Bilateral Rapidly Destructive Osteoarthritis of the Hip: Could We be Misdiagnosing? A Case Report

Introduction

Rapidly destructive osteoarthritis (RDO) of the hip is characterized by rapid joint destruction with no specific underlying diagnosis. Diagnostic protocols and algorithms to rule out other possible causes of the rapid destruction of the hip have not been described. Furthermore, microbiological diagnostic procedures in the medical field have dramatically changed since RDO was first described.

Case Report

We report the case of bilateral RDO in a Caucasian 84-year-old female treated with a bilateral total hip replacement and propose an etiology for this condition. This is the first case that specifically mentions obtaining cultures intraoperatively as a definitive diagnostic method. It is also a rare case as it describes a patient with the bilateral rapid destruction of the hip joints.

Conclusion

Total hip arthroplasty remains as the gold-standard for treatment of RDO due to clinical severity and radiographic findings. All current clinical guidelines do not recommend using a one stage total hip replacement in an active infected site due to high risk of early prosthetic joint infection. The evidence of an infectious etiology in all or some cases of RDO would have large-scale implications regarding diagnosis and treatment of this condition.

Fascia iliaca block for pain control in hip fracture patients

INTRODUCTION

Pain treatment for patients with hip fracture has been based on the use of nonsteroidal anti-inflammatories and opioid derived drugs. These medications have been associated with multiple adverse effects. Fascia iliaca block is a recent pain management alternative for these patients. The objective of this study was to evaluate the effectiveness of fascia iliaca block performed in the emergency room (ER) for patients over 65years of age with hip fracture.

MATERIALS AND METHODS

A cohort of 216 patients, from January to December 2016, was studied prospectively. Analyzed variables were: pain upon arrival at ER, pain after fascia iliaca block, need for rescue medication, protocol compliance, delay in analgesia administration and delay for surgery.

RESULTS

Differences between visual analogue scale (VAS), before and after the fascia iliaca block, were statistically significant (P<.001). Pre-block VAS recorded was 6.16 (SD=2.82). The mean VAS reduction after the block was 2.99 (95%CI: 2.45-3.53%). Twenty-six percent of patients required morphine as rescue medication in the first 8hours after diagnosis. Compliance with protocol administration was of 84%. Fascia iliaca block was performed in a mean time of 16minutes (SD=10.33) after diagnosis. The median delay for surgery was 1 day (RIQ 25-75%: 1-2).

CONCLUSION

Fascia iliaca block is a reproducible, safe and effective technique for pain management. It is a keystone in pain treatment for patients with a proximal femur fracture at our institution. Other objectives in our pain management protocol include early analgesia administration and reduction of time to surgery.

Neurovascular ultrasound in emergency settings: diagnostic and therapeutic aspects

INTRODUCTION

Neurovascular ultrasound is a non-invasive, portable and fast imaging method that, when performed by an experienced neurosonologist, offers reliable and reproducible information on the morphological and hemodynamic status of cervical and intracranial vessels.

AIM

To review the available evidence regarding the use of this tool in the approach to acute stroke.

DEVELOPMENT

Neurovascular ultrasound can be used in one of two ways: diagnostic and therapeutic. Considering the low recanalization rates of internal carotid artery and proximal medial cerebral artery occlusions with intravenous recombinant tissue plasminogen activator (r-tPA), neurovascular ultrasound used shortly in Emergency Department may help to select patients that could benefit from endovascular therapy. Moreover, ultrasound monitorization during intravenous r-tPA treatment allows the analysis of the pattern of arterial recanalization. Cervical ultrasound allows the assessment of the stenosis degree and the composition/surface of an arterial plaque that could, for instance, reveal earlier a candidate for carotid intervention. Finally, the therapeutic potential of ultrasound is also being investigated. Sonothrombolysis and sonolysis, that combine ultrasound technology with r-tPA and use exclusively the ultrasound to lyse the clot, respectively, showed promising results.

CONCLUSION

Neurovascular ultrasound has greatly expanded to assume an important role in the study of cerebrovascular disorders.

Impact of overweight and obesity in carotid intima-media thickness of portuguese adolescents

AIM

To measure carotid intima-media thickness (cIMT) in obese, overweight and normal-weight Portuguese adolescents, to evaluate the association between body weight early signs of atherosclerosis.

