Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial.

PURPOSE: To select in a 2-year survey of proximal humerus fractures accessing the emergency department, a population of osteoporotic stable impacted fractures and to randomize them into two groups, one with an immediate intensive mobilization program and the other with an immediate conventional mobilization program. METHODS: In emergency department, patients with clinical signs of shoulder girdle fracture were submitted to standard X-ray examination and CT scan. Patients with stable (absence of metaphyseal comminution or fifth fragment) osteoporotic (cortical bone thickness lower than 6 mm) impacted (Is any part of metaphysis or head impacted into the shaft? YES/NO) proximal humerus fractures were selected for randomization in one of the two groups. Group 1: early intensive mobilization; Group 2: early conventional mobilization. Functional and radiographic assessment was recorded at 3, 6 and 12 months of follow-up. RESULTS: In the considered period, 120 patients were affected by a stable impacted osteoporotic proximal humerus fracture. At the final follow-up, 36 patients in group 1 and 39 patients in group 2 were available for statistical analysis. Functional and radiographic scores were comparable, with a trend of significance in favor of group 2. No fracture in any of the group showed significant loss of reduction respect to 6 months of follow-up. 4 (10%) and 1 (2.5%) patients in groups 1 and 2 were not compliant with the rehabilitation program (p = 0.037). CONCLUSIONS: This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week, while no advantage is given by a more aggressive rehabilitation regimen. Self-assisted exercises should be explained to patients to maximize the effects of the assisted program. LEVEL OF EVIDENCE: Level 1, randomized controlled double-blinded trial.

Retroverted glenoid reconstruction using glenoid plate in reverse shoulder arthroplasty.

PURPOSE: The objective of this study is to evaluate the clinical and radiological results of reverse shoulder arthroplasty (RSA) with glenoid plating in a consecutive series of patients affected by cuff tear glenohumeral arthropathy with glenoid retroversion >15°. We hypothesized that autologous humeral head graft may be better stabilized between the baseplate and the native glenoid surface with the use of a glenoid plate. METHODS: Twenty consecutive patients affected by cuff tear arthropathy with glenoid retroversion >15° (B2 or C according to Walch classification) were enrolled in this study. To reconstruct the glenoid, a dedicated plate was used in addition to the standard reverse shoulder baseplate and the glenosphere. Clinical and radiological assessment was performed using constant score (CS), subjective shoulder value (SSV), X-rays and CT scan at 6, 12 and 24 months of follow-up. Healing and resorption of the graft and detection of the glenoid version were assessed. RESULTS: Sixteen patients were available for final follow-up. The mean preoperative retroversion of the glenoid was 24°, while the post-op was 2° (p = 0.002). At 24 months of follow-up, mean CS and SSV were 61 and 70. Respect to preoperative scores, the results were statistically significant (p < 0.001). The last CT scan revealed: a complete healing of the graft in 100% of cases; graft resorption less than 25% in two patients (12.5%); glenoid retroversion of 4°. A negative statistically significant correlation was found between final CS and preoperative glenoid retroversion (0.039). CONCLUSIONS: The present study reports the favorable outcomes of retroverted glenoid reconstruction with glenoid plates in RSA, an alternative method to address severe glenoid deficiency. LEVEL OF EVIDENCE: Level IV, case series with no comparison group.

Arm Squeeze Test: a new clinical test to distinguish neck from shoulder pain.

