Neuromarkers as diagnostic adjuvant to cranial CT in closed traumatic brain injury patients admitted to ICU: A preliminary comparative study

ObjectivesEvaluating the diagnostic and/or prognostic yield of serum levels of three neuromarkers, serum S100 protein, neuron-specific enolase (NSE) and Glial Fibrillary Acidic Protein (GFAP), in patients who were admitted to surgical intensive care unit (SICU) and had closed traumatic brain injury with suspicious presence of intracranial hematoma compared versus cranial CT (CCT) as a gold standard diagnostic modality.Patients and methodsThe study included 70 patients who had sustained a closed traumatic brain injury (TBI) requiring intensive care and/or surgical interference. All patients underwent clinical evaluation for all traumatized organs using Injury Severity Score (ISS) and concerning TBI Glasgow Coma Scale (GCS) score was recorded after non-surgical resuscitation. Then, all underwent CT scanning of the brain and patients with a surgically treatable mass underwent decompressive craniotomy, while patients free of hematoma or with minute-to-small hematoma not necessitating surgical interference were kept under observation. Venous blood samples were obtained from all enrolled patients at time of admission and patients who showed deterioration during conservative treatment gave second sample for ELISA estimation of serum S100 protein, NSE and GFAP.ResultsForty-three patients had intracranial hematoma (Positive CCT); 26 patients underwent surgical interference, while the other 17 hematoma patients and 27 hematoma free patients (Negative CCT) were kept under observation. Of them 15 patients; 10 with hematoma and five who were hematoma free developed symptoms of increased ICP and follow-up CCT examination defined five cases required surgical interference with 66.7% rate for unnecessary follow-up CCT. Thirty-nine patients (55.7%) responded to conservative treatment and were discharged to the ward, while a total of 31 patients (44.3%) had surgical interference. Mean serum levels of studied parameters were significantly higher in all patients compared to controls with significantly higher levels in patients who had positive CCT compared to those who had negative CCT and in patients who required surgical interference compared to those managed conservatively. Patients who showed deterioration had significantly 2nd sample higher serum levels of S100 protein and GFAP, but non-significantly higher serum NSE levels compared to at admission levels. Percentage of increase of serum GFAP levels in follow-up sample obtained from patients who had positive CCT was significantly higher compared to the percentage of increase in serum S100 protein and NSE.ConclusionEstimation of serum levels of neuromarkers as adjuvant diagnostic and prognostic tools for closed TBI patients, but serum level of GFAP showed superior applicability and was more valid prognostic modality that could spare unnecessary CCT if applied as the percentage of change in comparison to at admission levels.     

Nível de S100B e disfunção cognitiva após prostatectomia radical laparoscópica assistida por robô: estudo observacional prospectivo

BackgroundThe present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic‐Assisted Laparoscopic Radical Prostatectomy (RALRP).MethodsThe study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively and at 7 days and 3 months postoperatively.ResultsTwenty‐four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30 minutes and 24 hours in patients displaying POCD at postoperative 7 days (p  =  0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both).ConclusionsS100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD.Trial Registry NumberClinicaltrials.gov (N° NCT03018522).     

A Systematic Review of the Evidence for the Decipher Genomic Classifier in Prostate Cancer