METHODS

Cross-sectional study, enrolling 150 adolescents (50 normal weight, 50 overweight and 50 obese) with mean age of 12.9 years. All underwent clinical, analytical and carotid common artery ultrasonographic evaluation.

RESULTS

After adjusting for systolic blood pressure and plasma High-density lipoprotein, Low-density lipoprotein and Triglycerides levels, higher mean cIMT values were observed in both overweight and obese patients, when compared to normal-weight group. Moreover, adolescents with metabolic syndrome (MS) had greater cIMT [normal-weight: cIMT mean 0.418 mm (95% confidence intervals (95% CI) 0.399-0.437); overweight: 0.461 mm (95% CI: 0.444-0.477); obese: 0.472 mm (95% CI: 0.455-0.488); MS: 0.482 mm (95% CI: 0.444-0.520) p = 0.001]. When normal-weight and overweight adolescents were exclusively compared, differences in cIMT remained significant (p < 0.001). cIMT was positively correlated with body mass index (BMI) (r = 0.439, p < 0.001), waist circumference (r = 0.301, p = 0.018) and diastolic blood pressure (r = 0.266, p = 0.001).

CONCLUSIONS

We have shown that cIMT is positively associated with BMI increase in adolescents, even in moderate overweight ranges, independent of age, gender, systolic blood pressure and plasma lipid concentrations.

Interactive Policy Learning through Confidence-Based Autonomy

We present Confidence-Based Autonomy (CBA), an interactive algorithm for policy learning from demonstration. The CBA algorithm consists of two components which take advantage of the complimentary abilities of humans and computer agents. The first component, Confident Execution, enables the agent to identify states in which demonstration is required, to request a demonstration from the human teacher and to learn a policy based on the acquired data. The algorithm selects demonstrations based on a measure of action selection confidence, and our results show that using Confident Execution the agent requires fewer demonstrations to learn the policy than when demonstrations are selected by a human teacher. The second algorithmic component, Corrective Demonstration, enables the teacher to correct any mistakes made by the agent through additional demonstrations in order to improve the policy and future task performance. CBA and its individual components are compared and evaluated in a complex simulated driving domain. The complete CBA algorithm results in the best overall learning performance, successfully reproducing the behavior of the teacher while balancing the tradeoff between number of demonstrations and number of incorrect actions during learning.

Existence of Multiagent Equilibria with Limited Agents

Multiagent learning is a necessary yet challenging problem as multiagent systems become more prevalent and environments become more dynamic. Much of the groundbreaking work in this area draws on notable results from game theory, in particular, the concept of Nash equilibria. Learners that directly learn an equilibrium obviously rely on their existence. Learners that instead seek to play optimally with respect to the other players also depend upon equilibria since equilibria are fixed points for learning. From another perspective, agents with limitations are real and common. These may be undesired physical limitations as well as self-imposed rational limitations, such as abstraction and approximation techniques, used to make learning tractable. This article explores the interactions of these two important concepts: equilibria and limitations in learning. We introduce the question of whether equilibria continue to exist when agents have limitations. We look at the general effects limitations can have on agent behavior, and define a natural extension of equilibria that accounts for these limitations. Using this formalization, we make three major contributions: (i) a counterexample for the general existence of equilibria with limitations, (ii) sufficient conditions on limitations that preserve their existence, (iii) three general classes of games and limitations that satisfy these conditions. We then present empirical results from a specific multiagent learning algorithm applied to a specific instance of limited agents. These results demonstrate that learning with limitations is feasible, when the conditions outlined by our theoretical analysis hold.

Computerising a guideline for the management of diabetes

This paper reports an experience of computerising a clinical guideline for the management of non-insulin-dependent diabetes mellitus (NIDDM). The guideline, designed by the European NIDDM Policy Group is being used in a National Programme for Diabetes supported by the Portuguese Ministry of Health, who is keen to supporting its widespread use by general practitioners, namely in computerised form. The paper presents the main characteristics of the prototype that was implemented within the European project Prestige, and was developed according to the Prestige Protocol Model. The model is briefly described, together with the generic architecture that supports it. Then the main design decisions of the prototype are explained, regarding the modelling of a general practitioner workflow during a typical consultation and the user interface, two key issues for obtaining acceptance from the users. The limitations of the system are discussed and a number of directions are outlined in order to circumvent such limitations, and broaden the scope of applicability of the system.