PURPOSE: Objective of this study is to evaluate the diagnostic values of the Arm Squeeze Test. The test consists in squeezing the middle third of the upper arm. METHODS: 1,567 patients were included in this study. Diagnosis of cervical nerve root compression or shoulder disease was clinically formulated and confirmed with imaging before performing test. 350 healthy volunteers were recruited as controls. The test was positive when score on a VAS Scale was 3 points or higher on squeezing the middle third of the upper arm compared to acromioclavicular (AC) joint and anterolateral-subacromial area. RESULTS: Patients were subdivided as follows: 903 with rotator cuff tear, 155 with shoulder adhesive capsulitis, 101 with AC joint arthropathy, 55 with calcifying tendonitis, and 48 affected by glenohumeral arthritis. The study sample included 305 patients with cervical nerve root compression from C5 to T1 with shoulder radicular pain. The test was positive in 295/305 (96.7%) of patients with cervical nerve root compression, compared to 35/903 (3.87%), 3/155 (1.93%), 0/101 (0%), 1/55 (1.81%) and 4/48 (8.33%) of those with rotator cuff tear, adhesive capsulitis, AC arthropathy, calcifying tendonitis and glenohumeral arthritis, respectively. A positive result was obtained in 14/350 asymptomatic subjects (4%). If patients with cervical nerve root compression were compared to controls and patients with shoulder diseases, the test had sensitivity of 0.96 and specificity from 0.91 to 1. CONCLUSIONS: The Arm Squeeze Test may be useful to distinguish cervical nerve root compression from shoulder disease in case of doubtful diagnosis. A positive result to this test may lead to cervical etiology of the shoulder pain.

[Inferior vena cava interruption: a 17-years experience (1989-2006)]. / Interrupção da veia cava interior: 17 anos de experiência (1989-2006).

Venous thromboembolic disease is associated with significant morbidity and mortality. Anticoagulation is the gold standard therapy to the venous thromboembolism. However, in a small group of patients, anticoagulation might be ineffective or associated with increased risks of haemorrhage. In addition, anticoagulation might be contraindicated due to the coexistence of other pathologies like trauma, or perioperative period of major surgery. In these circumstances, caval interruption (definitive, temporary), by various methods, has been accepted as an alternative to anticoagulation, to prevent pulmonary embolism. The author reviews the history of the different methods of vena cava interruption, with special attention to the indications, types, and results of the different vena cava filters commonly employed. He presents a retrospective analysis of 106 definitive vein cava filters which were inserted under his guidance from January 1989 through March 2006. Finally, he analyses the most common complications and concludes that it is a simple technique, to be used selectively in recurrent pulmonary thromboembolismo and requiring a multidisciplinary approach.

[Phlebolits: a rare cause of symptoms in patients with venous malformations]. / Flebolitos: uma causa rara de sintomas em doentes com malformações venosas.

Phlebolits are rare lesions that may appear in all parts of the body (head, maxillary, pelvis and extremities) and can be diagnosed by radiologic means, without any symptomatology. However, in very rare cases, they can be responsible for pain and functional incapacity, mainly in the extremities and when they are related to congenital venous malformations. The authors report two clinical cases in young people, carrying venous malformations of the upper limbs, in which the pain was caused by phlebolits. The diagnosis was performed through radiologic examination and confirmed by the appearance of pain as consequence of the mobilisation of the lesions. The surgical resection of the phlebolits resulted in the prompt disappearance of the symptoms. Chemical analyses revealed that tricalcium phosphate was the main component of these calcifications. The authors discuss some hypothesis regarding the formation of this peculiar form of complication of venous malformations.

[Leg ulcers. The diagnostic and therapeutic options]. / Ulceras de perna. Opções diagnósticas e terapêuticas.

Leg ulcers, the cause of great morbidity, are a common malady. Diagnosis is sometimes difficult and inappropriate treatment may lead to serious consequences with the risk of amputation. The authors describe the basis for a simple diagnosis of these conditions as well as the usual medical therapy, with special attention to the local treatment of these lesions.

Lesäo traumática do bulbo carotídeo esquerdo: a propósito de um caso clínico / Traumatic injurie of the left carotid bifurcation: apropos of a clinical case

Os autores descrevem um caso de lesäo traumática do pescoço num homem de 34 anos, do qual resultou secçäo do bulbo carotídeo de 34 anos, do qual resultou secçäo do bulbo carotídeo. Após dificil controle da hemorragia, que levou à realizaçäo de procedimentos pouco habituais, procederam a reconstruçäo da carotida interna tendo laqueado a carotida externa. O pós-operatório decorreu sem complicaçöes e sem alteraçöes neurológicas significativas. Terminam fazendo uma revisäo da literatura sobre estes casos

Sexually transmitted diseases and sexual behaviour as risk factors for HIV-2 infection in Bissau, Guinea Bissau.