ContextMolecular biomarkers aim to address the established limitations of clinicopathologic factors to accurately risk stratify patients with prostate cancer (PCa). Questions remain as to whether sufficient evidence supports adoption of these biomarkers for clinical use.ObjectiveTo perform a systematic review of the available evidence supporting the clinical utility of the Decipher genomic classifier (GC).Evidence acquisitionThe review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed and conference abstracts from January 2010 to June 2020. Evidence was then graded using the criteria of Simon et al (Simon RM, Paik S, Hayes DF. Use of archived specimens in evaluation of prognostic and predictive biomarkers. J Natl Cancer Inst 2009;101:1446–52) and American Urology Association (AUA) criteria.Evidence synthesisIn total, 42 studies and 30 407 patients were included. GC performance data were available for localized, postprostatectomy, nonmetastatic castration-resistant, and metastatic hormone-sensitive PCa as part of retrospective studies (n = 12 141), prospective registries (n = 17 053), and prospective and post hoc randomized trial analyses (n = 1213). In 32 studies (n = 12 600), the GC was independently prognostic for all study endpoints (adverse pathology, biochemical failure, metastasis, and cancer-specific and overall survival) on multivariable analysis and improved the discrimination over standard of care in 24 studies (n = 8543). GC use changed the management in active surveillance (number needed to test [NNT] = 9) and postprostatectomy (NNT = 1.5–4) settings in five studies (n = 4331). Evidence strength was levels 1 and 2 by the Simon criteria for all disease states other than high-risk PCa, and grades A and B by AUA criteria depending on disease state.ConclusionsConsistent data are now present from diverse levels of evidence, which when viewed together, have demonstrated clinical utility of the GC in PCa. The utility of the GC is strongest for intermediate-risk PCa and postprostatectomy decision-making.Patient summaryIn this paper, we review the evidence of the Decipher genomic classification tool for men with prostate cancer. We found consistent evidence that the test helps identify which cancers are more or less aggressive, which in turn aids in personalized treatment decision-making.     

Variables linked to hepatitis B vaccination success in non-dialyzed chronic kidney disease patients: Use of a bayesian model

BackgroundHepatitis B vaccination is recommended for chronic kidney disease (CKD) patients before starting dialysis. We performed an analyis aimed to describe the clinical and biological parameters related to the success of vaccination in CKD patients before starting dialysis.MethodsWe extracted data of 170 non-dialyzed patients who were offered hepatitis B vaccination from a register. They received a first vaccination of 40 μg followed by boosters after one, two and six months. Patients were considered protected if their hepatitis B antibody level was > 10 IU/L, three months apart. A logistic regression and a Bayesian model were used to describe the relationships between variables and the success of vaccination.ResultsVaccination protected 50.6% of the patients. Model adjustment to the data was higher using the Bayesian model compared to the logistic regression (with area under the ROC curve of 0.955 ± 0.007 vs 0.775 ± 0.066 respectively). The Bayesian model's robustness studied using a 10 fold cross validation showed a percentage of misclassified subjects of 12.4 ± 1.8%, a sensitivity of 87.7 ± 0.3%, a specificity of 87.5 ± 0.3%, a positive predictive value of 87.8 ± 0.3% and negative predictive value of 87.4 ± 0.2%. As classified by the Bayesian model, the variables most related to successful vaccination were, in descending order: age, eGFR, protidemia, albuminemia, cause of renal failure, gender, previous vaccination and weight.ConclusionThe Bayesian network confirmed that both kidney function and nutritional status of patients are important factors to explain the success of vaccination against hepatitis B in CKD patients before dialysis. For research purposes, before an external validation, the network can be used online at www.hed.cc/?s=Bhepatitis&n=ReseauhepatiteBsup10.neta.     

Early dynamics of glial fibrillary acidic protein and extracellular DNA in plasma of mice after closed head traumatic brain injury

BackgroundGlial fibrillary acidic protein (GFAP) in plasma is an established biomarker of traumatic brain injury (TBI) in humans. Plasma extracellular DNA (ecDNA) is a very sensitive, although nonspecific marker of tissue damage including TBI. Whether plasma GFAP or ecDNA could be used as an early non-invasive biomarker in the mouse model of closed head injury is unknown. The aim of this paper was to describe the early dynamics of plasma GFAP and ecDNA in the animal model of closed head TBI.MethodsClosed head TBI was induced using the weight-drop method in 40 adult CD1 mice and blood was collected in different time points (1, 2 or 3 h) after TBI in different groups of mice. Plasma GFAP and ecDNA and ecDNA fragmentation from the experimental groups were compared to healthy controls. In the surviving mice, a static rods test was performed 30 days after TBI to assess the neurological outcome of TBI.ResultsDespite a trend of higher plasma GFAP after TBI the differences between the groups were not statistically significant. Plasma ecDNA was higher by 50% after 1 h (P < 0.05) and 2 h (P < 0.05) after TBI and was highly variable after 3 h. Plasma ecDNA, but not GFAP, was partially predictive of the neurological impairment of the mice.ConclusionIn this study, we have described the early dynamics of plasma GFAP and ecDNA after TBI in mice. According to our results, ecDNA in plasma is a more sensitive early marker of TBI than GFAP. Analysis of tissue-specific ecDNA might improve its predictive value regarding the survival and neurobehavioral outcome.     

