Outcome of bracing vs. surgical treatment in adolescents with idiopathic scoliosis based on device measured daily physical activity: a prospective pilot study

Adolescent idiopathic scoliosis (AIS) can be treated with bracing or surgery, which may affect patient's physical activity (PA). However, there are limited objective assessments of PA in patients with AIS. This study aims to compare the outcome of spinal bracing vs. surgery in patients with AIS based on a device that measured daily PA. In total 24 patients with AIS participated, including 12 patients treated with bracing and 12 with spinal surgery. Daily PA was measured throughout 4 consecutive days using four tri-axial accelerometers and patient-reported functional status was reported using the SRS-22 questionnaire. The participants were assessed both before the treatment and after treatment at a 12-month follow-up. Patients with AIS had no significant change in their PA levels at the 12-month follow-up after surgical correction. On the contrary, patients with AIS following a year-long bracing treatment had significantly reduced time spent active ( P  = 0.04) with an average reduction in walking steps by 2137 steps/day ( P  = 0.005). There was no significant difference in function, pain, self-image and mental health domains following both treatments, as reported by the SRS-22. There was a significant improvement in satisfaction for both treatment groups ( P  ≤ 0.02). Significantly reduced PA and increased sedentary time are reported in patients with AIS following bracing treatment. An objective PA assessment is recommended to track the effect of scoliosis treatment on PA. Patients with AIS should be actively encouraged to achieve and maintain their recommended daily PA levels irrespective of the type of treatment. Level of evidence: Level II.

Home-Based Health Care Interventions for People Aged 75 Years and Above With Chronic, Noninflammatory Musculoskeletal Pain: A Scoping Review

BACKGROUND AND PURPOSE

Chronic, noninflammatory musculoskeletal pain is common in the aged population and management can be challenging for older people due to multimorbidity, social isolation, and physical frailty. The aim of this scoping review is to summarize and discuss the evidence related to home-based health care interventions for older adults, with chronic, musculoskeletal pain.

METHODS

A review of the literature using 8 electronic databases (Embase, MEDLINE, CINAHL, PubMed, Cochrane Library, Physiotherapy Evidence Database [PEDro], Scopus, and Web of Science) was performed, following the PRISMA-ScR guidelines. English language published studies that assessed home-based health care intervention/s, in men and women 75 years and older, with chronic, noninflammatory musculoskeletal pain where included. Two authors independently reviewed the articles and extracted data into a preformulated chart.

RESULTS AND DISCUSSION

The database search identified 4722 studies of which 7 studies met the inclusion criteria. Six of the 7 studies were randomized controlled trials and 5 studies focused on a single-site pain. The type of home-based interventions in the included studies was physical therapy (n = 2), psychotherapy (n = 3), and multimodal therapy (combination of multiple therapies) (n = 2). Participation completion rate was more than 74% in 6 out of 7 studies. Most studies used pain and/or physical function as their primary outcome (n = 6). Music therapy showed a statistically significant reduction in visual analog scale score for pain, and there was a trend toward improvement of pain and function in the physical therapy studies. No significant differences in outcomes between intervention and control groups were observed in the multimodal studies.

CONCLUSION

This review highlights the scarcity of evidence related to home-based health interventions in older people 75 years and older, living with chronic, noninflammatory musculoskeletal pain. The findings were that physical, psychotherapeutic, and multimodal interventions are usually well tolerated and can be delivered as a safe self-management option. There remains a substantial need for more high-quality research with wider range of home-based interventions and comprehensive assessment of outcomes for this age group.

A propensity-score matched analysis of ventral-TAPP vs. laparoscopic IPOM for small and mid-sized ventral hernias. Comparison of perioperative data, surgical outcome and cost-effectiveness

PURPOSE

Laparoscopic techniques have been used and refined in hernia surgery for several years. The aim of this study was to compare an established method such as laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) with ventral Transabdominal Preperitoneal Patch Plasty (ventral-TAPP) in abdominal wall hernia repair.

