Locking in trochanteric fractures: a comparison of static versus dynamic locking using the Gamma3 nail.

PURPOSE: The Gamma3 nail (Stryker®) is an intramedullary device consisting of a proximal lag screw and distal interlocking screw. It is still unknown whether the screw locking mode could influence clinical outcomes. The aim of this study is to compare static and dynamic screw locking regarding their influence on surgical revisions and lag screw displacement. METHODS: A retrospective single-centre study was performed on patients ≥ 60 years admitted for a trochanteric fracture between September 2016 and January 2020. Surgical revisions and lag screw displacement were evaluated at 6 weeks and 1-year follow-up, respectively. RESULTS: A total of 142 patients were included for analysis. Surgical revisions were needed in 13 cases (9.2%). Indications included implant breakage (n = 3), lag screw cut-out (n = 3), lateral hip pain (n = 6) and non-union (n = 1). The number of surgical revisions was not different between static and dynamic locking (OR 2.55; 95%CI 0.73-8.56; p 0.142). The median lag screw displacement was 2.5 mm, which was similar for static and dynamic locking (2.3 mm versus 2.7 mm; p 0.785). CONCLUSION: The screw locking mode of the Gamma3 nail is not associated with a higher risk of surgical revisions. However, the design of the Gamma3 nail may not be suitable for static locking.

Effect of an interactive, educational app about venous thromboembolism and anticoagulation on patient satisfaction: A randomized controlled trial.

BACKGROUND: Adequate patient education is essential for patients to engage in shared decision-making when deciding to stop or continue anticoagulation after 3 months for venous thromboembolism (VTE). Our objectives were to evaluate the effect of an interactive, educational app on patients' level of satisfaction with information, perceived level of knowledge, decisional conflict and extent of shared decision-making when deciding on treatment duration of VTE. MATERIALS AND METHODS: This randomized controlled trial in 1 academic and 3 general Dutch hospitals included adult patients diagnosed with VTE without malignancy or prolonged anticoagulation for other indications. Patients were randomized in 1:1 ratio to receive the app (intervention group) in addition to hospital-specific standard of care. The app, created for this study, contains information on VTE and anticoagulation on an interactive timeline. In the week preceding the consultation when treatment duration is decided, patients were provided with daily videos using push notifications. Outcomes were assessed through self-reported questionnaires at baseline, 1-2 days before and 1 day after consultation. Data were analyzed using t-tests and linear mixed models for repeated measurements. RESULTS: Data of 56 patients were analyzed (mean age 57 ± 13; 27% female). On a numeric rating scale from 0 to 10, patients who received the app were 0.9 points (95%CI 0.0-1.7; p 0.04) more satisfied with the provided information. Patients who received the app experienced significantly less decisional conflict. No differences in other outcomes were observed. CONCLUSIONS: An educational app about VTE and anticoagulation increases patients' satisfaction and reduces decisional conflict when deciding on treatment duration of VTE. This study was registered in the Netherlands Trial Register (NL7037).

Grey zone amyloid burden affects memory function: the SCIENCe project.

PURPOSE: To determine thresholds for amyloid beta pathology and evaluate associations with longitudinal memory performance with the aim to identify a grey zone of early amyloid beta accumulation and investigate its clinical relevance. METHODS: We included 162 cognitively normal participants with subjective cognitive decline from the SCIENCe cohort (64 ± 8 years, 38% F, MMSE 29 ± 1). Each underwent a dynamic [18F] florbetapir PET scan, a T1-weighted MRI scan and longitudinal memory assessments (RAVLT delayed recall, n = 655 examinations). PET scans were visually assessed as amyloid positive/negative. Additionally, we calculated the mean binding potential (BPND) and standardized uptake value ratio (SUVr50-70) for an a priori defined composite region of interest. We determined six amyloid positivity thresholds using various data-driven methods (resulting thresholds: BPND 0.19/0.23/0.29; SUVr 1.28/1.34/1.43). We used Cohen's kappa to analyse concordance between thresholds and visual assessment. Next, we used quantiles to divide the sample into two to five subgroups of equal numbers (median, tertiles, quartiles, quintiles), and operationalized a grey zone as the range between the thresholds (0.19-0.29 BPND/1.28-1.43 SUVr). We used linear mixed models to determine associations between thresholds and memory slope. RESULTS: As determined by visual assessment, 24% of 162 individuals were amyloid positive. Concordance with visual assessment was comparable but slightly higher for BPND thresholds (range kappa 0.65-0.70 versus 0.60-0.63). All thresholds predicted memory decline (range beta - 0.29 to - 0.21, all p < 0.05). Analyses in subgroups showed memory slopes gradually became steeper with higher amyloid load (all p for trend < 0.05). Participants with a low amyloid burden benefited from a practice effect (i.e. increase in memory), whilst high amyloid burden was associated with memory decline. Memory slopes of individuals in the grey zone were intermediate. CONCLUSION: We provide evidence that not only high but also grey zone amyloid burden subtly impacts memory function. Therefore, in case a binary classification is required, we suggest using a relatively low threshold which includes grey zone amyloid pathology.