Definition and epidemiology of mild traumatic brain injury

Background/objectivesThe definition of mild traumatic brain injury (mTBI), also known as concussion, has been a matter of controversy, which makes comparison between studies difficult. Incidence varies greatly from one country to another. The present article reviews definitions and epidemiology.MethodsLiterature review.ResultsAccording to the Mild TBI Committee of the American Congress of Rehabilitation Medicine, revised by the World Health Organization (WHO), mTBI is defined by a Glasgow Coma Scale score between 13 and 15 at 30 minutes post-injury, and one or more of the following symptoms: <30 min loss of consciousness; <24 hours post-traumatic amnesia (PTA); impaired mental state at time of accident (confusion, disorientation, etc.); and/or transient neurological deficit. If a focal lesion is found on computed tomography (CT) or magnetic resonance imaging (MRI), the term “complicated mild TBI” has been proposed. Incidence of mTBI is 200–300/100,000 persons per year for hospitalized patients and probably twice as high if non-hospitalized patients are included. However, a few recent population-based studies reported a much higher rate (>700/100,000). A changing pattern of epidemiology has been found in high-income countries, related to a decrease in road-accident injuries in young adults, while conversely the proportion of falls has increased with population aging.ConclusionMild TBI is a major public health concern, the epidemiology of which has greatly changed in the last twenty years.     

Quantification of right ventricular extracellular volume in pulmonary hypertension using cardiac magnetic resonance imaging

PurposeThe purpose of this prospective study was to assess the value of biventricular extracellular volume (ECV) in pre-capillary pulmonary hypertension (PH) obtained using cardiac magnetic resonance imaging (CMR) and to correlate ECV with markers of prognosis such as strain echocardiography and blood biomarkers of fibrosis.Materials and methodsTwelve patients with PH (6 men, 6 women; mean age = 50 ± 16 [SD] years; age range: 22–73 years) underwent the same day: (i), transthoracic echocardiography including measurement of right ventricular (RV) fractional shortening (RVfs), tricuspid annular plane systolic excursion (TAPSE), maximal tricuspid annular velocity, RV global and segmental deformation; (ii), right heart catheterization measuring pulmonary arterial pressures (in mmHg) and cardiac output (in L/min); (iii), CMR at 1.5-T measuring RV volumes and ejection fraction; (iv), native and 15 min post-contrast T1 mapping using modified look-locker inversion-recovery sequence; and (v), serum quantification of two biomarkers of collagen turnover and hematocrit. Non-parametric Mann-Whitney tests were used to search for differences between categorical variables. Spearman correlation test was used for search for correlation between quantitative values.ResultsGlobal RV ECV was 34% ± 4.2 (SD) for our entire population. A significant correlation was found between RV ECV and RVfs (r = 0.6; P = 0.026), S wave velocity (r = 0.7; P = 0.009), TAPSE (r = 0.6; P = 0.040) and RV systolic ejection fraction on CMR (r = 0.6; P = 0.04). There were no correlations between the ECV values in the lateral wall of the RV and in the septum (r = 0.4; P = 0.206). A significant correlation was found between septal ECV and 2D septal strain (r = 0.7; P = 0.013).ConclusionECV in PH as obtained using CMR appears to correlate with known echocardiographic prognostic markers and more specifically with the markers, which assess RV systolic function.     

