Management of glenoid bone loss with impaction and structural bone grafting in reverse shoulder arthroplasty

INTRODUCTION

Glenoid bone loss is a commonly encountered problem in complex primary and revision shoulder arthroplasty. Addressing glenoid bone loss is critical to avoid complications like early loosening, impingement, notching and instability. A large number of techniques like bone grafting using autograft or allograft, eccentric reaming, augmented base plates, patient-specific instrumentations and custom-made implants are available to tackle bone loss.

MATERIALS AND METHODS

We prospectively collected the data of all patients with glenoid defects undergoing primary or revision reverse shoulder replacement between 2004 and 2017. This included demographic data, ranges of motion, Constant-Murley score and Subjective Shoulder Value (SSV). A pre-operative CT scan was done as well to plan the surgery and calculate the glenoid version. At each follow-up, the clinical function and shoulder scores were assessed. Additionally, the radiographs were assessed for graft incorporation, evidence of lysis and calculation of glenoid version.

RESULTS

Between 2004 and 2017, 37 patients underwent glenoid bone grafting during reverse shoulder arthroplasty. Average age was 72 years (range 46-88). Indications for surgery were cuff tear arthropathy (6 patients); revision of failed other prosthesis (23); primary osteoarthritis (4); rheumatoid arthritis (3); and second-stage revision for infection (1). The glenoid defect was contained in 24 patients, and therefore, impaction graft with a combination of bone graft substitute and/or humeral head autograft was performed. In 13 patients the glenoid defect was severe and uncontainable and therefore a graft-implant composite glenoid was implanted using humeral head autograft or allograft. Average follow-up was 3.6 years (range 1-10). Mean Constant score improved from 34 before surgery to 63 after surgery. Mean SSV score improved from 0.9/10 to 8.3/10. Active movements improved significantly with forward elevation increasing from 54° to 123°; abduction from 48° to 123°; external rotation from 24° to 38°; internal rotation from 57° to 70°. Radiographs at final follow-up showed no radiolucencies around the glenoid component and no evidence of loosening of the implant. In 2 cases there was a grade I notching. There was 100% survivorship at the last follow-up.

CONCLUSION

Impaction bone grafting along with structural grafting when required is an effective and reproducible way of managing severe glenoid bone loss. This technique gives consistent and good clinical and radiological results.

The "purse string" technique for anterior glenohumeral instability: long-term results 7-13-year follow-up

PURPOSE

The "Purse-String Technique" (PST) is an arthroscopic horizontal mattress suture technique for recurrent anterior shoulder instability that uses a single double-loaded suture anchor at the 4-o' clock position, achieving a Bankart labral repair and an infero-superior capsular shift. In this study, we describe the long-term results of the PST.

METHODS

The study included 69 individuals (70 shoulders), with a mean age of 30 years, who had recurrent post-traumatic anteroinferior instability. A purse-string suture anchor at the 4-o'clock position was used to address the Bankart lesion and capsular laxity, recreating the anterior glenoid bumper. All patients were assessed via telephone interview at a mean of 116 months after surgery (7-13-year follow-up).

RESULTS

Postoperatively, the mean Constant score was 94, mean Rowe score was 93 and mean Walch-Duplay score was 89. 89% of patients resumed their preinjury sport activities, with 61% of patients achieving preinjury levels and most professional athletes returning to full activity. Seven patients had recurrent dislocation postoperatively (10% failure rate). Of these patients, three had revision arthroscopic stabilization, one patient had revision arthroscopic stabilization with remplissage, two had a Latarjet procedure, whereas one patient decided to seek no further treatment.

CONCLUSION

The long-term results of PST are promising, with a low failure rate, high patient satisfaction and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV; Case series; Treatment study.

POS0404 IFNα-MEDIATED METABOLIC REPROGRAMMING IN HUMAN SLE MONOCYTES INVOLVES PERTURBATIONS IN GLYCOLYTIC AND LIPID METABOLISM TO REGULATE PROINFLAMMATORY MARKERS AND CYTOKINES

Background

Systemic Lupus Erythematosus (SLE) is a prototype interferonopathy characterized by multiple organ damage1. Metabolomic analyses of patient-derived sera indicate distinct metabolic pertubations in oxidative and lipid metabolism2,3. Among innate effectors, monocytes (Mo) are implicated in SLE pathogenesis and also display a perturbed metabolic phenotype4.

Objectives

Based on previous data indicating a prominent IFNα-gene signature in SLE monocytes even during disease remission5, we herein sought to delineate the metabolic repercussion of IFNα signaling contributing to SLE autoimmunity.