Systems of evidence-based healthcare and personalised health information: some international and national trends

In Europe, North America and elsewhere, growing interest has focussed on evidence-based healthcare systems, incorporating the deployment of practice guidelines, as a field of application for health telematics. The clinical benefit and technical feasibility of common European approaches to this task has recently been demonstrated. In Europe it is likely that, building on recent progress in electronic health record architecture (EHRA) standards, a sufficient state of maturity can be reached to justify initiation within CEN TC251 of a prestandards process on guideline content formats during the current 5th Framework of EC RT&D activity. There is now a similar impetus to agree standards for this field in North America. Thanks to fruitful EC-USA contacts during the 4th Framework programme, there is now a chance, given well-planned coordination, to establish a global consensus optimally suited to serve the world-wide delivery and application of evidence-based medicine. This review notes three factors which may accelerate progress to convergence: (1) revolutionary changes in the knowledge basis of professional/patient/public healthcare partnerships, involving the key role of the Web as a health knowledge resource for citizens, and a rapidly growing market for personalised health information and advice; (2) the emergence at national levels of digital warehouses of clinical guidelines and EBM knowledge resources, agencies which are capable of brokering common mark-up and interchange media definitions between knowledge providers, industry and healthcare organizations; (3) the closing gap in knowledge management technology, with the advent of XML and RDF, between approaches and services based respectively on text mark-up and knowledge-base paradigms. A current project in the UK National Health Service (the National electronic Library of Health) is cited as an example of a national initiative designed to harness these trends.

A computerised guideline for the management of diabetes

This paper describes an experience of computerising a clinical guideline for the management of Diabetes. This guideline is being used in a National Programme for Diabetes supported by the Health Ministry in Portugal, who is interested in supporting its use by General Practitioners. The prototype system was developed according to the Prestige Protocol Model that is briefly outlined. The main conclusions regarding practical design decisions are then reported, partly based on a preliminary evaluation of the system by GPs.

p53 gene status and expression of p53, mdm2, and p21Waf1/Cip1 proteins in colorectal cancer

Abrogation of the normal p53 pathway is the most common molecular alteration in human cancer. p53 Gene status can be potentially assessed through the expression of proteins known to be activated by the wild-type p53 (wt p53) system, such as mdm2 and p21Waf1/Cip1. In this study, the frequency of mdm2, p21Waf1/Cip1, and p53 protein expression was investigated using immunohistochemistry (IHC) in 88 colorectal carcinomas (CRCs). The relationship between these expressions and p53 status was examined. p53 status and the immunophenotypes characterizing these tumors were correlated with standard prognostic variables. Mutation of p53 was detected using single-strand conformational polymorphism (SSCP) analysis and sequencing. Concordance between p53 gene status and p53 immunoreactivity was seen in 62 of 88 (70.45%) carcinomas. Mdm2 expression was found in 22 of 45 (48.88%) and 5 of 43 (11.62%) of the tumors with wt p53 and mutated p53 (P<0.0001), respectively. Predominantly, higher p21Waf1/Cip1 expression was associated with wt p53 (P<0.001). All wt p53 cases that expressed mdm2 also expressed p21Waf1/Cip1. These results suggest that there is a subgroup of CRCs in which p53 is functionally active, inducing transcription of mdm2 and Waf1/Cip1. Their combined evaluation may provide important clues for planning adjuvant systemic therapy and gene therapy based on the restitution of p53 function. However, no significant association was found between the immunophenotypes and the standard prognostic variables investigated.

Guidelines in healthcare: the experience of the Prestige project

The paper reports the work and results of Prestige: Guidelines in Healthcare, a large EU project designed to applying ICT to assist the application of clinical practice guidelines.

Cooling therapy for acute stroke

BACKGROUND

Recent studies in acute stroke patients have shown an association between body temperature and prognosis.

OBJECTIVES

Our objective was to assess the effects of cooling when applied to patients with acute ischaemic stroke or primary intracerebral haemorrhage.

SEARCH STRATEGY

We searched the Cochrane Stroke Group's trial register (last searched in March 1999), plus MEDLINE searched up to November 1998 and EMBASE searched from January 1980 to November 1998. We contacted investigators, pharmaceutical companies and manufacturers of cooling equipment in this field.