Impacto de la presentación tardía al servicio de Urgencias por cólico renal agudo en los resultados bioquímicos y clínicos

Introduction and objectiveTo verify the impact of delay on biochemical and clinical outcomes for patients presenting to the emergency department (ED) with acute renal colic.Materials and methodsData were retrospectively collected from 3 institutions of 2 European countries between 01 January and 30 April 2020. Patients who presented to the ED with unilateral or bilateral renal colic caused by urolithiasis confirmed by imaging tests during the study period were included. A presentation after 24 hours since the onset of symptoms was considered a delay. Patients presenting before 24 hours from the symptom onset were included in Group A, while the patients presenting after 24 hours in Group B. Clinical and biochemical parameters and management were compared.Results397 patients who presented to ED with confirmed urolithiasis were analyzed (Group A, n = 199; Group B, n = 198. The median (IQR) delay in presentation was 2 days (1,5-4). At presentation, no statistically significant differences were found amongst the 2 groups of patients regarding presenting symptoms such as fever and flank pain, and the median serum levels of creatinine, C reactive protein and white blood cells. No differences were found in terms of conservative or operative management.ConclusionsDelay in consultation >24 hours is not associated with worsening biochemical parameters and clinical outcomes. Most patients with acute loin pain do not necessarily need urgent attendance to the ED and may be managed in the outpatients.     

Plate fixation in periprosthetic femur fractures Vancouver type B1—Trochanteric hook plate or subtrochanterical bicortical locking?

IntroductionProximal plate fixation in periprosthetic femur fractures can be improved by plate anchorage in the greater trochanter (lateral tension band principle) or bicortical locking screw placement beside the prosthesis stem in an embracement configuration. Both concepts were compared in a biomechanical test using a femoral hook plate (hook) or a locking attachment plate (LAP).MethodsAfter bone mineral density (BMD) measurement in the greater trochanter, six pairs of fresh frozen human femora were assigned to two groups and instrumented with cemented hip endoprostheses. A transverse osteotomy was set distal to the tip of the prosthesis, simulating a Vancouver B1 fracture. Each pair was instrumented using a plate tensioner with either hook or LAP construct. Cyclic testing (2 Hz) with physiologic profile and monotonically increasing load was performed until catastrophic failure. Plate stiffness was compared in a four-point-bending-test. Paired student’s-t-test was used for statistical evaluation (p < 0.05).ResultsMean BMD was 250 mgHA/ccm ± 47. The hook construct exhibited a significantly (p = 0.015) lower number of cycles and load to failure (26′177 cycles ± 2777; 3′118N ± 778) correlating significantly with BMD (R² = 0.83; p = 0.04) compared to the LAP construct (37′423 cycles ± 5′299; 4′242N ± 1′030) (R² = 0.71;p = 0.11). BMD was a significant covariate (p = 0.01). Plate stiffness was in a comparable range (hook Plate 468 N/mm ± 7; LCP 445 N/mm ± 6).ConclusionSubtrochanterically placed LAP provides an increased fixation strength under repetitive loading compared to hook plate fixation in the greater trochanter. Trochanteric fixation is highly BMD dependent and may be restricted to major greater trochanteric involvement requiring stabilization.     

Factors influencing the acquisition of Stenotrophomonas maltophilia infection in cystic fibrosis patients

BackgroundStenotrophomonas maltophilia is one of the most common multi-drug resistant organisms causing pulmonary infections in CF patients. It is unknown whether S. maltophilia infection follows the same pattern and shares similar risk factors for acquisition as described for Pseudomonas aeruginosa.MethodsWe examined all clinical events from 1997 to 2008 in the Toronto CF Database to identify risk factors for the acquisition of S. maltophilia and to define distinct patterns of infection.ResultsWe followed 601 patients over 12 years, during which time one quarter of subjects had at least one positive culture for S. maltophilia; the incidence rate was slightly higher in children (11.6/100 person years) compared with adults (10.6/100 person years). Using multi-variable Cox proportional hazards models, steeper rate of FEV₁ decline was a significant risk factor for S. maltophilia acquisition, whereas new infections were less likely to occur with greater oral antibiotic use and a history of Burkholderia cepacia complex infection.ConclusionsThis study illustrates the evolution of S. maltophilia infection over time in a large cohort of adults and children with CF. Younger CF patients, and those with greater lung function decline were at increased risk of S. maltophilia infection. The use of oral antibiotics to maintain lung function may be a way of decreasing the risk of infection. However, the optimal management of CF patients with persistent S. maltophilia infection is not yet known and requires further studies.     

