in the control group. The AVD intervention was statistically significant (P < 0.0001). CONCLUSION: AVD during local rigid cystoscopy is highly recommended, especially in patients undergoing the procedure for the first time.

Anti-Cancer and Immunomodulatory Activity of a Polyethylene Glycol-Betulinic Acid Conjugate on Pancreatic Cancer Cells.

Drug delivery systems involving polymer therapeutics enhance drug potency by improved solubility and specificity and may assist in circumventing chemoresistance in pancreatic cancer (PC). We compared the effectiveness of the naturally occurring drug, betulinic acid (BA), alone and in a polymer conjugate construct of polyethylene glycol (PEG), (PEG-BA), on PC cells (MIA PaCa-2), a normal cell line (Vero) and on peripheral blood mononuclear cells (PBMCs). PEG-BA, was tested for its effect on cell death, immunomodulation and chemoresistance-linked signalling pathways. The conjugate was significantly more toxic to PC cells (p < 0.001, IC50 of 1.35 ± 0.11 µM) compared to BA (IC50 of 12.70 ± 0.34 µM), with a selectivity index (SI) of 7.28 compared to 1.4 in Vero cells. Cytotoxicity was confirmed by increased apoptotic cell death. PEG-BA inhibited the production of IL-6 by 4-5.5 fold compared to BA-treated cells. Furthermore, PEG-BA treatment of MIA PaCa-2 cells resulted in the dysregulation of crucial chemoresistance genes such as WNT3A, TXNRD1, SLC2A1 and GATA3. The dysregulation of chemoresistance-associated genes and the inhibition of cytokines such as IL-6 by the model polymer construct, PEG-BA, holds promise for further exploration in PC treatment.

Reliability and versatility of the Wise pattern, medial pedicle for breast reduction in South Africa.

BACKGROUND: Breast hypertrophy is a condition of abnormal enlargement of the breast which may continue until each breast weighs more than 1.5 kg (macromastia) or even more than 2 kg (gigantomastia). Supporting such heavy weights leads to cervical and upper thoracic back pain, costochondritis, and fungal infections in the mammary folds, making reduction mammoplasty essential. However, there is a lack of consensus among plastic surgeons as to the best technique. This study reports the results of reduction mammoplasties in South African women using the Wise pattern, minimally undermined with a medial pedicle. METHODS: A retrospective record review of the reduction mammoplasties was conducted over a 1-year period. Patient records were assessed for early complications related to vascular reliability. RESULTS: One hundred and fourteen Wise pattern minimally undermined, medial pedicle techniques were performed on 57 consecutive patients in the 1-year period at the NetCare Rand Clinic in Berea, Johannesburg, South Africa (EN). The patients' sternal notch to nipple distances ranged from 28 to 52 cm. The volume of breast reduction ranged from 345 g to 3300 g per breast. The overall complication rate was 9.7%, consisting of fat necrosis (3.5%), infection (1.7%), dehiscence (3.5%), and nipple epidermolysis (0.9%). CONCLUSION: The minimally undermined Wise pattern medial pedicle breast reduction technique proved to be a reliable technique for breast reduction in the South African population. Safety in pedicle breast reduction with sternal notch to nipple distances of up to 50 cm, as well as reliability and versatility in a wide range of breast sizes, was demonstrated.

Baux Score as a Predictor of Mortality at the CHBAH Adult Burns Unit.

BACKGROUND: The Chris Hani Baragwanath Academic Hospital (CHBAH) Adult Burns Unit (ABU) often operates in excess of its capacity. Our aim was to investigate the risk factor profile of the ABU population and to apply the Baux score as a model for predicting mortality to assist with appropriate resource allocation. METHODS: In this retrospective study, the Baux score was calibrated to the mortality rates in ABU burn population and the effects of various variables on mortality were assessed with Mann-Whitney U-test, chi-square test, and regression analysis. RESULTS: The relationship between the Baux score and mortality rate was characterized by this regression equation: y = -0.0002×3 + 0.0547×2 - 2.5815× + 32.649, which was used to tabulate expected mortalities per Baux score band. Univariable regression analysis revealed that Baux score, gender, suspected inhalation injury, mechanism, and intent each had statistically significant associations with mortality (P-values <0.05), whereas the multivariable model showed that only Baux score, gender, and suspected inhalation injury were statistically significant factors in predicting mortality. CONCLUSIONS: An increase in the Baux score is the most predictive and statistically significant risk factor and is easy to calculate. Thus, expected mortality can be determined using the Baux score band versus mortality table created in this study to assist with prioritizing patients in a resource-limited environment.

Transient Expression of Interleukin-21 in the Second Hit of Acute Pancreatitis May Potentiate Immune Paresis in Severe Acute Pancreatitis.