Tau PET and relative cerebral blood flow in dementia with Lewy bodies: A PET study.

PURPOSE: Alpha-synuclein often co-occurs with Alzheimer's disease (AD) pathology in Dementia with Lewy Bodies (DLB). From a dynamic [18F]flortaucipir PET scan we derived measures of both tau binding and relative cerebral blood flow (rCBF). We tested whether regional tau binding or rCBF differed between DLB patients and AD patients and controls and examined their association with clinical characteristics of DLB. METHODS: Eighteen patients with probable DLB, 65 AD patients and 50 controls underwent a dynamic 130-minute [18F]flortaucipir PET scan. DLB patients with positive biomarkers for AD based on cerebrospinal fluid or amyloid PET were considered as DLB with AD pathology (DLB-AD+). Receptor parametric mapping (cerebellar gray matter reference region) was used to extract regional binding potential (BPND) and R1, reflecting (AD-specific) tau pathology and rCBF, respectively. First, we performed regional comparisons of [18F]flortaucipir BPND and R1 between diagnostic groups. In DLB patients only, we performed regression analyses between regional [18F]flortaucipir BPND, R1 and performance on ten neuropsychological tests. RESULTS: Regional [18F]flortaucipir BPND in DLB was comparable with tau binding in controls (p > 0.05). Subtle higher tau binding was observed in DLB-AD+ compared to DLB-AD- in the medial temporal and parietal lobe (both p < 0.05). Occipital and lateral parietal R1 was lower in DLB compared to AD and controls (all p < 0.01). Lower frontal R1 was associated with impaired performance on digit span forward (standardized beta, stß = 0.72) and category fluency (stß = 0.69) tests. Lower parietal R1 was related to lower delayed (stß = 0.50) and immediate (stß = 0.48) recall, VOSP number location (stß = 0.70) and fragmented letters (stß = 0.59) scores. Lower occipital R1 was associated to worse performance on VOSP fragmented letters (stß = 0.61), all p < 0.05. CONCLUSION: The amount of tau binding in DLB was minimal and did not differ from controls. However, there were DLB-specific occipital and lateral parietal relative cerebral blood flow reductions compared to both controls and AD patients. Regional rCBF, but not tau binding, was related to cognitive impairment. This indicates that assessment of rCBF may give more insight into disease mechanisms in DLB than tau PET.

Experience of collaboration between a Dutch surgical team in a Ghanaian Orthopaedic Teaching Hospital.

BACKGROUND: Surgery is an indivisible, indispensable part of healthcare. In Africa, surgery may be thought of as the neglected stepchild of global public health. We describe our experience over a 3-year period of intensive collaboration between specialized teams from a Dutch hospital and local teams of an orthopaedic hospital in Effiduase-Koforidua, Ghana. INTERVENTION: During 2010-2012, medical teams from our hospital were deployed to St. Joseph's Hospital. These teams were completely self-supporting. They were encouraged to work together with the local-staff. Apart from clinical work, effort was also spent on education/ teaching operation techniques/ regional anaesthesia techniques/ scrubbing techniques/ and principles around sterility. RESULTS: Knowledge and quality of care has improved. Nevertheless, the overall level of quality of care still lags behind compared to what we see in the Western world. This is mainly due to financial constraints; restricting the capacity to purchase good equipment, maintaining it, and providing regular education. CONCLUSION: The relief provided by institutions like Care-to-Move is very valuable and essential to improve the level of healthcare. The hospital has evolved to such a high level that general European teams have become redundant. Focused and dedicated teams should be the next step of support within the nearby future.

Plate fixation versus conservative treatment of displaced midshaft clavicle fractures: Functional outcome and patients' satisfaction during a mean follow-up of 5 years.