Methods

Using transcriptomic data, we compared the enriched metabolic categories of IFNα(+) and IFNα(-) SLE-Mo6. In order to compare metabolic perturbations pertaining to SLE, we performed transcriptomic Gene Set Enrichment Analysis (GSEA)7 from in vitro cultured IFNα-activated Mo. We supplemented the analysis with selective ex vivo biochemical inhibition of the metabolic pathways arising from the GSEA and evaluated the effect on inflammatory markers of healthy IFNα-Mo.

Results

We found a statistically significant enrichment of transcripts associated with glycolytic metabolism and lipid biosynthetic and catabolic processes in both IFNα(+)-SLE Mo and healthy IFNα-Mo, but not in IFNα(-)-SLE Mo, which in turn resembled healthy-Mo. Additionally, transcripts associated with cholesterol biosynthetic processes such PMVK, SQLE, LSS, DHCR7, and LDLR, MVK, FFT1 were significantly upregulated in IFNα(+)-SLE Mo and healthy IFNα-Mo respectively. In accordance, blockade of either glycolysis with the use of 2-DG hexokinase inhibitor, or mevalonic acid synthesis with the use of fluvastatin, attenuated proinflammatory cytokine secretion (IL6, CXCL10) associated with IFN-response in both IFNα(+)-SLE Mo and healthy IFNα-Mo.

Conclusion

Our results link IFNα mediated metabolic shifts in Mo with corresponding metabolic perturbations found in SLE patient-Mo. Pending further confirmation with targeted metabolomics, these data further rationalize the use of IFN blockade and also suggest the potential use of specific metabolites as novel therapeutic targets in SLE.

References

[1]Crampton, S. P., Morawski, P. A. & Bolland, S. Linking susceptibility genes and pathogenesis mechanisms using mouse models of systemic lupus erythematosus. Dis. Model. Mech. 9, 1033–1046 (2014).

[2]Yan, B. et al. Serum metabolomic profiling in patients with systemic lupus erythematosus by GC/MS. Mod. Rheumatol. 26, 914–922 (2016).

[3]Gkirtzimanaki, K. et al. IFNα impairs autophagic degradation of mtDNA promoting autoreactivity of SLE monocytes in a STING-dependent fashion. Cell Rep. 25, 921-933.e5 (2018).

[4]Huang, N. & Perl, A. Metabolism as a target for modulation in autoimmune diseases. Trends Immunol. 39, 562–576 (2018).

[5]Panousis, N. I. et al. Combined genetic and transcriptome analysis of patients with SLE : distinct, targetable signatures for susceptibility and severity. Ann. Rheum. Dis. 78, 1079–1089 (2019).

[6]El-Sherbiny, Y. M. et al. A novel two-score system for interferon status segregates autoimmune diseases and correlates with clinical features. Sci. Rep. 8, 5793 (2018).

[7]Subramanian, A. et al. Gene set enrichment analysis: A knowledge-based approach for interpreting genome-wide expression profiles. Proc. Natl. Acad. Sci. 102, 15545–15550 (2005).

Disclosure of Interests

None declared.

Diabetes and COVID-19; A Bidirectional Interplay

There seems to be a bidirectional interplay between Diabetes mellitus (DM) and coronavirus disease 2019 (COVID-19). On the one hand, people with diabetes are at higher risk of fatal or critical care unit-treated COVID-19 as well as COVID-19 related health complications compared to individuals without diabetes. On the other hand, clinical data so far suggest that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may result in metabolic dysregulation and in impaired glucose homeostasis. In addition, emerging data on new onset DM in previously infected with SARS-CoV-2 patients, reinforce the hypothesis of a direct effect of SARS-CoV-2 on glucose metabolism. Attempting to find the culprit, we currently know that the pancreas and the endothelium have been found to express Angiotensin-converting enzyme 2 (ACE2) receptors, the main binding site of the virus. To move from bench to bedside, understanding the effects of COVID-19 on metabolism and glucose homeostasis is crucial to prevent and manage complications related to COVID-19 and support recovering patients. In this article we review the potential underlying pathophysiological mechanisms between COVID-19 and glucose dysregulation as well as the effects of antidiabetic treatment in patients with diabetes and COVID-19.