METHODS

Patient-related data of 180 laparoscopic ventral hernia repairs between June 2014 and August 2020 were extracted from our prospectively maintained database. Of these patients, 34 underwent ventral-TAPP and 146 lap. IPOM. After excluding hernias with a defect size > 5 cm and obtaining balanced groups with propensity-score matching, a comparative analysis was performed in terms perioperative data, surgical outcomes and cost-effectiveness.

RESULTS

Propensity-score matching suggested 27 patients in each of the two cohorts. The statistical evaluation showed that intake of opiates was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.001). The Visual Analogue Scale (VAS) score after lap. IPOM repair was significantly higher at movement (p = 0.008) and at rest (p = 0.023). Also, maximum subjective pain during hospital stay was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.004). No hernia recurrence was detected in either group. The material costs of ventral-TAPP procedure (34.37 ± 0.47 €) were significantly lower than those of the lap. IPOM group (742.57 ± 128.44 € p = 0.001). The mean operation time was 65.19 ± 26.43 min in the lap. IPOM group and 58.65 ± 18.43 min in the ventral-TAPP cohort. Additionally, the length of hospital stay in the lap. IPOM cohort was significantly longer (p = 0.043).

CONCLUSION

Ventral-TAPP procedures represent an alternative technique to lap. IPOM repair to reduce the risk of complications related to intra-peritoneal position of mesh and fixating devices. In addition, our study showed that postoperative pain level, material costs and hospital stay of the ventral-TAPP cohort are significantly lower compared to lap. IPOM patients.

Increasing global accessibility to high-level treatments for cervical cancers

Human papillomaviruses (HPV)-related gynecological cancers are a major health care issue, and a leading cause of cancer death in low- and middle-income countries (LMIC). In 2020, the World Health Organization launched a program aimed at cervical cancer elimination, by screening and vaccination strategies. Offering the best possible care to women diagnosed with invasive cancer is a complementary objective. Treatment of cervical cancer as per modern standards is complex and multimodal, mainly relying on surgery, external-beam radiotherapy (+/-chemotherapy) and brachytherapy. In parallel with the pivotal role of multidisciplinary discussion, international societies provide guidance to define the most effective and least toxic anti-cancer strategy, homogenize treatment protocols and provide benchmark quality indicators as a basis for accreditation processes. The challenge is to offer the appropriate diagnostic workup and treatment upfront and to avoid non- evidence-based treatment that consumes resources, impairs quality of life (QoL), and compromises oncological outcome. Various strategies may be applied for improving treatment quality: development of surgical mentorship, companion-training programs and international cooperation. The lack of radiotherapy/brachytherapy facilities is a major concern in LMIC. Reinforcing international support in terms of education, training, research and development and technical cooperation with national projects is required to increase access to minimum requirements but also introduce modern techniques, upgrade radiotherapy/brachytherapy services, and expand access to modern systemic treatments. In countries with robust economies, compliance to standards should also be increased. Integrative cancer care and multidisciplinary approaches are needed to tackle the dual challenge of increasing cure rates while minimizing QoL impairment. Appropriate dimensioning of the resources to avoid harmful treatment delays and access to expert referral centers is also a priority.

Computed Tomography-Based Interstitial Brachytherapy for Recurrent Cervical Carcinoma in the Vaginal Apex

AIMS

To determine the factors influencing the outcomes of patients with recurrences post-hysterectomy for cervical cancers treated with external beam radiotherapy (EBRT) and interstitial brachytherapy.

MATERIALS AND METHODS

This prospective study accrued 90 patients between October 2008 and May 2014. All patients had had a prior hysterectomy and were diagnosed with recurrent vaginal apex cancers with squamous cell carcinomas. All underwent EBRT of 50 Gy (2 Gy/fraction) using tomotherapy-based image-guided intensity-modulated radiotherapy with concurrent chemotherapy of weekly cisplatin (40 mg/m²) followed by high dose rate interstitial brachytherapy boost of 20 Gy (4 Gy/fraction twice a day). Local relapse, disease-free and overall survival were determined.

