Long and short intramedullary nails for fixation of intertrochanteric femur fractures (OTA 31-A1, A2 and A3): A systematic review and meta-analysis

Previous studies have reported conflicting findings concerning the efficacy and safety of the treatment of intertrochanteric fractures (OTA 31-A1,A2 and A3) using short intramedullary nails (SIN) and long intramedullary nails (LIN). The present meta-analysis and literature review investigated the outcomes of SIN and LIN, thereby providing guidance for the treatment of intertrochanteric femur fractures. When used to treat intertrochanteric femur fractures, LIN did not decrease the secondary femoral shaft refracture or reoperation rates. Eight electronic databases were searched for studies related to the use of SIN compared to LIN in treating intertrochanteric fractures. The modified Jadad Scale and the Newcastle-Ottawa Scale (NOS) were used to assess the methodological quality and the risk of bias of these studies. The two groups were compared based on nine indicators, including the surgical times, intraoperative blood loss, transfusion, length of hospital stay, secondary femoral shaft refracture, reoperation, 1-year mortality, Harris hip scores (1 year) and complications. A total of 2431 patients were included in the analysis, with 1498 LIN cases and 940 SIN cases (bilateral nails were used in 7 cases), and the average patient age was 74.83 years. The pooled results indicated that patients in the LIN group had longer surgical times (MD [mean difference]: 12.56; 95% CI: 8.28-16.84; P<0.00001), more intraoperative blood loss (MD: 37.44; 95% CI: 8.06-66.82, P=0.01) and a higher transfusion rate (OR [odds ratio]: 1.53; 95% CI: 1.12-2.10, P=0.008) than patients in the SIN group. However, there was no significant difference in the length of hospital stay (MD: 0.24; 95% CI: -0.58-1.06, P=0.56), occurrence of secondary femoral shaft refractures (OR: 0.72; 95% CI: 0.34-1.53, P=0.39), reoperation rate (OR: 0.95; 95% CI: 0.60-1.50, P=0.82), 1-year mortality (OR: 1.1; 95% CI: 0.67-1.8, P=0.71), Harris hip score (MD: 1.87; 95% CI: -2.8-6.54, P=0.43) or complication rate (OR: 1.29; 95% CI: 0.84-1.99, P=0.25). LIN may not be a better method or provide more effective treatment for intertrochanteric femur fractures; the LIN patients demonstrated the same prognosis as the SIN patients, particularly in terms of secondary femoral shaft refracture and reoperation rate, but they experienced greater trauma. Due to the limitations of the included studies, however, more highly powered randomized controlled trials are needed to clarify the findings. Systematic review and meta-analysis.

LEVEL OF EVIDENCE

III.

Freewheel training decreases pro- and increases anti-inflammatory cytokine expression in mouse intestinal lymphocytes

Intestinal inflammation and inflammatory bowel diseases (IBD) may occur due to imbalances in pro- and anti-inflammatory cytokines. Long-term exercise reduces the risk for IBD. The purpose of this study was to determine the effect of long-term wheel running in healthy mice on intestinal lymphocyte (IL) expression of pro- and anti-inflammatory cytokine proteins. In addition, pro- and anti-apoptotic proteins and the percentage of early apoptotic, late apoptotic, and dead IL were measured with wheel running and following acute aerobic exercise. Female C57BL/6 mice were given 16 weeks of wheel running (WR) or a control condition (No WR) and at the end of training were assigned to a single acute treadmill exercise session with sacrifice immediately, 2h after, or 24h after completion of exercise, or were not run (sedentary) with respect to the acute treadmill exercise. Intestinal lymphocytes were assessed for pro-(TNF-α, IL-17) and anti-(IL-10) inflammatory, and pleiotropic (IL-6) cytokines, and pro-(caspase 3 and 7, AIF) and anti-(Bcl-2) apoptotic protein expression. The percent of early (Annexin(+)) and late (Annexin(+)PI(+)) apoptotic, and dead (PI(+)) IL was determined. WR mice had lower TNF-α and caspase 7, and higher IL-10 and IL-6 expression in IL than No WR mice. A single exposure to intense aerobic treadmill exercise increased pro-(TNF-α) and anti-(IL-10) inflammatory cytokine and pro-apoptotic protein (caspase 3) expression in IL. The percent of early and late apoptotic, and dead IL were higher after acute exercise. Although long-term voluntary wheel running did not protect against acute exercise-induced changes in IL cytokine expression or apoptosis, there was an overall 'anti-inflammatory' effect observed as a result of wheel running in healthy mice.