Patients enrolled in a hospital-based case control study (n = 1009) and a follow-up study (n = 130) of HIV-2 infection in Bissau were investigated with regard to sexual behaviour and sexually transmitted diseases (STD). A history of genital ulcer was more frequent in HIV-2 infected male patients (46.4%, 13 out of 28) than in seronegative male patients (17.9%, 7 out of 39) (P = 0.05). Serological evidence of a previous syphilitic infection was significantly related to HIV-2 infection (23%, 12 out of 52, of HIV-2 seropositive patients had a positive Treponema pallidum haemagglutination test compared with 7.1%, 5 out of 70, of seronegative patients, P = 0.025) and was equally frequent in men and women. There was no significant difference in number of non-marital sexual partners and frequency of intercourse between HIV-2 seropositive and seronegative individuals. The seroprevalence of HIV-2 infection was significantly higher among patients with a monogamous marriage, 23.1% (59 out of 255) among males and 31.3% (64 out of 204) among females, than among patients with an officially polygamous marriage, 10.3% (8 out of 77) among males and 11.8% (7 out of 59) among females (P = 0.025 for males and 0.005 for females). Infection-control measures directed at patients with STD should be promoted in Guinea-Bissau. Further research on sexual behaviour and attitudes is needed.

Clinical and immunological follow-up of previously hospitalized HIV-2 seropositive patients in Bissau, Guinea-Bissau.

A follow-up study was done in Bissau on 113 HIV-2 seropositive patients and 97 HIV-2 seronegative patients 3-15 months after hospitalization. Follow-up totalled 63.5 person years for seropositive patients and 62 for seronegative patients. The mortality during the follow-up period was 43.3% among the seropositive patients (rate 72/100 person years; p.y.) and 25.8% among the seronegative patients (40/100 p. y.). Among 25 HIV-2 associated AIDS cases the mortality was 80% (rate 117/100 p. y.). The median survival time for the AIDS patients was 8 months. Among 48 HIV-2 seropositive patients who lacked signs or symptoms included in the WHO case definition for AIDS at the time of hospitalization 6 patients (12.5%) developed AIDS related symptoms (ARS) during altogether 31.5 person years of follow-up (rate 19/100 p. y.). Tuberculin anergy was demonstrated in 83.3% (15/18) of HIV-2 seropositive patients with AIDS or ARS, in 14.3% (6/42) of seropositive patients without HIV-related symptoms and in 6.9% (5/72) of seronegative patients. A low CD4 T-lymphocyte count in combination with a low CD4/CD8 T-cell ratio was found significantly more often in HIV-2 seropositive patients with AIDS or ARS (62.5%, 10/16) than in HIV-2 seropositive patients without HIV associated symptoms (6.9%, 2/29) or in seronegative patients (2.7%, 1/37). Thus the mortality among recently hospitalized HIV-2 seropositive patients was high and a high proportion of seropositive patients with HIV-related symptoms had evidence of immunodeficiency.

Improved detection of HIV-2 DNA in clinical samples using a nested primer-based polymerase chain reaction.

A two-step polymerase chain reaction (PCR), with four double (nested) primer pairs, used for the detection of HIV-2 in clinical samples is described. With these four nested primer pairs we could detect HIV-2 DNA in 17 of 17 virus isolates and in blood mononuclear cell samples from 31 of 37 (83.7%) seropositive individuals after ethidium bromide staining of the amplified DNA. The nested primer PCR was also compared with a single primer pair-based PCR followed by hybridization. The sensitivities of the two methods were almost equal, but the nested primer PCR offered obvious technical advantages.

HIV-2 infection in hospitalized patients in Bissau, Guinea-Bissau.