RESULTS

At a median follow-up of 74 months (4-123 months), 10/90 (11%) patients had local failure as the first site of relapse and 12/90 (13.3%) had first distant relapse. Only one patient had synchronous local and distant relapse. The 7-year local relapse-free, disease-free and overall survival were 87.6, 68.3 and 68.3%, respectively. Grade 2 and 3 rectal toxicity were seen in 5.6 and 3.1% of patients, respectively. Among these, two (2.2%) patients underwent temporary diversion colostomy due to vaginal sigmoid and rectovaginal fistula. Grade 2 and 3 bladder toxicity were seen in 5.6 and 1.1% of patients, respectively. In summary, the lateral disease extent (P = 0.048) and the presence of nodal disease at diagnosis (P = 0.08) had a statistically significant or borderline impact on local relapse without any impact on disease-free survival. Tumour size in itself did not affect overall survival.

CONCLUSION

With the integration of EBRT and interstitial brachytherapy, most vaginal apex recurrences can be salvaged. An excellent local control and survival is achievable using intensity-modulated radiotherapy with image guidance and concurrent chemotherapy followed by high dose rate interstitial brachytherapy.

Surgery due to mechanical bowel obstruction in relapsed ovarian cancer: clinical and surgical results of a bicentric analysis of 87 patients

Introduction

Mechanical bowel obstruction is a frequent acute and life-threatening event in relapsed ovarian cancer. Salvage surgery after failure of all conservative approaches, resulting in short bowel syndrome (SBS) constitutes a therapeutic dilemma. Our aim was to evaluate patients’ surgical and clinical outcome in these highly palliative situations. Previous, limited, data reported a high morbidity and mortality. However, recent surgical and therapeutical improvements in relapsed ovarian cancer (ROC) offer better identification of patients who might benefit from surgery in an effort to extend the window of opportunity to subsequently offer these patients novel systemic therapeutic approaches.

Material and methods

All subsequent ROC patients between 2012 and 2017 with acute mechanical bowel obstruction who underwent salvage extraperitoneal en bloc intestinal resection were retrospectively identified. Data were collected from two ESGO certified Ovarian Cancer Centers of Excellence (Charité Berlin and Imperial College London) and systematically evaluated regarding surgical and clinical outcomes.

Results

Overall, 87 ROC patients were included in the analysis (median age 56 years, range 24–88), 47% were platinum resistant. High grade serous was the most common histology (76%) while most of the patients (67%) had at least two previous lines of treatment. Mean observed OS was 7.8 months. After salvage surgery, 46% of the patients had a residual small bowel length < 180 cm and 18% > 180 cm resulting in 41% in need of total parental nutrition. In 80% of the patients a permanent stoma was necessary. 30d morbidity and mortality was 74% and 10%, respectively. More than half of the patients were able to receive further courses of chemotherapy after surgery.

Discussion

Salvage surgery for bowel obstruction in ROC patients needs careful consideration and identification of optimal surgical candidates to have the maximal therapeutic benefit. Despite the challenging morbidity profile, most patients managed to proceed to subsequent novel and conventional systemic treatment and so have their window of therapeutic opportunity extended.

Mortality Rate and Ten Years Survival of Elderly Patients Treated with Total Hip Arthroplasty for Femoral Neck Fractures

Introduction:

Mortality following traumatic femoral neck fractures in the elderly (age >60 years) is influenced by many factors. Addressing some of them may reduce the mortality rate thus improving patient survival and quality of life.

Materials and methods:

This study was a retrospective research using data collected from Hospital Sultanah Bahiyah, Kedah between the years 2008-2018. We measured outcomes such as age, gender, hospital stay, default rate, ambulation post-surgery, American Society of Anaesthesiologists score (ASA) and surgical timing in correlation with mortality rate and 10-year survival of elderly patients treated with Total Hip Arthroplasty for femoral neck fractures in this centre.