INTRODUCTION: The aim of the present prospective clinical trial was to compare patient-oriented and surgeon-based outcomes after non-operative care with operative treatment of displaced midshaft clavicle fractures. PATIENTS/METHODS: Between January 2009 and July 2011, 97 consecutive patients presenting with a midshaft clavicle fracture were prospectively recorded and included in this study. The patients were placed in either of the treatment groups on their own preference. They were then seen in outpatient clinic at two, six and 24 weeks were all endpoints were investigated and motivation of choice of treatment was noted. Study follow-up was continued until Augustus 2014, being the time point that long-term functional outcome was measured through a DASH score by letter. RESULTS: 97 patients were included in the functional outcome analysis. The mean DASH and Constant scores were significant better in the operative (90.9±14.2 and 15.7±17.2) than in the conservative treatment group at six weeks (78.7±17.0 and 24.8±16.7). There was a significant improvement in the Constant (95.9±10.5 versus 94.5±5.9) and DASH scores (8.8±12.0 versus 7.1±10.7) for both groups at 24 weeks but there was no significant difference in functional scores between the groups. Four patients developed a non-union, one patient in the operative and three patients in the conservative group. Overall complications were significantly higher in the operative group (31%) compared to the conservative group (9%) (p<0.001). There was no significant difference in long-term functional outcome between the two treatment groups (5.2±9.8 versus 2.5±4.9 p=0.12). Patient's satisfaction was higher in the operative than in the conservative group (p<0.04). CONCLUSION: Significant superior outcome scores were seen at six weeks for the operative group. However, at 24 weeks and 5-year follow-up no difference was seen in functional outcome scores for both treatment groups. Therefore, the challenge for the future is to better identify the subgroup of patients who might benefit from primary surgical intervention.

Survival after resection of a primary malignant melanoma of the small intestine in a young patient: report of a case.

The occurrence of primary melanoma of the small intestine is rare. We describe the case of a 25-year-old man found to have a primary melanoma of the ileum. The patient presented with gradual onset of abdominal pain, fever, diarrhea, weight loss and fatigue. A preoperative diagnosis of a small intestinal tumor was based on the findings of computed tomography scanning. This diagnosis was confirmed at laparoto-my and a partial small bowel resection was performed. Histopathological examination of the resected specimen clarified the exact nature of the lesion, confirming the diagnosis of melanoma. Thorough postoperative investigation did not reveal a primary lesion in the skin, gastrointestinal tract, oculus or brain. Thus, we diagnosed this tumor as a primary lesion. One year after his operation, the patient remains well without any evidence of recurrence. Thus, we diagnosed this small bowel tumor as a primary melanoma of the small intestine.

Patients' characteristics associated with readmission to a surgical intensive care unit.

BACKGROUND: Readmission within 48 hours is a leading performance indicator of the quality of care in an intensive care unit. OBJECTIVE: To investigate variables that might be associated with readmission to a surgical intensive care unit. METHODS: Demographic characteristics, severity-of-illness scores, and survival rates were collected for all patients admitted to a surgical intensive care unit between 1995 and 2000. Long-term survival and quality of life were determined for patients who were readmitted within 30 days after discharge from the unit. Quality of life was measured with the EuroQol-6D questionnaire. Multivariate logistic analysis was used to calculate the independent association of expected covariates. RESULTS: Mean follow-up time was 8 years. Of the 1682 patients alive at discharge, 141 (8%) were readmitted. The main causes of readmission were respiratory decompensation (48%) and cardiac conditions (16%). Compared with the total sample, patients readmitted were older, mostly had vascular (39%) or gastrointestinal (26%) disease, and had significantly higher initial severity of illness (P = .003, .007) and significantly more comorbid conditions (P = .005). For all surgical classifications except general surgery, readmission was independently associated with type of admission and need for mechanical ventilation. Long-term mortality was higher among patients who were readmitted than among the total sample. Nevertheless, quality-of-life scores were the same for patients who were readmitted and patients who were not. CONCLUSION: The adverse effect of readmission to the intensive care unit on survival appears to be long-lasting, and predictors of readmission are scarce.

Traumatic hemipelvectomy: Improvements in the last decennia illustrated by 2 case reports.

