What is the clinical relevance of erosions and joint space narrowing in RA?

The association between joint damage and disability in rheumatoid arthritis (RA), especially in the later stages of disease, is a main reason why radiographic joint damage is a common and valid outcome measure in RA clinical trials. Most studies have assessed the effect of global joint damage, which has limited our knowledge regarding the individual effects of erosions and cartilage damage on physical function. However, recent data have indicated that joint space narrowing is more closely related to functional status than erosions. Modern imaging techniques that provide improved assessment of the cartilage itself, instead of only joint space narrowing, might help disentangle the separate associations of erosive bone damage and cartilage damage with physical function in patients with RA. The aim of this article is to discuss the current knowledge within this field and the clinical consequences thereof.     

The role of prospective randomized clinical trials in pediatric surgery: state of the art?

PURPOSE: This study sought to determine the role of randomized controlled trials (RCT) in the evolution of pediatric surgical practice. METHODS: The authors used a computer-assisted literature search to identify all clinical trials related to pediatric surgery published in the English-language literature from 1966 through 1999. Each article was reviewed in detail for purpose, content, conduct, and quality of the trial. The authors assessed quality with a previously validated instrument (Chalmers Qualitative Assessment). RESULTS: The authors identified 134 RCTs related to pediatric surgery over the past 33 years. This accounts for 0.17% of 80,377 articles published in the field. The areas of surgery studied were analgesia 65 (49%), antibiotics 17 (13%), extracorporeal membrane oxygenation (ECMO) 9 (7%), gastrointestinal, burns, oncology, minimally invasive surgery, vascular access, congenital anomalies, and trauma (each <5%). Only 16 (12%) trials compared 2 surgical therapies, 9 (7%) compared a medical versus a surgical therapy, and 109 (81%) compared 2 medical therapies in surgical patients. Fourteen (10%) RCTs were funded by peer-reviewed agencies. Only 17 (13%) RCTs included a biostatistician as an author or a consultant. Trial design included calculation of sample size and statistical power in 21 (16%) RCTs. Method of randomization was reported in only 51 (38%). The test statistic and observed probability value was reported in 15 (11%). CONCLUSIONS: Clinical trials are used infrequently to answer questions related to pediatric surgery. When RCTs are utilized, they often suffer from poor trial design, inadequate statistical analysis, and incomplete reporting. Pediatric surgery could benefit from increased expertise, funding, and participation in clinical trials.     

Mortality, malnutrition, and atherosclerosis in ESRD: what is the role of interleukin-6?

There is growing evidence that increased plasma concentrations of CRP strongly predict cardiovascular death in both non-renal and renal patient populations. The interleukin-6 (IL-6) system activity, which is the major mediator of the acute phase response, is often markedly up-regulated in uremic patients and has also been shown to predict outcome. This raises the issue of whether or not IL-6 per se may contribute to increased mortality from malnutrition and atherosclerotic cardiovascular disease in uremic patients. The causes of elevated IL-6 levels in the uremic circulation are not fully understood, although a number of factors prevalent in uremic patients, such as hypertension, adiposity, infections, and chronic heart failure may all contribute. However, factors associated with the dialysis procedure, such as bioincompatibility and non-sterile dialysate, may stimulate IL-6 production. Furthermore, available evidence suggests that genetic factors may also have an impact on circulating plasma IL-6 levels. We advance the hypothesis that IL-6 may play a central role in the genesis of inflammatory-driven malnutrition and that it may be regarded as a significant proatherogenic cytokine. This hypothesis may provide a rationale to test if targeted anti-cytokine therapy may be one way to combat the unacceptable high cardiovascular mortality rate among dialysis patients.     

Latarjet procedure: evolution of the bone block and correspondent clinical relevance—a clinical and radiological study

Introduction

Valgus deformity in knees is a common concern in Morquio-A patients, preceding premature arthrosis and pain leading to walking disability and loss of ambulatory status. Treatment alternative is the guided growth, but this is sometimes not applied on time. Due to short height reached on these patients, not all will benefit from guided growth surgery.

Purpose

The purpose of this study is to describe early results of physeal osteotomy for acute valgus correction in adolescent patients and those almost at height peak to achieve alignment.

Methods

We perform the osteotomy in four knees of 10- and 14-year-old patients, fixed with Kirschner wires, and allow early weight bearing. This is compared with one patient who was managed by guided growth.

Results

The average acute correction osteotomy was 39 degrees with intermalleolar distance of 350 and 240 mm. At final follow-up, this measure was reduced to 70 and 20 mm, respectively, with clinical valgus of 4° and 2°. For the patient with guided growth, she was operated at 10.2 years old and 36 months in follow-up; preoperative valgus was 28/24° with intermalleolar distance of 140 mm. At the end of follow-up, this distance was increased to 150 mm with clinical valgus of 18/22°. During this follow-up, none of the patients lost ambulatory status. As a part of multi-organic disease progression, none of the three patients completed the 6-min walking test at final follow-up.

Conclusions

This physeal osteotomy is a feasible and optimal option to achieve acute valgus correction on severe deformity when there is not enough remaining growth on adolescent Morquio-A patients, and may help reduce arthritis progression in adjacent joints.

     

The role of perceived control in the relationship between job insecurity and psychosocial outcomes: moderator or mediator?

The aim of the current study was to address the intervening role of perceived control in the job insecurity–strain relationship. Two alternatives were investigated: (1) perceived control as a buffer of the relationship between job insecurity and outcome variables (i.e. job satisfaction, organizational commitment, psychological distress and turnover intentions); and (2) perceived control as a mediator of the relationship between job insecurity and the outcomes. Cross‐sectional data of 211 employees were used to test the hypotheses. The results showed that perceived control did not buffer the relationship between job insecurity, and job satisfaction, organizational commitment, psychological distress and turnover intentions. However, perceived control was found to partially mediate the association between job insecurity and these outcomes. The results are explained using the cognitive theory of stress and coping of Lazarus and Folkman, and suggest that job insecurity is stressful because it decreases the experience of control. Copyright © 2010 John Wiley & Sons, Ltd.     

Paradigm shift in gastrointestinal surgery − combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data

A growing body of evidence has demonstrated the prognostic significance of sarcopenia in surgical patients as an independent predictor of postoperative complications and outcomes. These included an increased risk of total complications, major complications, re-admissions, infections, severe infections, 30 d mortality, longer hospital stay and increased hospitalization expenditures. A program to enhance recovery after surgery was meant to address these complications; however, compliance to the program since its introduction has been less than ideal. Over the last decade, the concept of prehabilitation, or “pre-surgery rehabilitation”, has been discussed. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory “buffer” for the imminent reduction in physiological reserve post-surgery. Initial results have been promising. We review the literature to critically review the utility of prehabilitation, not just in the clinical realm, but also in the scientific realm, with a resource management point-of-view.     

The role of inflammation in early and late venous thrombosis: Are there clinical implications?

Venous thrombosis is associated with a significant inflammatory response. Inflammatory cells, adhesion molecules (especially selectins), cytokines, and procoagulant microparticles appear to be associated with the thrombogenic process. Once thrombus forms, inflammatory cells are important to thrombus resolution along with fibrinolytic agents and proinflammatory mediators. Collagen and elastin breakdown by the DVT renders the vein wall stiff and non-compliant. Rapid and complete thrombus resolution should lessen vein wall damage and lessen or prevent the development of chronic venous insufficiency. Understanding the basic biology of thrombogenesis and thrombus resolution is important, as novel therapies to both prevent and treat venous thrombosis and hasten thrombus resolution should result from a better understanding of the basic biological mechanisms.