Search for Serum Biomarkers Associated with Abdominal Aortic Aneurysm Growth – A Pilot Study

IntroductionSerological biomarkers could reflect asymptomatic infrarenal aortic aneurysm (AAA) activity and guide patient management.ReportSerum concentrations of C-reactive protein (CRP), alpha 1-antitrypsin and lipoprotein(a) were measured in blood samples from 35 AAA patients and 35 controls and correlated with the aortic diameter and AAA growth in the previous 12 months.We found a positive correlation between CRP and AAA diameter (r = 0.46; p = 0.007) and alpha 1-antitrypsin and AAA growth (r = 0.55; p = 0.004).ConclusionsAlpha 1-antitrypsin may be a promising biomarker of AAA growth.     

Eosinophilic COPD Patients Display a Distinctive Serum miRNA Profile From Asthma and Non-eosinophilic COPD

BackgroundAsthma and chronic obstructive pulmonary disease (COPD) are common chronic airway diseases that may overlap in some individuals. Asthma COPD overlap (ACO) is a heterogeneous conditions that includes smoking-asthma (SA) and COPD with eosinophilia (COPDe). MicroRNAs (miRNA) are regulators of gene expression with a great potential as biomarkers.ObjectivesThe objective of this study was to identify distinctive miRNA signatures in patients from the whole spectrum of chronic obstructive bronchial disease (SA, COPDe, non-smoking asthmatics (NSA), and COPD) that could serve as diagnostic biomarkers or describe differential molecular mechanisms with potential therapeutic implications.MethodsFrom a previously characterized cohort of ACO, COPD and asthma patients, we selected a discovery group of 40 patients for miRNA expression profiling by means of microarray technology. Differential expression of miRNAs were validated by quantitative PCR in the complete cohort (n = 274).ResultsThirty differentially expressed miRNAs (eBAYES p < 0.05, fold change ≥2) were found among the different groups of patients regarding COPDe: 19 COPD-vs-COPDe, 13 NSA-vs-COPDe, 11 SA-vs-COPDe. A characteristic down-regulated miRNA expression pattern was identified in COPDe patients. Differential expression of miR-619-5p and miR-4486 in COPDe patients were validated in the complete cohort (n = 274).ConclusionsWe postulate that COPDe patients show a characteristic expression profile of miRNAs distinctive from asthma and COPD. Also that SA and COPDe patients, which have been typically clustered in the ACO group, display distinct molecular events.     

HLA-B27 homozygosity has no influence on radiographic damage in ankylosing spondylitis: Observation Study of Korean spondyloArthropathy Registry (OSKAR) data

ObjectivesTo evaluate the influence of homozygosity for HLA-B27 on the radiographic damage in ankylosing spondylitis (AS).MethodsA total of 368 AS patients with positive HLA-B27 status from the Observation Study of Korean spondyloArthropathy Registry (OSKAR) cohort were recruited for this study. HLA-B27 positive patients out of all AS patients were assessed for whether they had homozygosity or heterozygosity for HLA-B27. First, all data were stratified in relation to the carrier state of positive HLA-B27 for cross-sectional survey. Then we compared the radiographic damage score between groups. Second, we evaluated collected clinical and radiographic parameters at two different time points. Then we compared radiographic progression between groups. To use the mSASSS, cervical and lumbar spinal radiographs were examined by two experienced bone and joint radiologists (S. Lee, K.B. Joo).ResultsThe agreement between the two readers regarding mSASSS was very good: ICC coefficient 0.70 (95% CI 0.60–0.81). The mean age (SD) of the AS patients was 37.0 (9.2) years, and the mean disease duration (SD) was 15.6 (9.1) years. Of these patients, 34.5% (127 patients) had HLA-B27 homozygosity. The mean mSASSS unit (SEM) was not significantly different between groups (homozygosity 28.57 ± 4.12 vs heterozygosity 23.34 ± 3.44, P = 0.344) on cross-sectional survey. When it comes to radiographic progression between groups over 5 years, there was no significant difference in spite of adjusting for confounding variable (homozygosity 4.98 ± 0.98 vs heterozygosity 4.21 ± 0.82, P = 0.562).ConclusionThe carrier state of positive HLA-B27 plays no role in determining the radiographic progression in AS.     