OBJECTIVES: Interleukin-21 (IL-21) is a cytokine associated with tissue inflammation, autoimmune and infectious diseases. Organ dysfunction and death can occur in patients with acute pancreatitis (AP) in two distinct clinical phases. Initially, a systemic inflammatory response syndrome may be followed by systemic sepsis from infected pancreatic necrosis, known as the "second hit." The expression and possible role of IL-21 in AP has not been established. METHODS: Thirty-six patients with mild, moderate, and severe AP (SAP) were enrolled. Peripheral blood samples of patients were drawn on days 7, 9, 11, and 13. Reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay were performed to determine the expression and concentration of IL-21. RESULTS: Interleukin-21 mRNA levels increased significantly at day 9 in severe (P = 0.002) pancreatitis compared with both the mild and control patient groups. At the protein level, IL-21 was elevated in SAP patients compared with those with mild pancreatitis, although this was not significant. Furthermore, day 9 IL-21 was elevated in septic SAP patients and patients with pancreatic necrosis. CONCLUSIONS: Interleukin-21 is transiently elevated in SAP compared with the mild/moderate group, and hence IL-21 may contribute to the immune imbalance that occurs in AP.

Modeling of cellular arginine uptake by more than one transporter.

Determining the kinetic constants of arginine uptake by endothelial cells mediated by more than one transporter from linearization of data as Eadie-Hofstee plots or modeling which does not include the concentration of trace radiolabeled amino acid used to measure uptake may not be correct. The initial rate of uptake of trace [³H]L-arginine by HUVECs and ECV304 cells in the presence of a range of unlabeled arginine and modifiers was used in nonlinear models to calculate the constants of arginine uptake using GraphPad Prism. Theoretical plots of uptake derived from constants determined from Eadie-Hofstee graphs overestimated uptake, whereas those from the nonlinear modeling approach agreed with experimental data. The contribution of uptake by individual transporters could be modeled and showed that leucine inhibited the individual transporters differently and not necessarily competitively. N-Ethylmaleimide inhibited only y⁺ transport, and BCH may be a selective inhibitor of y⁺L transport. The absence of sodium reduced arginine uptake by y⁺L transport and reduced the K(m)', whereas reducing sodium decreased arginine uptake by y⁺ transport without affecting the K (m)'. The nonlinear modeling approach using raw data avoided the errors inherent in methods deriving constants from the linearization of the uptake processes following Michaelian kinetics. This study provides explanations for discrepancies in the literature and suggests that a nonlinear modeling approach better characterizes the kinetics of amino acid uptake into cells by more than one transporter.

The BEST study--a prospective study to compare business class versus economy class air travel as a cause of thrombosis.

BACKGROUND: As many as 10% of airline passengers travelling without prophylaxis for long distances may develop a venous thrombosis. There is, however, no evidence that economy class travellers are at increased risk of thrombosis. OBJECTIVES: A suitably powered prospective study, based on the incidence of deep-vein thrombosis (DVT) reported in previous studies on long-haul flights, was designed to determine the incidence of positive venous duplex scans and D-dimer elevations in low and intermediate-risk passengers, comparing passengers travelling in business and economy class. PATIENTS/METHODS: Eight hundred and ninety-nine passengers were recruited (180 travelling business class and 719 travelling economy). D-dimers were measured before and after the flight. A value greater than 500 ng/ml was accepted as abnormal. A thrombophilia screen was conducted which included the factor V Leiden mutation, the prothombin 20210A mutation, protein C and S levels, antithrombin levels, and anticardiolipin antibodies immunoglobulin G (IgG) and immunoglobulin M (IgM). On arrival, lower limb compression ultrasonography of the deep veins was performed. Logistical regression analysis was used to determine the risk factors related to abnormally high D-dimer levels. RESULTS: Only 434 subjects had a full venous duplex scan performed. None had ultrasonic evidence of venous thrombosis. Nine passengers tested at departure had elevated D-dimer levels and these volunteers were excluded from further study. Seventy-four of the 899 passengers had raised D-dimers on arrival. Twenty-two of 180 business class passengers (12%) developed elevated D-dimers compared with 52 of 719 economy class passengers (7%). There was no significant association between elevation of D-dimers and the class flown (odds ratio (OR) 0.61, p = 0.109). The factor V Leiden mutation, factor VIII levels and the use of aspirin were, however, associated with raised D-dimers (OR 3.36, p = 0.024; OR 1.01, p = 0.014; and OR 2.04, p = 0.038, respectively). Five hundred and five passengers were contacted within 6 months and none reported any symptoms of a clinical thrombosis or pulmonary embolus. CONCLUSION: The incidence of ultrasonically proven DVT is much lower than previously reported. However, more than 10% of all passengers developed raised D-dimers, which were unrelated to the class flown. A rise in D-dimers is associated with an inherent risk of thrombosis and/or thrombophilia, demonstrates activation of both the coagulation and fibrinolytic systems during long-haul flights, and may indicate the development of small thrombi.