The chauffeur's fracture: simple or complex?

14 chauffeur's-type fractures were treated by open reduction and internal fixation, mainly with Herbert screws. At average follow-up of 18 months, all had good or excellent functional results. The presence of an associated carpal injury in four cases indicates that the mechanism of injury may not be one of simple "backfire" and that a radial styloid fracture may represent the first stage of a more complex pattern.     

Appendicectomy for simple appendicitis: video-assisted or intracorporeal?

BACKGROUND: We reviewed our experience with laparoscopic appendicectomy (LA) to compare the video-assisted and intracorporeal approaches. MATERIALS AND METHODS: One hundred and sixty-one (161) patients undergoing LA for simple appendicitis were considered. The procedure was video-assisted with an extracorporeal appendicectomy in 74 cases operated on during the first 5 years of our experience (group A), whereas it was entirely intracorporeal in the subsequent 87 (group B). In the latter group, the dissection of the mesoappendix was accomplished by using titanium clips in 38 cases, with monopolar coagulation in 42 and other devices in 7. The base of the appendix was closed by using endoloops in 11 patients and a stapler in 76. In all the intracorporeal LAs, the appendix was delivered through a port site. A very low position of the two accessory ports was adopted in 34 group B patients. RESULTS: No difference in outcome was found between the two groups, except in operating time (48 vs. 29 minutes) and length of hospital stay (3 vs. 1 day). The complication rate was not statistically different among the various techniques used in group B to divide the mesoappendix and to close the base of the appendix. The cost of disposable instruments for intracorporeal LA was 3- to 6 folds higher than for the extracorporeal one. An extremely low position of the ports did not interfere with the procedure in any case. CONCLUSIONS: LA for simple appendicitis can be performed safely with many techniques. The intracorporeal procedure allows for a shorter operating time, but can dramatically increase the costs of the disposable instruments that are required.     

Pressure therapy for scars: Myth or reality? A systematic review

BackgroundHypertrophic scarring is a deviate occurrence after wound closure and is a common burn sequela. The mainstay of scar treatment consists of a trifold approach: hydration, UV-protection and the use of pressure garments with or without extra paddings or inlays to provide additional pressure. Pressure therapy has been reported to induce a state of hypoxia and to reduce the expression pattern of transforming growth factor-β1 (TGF-β1), therefore limiting the activity of fibroblasts. However, pressure therapy is said to be largely based on empirical evidence and a lot of controversy concerning the effectiveness still prevails. Many variables influencing its effectivity, such as adherence to treatment, wear time, wash frequency, number of available pressure garment sets and amount of pressure remain only partially understood. This systematic review aims to give a complete and comprehensive overview of the currently available clinical evidence of pressure therapy.MethodsA systematic search for articles concerning the use of pressure therapy in the treatment and prevention of scars was performed in 3 different databases (Pubmed, Embase, and Cochrane library) according to the PRISMA statement. Only case series, case-control studies, cohort studies, and RCTs were included. The qualitative assessment was done by 2 separate reviewers with the appropriate quality assessment tools.ResultsThe search yielded 1458 articles. After deduplication and removal of ineligible records, 1280 records were screened on title and abstract. Full text screening was done for 23 articles and ultimately 17 articles were included. Comparisons between pressure or no pressure, low vs high pressure, short vs long duration and early vs late start of treatment were investigated.ConclusionThere is sufficient evidence that indicates the value of prophylactic and curative use of pressure therapy for scar management. The evidence suggests that pressure therapy is capable of improving scar color, thickness, pain, and scar quality in general. Evidence also recommends commencing pressure therapy prior to 2 months after injury, and using a minimal pressure of 20–25 mmHg. To be effective, treatment duration should be at least 12 months and even preferably up to 18–24 months. These findings were in line with the best evidence statement by Sharp et al. (2016).     

Carpal tunnel syndrome in lysosomal storage disorders: simple decompression or external neurolysis?

Thirty-two patients (61 limbs) with lysosomal storage disorders underwent surgery for 'carpal tunnel syndrome'. Twenty-two limbs underwent a simple decompression whereas 39 limbs underwent additional neurolysis and tenosynovectomy. Data were incomplete for six patients (12 limbs). The mean age at operation for the decompression group (11 patients) was 10.5 years and for the neurolysis group (15 patients), 6.9 years. Overall, using a neurophysiological rating system, 39% of limbs demonstrated sensory improvement and 47% motor improvement with no significant difference between the groups. Only in the neurolysis group was a decline in motor conduction (2/29 limbs) or sensory conduction (four limbs) noted. Using neurophysiological criteria, no added benefit from external neurolysis was identified.     

Primer: questionnaires versus urodynamics in the evaluation of lower urinary tract dysfunction-one, both or none?

What is the role of urodynamic assessments and have we made too much use of them? Is there a correlation between symptoms and underlying pathophysiology? These questions are addressed in this article. There are disparities in the assessment of lower urinary tract dysfunction between the accuracy of symptomatic assessment and the underlying pathophysiology. This is particularly evident with voiding symptoms, in contrast to storage symptoms, and has fuelled the debates that have resulted in the abandonment of the term 'prostatism' in favor of 'lower urinary tract symptoms', whereas the term 'overactive bladder syndrome' has been embraced as a storage symptom complex. Clearly, voiding disorders principally affect men, whilst storage disorders are more common in women. Much has been written and spoken about regarding the use of symptomatic assessment versus urodynamics in the assessment of lower urinary tract symptoms in men, whilst there has been a clearer consensus on the potential usefulness of urodynamics in the assessment of storage disorders, and so this article focuses principally on the latter topic.     