INTRODUCTION: In this article we present two cases of young men who sustained a traumatic hemipelvectomy. PRESENTATION OF CASE: The first case occurred more than 10 years ago and the second case happened less than 1 year ago. Changes in the management for resuscitation, surgical intervention, and in postoperative treatment are detailed. Goal of this article is to evaluate the changes over time in the treatment of trauma in general and this specific injury in particular. DISCUSSION: Maximum survival chance could be achieved by an aggressive resuscitation (following a massive transfusion protocol-ratio of 1:1:1 unit of blood-products), starting pre-hospitally and continued in the emergency department, immediate control of the haemorrhage and direct surgical intervention. Early and frequent re-explorations are necessary to prevent complications as sepsis and to minimize the chance for complications such as disturbed wound healing and fistula formation. The use of the Vacuum-Assisted Closure therapy nowadays gives the patient an earlier recover and lesser chance at developing complications. Early consultation with plastic surgeons needs to be done in order to achieve an adequate definitive wound-closure (reconstructive surgery). CONCLUSION: A traumatic hemipelvectomy is a catastrophic and mutilating injury, seldom survivable. Maximum survival chance could be achieved by an aggressive resuscitation, frequent re-explorations, the use of VAC therapy and early consultation with a plastic surgeon for reconstructive surgery.

Improvement of sperm count and motility after ligation of varicoceles detected with colour Doppler ultrasonography.

The debate regarding the efficacy of varicocele ligation for improvement of semen parameters and pregnancy rates is ongoing. In addition, no consensus exists as to the benefit of treatment of subclinical varicoceles. The aim of this study was to investigate, retrospectively, the effect of high ligation of both subclinical and clinical varicoceles on sperm count and motility. The value of several factors from history-taking and physical examination for the prediction of successful varicocelectomy was analysed. A total of 139 patients, operated on for a unilateral varicocele on the left side, were studied. Varicoceles were subclinical in 73 patients, based on colour Doppler ultrasonography, and 66 varicoceles were clinical, based on palpation in addition to ultrasonography. Comparison of semen parameters before and after surgery revealed a significant improvement. The median sperm count increased from 10.0 to 14.7, and from 18.2 to 28.6 million/ejaculate, in patients with subclinical and clinical varicoceles, respectively (p < 0.001). The percentage improvement in median sperm count in subclinical varicoceles was not statistically different from the improvement in clinical varicoceles. Mean progressive motility improved significantly after ligation (p < 0.001). The improvement in motility in subclinical varicoceles, from 16 to 23%, was significantly larger than the 24 to 27% improvement in clinical varicoceles. The increase in sperm count was related positively to testicular volume before surgery (p < 0.05). The increase in sperm motility was significantly lower in patients with a history of cryptorchidism (n = 22, p < 0.05). The present data show that ligation of varicoceles detected using Doppler ultrasonography, whether palpable or not, results in an increase in sperm concentration and motility.

The graduate training in medical information sciences in the Academic Medical Centre at the University of Amsterdam.

Since its inception in 1987, the 4-year Medical Information Sciences (MIS) curriculum at the Academic Medical Centre (AMC), Amsterdam has gone through several major changes. The present curriculum started in 1994. The course takes 4 years, the first 3 years are programmed in integrated modules of 7 weeks in duration each. In these modules much attention is given to interactive teaching, problem based learning and private study. Typical for the Amsterdam curriculum is a strong emphasis on the role and significance of data and information in health care and its management. The authors see information technology per se as auxiliary to this orientation. Presently, about 150 students follow the courses.

Restructuring routinely collected patient data: ORCA applied to andrology.

Hospital information systems do not always cover all required detail per specialty. This may lead to scattering of data over disparate systems and the paper record. The ORCA (Open Record for CAre) CPR offers a generic structure for record sharing, and record keeping tailored to specific needs. We studied whether a semantic integration of existing and new data was possible, using the ORCA structure. Existing andrology data, originating from separate sources, were utilized for this purpose. During normalization, validation and explication steps, latent problems in the source data were exposed and removed, followed by a merge with new data items. By conversion of source data to ORCA, a unique representation of medical concepts in the database was attained, facilitating retrieval of univocal data for multiple purposes. We conclude that the expansion to the andrology domain, including transparent integration of existing data, provides support for the generality of ORCA.

Trends in Integrated Clinical Workstations.

During the last decade, several projects aiming at integrated clinical workstations have been described and several prototypes have been demonstrated. In most of these projects, the clinical workstation accesses information and functionality provided by the present proprietary legacy systems of health-care institutions. We discuss trends in integrated clinical workstations from the viewpoints of software engineering and integration, considering that the clinical workstation itself basically consists of three layers: a presentation layer, a data integration layer, and a communication layer. The software engineering view on clinical workstations focuses on the development of basic building blocks from which clinical workstations, specific to a particular medical domain, can be composed. The integration view on clinical workstations addresses methods and techniques to deal with the, in general, intrinsically closed information systems in health-care institutions.