Comparison of different locking plate fixation methods in lateral malleolus fractures

BackgroundSeveral fixation methods may be used for displaced lateral malleolar fractures. We aimed to compare clinical and radiologic outcomes associated with use of locking one third tubular plate vs. anatomical distal fibula locking plate in lateral malleolar fractures.MethodsA total of 62 orthopedic patients operated for lateral malleolus fracture were included in this retrospective study. Patients were divided into two groups regarding the plate used for fixation as locking one third tubular plate (group I; n = 37) and locking anatomical distal fibula plate (group II; n = 25). Data on Danis–Weber ankle fracture classification (Type A, Type B), duration of follow up, clinical outcome [ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score], radiological outcomes (adequacy of reduction, loss of alignment), time to fracture healing and complications were recorded in study groups.ResultsNo significant difference was noted between groups in terms of AOFAS score [87.0 (73–100) vs. 85.0 (71–100), respectively (p = 0.339)] and no patients had severe restriction in sagittal and hindfoot motion in both groups. The two groups showed similar healing time [9.0 (7–13) weeks vs. 10.0 (8–13) weeks, respectively (p = 0.355)] and complication rate [0.0% vs. 4.0%, respectively (p = 0.403)].ConclusionsThis study revealed no significant difference between use of locking one third tubular plate and locking anatomical distal fibula plate in lateral malleolar fixation, in terms of clinical and radiological outcomes, complication rates and fracture healing time.     

Long-term radiographic appearance of calcium-phosphate synthetic bone grafts after surgical treatment of tibial plateau fractures

ObjectivesSynthetic bone grafts (SBGs) are widely used to fill bone defects after fracture reduction. This study assessed the long-term resorption of two different calcium phosphate products (A = ChronOS™ inject and B = Norian^® SRS^®; both DePuy Synthes, Oberdorf, Switzerland) used in the surgical treatment of tibial plateau fractures.DesignLong-term clinical and radiologic follow-up of 52 patients after surgical treatment of intraarticular tibial plateau fractures augmented with SBGs.SettingThe study was performed at a level 3 trauma center.PatientsBetween January 2000 and December 2006 a total of 52 patients with intraarticular tibial plateau fractures were operatively treated and augmented with SBGs consisting of a Brushite matix with β-TCP granules (SBG A) or hydroxylapatite with 4–6% carbonate content (SBG B). 46 patients could be contacted and 38 were included in the study. Half of the patients received SBG A and the other half SBG B.Main outcome measurementsLoss of reduction and SBG resorption was investigated by comparison of follow-up X-ray images to pre- and postoperative X-ray images. Furthermore, pain, activity level and knee function were evaluated by means of questionnaires and clinical examination.ResultsThe mean age of patients was 59.7 ± 12.5 years. The follow-up was 8.6 ± 0.9 years for SBG A and 11.6 ± 1.4 years for SBG B (p < 0.001). In most cases SBG A was completely resorbed in a homogenous pattern, while SBG B was still visible on the X-ray images revealing a peripheral resorption pattern. A loss of reduction (>2 mm) could be observed in two patients with SBG A and two patients with SBG B, although only one of them had an impaired knee function.ConclusionsThe composite SBG A reveals a comprehensive long-term resorption in comparison to SBG B. Nevertheless, both provided suitable mechanical support as part of the surgical treatment of tibial plateau fractures.Level of evidenceCase series, Level IV.     

Alterations of the biomarker S-100B and NSE in patients with acute vertebral spine fractures