Results:

A total of 291 traumatic femoral neck fractures aged above 60 years post total hip arthroplasty performed were included. There was higher number of female (n =233) compared to male (n=53) Estimated 10 years survival from Kaplan Meier was 42.88% (95% CI: 33.15, 52.54). One year mortality rate in our study was found to be 18.9%. The average time to event was 7.1 years (95% CI:33.15, 52.24) with a mean age group of 75.

Discussion:

Total hip arthroplasty patients not ambulating after surgery had a 4.2 times higher hazard ratio compared to ambulators. Those with pre-existing systemic disease (ASA III and IV) were found to have the highest hazard ratio, almost five times that of healthy patients, after adjusting for confounding factors. Delay of more than seven days to surgery was found to be a significant factor in 10-year survival with a hazard ratio of 3.8, compared to surgery performed earlier.

Conclusion:

Delay of more than 7 days to surgery in 10 years survival was significant with high hazard ratio. It is a predictor factor for survival in 10 years. A larger sample size with a prospective design is required to confirm our findings regarding “unacceptable surgical timing” for femoral neck fractures in patients above 60 years of age.

Atoltivimab/maftivimab/odesivimab (Inmazeb) combination to treat infection caused by Zaire ebolavirus

Zaire ebolavirus has been responsible for several catastrophic outbreaks with a high mortality rate. Unfortunately, there were no approved therapies or vaccines to treat or prevent infections caused by Ebola virus (EBOV) or other filoviruses. Atoltivimab/ maftivimab/odesivimab (Inmazeb) is the first Food and Drug Administration (FDA)-approved treatment for Zaire ebolavirus infection in adult and pediatric patients, including neonates born to a mother who is reverse transcription polymerase chain reaction (RT-PCR)-positive for Zaire ebolavirus infection. The efficacy of Inmazeb has been established in vivo and it has successfully completed a phase I clinical trial in healthy individuals with no drug-related adverse effects. Additionally, Inmazeb has displayed significant reduction in mortality in the PALM (PAmoja tuLinde Maisha) trial, when compared with the control arm receiving ZMapp. Inmazeb has received orphan drug designation from both the U.S. FDA and the European Medicines Agency (EMA).

[Digital documentation of complications in visceral surgery: possibilities and evaluation of an instrument for quality management]

Against the background of the growing economization of clinical medicine, in the last decades the topics of risk and complication management have also become more important in surgical disciplines. The standardization and reproducible documentation of outcome and complication data play a key role for valid quality control. In this article a digital system implemented at the surgical clinic of the Charité University Medicine in Berlin is analyzed with respect to its practicability for perioperative and postoperative monitoring of complications within the framework of quality assurance.

Update on nifurtimox for treatment of Chagas disease

Chagas disease is a vector-borne neglected tropical disease caused by Trypanosoma cruzi. It is a systemic and chronic parasitic infection which is endemic in 21 countries with 10 million cases worldwide and 12,000 annual deaths. Around 70 million people in the Americas are at risk of contracting this disease, and less than 1% of infected people are treated due to low disease awareness and limited access to treatment. The current treatment for Chagas disease consists of benznidazole and nifurtimox under the World Health Organization (WHO) authorization protocol. The current treatment has limitations in terms of efficacy against the chronic phase of infection and side effects associated with prolonged therapy. This review provides an update on nifurtimox progress over the years and its recent approval by the U.S. Food and Drug Administration (FDA) in 2020 for the treatment of Chagas disease in pediatric patients under 18 years of age.

Bilateral gait asymmetry associated with tibiotalocalcaneal arthrodesis versus ankle arthrodesis

BACKGROUND

Gait asymmetries have been reported following ankle arthrodesis. However, similar reports do not exist for tibiotalocalaneal arthrodesis (TTCA), which involves further articular fusion. This study aimed to assess the extent of gait asymmetry following TTCA when compared to ankle arthrodesis.