SELECTION CRITERIA

All completed randomised controlled trials or controlled clinical trials, published or unpublished, where cooling therapy (therapy given by physical devices or antipyretic drugs primarily to lower body temperature independently of basal temperature at the beginning of treatment) was applied up to two weeks of an acute ischaemic stroke or primary intracerebral haemorrhage.

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched for relevant trials.

MAIN RESULTS

No randomised trials or controlled trials were identified; one placebo-controlled trial of metamizol is currently underway.

REVIEWER'S CONCLUSIONS

There is currently no evidence from randomised trials to support the routine use of physical or chemical cooling therapy in acute stroke. Since experimental studies showed a neuroprotective effect of hypothermia in cerebral ischaemia, and hypothermia appears to improve the outcome in patients with severe closed head injury, trials with cooling therapy in acute stroke are warranted.

From hospital information system components to the medical record and clinical guidelines & protocols

This paper introduces an ongoing project towards the development of a new generation HIS, aiming at the integration of clinical and administrative information within a common framework. Its design incorporates explicit knowledge about domain objects and professional activities to be processed by the system together with related knowledge management services and act management services. The paper presents the conceptual model of the proposed HIS architecture, that supports a rich and fully integrated patient data model, enabling the implementation of a dynamic electronic patient record tightly coupled with computerised guideline knowledge bases.

Inter- and intraobserver variation in the interpretation of electromyographic tests

This study was undertaken with the aim of evaluating inter- and intraobserver variation on the pathophysiological interpretation of individual electromyographic (EMG) tests on muscles and nerve segments. Seven physicians from 6 European EMG laboratories independently interpreted 81 EMG studies comprising 735 muscle tests and 726 tests on nerve segments. Pathophysiological conclusions were inferred from findings of these tests without considering clinical information. For most combinations of findings, both the inter- and intraobserver variations on the interpretation were low, suggesting that common criteria for pathophysiological interpretations were used and that these were used consistently. For some combinations of findings, however, there was disagreement on whether these indicated specific or unspecific pathophysiological changes. In particular disagreement on whether findings indicated demyelination may be of clinical significance. A large part of the intraobserver variation may be explained by a change towards more cautious interpretations during the study for most of the physicians. It is concluded that there is a need to seek for consensus on the pathophysiological interpretation of individual findings and for incentives to ensure consistency in interpretations. The fact that experienced physicians changed their ways to interpret findings during the study suggests that agreement may be improved globally.

Variation in performance of the EMG examination at six European laboratories

The quality of the EMG examination might be improved by standardization. However, knowledge about interlaboratory differences in the performance of the EMG examination is a prerequisite for standardization. The aim of this study was to describe differences in EMG techniques used and number of muscles and nerves examined per patient at 6 European EMG laboratories. The EMG results of 595 patients were prospectively sampled. The average number of muscles examined per patient in different disorders varied from laboratory to laboratory, for example from 3.0 to 10.8 muscles in anterior horn cell disorders and from 2.0 to 5.5 muscles in myopathies. The average number of muscles examined by quantitative EMG varied from 0 to 4.3 in anterior horn cell disorders and from 0.0 to 4.5 in myopathies. Also the average number of nerve segments examined per patient varied from laboratory for example from 2.7 to 17.7 for motor segments and from 3.1 to 9.0 for sensory segments in polyneuropathies. The laboratories that used needle electrodes for nerve conduction studies and quantitative analysis of individual motor unit potentials examined a smaller number of muscles and nerves than laboratories using surface electrodes for nerve conduction studies and qualitative EMG studies. The results of this study may have impact on guidelines and examination protocols as well as on quality assurance.

FLECS: Planning with a Flexible Commitment Strategy

There has been evidence that least-commitment planners can efficiently handle planning problems that involve difficult goal interactions. This evidence has led to the common belief that delayed-commitment is the "best" possible planning strategy. However, we recently found evidence that eager-commitment planners can handle a variety of planning problems more efficiently, in particular those with difficult operator choices. Resigned to the futility of trying to find a universally successful planning strategy, we devised a planner that can be used to study which domains and problems are best for which planning strategies. In this article we introduce this new planning algorithm, FLECS, which uses a FLExible Commitment Strategy with respect to plan-step orderings. It is able to use any strategy from delayed-commitment to eager-commitment. The combination of delayed and eager operator-ordering commitments allows FLECS to take advantage of the benefits of explicitly using a simulated execution state and reasoning about planning constraints. FLECS can vary its commitment strategy across different problems and domains, and also during the course of a single planning problem. FLECS represents a novel contribution to planning in that it explicitly provides the choice of which commitment strategy to use while planning. FLECS provides a framework to investigate the mapping from planning domains and problems to efficient planning strategies.

