Diagnosis of finger flexor pulley injury in rock climbers: A systematic review

BACKGROUND:

Closed injury to the finger flexor pulley system is found frequently in rock climbers. There are no evidence-based published guidelines on the diagnosis and treatment of these injuries.

OBJECTIVES:

The present systematic review was undertaken to answer the following questions: what are the most commonly recommended diagnostic criteria for finger flexor pulley injury in rock climbers; and, based on the available evidence, what is the best diagnostic test for these injuries?

METHODS:

Four electronic databases were searched using specific key terms, with limits set for language and date. Two reviewers independently identified potentially relevant titles based on inclusion criteria. Inter-reviewer variability was assessed using the Kappa statistic. The scientific quality of articles was assessed using validated scales.

RESULTS:

Of the 93 articles identified, 29 were included in the present analysis. The inter-rater agreement for selection of potentially relevant titles was 88% (kappa=0.74). The most commonly cited diagnostic criterion for closed finger pulley injury was clinical bow-stringing of the flexor tendons over the volar aspect of the proximal interphalangeal joint. However, the best study of diagnostic accuracy for these injuries supports the use of dynamic ultrasound.

CONCLUSIONS:

Dynamic ultrasound is recommended for the diagnosis of closed finger pulley injuries in rock climbers. The prevailing notion that these injuries can be diagnosed by testing for clinical bowstringing is not supported by evidence.     

A cost-analysis comparison of laparoscopic radical prostatectomy versus open radical prostatectomy: the McMaster Institute of Urology experience

Introduction:

The objective of this study was to identify and compare the costs of laparoscopic radical prostatectomy (LRP) and radical retropubic prostatectomy (RRP) at our centre.

Methods:

We conducted a retrospective chart review of our first 70 consecutive LRP cases and 70 consecutive RRP cases at St. Joseph’s Healthcare in Hamilton, Ontario, Canada. We performed cost analysis, including operating room costs, disposable instruments, blood transfusions, analgesic requirements and length of hospital stay. Overall expenses were then analyzed and compared.

Results:

Preoperative patient demographics and disease stages were comparable between the LRP and RRP groups. On a per procedure basis, large discrepancies were found in mean disposable instrument costs (LRP = $659.18 vs. RRP = $236.59), operating room costs (LRP = $4278.00 vs. RRP = $3139.00), mean cost of blood transfusions (LRP = $21.00 vs. RRP = $394.34), mean analgesia requirements (LRP = $12.94 vs. RRP = $41.06) and mean hospital stay bed costs (LRP = $3690.00 vs. RRP = $5027.14). Overall, costs for all patients in the LRP and RRP groups, respectively, were $606 307.29 and $618 721.57 with a cost saving of $12 414.28 in favour of the LRP arm.

Conclusion:

At our institution, we found that LRP costs are slightly less than those for RRP. Higher operative time and disposable instrument expenses are offset by the shorter hospital stays, fewer blood transfusions and less analgesic requirements for the LRP group. Further financial advantages for LRP will likely be achieved with additional reduction of operating room time and by minimizing disposables.     

Left thoracotomy utilizing splenectomy in blunt thoracic injury: An alternative surgical approach

INTRODUCTIONPosterolateral thoracotomy could be an alternative surgical approach in selected cases coexistence of abdominal injuries with ipsilateral thoracic injury.PRESENTATION OF CASEA 65-year-old male with left sided chest injury was initially admitted to a regional health center after a crawler overthrow accident. He underwent chest tube drainage of left hemithorax and he was transferred immediately to our hospital. A CT scan showed a large spleen which was injured by a wedged splint of the 10th rib into its parenchyma. Lung parenchyma was also lacerated by chest tube misplacement with associated hemothorax. He underwent a lower left lateral thoracotomy. Splenectomy was performed via a phrenotomy and subsequently the injured lung was repaired. His postoperative course was uneventful.DISCUSSIONIncisions in the diaphragm are commonly made to provide adequate exposure during a variety of thoracic and abdominal operations. Thoracic approach could potentially be advantageous for thoracic and abdominal injuries.CONCLUSIONThoracic approach is a safe alternative, providing excellent exposure of upper abdominal organs, and should be considered in selected cases of abdominal trauma, especially when an ipsilateral thoracic injury coexists.     

