A cross-sectional observational study comparing individuals with a symptomatic full-thickness rotator cuff tear with age-matched controls

Background

A full-thickness rotator cuff tear (FTRCT) is defined as a complete tear of one of the four rotator cuff muscle tendons (supraspinatus, infraspinatus, subscapularis or teres minor). This condition can lead to pain and reduced function. However, not all FTRCT are symptomatic. A better understanding of the characteristics that lead some individuals with FTRCT to experience pain is fundamental to improve strategies used to manage this condition. This level II descriptive study aimed to explore potential sociodemographic, anatomical, psychosocial, pain sensitivity, biomechanical and neuromuscular variables that may differ between individuals with symptomatic FTRCT and age-matched individuals with asymptomatic shoulders.

Methods

In this cross-sectional observational study, adults aged 50 to 80 years of age, either with symptomatic FTRCT or no shoulder pain, were recruited via convenience sampling. Participants filled out questionnaires on sociodemographic and psychosocial variables. Then, various tests were performed, including pain pressure threshold, shoulder range of motion, shoulder muscle strength, shoulder ultrasound and radiologic examination, and sensorimotor functions testing. Each variable was compared between groups using univariate analyses (independent t-tests, Mann-Whitney U tests, exact probability Fisher tests). Significance was set at 0.05.

Results

FTRCT (n = 30) and Control (n = 30) groups were comparable in terms of sex, age, and number of comorbidities. The symptomatic FTRCT group showed a higher proportion of smokers (P = .026) and more participants indicated consuming alcohol or drugs more than they meant to (P = .010). The FTRCT group had a significantly higher prevalence of glenohumeral osteophytes (48% vs. 17%; P = .012). Participants in the FTRCT group were significantly more stressed (P = .04), anxious (P = .003) and depressed (P = .002). The FTRCT group also showed significantly higher levels of pain catastrophisation (P < .001) and sleep disturbance (P < .001). The FTRCT group showed significantly lower range of motion for flexion (P < .001), and external rotation at 0° (P < .001) and 90° (P < .001) of abduction. Isometric strength in both abduction and external rotation were weaker (P = .005) for the FTRCT group.

Conclusion

Sociodemographic, anatomical, psychosocial and biomechanical variables showed statistically significant differences between the FTRCT and Control groups.

Pes varus correction in dachshunds with mini hybrid external skeletal fixators

AIM

To evaluate the clinical and radiographic outcome of pes varus deformity correction in dachshunds managed with acute medial opening wedge osteotomy of the distal tibia and stabilised with a mini hybrid external skeletal fixator (HESF).

METHODS

Surgical correction involved a transverse osteotomy over the premeasured location at the distal tibia and application of a IMEX mini HESF. All corrections were evaluated using centre of rotation and angulation methodology.

RESULTS

Medical records and radiographies of 20 dachshunds (28 pes varus corrections) were reviewed. All osteotomies healed and fixators were removed between 6 and 12 weeks. Lameness resolved in 18 dachshunds (90%) and significantly improved in two dachshunds (10%). Lateral patella luxation (LPL) was detected in 11/28 (39.2%) of the involved pelvic limbs, all of which resolved following pes varus correction. Mean frontal plane alignment (FPA) of the normal and abnormal tibiae were 12.3° valgus (range: 4°-18°) and 25° Varus (range: 16°-41°) respectively. Angular correction ranged between 30° and 50° (Mean: 39°) and the mean post-operative FPA was 13° valgus (range: 5°-21°).

CLINICAL SIGNIFICANCE

Pes varus deformity in dachshunds can be corrected by medial opening wedge osteotomy of the distal tibia stabilised by HESF. Single-session bilateral pes varus corrections can also be performed with minimal morbidity. LPL was commonly detected in dogs with pes varus deformity and all resolved spontaneously following pes varus correction alone.

Predictors of clinical success in runners with patellofemoral pain: Secondary analyses of a randomized clinical trial

OBJECTIVES

To identify predictors of outcome to a rehabilitation program focused on education and management of training loads in runners with patellofemoral pain (PFP).

DESIGN

Secondary analyses of a randomized clinical trial.

METHODS

Fifty-eight runners with PFP (62% female, aged 31.2±6.6years, running 20.3±5.6km/week) were included in analyses. Following baseline collection of demographics, anthropometry, symptomatology, isometric strength, running mechanics and radiological data, runners were randomized to one of the three 8-week intervention program: (1) Education on symptoms management and training modifications; (2) Education+Exercise program; (3) Education+Gait retraining. Clinical success was defined as an increase ≥13.6% on the Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS) at 3 months following program completion. Potential predictors were entered into logistic regression analyses.