During 11 months in 1989-1990, 1009 consecutive hospitalized adult patients admitted to the medical wards of the National Hospital in Bissau were interviewed, examined clinically, and tested for antibodies to HIV-1 and HIV-2. The prevalence of HIV-2 infection was 20.4% (206 out of 1009) and of HIV-2-associated AIDS 4.4% (44 out of 1009). HIV-2 infection was more frequent in women (25%, 110 out of 440) than in men (16.9%, 96 out of 569). HIV-1 infection was diagnosed in one patient only, and one patient (with AIDS) had reactivity to both HIV-1 and HIV-2. Among HIV-2-seropositive patients, AIDS was demonstrated in 21.3% and AIDS-related symptoms (not fulfilling the AIDS criteria) in 19.4%. The frequency of AIDS-associated symptoms was significantly higher in HIV-2-seropositive patients than in seronegative patients. The clinical profile of the HIV-2-associated AIDS cases was very similar to that described in HIV-1-associated AIDS cases in Africa. Seven out of 51 patients fulfilling the clinical criteria for AIDS were HIV-seronegative. The World Health Organization (WHO) clinical case definition for AIDS in Africa had a specificity of 99% and a positive predictive value of 86%. Tuberculosis was more common in HIV-2-seropositive patients (6.3%) than in HIV-2-seronegative patients (2.2%). A history of blood transfusion was a significant risk factor for HIV-2 infection. HIV-2 infection and AIDS are public health problems in Guinea-Bissau.

Risk factors for HIV-2 infection in Guinea-Bissau.

To define the epidemiology of HIV-2 infection, we conducted a case-control study among hospitalized patients at an acute care hospital in Bissau, Guinea-Bissau, a country with endemic HIV-2 infection. Among 128 patients with various diagnoses, 23 (18%) were positive for HIV-2 by ELISA and Western blot. One of these patients was serologically reactive for HIV-1 also, but PCR and viral culture revealed the presence of HIV-2 only. To study risk factors, behaviors, and AIDS knowledge related to the acquisition of HIV infection, 22 HIV-2-seropositive and 21 seronegative hospitalized patients were given a physical examination and administered a questionnaire. Among women, transfusion was associated with HIV-2 infection (OR = 14.4, p = 0.02); among men, sex with a prostitute was the principal risk factor (OR = undefined, p = 0.02). Although 79% of HIV-infected patients and controls had heard of AIDS, only 17% of all study participants and 50% of males reporting sex with prostitutes had used condoms in the previous year. These data suggest that the risk factors for HIV-2 infection are similar to those for HIV-1 and support previous studies showing that HIV-2 is the predominant HIV in Guinea-Bissau. Efforts to decrease transmission of HIV-2 should include screening for HIV-2 in blood for transfusion in endemic areas (now done in Bissau) and education about the risk of sexual transmission.

Replicative capacity of HIV-2, like HIV-1, correlates with severity of immunodeficiency.

We have obtained 15 HIV-2 isolates from the peripheral blood mononuclear cells (PBMCs) of 24 HIV-2-infected west African people. The frequency of virus isolation correlated with the severity of HIV-2 infection; only three isolates were obtained from 11 asymptomatic individuals, whereas virus was isolated from nearly all (12 of 13) individuals with symptoms. The HIV-2 isolates showed distinct replicative and cytopathic characteristics and, similarly to HIV-1 isolates, could be divided into two major groups: rapid/high and slow/low. Rapid/high isolates, i.e. isolates with the ability to replicate in tumour cell lines, were obtained from individuals with symptomatic HIV-2 infection and CD4+ lymphocyte counts less than 360/microliters blood; these isolates induced syncytia in PBMC cultures. HIV-2 isolates unable to replicate continuously in tumour cell lines (slow/low isolates) induced small syncytia, cell death, or no cytopathic effect at all. All HIV-2 isolates obtained from asymptomatic individuals showed a slow/low replication pattern.