Utility of screening for diabetes in a burn center: Hemoglobin A1c,Diabetes Risk Test,or simple history?

Objective

Rates of diabetes mellitus (DM) are increasing. Early identification and treatment of hyperglycemia in the critical care setting can decrease morbidity and mortality. Many burn centers measure hemoglobin A1c (A1c). This study evaluates the prevalence of pre-existing DM and the utility of using A1c for identifying DM compared with a non-invasive risk assessment.

Methods

Adult patients admitted to our regional ABA-verified burn center from July 2008 to July 2009 had A1c levels evaluated and were asked to complete the American Diabetes Association Diabetes Risk Test (DRT).

Results

Forty-one patients consented to participate: 24 patients with burn (19 male) and 17 patients with non-burns (10 male). Non-burn patients had greater BMIs (BMI 32 vs. 28, p = 0.093) and had a higher rate of DM prior to admission (35% vs. 17%, p = 0.159) than the burn patients. These differences were not statistically significant. Most patients (23/41) were at high risk for developing DM based on the DRT. Patients with pre-existing DM were significantly more likely to have elevated A1c levels (>6.5%) compared with those without pre-existing DM (60% vs. 0%, p < 0.001). Compared with history of DM, DRT had a poor positive predictive value of 36% and 50% (burn and non-burn respectively) but a 100% negative predictive value for DM for both groups.

Conclusion

DM and obesity were more common in non-burn patients than in burn patients. A history of DM provides a simple, accurate method for identifying patients with DM. Use of A1c in the ICU provides little additional data for diagnosis of DM and does not impact patient management.     

Psychological evaluation of self-inflicted burn patients: suicide or parasuicide?

Self-inflicted burns have an increasing incidence all around the world. There is a high mortality and morbidity rate among these patients. We retrospectively analysed the psychiatric characteristics of self-inflicted burn patients. The results showed that these attempts are somewhat different from suicidal acts and may be defined as parasuicides. The treatment and rehabilitation strategies of so called parasuicidal burns are discussed.     

Cyclooxygenase-2 in the kidney: good, BAD, or both?

Hypertonic stress in the kidney inner medulla is common, yet inner medullary cells adapt to limit cell death. Küper et al. have identified a cell-survival response by which increased cyclooxygenase-2 (COX-2) stimulates a prostaglandin E(2) (PGE(2))/protein kinase A (PKA)-mediated inactivation of the pro-apoptotic protein BAD. However, the PGE(2)/PKA pathway is not the only means to inactivate BAD and limit cell death. This Commentary shows a broader picture of this pathway to examine the kidney's BAD options.     

Uromodulin in kidney injury: an instigator, bystander, or protector?

Uromodulin, also known as Tamm-Horsfall protein, is a glycoprotein expressed exclusively by renal tubular cells lining the thick ascending limb of the loop of Henle. Although the physiologic functions of this protein remain elusive, significant progress has been made during the last decade that highlights the importance of uromodulin in the pathophysiology of various diseases, such as medullary cystic kidney disease, urinary tract infections, and nephrolithiasis. Meanwhile, there is renewed interest in the role of uromodulin in kidney injury, both acute and chronic. In this article, we review the existing evidence that supports a role for uromodulin in acute kidney injury, chronic kidney disease, and renal inflammation. Contrary to the conventional view of uromodulin as an instigator in kidney injury, new data from uromodulin knockout mice show a protective role for this protein in acute kidney injury, possibly through downregulating interstitial inflammation. In chronic kidney disease, uromodulin excretion, when adjusted for kidney function, is increased; the significance of this is unclear. Although it has been suggested that uromodulin exacerbates progressive kidney injury, we propose that the elevation in uromodulin secretion is instead reactive to injury and reflects an increase of uromodulin in the renal parenchyma, where it slows the injury process.     

Why knees fail in 2011: patient, surgeon, or device?

The outcome of total knee arthroplasty (TKA) is influenced by multiple interconnected factors, including patient selection, implant design, and surgical technique. Total knee arthroplasty has been shown to be highly successful, with patient satisfaction rates reported from 85% to 95% with low rates of failure, but if failure occurs, its impact is significant. In 2003, 402,000 primary TKAs and 32,000 revision TKAs were performed in the United States, and the number of TKAs is expected to double by 2015. Recent data on modern implant designs and techniques have demonstrated a surprising number of early failures, although the true number of early failures is unknown. Patient medical comorbidities should be optimized preoperatively, while psychosocial issues and workers compensation are more nebulous yet contribute greatly to patient perceived outcomes. Understanding current failure mechanisms of primary TKA and how to prevent complications will be critical to help manage a potentially overwhelming TKA revision burden. This article discusses failure rates as well as factors from the patient, surgeon, and device, that contribute to TKA failure.