Raw and modified palygorskite in water treatment applications for low-concentration ammonium removal

Raw palygorskite (Pal) samples went under acid (H-Pal), NaCl (Na-Pal), and CaCl₂ treatment (Ca-Pal) in order to be examined as ammonium (NH₄ ⁺ ) sorbents from aqueous solutions. The samples were characterized by XRD and FT-IR techniques to examine potential structural differences after modifications, and batch kinetic experiment series were applied to determine the optimal conditions for NH₄ ⁺ removal. According to thermodynamic analysis, the removal reaction for sodium- and calcium-treated samples was endothermic (ΔΗ⁰  > 0, 1.65 kJ/mol and 24.66 kJ/mol, respectively), in contrast with the exothermic reactions of raw and acidic-treated palygorskite samples (ΔΗ⁰  < 0, -37.18 kJ/mol and -27.56 kJ/mol respectively). Moreover, each sample presented a different order of sorbed ions preference, whereas the strong affinity for Ca²⁺ sorption was common in all cases since the NH₄ ⁺ removal inhibited. Nevertheless, a similar pattern was followed for raw and modified samples at isotherm study, rendering the linear form of Freundlich isotherm to express better the NH₄ ⁺ sorption on palygorskite sample, indicating that it is a heterogeneous procedure. In all cases, the NH₄ ⁺ maximum uptake was within 15 min using 8 g/L of each sorbent, especially for the Na-Pal sample, which could reach almost 100% removal of low concentration NH₄ ⁺ . PRACTITIONER POINTS: Modified palygorskite samples were tested for NH₄ ⁺ removal from aqueous solutions. NaCl-treated palygorskite had the higher removal efficiency, which could reach almost 100% removal of low concentration NH₄ ⁺ . NH₄ ⁺ maximum uptake was within 15 minutes using 8 g/L of each sorbent. NH₄ ⁺ adsorption was an endothermic reaction for NaCl- and CaCl₂ -treated palygorskite sorbents. NH₄ ⁺ adsorption was an exothermic reaction for raw and acid-treated palygorskite sorbents.

Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients

INTRODUCTION

Various surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique.

METHODS

A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed.

RESULTS

Between 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty.

CONCLUSION

This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

Avoiding hypoglycemia: the use of insulin pump combined with continuous glucose monitor in type 1 diabetes crossing a Rocky Gorge

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring systems (CGMS) have been proven very effective in diabetes management.

AIM

This study evaluated the usefulness of these devices during prolonged, intense physical activity in an uncontrolled natural environment away from the clinical research center.

DESIGN

Non-randomized, prospective and observational study.

METHODS

During the summer, 38 participants with type 1 diabetes crossed the Samaria gorge, the second largest gorge in Europe (17 km). Twenty subjects on CSII combined with real-time CGMS and 18 on multiple daily injections (MDI) combined with professional (retrospective) CGMS participated in the program. All participants were unsupervised during the event.

RESULTS

All 38 participants managed to reach the destination point safely. There were no episodes of severe hypoglycemia. The duration of the exercise (mean ±SD) was 6.4 ± 1.3 h. The CSII group exhibited significantly lower hypoglycemic episodes during exercise (0.1 ± 0.3 vs. 0.4 ± 0.6; P = 0.047) as well as lower AUC below 70 mg/dl compared with the MDI, during the 24 h (0.61 ± 0.78 vs. 1.84 ± 1.55; P = 0.007). Individuals on CSII were significantly less likely to develop a hypoglycemic episode during exercise (P = 0.038). Exercise induced nocturnal hypoglycemia was not prevented effectively in neither group.

CONCLUSIONS

CSII combined with CGMS is effective in controlling blood glucose levels in type 1 diabetics who perform prolonged strenuous exercise. The use of insulin pump technology in regions with hot Mediterranean climates is safe and can provide protection against exercise-induced hypoglycemia. Development of precise instructions for T1DM who occasionally get involved in exercise activities, requires further studies.

WHICH FACTORS MAY AFFECT THE QUALITY OF LIFE IN PATIENTS WITH TYPE 1 DIABETES MELLITUS USING THE MEDTRONIC VEO CONTINUOUS SUBCUTANEOUS INSULIN INFUSION PUMP?