Background contextAlthough several publications concerning the use of the biomarkers S100B and neuron-specific enolase (NSE) in vertebral spine fractures in animal experimental studies have proven their usefulness as early indicators of injury severity, there are no clinical reports on their effectiveness as indicators in patients with spinal injuries. As these biomarkers have been examined, with promising results, in patients with traumatic brain injury, there is a potential for their implementation in patients with vertebral spine fractures.PurposeTo investigate the early serum measurement of S100B and NSE in patients with vertebral spine fractures compared with those in patients with acute fractures of the proximal femur.Study designProspective longitudinal cohort study.Patient sampleA cohort of 34 patients admitted over an 18-month period to a single medical center for suspected vertebral spine trauma. Twenty-nine patients were included in the control group.Outcome measuresS100B and NSE serum levels were assessed in different types of vertebral spine fractures.MethodsWe included patients older than 16 years with vertebral spine fractures whose injuries were sustained within 24 hours before admission to the emergency room and who had undergone a brief neurologic examination. Spinal cord injuries (SCIs) were classified as being paresthesias, incomplete paraplegias, or complete paraplegias. Blood serum was obtained from all patients within 24 hours after the time of injury. Serum levels of S100B and NSE were statistically analyzed using Wilcoxon signed-rank test.ResultsS100B serum levels were significantly higher in patients with vertebral spine fractures (p=.01). In these patients, the mean S100B serum level was 0.75 μg/L (standard deviation [SD] 1.44, 95% confidence interval [CI] 0.24, 1.25). The mean S100B serum level in control group patients was 0.14 μg/L (SD 0.11, 95% CI 0.10, 0.19). The 10 patients with neurologic deficits had significantly higher S100B serum levels compared with the patients with vertebral fractures but without neurologic deficits (p=.02). The mean S100B serum level in these patients was 1.18 μg/L (SD 1.96). In the 26 patients with vertebral spine fractures but without neurologic injury, the mean S100B serum level was 0.42 μg/L (SD 0.91, 95% CI 0.08, 0.76). The analysis revealed no significant difference in NSE levels.ConclusionsWe observed a significant correlation not only between S100B serum levels and vertebral spine fractures but also between S100B serum levels and SCIs with neurologic deficit. These results may be meaningful in clinical practice and to future studies.     

Comorbid mild traumatic brain injury increases pain symptoms in patients suffering from an isolated limb fracture

ObjectivesThis study seeks to evaluate the effects of a mild traumatic brain injury (mTBI) on pain in patients with an isolated limb fracture (ILF) when compared to a matched cohort group with no mTBI (control group).Patients and methodsAll subjects included in this observational study suffered from an ILF. Groups were matched according to the type of injury, sex, age, and time since the accident. Main outcome measurements were: Standardized semi-structured interviews at follow-up of a Level I Trauma Center, and a questionnaire on fracture-related pain symptoms. Factors susceptible to influence the perception of pain, such as age, sex, severity of post-concussive symptoms, and worker compensation were also assessed.ResultsA total of 68 subjects (36 females; 45 years old) with an ILF were selected, 34 with a comorbid mTBI and 34 without (24/34 with an upper limb fracture per group, 71% of total sample). Patients with mTBI and an ILF reported significantly higher pain scores at the time of assessment (mean: 49 days, SD: 34.9), compared to the control group (p < 0.0001; mean difference 2.8, 95% confidence interval 1.8–4.0). Correlational analyses show no significant association between the level of pain and factors such as age, sex, severity of post-concussive symptoms, and worker compensation.ConclusionsResults suggest that mTBI exacerbate perception of pain in the acute phase when occurring with an ILF, and were not explained by age, sex, post-concussive symptoms, or worker compensation. Rather, it appears possible that neurological sequelae induced by mTBI may interfere with the normal recovery of pain following trauma.     

The outcomes of pediatric femoral shaft fractures treated surgically by different types of orthopedists

BackgroundThe objective of this study was to compare the outcomes of pediatric femoral shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists.MethodsFrom May 2006 to June 2014, 88 children with femoral shaft fractures were randomized to operative stabilization either by pediatric orthopedists (Group A, 44 cases) or by non-pediatric orthopedists (Group B, 44 cases). Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, associated injuries and interval from injury to surgery) were comparable between the two groups before surgery. Peri-operative data, clinical and functional outcomes between the two groups were recorded.ResultsThe mean follow-up period was 20.9 ± 4.5 months for Group A and 20.0 ± 3.6 months for Group B (P = 0.356). There was no significant difference in the time to union, length of hospitalization, full weight-bearing time and TEN scores between the two groups (P = 0.785, P = 0.835, P = 0.803, P = 0.940, respectively). However, the mean operating time and radiation time was longer in Group B than in Group A (P = 0.001 and P = 0.047, respectively). Also, there was a trend for patients of Group B to have a higher rate of open reduction (P = 0.047). When comparing the total complications, no significant difference existed between the groups (P = 0.978).ConclusionsThis study indicated that both pediatric and non-pediatric orthopedists provided satisfactory clinical and functional results in treating these common injuries.     