RESULTS

Forty-five runners (78%) were categorized as Success. Together, KOS-ADLS score (<70%), knee extension isometric strength (<70% bodyweight), presence of patellar tendinopathy (Grade >0) and level of usual pain (>2/10) at baseline predicted treatment outcome with 87.9% accuracy. The model provided sensitivity of 0.93 (95% C.I. 0.82-0.98), specificity of 0.69 (95% C.I. 0.42-0.87), positive likelihood ratio of 3.0 (95% C.I. 1.3-6.9), and negative likelihood ratio of 0.1 (95% C.I. 0-0.3). The best individual predictors were KOS-ADLS score and knee extension strength.

CONCLUSIONS

The combination of KOS-ADLS, knee extensors strength, patellar tendon integrity and usual pain best predicted clinical outcome of runners with PFP following an intervention that had a common education component. Further testing is needed before a clinical prediction rule can be recommended to clinicians.

Ipsilateral diaphragmatic motion and lung function in long-term pneumonectomy patients

BACKGROUND

The physiologic advantages of preserving phrenic nerve integrity and normal diaphragmatic motion (DM) during the course of pnemonectomy are incompletely understood. This study was conducted to investigate potential benefits of this strategy on postoperative lung function.

METHODS

Among 523 consecutive patients who underwent pneumonectomy for lung cancer between January 1992 and September 2001, 117 were alive at the time of study (March to December 2006) and thus had 5 years' minimum follow-up. Of those, 17 were excluded and 12 could not have magnetic resonance imaging (MRI), leaving 88 patients available for study. Diaphragmatic motion was assessed by MRI during deep breathing, and patients were classified as having normal and synchronous diaphragmatic motion (n = 44) or abnormal diaphragmatic motion (immobile or paradoxical, n = 44). These findings were correlated with expiratory volume measurements, gas exchange (arterial blood gases), and exercise tolerance (6-minute walk test).

RESULTS

The mean follow-up time was 9.3 years. Patients with abnormal DM were younger than patients with normal DM and were more likely to have had a right or an extended pneumonectomy (p < 0.01). Despite comparable preoperative lung function, patients with abnormal DM had significantly worse postoperative lung volumes (forced expiratory voume in 1 second, forced vital capacity, lung diffusion capacity for carbon monoxide; p < 0.01) and exercise capacity (6-minute walk test, percent predicted, p < 0.05) than patients with normal DM.

CONCLUSIONS

Because the long-term effects of a paralyzed hemidiaphragm in pneumonectomy patients are characterized by significant alterations in lung function, all surgeons doing this type of work should take every precaution to avoid technical errors that could lead to phrenic nerve injury or interruption.

Factorial randomised controlled trial of glucocorticoids and combination disease modifying drugs in early rheumatoid arthritis

OBJECTIVE

Treating early active rheumatoid arthritis (RA) with disease modifying antirheumatic drug (DMARD) monotherapy achieves incomplete outcomes and intensive treatment seems preferable. As the relative benefits of combining two DMARDs, one DMARD with glucocorticoids and two DMARDs with glucocorticoids are uncertain we defined them in a factorial trial.

METHODS

A 2-year randomised double-blind factorial trial in patients with RA within 2 years of diagnosis treated with methotrexate studied the benefits of added ciclosporin, 9 months intensive prednisolone or both (triple therapy). The primary outcome was the number of patients with new erosions. Secondary outcomes included Larsen's x-ray scores, disability, quality of life and adverse events.

FINDINGS

1391 patients were screened and 467 randomised. Over 2 years 132 (28%) changed therapy and 88 (19%) were lost to follow-up. The number of patients with new erosions was reduced by nearly half by adding ciclosporin or prednisolone (p = 0.01 and 0.03); both treatments reduced increases in Larsen's x-ray scores by over 2 units (p = 0.008 and 0.003). A further reduction in erosive damage was seen with combined use of both treatments. Their effects on erosive damage appeared independent. Triple therapy reduced disability and improved quality of life compared with methotrexate; ciclosporin and prednisolone acted synergistically. More patients withdrew because of adverse events with triple therapy, without an increase in serious adverse effects.

CONCLUSIONS

This study confirms the existence of a "window of opportunity" in early RA, when intensive combination therapy produces sustained benefits on damage and disability. Although methotrexate-prednisolone combinations reduce erosive damage, the synergistic effect of two DMARDs is needed to improve quality of life.