Continuous Subcutaneous Insulin Infusion (CSII) is considered an effective therapeutic approach to the treatment of patients with Type 1 Diabetes Mellitus (T1DM). Literature offers limited information regarding the quality of life (QoL) in patients using CSII. The aim of the study was to investigate the impact of diabetes related factors on the QoL of patients with T1DM on CSII treatment, in a Greek urban population. A cross-sectional study was conducted on 80 patients with T1DM using CSII. [(Mean±SD) age: 35.9±11.4 years, duration of diabetes: 24.2±10.3 years, BMI: 24.6±3.5kg/m2, duration of Insulin pump use: 7.1±3.9 years, HbA1c: 7.7±1.1%, gender: 37 males-43 females)]. QoL was assessed using the patient self-administered EuroQol EQ 5D validated in Greek. Correlation and regression analyses were performed to examine the relationship between EQ index - EQ VAS scores and diabetes related factors. Hypoglycemia Awareness was measured using Clarke and Gold Score questionnaires, Hypoglycemic Episodes were expressed as number of episodes per week and the Fear of Hypoglycemia was measured using the worry subscale of the Hypoglycemia Fear Survey (HFS-W). Results were as follows: Gold score: 2.8±1.5, Clarke score: 2.8±2.1, Hypoglycemia Fear Score: 20.6±11.2, Number of hypoglycemic Episodes per week: 4.3±2.9, VAS score: 68.7±18.1, EQ index: 0.79±0.24. In univariate analyses QoL was negatively correlated with Hypoglycemic episodes, HbA1c, Hypoglycemia Fear Score and Hypoglycemia Awareness status. After regression analysis, only HbA1c and the number of hypoglycemic episodes per week remained independently related to QoL scores. Prevention of hypoglycemia and glycemic control should be emphasized in order to improve QoL in patients with T1DM with CSII.

Trans-Scaphoid Transcapitate Perilunate Fracture-Dislocation

Trans-scaphoid transcapitate (TSTC) perilunate fracture-dislocation (PLFD) is a rare type of perilunate injury. Because of the rarity and complexity of this entity, initial diagnosis may be delayed and the extent of osseous and ligamentous lesions underestimated. Early surgical treatment by open reduction and fracture stabilization is recommended to avoid complications such as avascular necrosis, nonunion, posttraumatic arthritis, and functional impairment. In this article, we report the case of a 32-year-old man who sustained a TSTC-PLFD. We describe the radiographic and intraoperative findings, review the current surgical principles for reduction and stabilization of this injury, and assess the clinical and radiologic outcomes.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

The diagnostic value of earlier and later components of Vestibular Evoked Myogenic Potentials (VEMP) in multiple sclerosis

AIM OF THE STUDY

To evaluate the ability of VEMP to disclose spatial dissemination of Multiple Sclerosis.

MATERIALS AND METHODS

Forty-six MS patients with auditory and/or vestibular symptoms were studied. Patients were divided in two groups. Group 1 included 24 patients with brainstem MRI findings, and Group 2 included 22 patients without MRI findings. VEMP and BAEP have been recorded and assessed.

RESULTS

Abnormal p13n23 wave was observed in 50%, while unilateral absence or bilateral delay of the n34p44 in 43% of the patients. The overall diagnostic value considering abnormal cases suggested by both first and second VEMP waves was increased to 71%. Statistically significant differences revealed between patients and controls for p13 latency (p=0.018). The p13n23 was abnormal in 7 patients, although MRI scanning did not reveal brainstem lesions. In 9 out of 18 MS patients suffering from unilateral hearing loss, n34p44 was present in the unaffected ears and absent in the affected side, although p13n23 was normal.

CONCLUSION

Abnormal VEMP imply the presence of lesions undetected by MRI neuroimaging, which verifies the diagnostic value of the method. Unilateral absence of n34p44 complex was related with sensorineural hearing loss, supporting the hypothesis that n34p44 is of cochlear origin.

Palliative care training and burnout in oncology fellows

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Background: Burnout among physicians is associated with fatigue, exhaustion, and depression, and can result in increased medical errors and sub-standard patient care. We sought to determine rates and predictors of burnout in oncology fellows. Methods: As part of a larger study on fellows' attitudes, education, and experiences in palliative care, we administered the 22 item Maslach Burnout Inventory (MBI) to second year U.S. oncology fellows. The 104 item instrument, modified from a survey of medical students, was revised after field testing and a pilot survey. The MBI measures three domains: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA); higher EE and DP scores and lower PA scores indicate burnout. Bivariate and multivariate analyses were used to find associations between burnout and fellow demographics, attitudes, and educational experiences. To accommodate for multiple testing, p<0.01 was considered statistically significant. Results: The response rate was 63.2% (254 of 402 eligible fellows). Gender, race, and location of medical school (U.S. vs. other) did not differ between respondents and non-respondents. Among respondents, 28.1% reported high EE, 30.0% reported high DP, and 26.8% reported low PA. Over half reported burnout in at least one domain (32.9% in one, 16.5% in two, and 5.5% in all three domains). The following associations were found on multivariate analyses. Fellows who identified as white had higher rates of EE (p=0.0006) while EE was lower in those who: 1) rated their program's overall teaching ‘very good‘ or ‘excellent‘ (p=0.005), 2) felt prepared to address spiritual issues around end-of-life care (p=0.002), and 3) felt prepared to manage their own feelings about illness and dying (p=0.008). Fellows who identified as white (p=0.008) or reported dreading encounters with emotionally distressed family members (p=0.0002) had higher DP. The only factor associated with higher PA scores was agreement that doctors have a responsibility to help patients prepare for death (p<0.0001). Conclusions: Over half of oncology fellows experience at least one domain of burnout. Higher quality teaching within their fellowship program and higher levels of self-assessed preparation to care for patients at the end of life are associated with lower levels of burnout.