METHOD

Gait assessment was performed on 36 participants, including 12 ankle arthrodesis, 12 TTCA and 12 controls - using 3-D inertial sensors and pressure insoles. 48 gait parameters were monitored on both operated and non-operated sides. Questionnaires including AOFAS, FAAM, EQ-5D were used to assess both operative groups, comparatively.

RESULTS

Both operative groups reported significantly smaller stride, slower walking speed, altered stance phase with longer loading and shorter push-off compared to controls. Joint range of motion was significantly reduced on the operated side of both operative groups at hindfoot, forefoot and toe intersegments. However, the ankle arthrodesis group reported a significantly higher alteration compared to controls in maximum contact force and pressure distribution. Furthermore, bilateral comparison showed extended gait asymmetry in the ankle arthrodesis group with 29 out of 48 parameters being significantly different between the two sides, whereas only 16 out of 48 gait parameters showed bilateral difference in the TTCA group.

CONCLUSION

Both ankle salvage operations led to significant gait alteration and bilateral asymmetry. However, extended joint restriction in TTCA does not seem to worsen the gait outcomes. Further investigation is needed to understand the long-term impact of altered gait, on neighboring joints, following TTCA.

Workplace violence against doctors: Characteristics, risk factors, and mitigation strategies

Workplace violence is a major occupational issue concerning doctors that has a significant impact on their physical and psychological well-being. This ultimately affects the health care services of the country. Patient-led episodes of verbal violence are more prevalent in Asian countries, especially in the emergency department, psychiatric wards, and intensive care units, mostly faced by junior doctors and residents. Some common precursors of violence against doctors are patients and their attendants' dissatisfaction and low impulse control, poor administration, miscommunication, infrastructural issues especially differences in services between private and public hospitals, and negative media portrayal of doctors. The assessment of risk factors, development and implementation of workplace violence programs, and addressing underreporting of violent episodes have been suggested as some successful organizational mitigation strategies. Recommendations on the management of workplace violence include the development of participative, gender-based, culture-based, nondiscriminatory, and systematic strategies to deal with issues related to violence. This article aims to present a comprehensive review of workplace violence against doctors, discussing the prevalence, degree of violence, predictors, impact on physical and psychological health and intervention strategies to devise practical actions against workplace violence.

Long-term evaluation of the distal transverse plantar approach for Morton's neuroma excision

BACKGROUND

There is currently no consensus on the ideal approach for the operative treatment of Morton&rsquo;s neuroma. The distal transverse plantar approach aims at optimal exposure without the scar complications associated with the longitudinal plantar approach. Long-term evaluation based on validated outcome instruments is lacking. The main purpose of this retrospective study was to evaluate the long-term clinical outcome of this approach using validated function and scar evaluation scores.

METHODS

Forty-nine patients operated on at our institution were examined clinically by two independent observers using the Foot and Ankle Ability Measure (FAAM) and the Vancouver Scar Scale (VSS). Patients who underwent neurectomy alone and those who had additional foot surgery were compared.

RESULTS

Assessment at a mean of 7.9 years (range 4&ndash;12) postoperatively revealed a mean FAAM score of 84.8 &plusmn; 25% and a mean VSS score of 1.57 &plusmn; 1.7. Patients who underwent neurectomy alone had higher FAAM scores at follow up. We observed no complication that required an additional procedure.

CONCLUSIONS

The transverse plantar approach results in good objective outcome scores, including scar healing, in the long term. This is our preferred technique because, in our experience, it offers optimal visualisation of the nerve, does not require deep dissection and allows the exposure of two adjacent web spaces of the foot through a single incision.