Paranasal sinus and midfacial reconstruction

Midface defects pose the most difficult of the facial reconstruction problems. Current reconstruction relies heavily on microsurgical techniques, among which there are numerous possibilities. Although midface defects frequently extend to the upper and lower face, often an awareness of the midface subunits most involved can be of critical importance. This article presents an approach that will help the surgeon to identify the defect-related problems, prioritize the reconstructive goals, and select the best surgical option in the total patient context.     

Challenges in creating a good randomized controlled trial in hand surgery

The goal of this article is to inform readers of hand surgery literature and, more importantly, investigators about key design issues in randomized trials in hand surgery. Specifically, it describes the application of the Consolidated Standards of Reporting Trials in hand surgery trials and provides tips for reading the hand surgery literature. Unique challenges in the execution of a randomized controlled trial in hand surgery are explained, including the surgical learning curve, randomization, concealment and blinding, loss to follow-up, intention to treat analysis, surgical equipoise, differential care, and treatment effect and its implications for sample size. Additionally, the relevance of incorporating economic analyses into hand surgery trials and the importance of changing the hand surgeons' research culture are addressed.     

Molecular epidemiology of extended-spectrum beta-lactamases produced by clinical isolates in a university hospital in Greece: detection of SHV-5 in Pseudomonas aeruginosa and prevalence of SHV-12

To assess the nature and diversity of various types of SHV and TEM derivatives in our hospital a survey was conducted. Sixty-seven extended-spectrum beta-lactamases (ESBL)-producing nosocomial pathogens, isolated over a 12-month period, were analyzed by means of PCR and direct sequencing. SHV-5 was the predominant ESBL found in our region (38 strains). Other less frequent variants included SHV-2 and SHV-12 with two and three isolates, respectively. For the first time, an outbreak of 11 Pseudomonas aeruginosa producing SHV-5 was encountered. All blaTEM-positive strains carried the non-ESBL TEM-1. The incidence of non-SHV non-TEM ESBLs was remarkably high as almost one out of three isolates harbored such an ESBL. The epidemiological and clinical impact of these findings must be carefully investigated and interpreted.     

Allograft prolongation with synthetic progestins

Experimental evidence that medroxyprogesterone acetate (MPG) prolongs survival of rabbit skin allografts and the survival of dogs with renal allografts has been reported previously. Reviewed in this study are additional experience with MPG and evaluation of melengestrol acetate (MGA), a more potent progestin. Skin grafts were exchanged between New Zealand white and California rabbits of both sexes. Recipients were treated with intramuscular injections of MPG, 50 mg/ml; MGA, 50 mg/ml; estradiol cypionate, 2 mg/ml; horse antirabbit thymocyte globulin (ALG); or combinations of these agents. MPG or MGA significantly prolonged survival of rabbit skin allografts. Large doses of MPG also prolonged survival of dogs with renal allografts, but MGA did not. Rabbit skin allografts survival was further enhanced when MPG was combined with estradiol or when suboptimal doses of MPG and MGA were combined with a suboptimal dose of ALG. When MPG or MGA were combined with azathioprine, a marked prolongation on survival of dogs with renal allografts was observed. In a preliminary trial of MPG in humans with intrafamilial renal transplants, chronic slow rejection was not halted by addition of MPG to the immunosuppressive regimen. In patients whose renal function was stable at the time of initiation of MPG therapy, prednisone dosage could be lowered to an average of 37% of the previous dose and the patient's Cushingoid appearance or aseptic necrosis of the hips either did not progress or improved.