No significant financial relationships to disclose.

Using vestibular evoked myogenic potentials to localise brainstem lesions. A preliminary report

BACKGROUND

Vestibular Evoked Myogenic Potentials (VEMPs) are saccular responses to acoustic stimuli. They can be recorded from the sternocleidomastoid muscle ipsilaterally to the stimulated ear. Their reflex arc includes the ipsilateral vestibular nuclei.

OBJECTIVE

To determine the usefulness of VEMPs in localising brainstem lesions.

METHODS

We used VEMPs, Blink Reflex (BR) and Brainstem Auditory Evoked Responses (BAERs) to evaluate six patients presenting with acute ischaemic or haemorrhagic brainstem lesions, or basilar dolichoectasia.

RESULTS

MRI in patient one revealed a dorsolateral medullary infarct on the right. VEMP amplitude was reduced ipsilaterally. The R2 BR component was delayed bilaterally upon stimulation of the affected side. Patients two and three had suffered a left lateral lower pontine infarct and a right lateral lower pontine haemorrhage. In patients four and five, MRA revealed dolichoectasia of the basilar artery exerting pressure on the lower lateral pons. VEMP amplitude was reduced ipsilaterally. Patient six had an ischaemic lesion in the right upper lateral pons. The R1, R2i and R2c BR components were delayed ipsilaterally. BAERs waves IV and V were absent on the right. VEMPs were normal.

CONCLUSIONS

VEMPs are affected by lesions of the lateral lower pons and upper medulla. Our results suggest that they may be a useful addition in the localisation of such lesions.

Neurophysiological monitoring of brainstem function in a patient with Wallenberg syndrome, using Vestibular Evoked Myogenic Potentials

PURPOSE

We evaluated the use of Vestibular Evoked Myogenic Potentials (VEMPs) in the assessment of neural function, following medullary lesions.

METHODS

A 54-year-old male presented with symptoms and signs typical of right lateral medullary (Wallenberg) syndrome. He underwent brain MRI and three successive neurophysiological investigations, which included VEMPs, Brainstem Auditory Evoked Responses (BAERs) and the blink reflex.

RESULTS

VEMPs amplitude on the left (unaffected) side was 256.8 microv in the first investigation and remained approximately equal to that value in the following two ones. Their amplitude on the right (affected) side was 37.9 microv, 154.2 microv and 235.2 microv correspondingly. At the same time vertigo, diplopia and nystagmus gradually improved. Right blink reflex comprised a normal R1, but delayed R2 ipsilateral and R2 contralateral responses, which remained unaltered during the follow-up period. Brain MRI disclosed a right dorsolateral medullary infarct.

CONCLUSIONS

VEMPs amplitude progressively increased, parallel to the improvement of vestibular symptoms. The blink reflex evolved differently, while BAERs were not affected. As the three evoked responses are mediated by separate neural circuits, they provide information on different aspects of brainstem function. Thus, VEMPs seem to be a useful method that complements existing ones in the assessment of brainstem lesions.

Underutilization of aspirin in hemodialysis patients for primary and secondary prevention of cardiovascular disease

BACKGROUND

Patients on hemodialysis are at high risk for cardiovascular disease (CVD). Aspirin is an established therapy for primary and secondary prevention of CVD that may be underutilized in hemodialysis patients. To better understand the use of aspirin in hemodialysis patients, we examined the experience of an urban hemodialysis center. Guidelines for use as well as associated risks and benefits are reviewed.

METHODS

Medical records for patients receiving hemodialysis treatment at our center (New York City, USA) in May 2004 were reviewed for aspirin use, presence of CVD, and potential contraindications to aspirin therapy. CVD was defined as a history of coronary artery disease, ischemic stroke, transient ischemic attack, or peripheral vascular disease. Potential contraindications to aspirin therapy included history of clinically significant bleeding or increased risk of bleeding, aspirin allergy and routine treatment with other anticoagulants.