Cytomegalovirus remains viable in naturally infected breast milk despite being frozen for 10 days

Cytomegalovirus culture positive breast milk was obtained from four mothers of very premature babies. The milk was stored at 0-5 degrees C in a domestic refrigerator for 48 hours or frozen for different durations at -20 degrees C. Cytomegalovirus survived in breast milk despite being frozen for 10 days at -20 degrees C.

Fas/Fas ligand-mediated death pathway is involved in oxLDL-induced apoptosis in vascular smooth muscle cells

Oxidized low-density lipoprotein (oxLDL) is a potent inducer of apoptosis for vascular cells. In the present study, we demonstrate that the expression of death mediators, including p53, Fas, and Fas ligand (FasL) was substantially upregulated by oxLDL in cultured vascular smooth muscle cells (SMCs). The induction of these death mediators was time dependent and was accompanied by an increase in apoptotic death of SMCs following oxLDL treatment. Two oxysterols, 7beta-hydroxycholesterol and 25-hydroxycholesterol, were also effective to induce the expression of death mediators and apoptosis. alpha-Tocopherol and deferoxamine significantly attenuated the induction of death mediators and cell death induced by oxLDL and oxysterols, suggesting that reactive oxygen species are involved in triggering the apoptotic event. Incubation of cells with FasL-neutralizing antibody inhibited the oxLDL-induced cell death up to 50%. Furthermore, caspase 8 and caspase 3 activities were induced time dependently in SMCs following oxLDL treatment. Collectively, these data suggest that the Fas/FasL death pathway is activated and responsible for, at least in part, the apoptotic death in vascular SMCs upon exposure to oxLDL.

Little effect of praziquantel or artemisinin on clonorchiasis in Northern Vietnam. A pilot study

The first choice for treatment of Clonorchis sinensis infections is praziquantel. Experimental data suggest that artemisinin derivatives are active against C. sinensis. The efficacy of both drugs against clonorchiasis was evaluated in a pilot study in clonorchiasis patients in an endemic area in the North of Vietnam. Twenty-one patients received praziquantel 25 mg/kg o.d. for three days, the regular regimen in that area, and 21 patients were treated with artemisinin 500 mg b.i.d. for 5 days. Faecal egg counts were performed before as well as 6 days and 5 weeks after treatment. In the praziquantel group the faecal egg count decreased significantly from a mean value of 1632 eggs per gram faeces (epg) to 37 epg 5 weeks after treatment (P < 0.01) but, surprisingly, the eradication rate (95% confidence limit) at week 5 was only 29% (11-52%). In the artemisinin-treated group the reduction of the egg count was insignificant: from 1103 to 542 epg (P > 0.05). The proportion of patients (95% c.l.) with C. sinensis eggs in their stool on week 5 was 90% (70-99%) in the artemisinin group and 71% (48-89%) in the praziquantel group (P > 0.05) and the eradication rate (95% c.l.) at week 5 was only 10% (1-30%). With a sensitivity of detection of eggs in stool > 0.89, this implies a statistically significant but clinically unsatisfactory reduction for treatment with praziquantel. Sensitivity is probably less. For artemisinin there was no significant reduction. In conclusion, for human clonorchiasis in the North of Vietnam, the efficacy of praziquantel 25 mg/kg o.d. for 3 days was unsatisfactory and artemisinin for 5 days is not an effective alternative.

A Canadian survey of prophylactic antibiotic use among hip-fracture patients

OBJECTIVE

To study how surgical prophylactic antibiotics (SPAs) were utilized in the perioperative management of surgery for hip fractures.

DESIGN

Retrospective chart review of randomly selected medical records.

SETTING

Twenty-two hospitals (teaching, nonteaching, community, and large urban referral centers) from across Canada.

PATIENTS

Patients admitted in 1990 with a diagnosis of hip fracture.

METHODS

Complete medical records of 438 patients were examined; 352 cases who underwent surgical repair of a fractured hip with insertion of prosthetic material were included in analysis. Perioperative SPA use was assessed by abstracting the agent(s) chosen, dosages, time given with respect to the incision, and duration of postoperative use. Fourteen patient and process-of-care variables related to SPA were examined.

RESULTS

247 (70%) of 352 cases did not receive a dose of SPA 2 hours preoperatively. Ten percent of preoperative SPA was administered either too early or during the procedure. In 91 (39%) of 231 cases receiving SPA, the first dose was not administered until the end of the procedure. Preoperative SPA consisted of a parenteral first-generation cephalosporin for 94% of cases. SPAs were continued more than 24 hours postoperatively in 78% of cases. Lack of a written order for SPA, being a nonteaching hospital, and shorter duration of surgical procedure were predictive of failure to receive SPA in an effective manner.