Morphological, haemodynamic, and clinical variables as predictors for management of isolated ventricular septal defect.

OBJECTIVE: To assess the predictive impact of morphological, haemodynamic, and clinical variables in the management of patients with isolated ventricular septal defect. DESIGN: Retrospective analysis of variables by a sophisticated database management system. PATIENTS AND METHODS: 263 consecutive patients with isolated ventricular septal defect diagnosed by echocardiography. The morphological type and haemodynamic character of the ventricular septal defect was characterised in each patient. In addition, variables were introduced to represent the need for diuretics, growth, and potential delay in growth. In 43 patients (16.3%) the ventricular septal defect was closed surgically; 220 patients (83.7%) were managed conservatively and spontaneous closure of the ventricular septal defect occurred in 65 (29.5%). There were no deaths. RESULTS: All patients managed surgically had non-restrictive defects and were operated on during the first year of life. A few patients with non-restrictive defects were managed conservatively. The two groups differed significantly only with respect to mean growth delay (0.65 (0.27) v 0.9 (0.21), P < 0.001). Only the morphology of the ventricular septal defect significantly (P < 0.001) influenced the probability of closure. CONCLUSIONS: Findings imply that early surgical closure of ventricular septal defect is indicated in patients with non-restrictive ventricular septal defect and severe growth delay. Other patients should be managed conservatively. In these patients the morphological type of the defect determines the probability of spontaneous closure and provides an estimate of the period over which decreased in size or closure can be expected.

ARIS: integrating multi-source data for research in andrology.

Although the concept of distributed systems for the storage of patient data is more and more commonly accepted, for some considerable time yet most patient data will be stored in centralized rather than departmental systems. An important advantage of storage in a central system is hospital-wide access to much of the patient data. Disadvantages are however that these data cannot be reviewed through one user interface, and that the structure of the data does not lend itself to exploitation for other purposes. We describe the implementation of an Andrology Research Information System in which these data are integrated in a well-structured database facilitating multiple views on the patient data through a graphical user interface, and clinical research, quality control and summary reports. The data can be analyzed directly using the Hermes workstation. In this way the strengths of the centralized system are combined with those of the dedicated ARIS system.

SmaCS: smart classification system for the design, maintenance and use of complex terminologies. Application in pediatric cardiology.

The development of a generic Smart Classification System (SmaCS) for the design, construction, maintenance, and use of complex controlled terminologies is described. The ability of SmaCS to create and maintain terminologies that are combinations of structured terms and domain-specific knowledge is an important aspect of its design. SmaCS can therefore be used both for both controlled data-collection, using integrity rules included in the terminology, and intelligent data-retrieval. The design and implementation of SmaCS and application in the domain of pediatric cardiology are described.

Problems with integrating legacy systems.

The economic and organizational impact of imposing state-of-the-art technology to the large number of proprietary legacy systems operational in most hospitals requires integrated clinical professional workstations to provide flexible encapsulation mechanisms for these systems rather than reengineering these systems to this new technology. In this paper the implications of different input/output and translation models of legacy systems for their integration into a clinical workstation is described. Examples of legacy systems that have been integrated in the HERMES clinical workstation are presented as examples of the range of difficulties one might encounter. The features that an integrated workstation should offer for integrating a broad range of legacy systems are also addressed in this paper.

Smart Classification System (SmaCS): design, implementation, and application for congenital heart disease terminology.

The development of a generic Smart Classification System (SmaCS) for the design, construction, maintenance, and use of complex controlled terminologies is described. SmaCS is used to create a knowledge-base containing more than 2,500 items for the description of abnormalities, treatments, complications, etc. within the domain of congenital heart disease. The purpose of the combination of domain specific knowledge and terminology is to provide a tool useful for both data entry and the subsequent analysis of the data collected.

HERMES: a health care workstation integration architecture.

An architecture is described that facilitates integration of existing databases and applications without modifying them. By means of this architecture, data from different sources dispersed in a network can be combined and directly used in existing applications or applications that have been developed specially for integration. This feature of combining data from different sources into one workstation is viewed as the enabling technology on which computer-based patient records can be built. The abstraction of computer-, network- and application-specific details is completely dealt with by the integration architecture. This integration architecture has been developed with extendibility and flexibility in mind, and allows for a growth-path towards application of the open system paradigm in medicine.