RESULTS

176 patients were eligible for the study and 172 (98%) were included. Although 74 patients had a history of CVD, only 38 (51 %) of these were treated with aspirin. Among patients with a history of CVD who were not treated with aspirin, 19 (53%) had no identifiable contraindications to aspirin therapy for secondary prevention of CVD. Ninetyeight patients had no history of CVD, and 18 (18%) of these were treated with aspirin. Of patients without a history of CVD who were not treated with aspirin, 57 (71%) had no identifiable contraindications to aspirin therapy for primary prevention of CVD.

CONCLUSIONS

Aspirin is underutilized in hemodialysis patients for the primary and secondary prevention of CVD. Given the high risk of CVD in hemodialysis patients, therapy with aspirin may be of significant benefit and prospective studies of aspirin therapy are needed.

Increasing incidence of focal segmental glomerulosclerosis and an examination of demographic patterns

BACKGROUND

Idiopathic focal segmental glomerulosclerosis (FSGS) is one of the leading causes of the nephrotic syndrome in adults and an important cause of end-stage renal disease. Its incidence has dramatically increased in the last two decades and it is especially prevalent among black patients. The trend of FSGS incidence has not been reported beyond 1997.

METHODS

We retrospectively reviewed all renal biopsies performed at our institution between 1986 and 2002 and identified patients with diagnoses consistent with primary glomerulopathy (PG), which included: minimal-change disease (MCD), idiopathic focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MGN), IgA nephropathy (IgA), membrano-proliferative glomerulonephritis (MPGN) and mesangioproliferative glomerulonephritis. Patients with possible secondary causes for their renal disease were excluded. Clinical data at the time of biopsy and follow-up data were collected and analyzed.

RESULTS

During the period from January 1986-December 2002, 299 renal biopsies were performed and 132 patients were diagnosed with PG. FSGS was the most common form of PG representing 37.8% of all PG followed by IgA 27.3%, MGN 16.6% and MCD 9.1%. Among FSGS patients 59% were females, 64% had nephrotic range proteinuria and 54% had the nephrotic syndrome. Mean serum creatinine was 2.0 +/- 0.2 mg/dl and mean protein excretion was 6.1 +/- 1.0 g/day. The incidence of FSGS increased from 19.3% (1986-1991) and 16.6% (1992-1997) to 58.5% in the period from 2002. The increase occurred among black and Hispanic patients (33.3-79.2%) as well as white patients (12.5-51.5%). Black and Hispanic patients with PG presented for renal biopsy at a significantly younger age than white patients (p = 0.003), with mean age 37.5 +/- 2.0 years vs. 50.3 +/- 1.8 years. White FSGS patients were significantly older than white non-FSGS patients (mean age 56.4 +/- 3.2 years vs. 48.0 +/- 2.0 years, p = 0.03). Black and Hispanic FSGS patients were also older when compared to their non-FSGS counter-parts (mean age 40.6 +/- 2.8 years vs. 32.1 +/- 2.0 years, p = 0.04). When patients were stratified by age (< 45 years and > or = 45 years), FSGS was the most common diagnosis in both age groups among black and Hispanic patients (55.1% and 88.8%) but only among older white patients (36.2%).

CONCLUSIONS

The incidence of FSGS as a proportion of PG in our population has increased markedly in the most recent time period analyzed (1998-2002). The increase has occurred among both white and black and Hispanic patients. We also found that FSGS was most prevalent in patients > or = 45 years.

Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique

The current surgical literature has not clearly demonstrated an optimal technique for abdominal closure. Prospective randomized studies published between 1980 and 1998 were analyzed and the relevant data derived from those studies were pooled for statistical evaluation. The outcome variables of dehiscence, infection, hernia formation, suture sinus formation, and pain were studied and the probability of their occurrence in association with different techniques was calculated. In relation to the outcome features of dehiscence and infection no statistically significant difference was seen when absorbable suture material was compared with nonabsorbable material. In regard to the probability of hernia formation no statistically significant difference was seen when monofilament absorbable material was compared with nonabsorbable material. There was, however, a higher incidence of hernia formation when braided absorbable suture material was used. In addition there was a higher incidence of incision pain and suture sinus formation when nonabsorbable suture material was used. Absorbable monofilament suture material is superior to both absorbable braided and nonabsorbable suture for abdominal fascial closure. A continuous mass (all-layer) closure with absorbable monofilament suture material is the optimal technique for fascial closure after laparotomy.