Does exercise protect from cognitive decline by altering brain cytokine and apoptotic protein levels? A systematic review of the literature

Regular exercise is thought to provide protection against age-related cognitive decline and possibly reduce risk of dementias. The mechanisms for the exercise protective effects are not known although changes in inflammatory cytokine levels may be involved. We conducted a systematic review of the literature to assess (1) the effects of exercise on cytokines in the brain, (2) the methodological rigour of studies which have examined these exercise effects and (3) the potential role of regular exercise in reducing the pro-inflammatory cytokine milieu that may contribute to dementia. We also reviewed the effects of exercise on concurrent pro and anti-apoptotic protein expression in the brain as related to cytokine changes. Five databases were searched until January 2010 with an initial 630 articles identified; 61 articles were retrieved of which 10 met study inclusion criteria. Investigations of both acute and chronic (training) exercise were assessed for methodological quality using a modified PEDro scale. Two studies were carried out with human participants and eight with mouse or rat models; studies differed markedly in design and methodological rigour; the types, intensities and durations of exercise, the cytokine and apoptotic proteins measured, and the regions of the brain (or proxy compartments) sampled. Despite variations in design, specific cytokine outcomes, and exercise type, the 10 studies provide limited evidence that acute strenuous exercise increases and exercise training decreases pro-inflammatory cytokines centrally. Two animal studies relate training associated decreases in pro-inflammatory cytokines with improved cognitive function using behavioural assessments such as the Morris maze. Recommendations for the design of future research on exercise, central cytokines, and cognition are offered.

Voluntary exercise training in mice increases the expression of antioxidant enzymes and decreases the expression of TNF-alpha in intestinal lymphocytes

Acute exercise in mice induces intestinal lymphocyte (IL) apoptosis. Freewheel running reduces apoptosis and forced exercise training increases splenocyte antioxidant levels. The purpose of this study was to examine the effect of freewheel running and acute exercise on mouse IL numbers and concentrations of apoptosis and antioxidant proteins and pro-inflammatory cytokines in IL. Female C57BL/6 mice had access to in-cage running wheels (RW) or cages without wheels (NRW) for 16 weeks and were randomized at the end of training to no exercise control (TC) or to treadmill exercise with sacrifice after 90 min of running (TREAD; 30 min, 22 m min(-1); 30 min, 25 m min(-1); 30 min, 28 m min(-1); 2 degrees slope). IL were analyzed for pro-(caspase 3 and 7) and anti-(Bcl-2) apoptotic proteins, endogenous antioxidants (glutathione peroxidase: GPx; catalase: CAT) and the pro-inflammatory cytokine, TNF-alpha. RW mice had higher cytochrome oxidase (p<0.001) and citrate synthase (p<0.01) activities in plantaris and soleus muscles and higher GPx and CAT expression in IL (p<0.05) (indicative of training) compared with NRW mice. TNF-alpha expression was lower (p<0.05) and IL numbers higher (p<0.05) in RW vs. NRW mice. No training effect was observed for apoptotic protein expression, although TREAD resulted in higher caspase and lower Bcl-2. These results suggest that freewheel running in mice for 16 weeks enhances antioxidant and reduces TNF-alpha expression in IL but does not reduce pro-apoptotic protein expression after acute exercise. Results are discussed in terms of implications for inflammatory bowel diseases where apoptotic proteins and TNF-alpha levels are elevated.

Electron microscopic studies of testes in Kallman syndrome

A patient with Kallman syndrome is presented emphasizing the urologic aspects of this unusual disorder. Testes biopsy at the time of orchiopexy demonstrated infantile testes with interstitial fibrosis and a diminished Leydig and Sertoli cell population. The electron micrograph confirmed type B Sertoli cells. The implications of these findings are discussed and details of treatment given.

Cutaneous metastases from prostatic carcinoma

A case of prostatic adenocarcinoma associated with extensive cutaneous metastases and malignant acanthosis nigricans is reported. Pertinent literature is reviewed. The pathogenesis of the possible mechanism of the development of cutaneous metastases in this as well as other related cases is discussed.