Quality assurance in clinical neurophysiology: the ESTEEM project example

This paper describes the current status of the utilisation of clinical practice guidelines (protocols) in the ESTEEM project as one form of the clinical quality assurance procedures considered in the project. The performance of electrodiagnostic studies, in terms of which types of conclusions need to be inferred during the examination plan, is briefly described. The main focus of the paper is a description of an European multicentre clinical audit in the field of Clinical Neurophysiology, using a common data-entry protocol for prospective EMG case collection and assessment with the ultimate objective of building up a multicentre reference database of EMG cases.

ESTEEM (European Standardised Telematic Tool to Evaluate EMG Knowledge-Based Systems and Methods): AIM Project A2010

ESTEEM is an AIM project which is primarily concerned with how to develop, integrate and clinically test knowledge-based systems for electromyography (EMG) in order to get them generally acceptable, useful and applicable into disseminated clinical routines. A medical workstation entitled the 'EMG-Platform' on which different kinds of application modules including KBSs can be interfaced to a kernel is being developed. Accordingly, an EMG communication protocol is being developed. The ESTEEM consortium is composed of a technical specialist group and a group of clinical experts in EMG from seven European countries. The last group has, besides extensive data collection for building up a multicentre EMG database, agreed on a common EMG terminology and a subsequent general EMG data set specification which covers the informatic needs for describing an EMG examination of different 'EMG schools'.

[Cytogenetic studies in myelodysplasias]

Cytogenetic studies were performed in 29 patients with myelodysplasia, 12 males and 17 females with a mean age of 61 years. The distribution of patients according to FAB groups were as follows: refractory anemia (RA) 7, sideroblastic refractory anemia SRA) 6, refractory anemia with excess blasts (RAEB) 12 and refractory anemia with transformation excess blasts (RAEB-t) 4. Cytogenetic anomalies were found in 48% over all, 78% in patients with RAEB and RAEB-t forms and only 23% in patients with simpler forms of myelodysplasia. Multiple and complex chromosomal alterations were found in 50% of abnormal studies, only in patients with complex forms. In general, structural rearrangements and deletions were less frequent than numeric defects, with a slight preponderance of chromosomal losses. Alterations of chromosomes 5, 7, 28, 21, 22, 8, 11 and 15 were the most commonly observed. Survival was decreased from 60 months in patients with normal karyotype to 6 months in those with chromosomal alterations. Thus, chromosomal abnormalities are related to excess blasts and to survival in patients with myelodysplasia.

[Munchausen's syndrome: a study of 6 cases]

We report 6 patients with Munchausen syndrome, a fictitious disorder with physical symptoms. There were 4 females and 2 males, the age ranged from 21 to 29 years. Abdominal pain (2), hemoptysis, shock and hypoglycemia were the presenting symptoms. The diagnosis was made after a prolonged and costly hospital course, including invasive and non invasive diagnostic procedures. Two patients were ill enough to be at risk of death. An early diagnosis may help prevent unnecessary or risky procedures in these patients.

[A case of Wilson's disease studied using magnetic resonance: a new approach?]

Wilson's disease is a genetically determined disorder of copper metabolism with increased deposition in brain and liver. With current imaging techniques--CT scan and conventional Nuclear Magnetic Resonance (NMR)--it has been possible to demonstrate oedema, neuronal loss and reactive gliosis, but not copper deposition. In the present study we report the observations, done in one patient, using a new high magnetic field (1.5 Tesla) NMR device. In these circumstances, we are able to expand the CT scan analysis by showing not only the oedema and the brain cell death but also the probable existence of copper deposits. Will this be true, it is first instance in which it has been possible to demonstrate, by a non invasive method, increased copper deposition in Wilson's disease. This possibility may be important to monitor the therapeutic efficacy of chelating agents and also to distinguish asymptomatic homozygous patients from heterozygous healthy carriers.