[Laparoscopic versus open gastrectomy for advanced gastric cancer : Operative and postoperative results]

BACKGROUND

Minimally invasive gastrectomy is increasingly becoming established worldwide as an alternative to open gastrectomy (OG); however, the majority of available articles in the literature refer to Asian populations and early stages of gastric cancer. This makes an international comparison difficult due to a discrepancy in patient populations and tumor biology as well as Asian and western treatment approaches. Little is known, therefore, whether laparoscopic gastrectomy (LG) can be performed in advanced cancer, in particular with respect to laparoscopic D2 lymphadenectomy, with sufficient radicality and safety in this country.

MATERIAL AND METHODS

All gastrectomies performed for the treatment of advanced gastric cancer with clinical UICC stages 2 and 3 between 2005 and 2017 were analyzed. A case match by age, gender and UICC stage was performed to compare the operative and early postoperative results of LG and OG.

RESULTS

A total of 243 patients with advanced gastric cancer were analyzed. Of these 81 patients (33.3%) underwent LG. The operative time for LG was around 74 min longer (279.2 min vs. 353.4 min, OG vs. LG; p < 0.001), the hospital stay after LG was around 4 days shorter (22.9 days vs. 18.4 days, OG vs. LG; p < 0.001). Significantly more lymph nodes were resected by LG (24.1 lymph nodes vs. 28.8 lymph nodes, OG vs. LG; p < 0.001). In terms of morbidity and mortality there were no differences between the groups.

CONCLUSION

The present study showed that minimally invasive gastrectomy can be performed safely and with comparable histopathological results to open surgery, even in advanced gastric cancer in western populations; however, larger case series and evidence from high-quality studies are urgently needed especially to compare short-term and long-term survival.

Lascufloxacin hydrochloride to treat bacterial infection

Lascufloxacin hydrochloride (AM-1977) is a novel 8-methoxy fluoroquinolone antibacterial agent with a unique pharmacophore at the 1st and 7th positions of the quinoline nucleus developed by Kyorin Pharmaceutical Co., Ltd. (Tokyo, Japan). It has been approved by the Japanese Ministry of Health, Labour and Welfare (MHLW) for treatment of respiratory tract and ear, nose and throat infections including community-acquired pneumonia and otorhinolaryngological infections, and shows great promise against fluoroquinolone-resistant strains of major pathogens which infect the respiratory tract. It is suitable for treating infections caused by Staphylococcus, Streptococcus, Pneumococcus, Moraxella (Branhamella) catarrhalis, Klebsiella, Enterobacter, Haemophilus influenzae, Legionella pneumophila, Prevotella and Mycoplasma pneumoniae that are sensitive to this drug.

Levonadifloxacin arginine salt to treat acute bacterial skin and skin structure infection due to S. aureus including MRSA

Acute bacterial skin and skin structure infections (ABSSSIs) are one of the most common types of infections due to methicillin-resistant Staphylococcus aureus (MRSA). The standard of care for ABSSSI includes glycopeptides such as vancomycin, teicoplanin, oxazolidinones and fluoroquinolones, which are potent broad-spectrum antibacterial agents. Unfortunately, due to indiscriminate utilization, resistance to these agents is rising and identification of novel agents is an urgent unmet medical need. In this context, levonadifloxacin (WCK-771) is a novel, hydrate arginine salt of nadifloxacin with improved bactericidal activity against MRSA as well as fluoroquinolone-resistant S. aureus by targeting bacterial DNA supercoiling enzymes DNA gyrase and topoisomerase IV. Levonadifloxacin displays a broad-spectrum bactericidal activity against Gram-positive and Gram-negative bacteria, atypical bacteria, anaerobic bacteria and bioterror pathogens with a very low frequency of mutation. Levonadifloxacin also displays improved activity under low pH biofilm environments. The drug has successfully completed phase I, phase II and phase III clinical trials in India. The U.S. Food and Drug Administration (FDA) granted a Qualified Infectious Disease Product (QIDP) designation to levonadifloxacin for the treatment of MRSA infections in August 2014.