Continuous epidural pumping of saline contributes to prevent and treat postdural puncture headache

Study ObjectivePostdural puncture headache (PDPH) is the most common symptom of accidental dural puncture, a frequent complication of intraspinal anesthesia. We developed a postoperative intervention technique to prevent and treat PDPH in accidental dural puncture patients, including epidural pumping of saline. This retrospective study aimed to retrospectively evaluate this new technique for PDPH prevention and treatment.DesignRetrospective study.SettingBeijing Obstetrics and Gynecology Hospital affiliated to the Capital Medical University, between January 2006 and December 2012.PatientsEighty-seven cases undergoing intraspinal anesthesia were assessed.InterventionsOf these patients, 68 cases had successful repuncture and were assigned to group A (epidural filling group, n = 68), receiving continuous epidural pumping of 0.9% NS (150 mL) at a rate of 6 mL/h; the remaining cases were assigned to group B (conservative therapy group, n = 19).MeasurementsAge, height, and body weight were collected, and postoperative headache was assessed using a visual analog scale.Main ResultsOf 68 patients in group A, 49 (72.1%) developed PDPH, whereas all in group B developed PDPH (P = .009). In addition, all patients showed PDPH within 3 days after surgery regardless of treatment group. However, a statistically significant difference was obtained for PDPH duration between groups A and B (P < .001). Multivariate logistic regression analysis showed that frequency of epidural puncture and continuous epidural pumping of saline were significant risk factors for PDPH.ConclusionsOur data indicated that application of 6 mL/h saline effectively contributes to PDPH management, and its clinical application should be broadened.     

A fast and reproducible method to estimate left atrial volume using cardiac computed tomography

PurposeThe purpose of this study was to do better than the simple maximal axial area (MArea_ax) and to validate simple, fast and robust orthogonal methods for determining the left atrium volume (LAV) with cardiac CT (CCT).Material and methodsA total of 60 patients who underwent CTT were retrospectively included. There were 30 men and 30 women with a mean age of 59 ± 12 (SD) years (range: 27–80 years), using four methods to assess LAV beyond the MArea_ax: two orthogonal methods requiring the measurements of axial, coronal and sagittal planes of 3 diameters LAV_3diam or 3 area LAV_3Areas; Area-length biplane method LAV_biplane; and volumetric method LAV_volumetric using a semi-automated tool that served as the reference standard. The orthogonal methods were applied on contrast-enhanced (IV+) and unenhanced (IV-) CCT images. Comparisons were performed using Pearson correlation test (r) and Bland-Altman analysis. Inter- and intra-observer variability were assessed using intraclass correlation coefficient (ICC) with a two-way mixed-effects model.ResultsOn IV+ CCT, LAV_biplane, LAV3diam_-IV+, LAV_3Areas-IV+ underestimated LAV (-15 ± 1.99 mL; -21 ± 1.37 mL; -15 ± 1.98 mL; all P < 0.001). LAV_3diam-IV+, LAV3_Areas-IV+ better correlated with reference standard (r = 0.97 and 0.98) than LAV_biplane (r = 0.79) as well as MArea_ax (r = 0.90). Estimating LAV on IV- further showed high correlation against the reference (r = 0.93 and 0.95 for LAV3diam_-IV- and LAV_3Areass-IV-, respectively). Intra- and inter-observer ICC increased from LAV_volumetric (2.43% and 3.09%); LAV_3Areas-IV+ (3.04 and 3.30%); LAV_3Areas-IV-(3.34 and 4.23%), LAV3diam_-IV+ (3.36 and 5.11%); LAV3diam_-IV- (5.16 and 6.90%); to LAV_biplane (9.65 and 10.28%).ConclusionsBetter than MArea_ax, orthogonal methods using either diameter or surface are fast and reproducible methods to assess LAV on CCT when performed with or without intravenous administration of contrast material.