CONCLUSIONS

Most hip-fracture-surgery patients did not receive effective antibiotic prophylaxis as required to prevent serious wound infections. This important variable can be included for surveillance, so that corrective measures can be taken to assure effective prophylactic antibiotic administration.

Effect of cervical vagotomy on catecholaminergic neurons in the cranial division of the parasympathetic nervous system

This study provides evidence of catecholaminergic neurons in the cranial division of the parasympathetic nervous system. Presumptive catecholaminergic preganglionic neurons in the dorsal motor nucleus of the vagus (DMX) were revealed by a clearcut depletion of intracellular catecholamine-synthesizing enzyme immunoreactivity induced by unilateral cervical vagotomy and identified on tissues immunocytochemically processed for tyrosine hydroxylase (TH), dopamine beta-hydroxylase (D beta H) or phenylethanolamine N-methyltransferase (PNMT). This experimental design was essential because of the recent failure in two species to reproduce data previously obtained in double-label (combined immunocytochemical-retrograde transport) studies. Vagotomy data confirmed three spatially-segregated populations of catecholaminergic visceromotor neurons in the DMX. These cell bodies were morphologically identical to preganglionic neurons observed on alternate tissues stained for Nissl substance or immunostained for choline acetyltransferase (ChAT), the enzyme biosynthesizing acetylcholine. Neurons in the central and medial DMX demonstrated fall-off of TH-like immunoreactivity (LI) ipsilateral to the vagotomy at levels caudal to the obex. This cell group is assumed to be predominantly dopaminergic since relatively few neurons at this level of the DMX expressed D beta H-LI and none were immunostained for PNMT. A second population of immunoreactive neurons, concentrated in the rostral-lateral region of the DMX, was depleted of D beta H-LI on the ipsilateral side but did not express PNMT. These visceromotor neurons may, therefore, biosynthesize noradrenaline and belong to the rostral pole of the A2 area. A third population of presumptive adrenergic vagal dorsomotor neurons in the rostral-medial DMX was depleted of TH-, D beta H- and PNMT-LI at levels of the ipsilateral nucleus anterior to obex. Patterns of depletion of cytoplasmic enzyme-immunoreaction product were identical in all cases irrespective of the site of the transection or the postoperative survival period. Quantitative analysis demonstrated statistically significant loss of immunolabeled neurons in rostral and caudal subgroups of the DMX on the side ipsilateral to the vagotomy. It is concluded that catecholaminergic processes in the vagus nerve, as previously identified by the aldehyde-induced histofluorescence method, may partly arise from the lower brainstem.

Monocyte membrane ferritin in hemochromatosis

To further evaluate a possible abnormality in the reticuloendothelial cells in hemochromatosis, the binding of a monoclonal anti-human liver ferritin antibody to monocytes was studied in 19 patients with hemochromatosis, 8 patients with secondary iron overload, 1 patient with hyperferritinemia without iron overload, and 15 normal volunteers. Binding of the antibody to the monocytes was analyzed using a fluorescence-activated cell sorter (FACS). Binding of the anti-ferritin antibody to monocytes was demonstrated in 34.7 +/- 4.5% (mean +/- standard error) of the monocytes in untreated hemochromatosis patients (mean serum ferritin = 2294 +/- 415 micrograms/L), 6.75 +/- 2.03% in treated hemochromatosis patients (mean serum ferritin = 263 +/- 85 micrograms/L), 12.3 +/- 2.7% of the monocytes in the secondary iron overload patients (mean serum ferritin = 2476 +/- 867 micrograms/L), 4.1% in the patient with hyperferritinemia (serum ferritin = 1192) and 4.1 +/- 0.5% of the monocytes in the normal volunteers (mean serum ferritin = 55.2 +/- 11.9 micrograms/L). % binding of anti-ferritin antibody was significantly greater in hemochromatosis patients compared to patients with secondary iron overload (p less than 0.05) despite a comparable degree of iron overload in the secondary iron overload group. The addition of exogenous human ferritin to samples from treated hemochromatosis patients and normal volunteers did not significantly increase the % of monocytes binding anti-ferritin antibody. These results suggest that monocytes from iron-loaded hemochromatosis patients express increased surface ferritin which may represent release of ferritin and a metabolic defect characteristic of hemochromatosis.