Gangrenous and perforated appendicitis: a meta-analytic study of 2532 patients indicates that the incision should be closed primarily

BACKGROUND

Surgical incisions after appendectomy for complicated (gangrenous or perforated) acute appendicitis are often managed with delayed closure (DC) rather than primary closure (PC). This study synthesizes the results of other studies in the surgical literature and supports the routine use of PC.

METHODS

Studies dealing with complicated appendicitis were reviewed to assess the results of PC in comparison with DC. The rate of incision (wound) infection in groups of patients managed by PC and DC were compared with the use of a statistical technique that defined the probability of expected results by incorporating data derived from all of the various study groups.

RESULTS

Of the 2532 patients who had been treated for complicated appendicitis and who were assessed, 1724 patients underwent PC and 808 patients underwent DC. The rate of incision infection was 4.7% and 4.6% in the PC and DC groups, respectively. With a 95% confidence interval, there was no demonstrable difference between the 2 types of operative site management (P < .01).

CONCLUSIONS

PC of the skin and subcutaneous tissue after appendectomy for gangrenous or perforated appendicitis, combined with the use of antibiotic therapy in the perioperative period, is not associated with an increased risk of incision infection when compared with DC.

Perceived value of the American Board of Surgery certificate: a survey of 2,000 Fellows of the American College of Surgeons

BACKGROUND

This study was undertaken to identify perceptions of surgeons of the value of the American Board of Surgery (ABS) certificate.

STUDY DESIGN

Two-thousand Fellows of the American College of Surgeons received a 30-item survey designed to identify their demographics and their assessments of the functional and financial value of the certificate. Functional value was assessed using a 5-point scale in the areas of professional recognition, personal satisfaction, court proceedings, job security, mobility, and advancement, whether the certificate was necessary to obtain an academic or a clinical position, and whether it served as an indicator of depth or breadth of surgical knowledge or of clinical competence. Perceived professional lifetime financial value of the certificate was also assessed.

RESULTS

Return response rate was 37.2%. The ABS certificate was perceived to be most valuable in obtaining an academic or a clinical position and playing a significant role in court proceedings. It was perceived as least valuable in indicating breadth of knowledge and clinical competence. Sixty-seven percent responded that certified surgeons should earn more, and 49% estimated the certificate's lifetime financial value as more than $500,000. Sixty-two percent of surgeons approved of continuing the recertification process every 10 years.

CONCLUSIONS

The ABS certificate is perceived as an objective credentialing instrument that affords diplomates power, status, an opportunity to obtain an academic or clinical position, job mobility, protection in court proceedings, and greater income. Although it is perceived as an instrument that could aid a career, it is not viewed as an indicator of a person's clinical competence.

The Perceived Value of the American Board of Anesthesiology Certificate: A Survey of 2,000 Anesthesiologists

BACKGROUND

The present study was undertaken in order to identify anesthesiologists' perceptions regarding the value of the ABA certificate.

METHODS

2,000 anesthesiologists received a 31-item survey designed to identify their demographics and their assessments of the functional and financial value of the certificate. Functional value was assessed using a five-point scale in the domains of professional recognition, personal satisfaction, job security, mobility and advancement, whether the certificate was necessary to obtain an academic or a clinical position, and whether it served as an indicator of depth or breadth of anesthesia knowledge or of clinical competence. Perceived professional lifetime financial value of the certificate was also assessed. Return response rate was 45.4%. Data were analyzed using descriptive statistics and student's t-tests.

RESULTS

The ABA certificate was perceived to be most valuable in obtaining an academic position (3.4 ± .9) and least valuable in indicating clinical competence (1.6 ± 1.2). Certified anesthesiologists consistently ascribed greater value to it than non-certified ones (p<.001) on all but the academic domain. No gender differences were observed except that females attributed a greater value to the certificate as a requisite for achieving job security. Sixty percent responded that certified anesthesiologists should earn more than non-certified ones and 54% ascribed to a professional lifetime financial value of over $100,000 to ABA certification.

CONCLUSIONS

Although perceived as an objective credentialing instrument which could aid one's career, the ABA certificate was not viewed as an indicator of clinical competence.

Decreased intrinsic factor secretion in AIDS: relation to parietal cell acid secretory capacity and vitamin B12 malabsorption

AIDS-associated gastric secretory failure has been characterized by decreased secretion of acid, pepsin, and gastric juice volume. To determine whether decreased intrinsic factor secretion and vitamin B12 malabsorption occur in this entity, we performed prospective measurements of maximal acid output, intrinsic factor output, vitamin B12 absorption, serum vitamin B12, and holotranscobalamin II in 10 consecutive AIDS patients. Four of 10 patients had low maximal acid output, i.e., < or = 1.5 mEq/h (control = 12.8 +/- 9.0, range 2.5-25 mEq/h). Four patients had low intrinsic factor output, i.e., < or = 1.1 microgram/h (control = 8.2 +/- 6.9, range 3.1-19.4 micrograms/h). One patient with low intrinsic factor output had low serum vitamin B12 and a Schilling test consistent with pernicious anemia. A second patient with very low intrinsic factor output (0.16 micrograms/h) had low parts I and II Schilling tests; malabsorption most likely resulted from both low intrinsic factor secretion and ileal disease. One of three vitamin B12 malabsorbing patients, with normal serum vitamin B12, had low holotranscobalamin II, 25 pg/ml (control holotranscobalamin II = 76 +/- 44, range 44-152 pg/ml). Maximal acid output and intrinsic factor output did not correlate in AIDS (r = 0.36, p = 0.30) in contrast to the expected correlation in controls (r = 0.91, p = 0.03). We conclude that low intrinsic factor secretion is common in AIDS and contributes to vitamin B12 malabsorption. Decreased parietal cell secretion of intrinsic factor and acid may occur independently in human immunodeficiency virus-associated gastric secretory failure. Low holotranscobalamin II, an early manifestation of vitamin B12 malabsorption, results in decreased delivery to vitamin B12-dependent tissues prior to depletion of serum vitamin B12. Regular supplementation with vitamin B12 may therefore be warranted in patients with advanced HIV infection.

A survey of 800 patients' knowledge, attitudes, and concerns regarding anesthesia

The present study was undertaken to assess patients' knowledge, attitudes, and concerns regarding anesthetic management. A survey of 34 items was developed and administered preoperatively to 800 consecutive patients. Included were 303 men and 497 women with a mean age 52 yr and a mean educational level of 12 yr. Patients were interviewed on their knowledge of the role and training of anesthesiologists and on their preferences regarding anesthetic management. Patients also rated the intensity of their concern on 20 written statements expressing potential anesthetic complications. Results indicated that patients' perceptions of the anesthesiologist's training and role were accurate. Most patients preferred (a) general to regional anesthesia and (b) not to select their own anesthesiologist. Most significant preoperative concerns regarding the anesthesiologist focused on experience, qualifications, and presence or absence during the anesthesia. Patient concerns also included the possibility of not waking up postoperatively, experiencing pain, and becoming paralyzed. Intensity of concern was inversely related to age and unrelated to educational level or occupation. Variables related to type of concern included patient's sex, type of anesthesia, and proposed surgical procedure. Issues of least concern included disclosure of personal matters during anesthesia, experiencing impaired judgment postoperatively, and being asleep or bedridden for a prolonged period of time. It is suggested that anesthesiologists address significant patient concerns during the preoperative visit to enhance their effectiveness in patient care. Efforts to educate the public on the anesthesiologist's role in perioperative care should improve patient confidence.

Morphometric and freeze-fracture studies on peripheral nerve in shiverer mice

Observations have been made on the peripheral nerves of shiverer (shi/shi) mice in comparison with control animals. Although this mutant lacks P1 myelin basic protein in peripheral and central myelin, myelin is defective only in the central nervous system. No ultrastructural abnormalities were observed in the shiverer nerves. Myelin spacing was normal. The density and distribution of intramembranous particles on the E and P faces of myelin and in the axolemma of myelinated and unmyelinated axons did not differ between the shiverer and control mice. Morphometric studies showed that external myelinated fiber diameter was significantly less and that myelin thickness was slightly but significantly greater in relation to axon diameter in the shiverer mice, suggesting a minor degree of axonal atrophy. It is concluded that P1 protein is not necessary for the formation and maintenance of the normal structure of peripheral myelin. The failure to detect differences in intramembranous particle density in myelin between shiverer and control mice indicates that P1 protein is not detected in freeze-fracture preparations.

Stature and longitudinal growth in thalassemia major. A study of 229 Greek patients

A high percentage of Greek children with homozygous b-thalassemia were short and had a lag in growth, though some severely affected attained normal height. Bone age lagged significantly behind the chronologic age, even in those with normal height for their age. A longitudinal study demonstrated an initial normal growth velocity which decreased after the age of six for males and eight for females. No patient had a spurt of growth at adolescence. Height gain continued up to the age of 21 and then ceased. Statistical analysis with a multiple regression equation showed a significant relationship between the age and height of the patients. Low hemoglobin levels and severity of the disease seemed to hinder normal growth, but neither relationship was statistically significant.