Fixation of complex proximal humeral fractures in elderly patients with a locking plate: A retrospective analysis of radiographic and clinical outcome and complications

Purpose: The optimal surgical treatment of displaced type B and C fractures of the proximal humerus in the elderly remains controversial. Good clinical results have been reported by plating these fractures as well as a high rate of complications. Our retrospective study aims to evaluate clinical recovery and complications using the S3 locking plate in elderly patients. Methods: Fifty-one patients older than 65 years of age, with a complex proximal humeral fracture type B or C (AO classification system), were included. Patients have been followed up for a minimum of 12 months. We assessed callus formation, radiological results, clinical outcome (according to the Constant Shoulder Score System) and complications. Any difference in the clinical recovery among the 2 types of fracture pattern (B and C) was investigated. Results: The mean time of fracture healing was 12.4 weeks. The mean Constant score at 3, 6 and 12 months was 68, 73 and 75 respectively. No statistically significant difference in the clinical outcome was observed between the B and C fracture patterns (p > 0.05). We noticed an overall of 5 complications (9.8%). There was no need to revision any of the implants. Conclusion: Anatomic reduction and proper plate positioning are essential for minimizing implantrelated complications. In our experience the S3 angular stability system offers a proper osteosyntesis and a good clinical recovery with a low rate of complications.     

Coronary Artery Perforation following PCI: An Interesting Finding into the Pericardial Space

Coronary artery perforation is a known complication of percutaneous coronary intervention and potentially life threatening. Normally, these perforations are small and localized. We report the successful surgical management of a coronary artery perforation following stent insertion with extrusion of an 8-cm endarterectomy length of the circumflex coronary artery with a brief review of the recent literature.     

Ileal Neobladder and Its Variants

Orthotopic neobladder substitution represents an important step in the evolution of urinary diversion. It is now considered the diversion of choice for the majority of patients, both male and female, who undergo cystectomy and is the procedure with which other types of diversion must be compared. Nevertheless, in the preoperative setting, all options for urinary diversion should be explained comprehensibly to the patient, along with the potential short- and long-term risks and the beneficial effects of each type of diversion. With regard to the risk of urethral recurrence, the decision to perform a neobladder ultimately depends on the intraoperative frozen section analysis of the distal urethral margin.Neobladder construction is based on the concept of detubularization and folding to construct a low-pressure reservoir. All parts of the small and large intestine as well as the stomach have been intensely studied for the construction of neobladders. In this respect, there is substantial agreement in the literature that the terminal ileum possesses superior anatomic and functional characteristics.Given the lack of prospective randomized trials, controversies still exist with regard to the technique for preventing reflux in orthotopic substitutes and the superiority of one neobladder technique over others, provided the detubularized intestinal segment is reconfigured to an adequate-sized spherical reservoir.     

Plasminogen activator inhibitor-1 4G/5G polymorphism and risk of ischemic stroke: a meta-analysis.

This study investigated the hypothesis that the insertion/deletion (4G/5G) polymorphism of the plasminogen activator inhibitor type-1 gene affects the risk for ischemic stroke, since results concerning this association have been controversial. We therefore performed a meta-analysis of published data regarding this issue. A comprehensive electronic search was carried out until January 2006. The analysis was performed using random-effects models and meta-regression. Eighteen eligible studies were retrieved (15 case-control studies and three cohort studies). The case-control studies included 3104 cases and 4870 control individuals concerning the contrast of 4G/4G versus remaining genotypes. The 4G pooled allele frequencies in cases and controls were 54.21 and 54.75%, respectively. Overall, the per-allele odds ratio of the 4G allele was 0.98 (95% confidence interval, 0.858-1.121). Regarding genotypes, we derived nonsignificant odds ratios in all contrasts. The subanalysis including the three studies with a prospective design in the 4G/4G versus 5G/5G contrast derived a significant result (relative risk, 0.523; 95% confidence interval, 0.353-0.775), but the estimated effect size was insignificant when cohort and case-control studies were analyzed together (relative risk, 0.848; 95% confidence interval, 0.662-1.087). We failed to demonstrate a significant association between the 4G/5G polymorphism and ischemic stroke under basal conditions. Determination of plasminogen activator inhibitor type-1 function seems of much higher clinical value than determination of the 4G/5G polymorphism. The effect of this genotype on risk of ischemic stroke in acute stressful diseases and the role of cohort studies in genetic epidemiology, however, warrant further investigation.     

Type 1 and type 2 cytokine-producing CD4+ and CD8+ T cells in primary antiphospholipid syndrome

Antiphospholipid syndrome (APS) is an autoimmune condition characterized by thrombosis and/or recurrent fetal loss as well as the presence of autoantibodies against epitopes present on phospholipid-binding proteins. The role of cellular immunity in the pathogenesis of the syndrome remains unclear. We studied the cellular phenotype and the production of type 1 [interferon (IFN)-, interleukin (IL)-2] and type 2 (IL-4, IL-10) cytokines by CD4+ and CD8+ T-lymphocyte subsets in 13 patients with untreated primary APS (PAPS) and in 32 healthy controls. The production of cytokines was determined in T cells after a 5-h culture with or without mitogenic stimulation using a flow cytometric method of intracellular cytokine staining. In six of the patients these studies were repeated 6 months later. In PAPS patients we found a reduced percentage of circulating CD4+CD45RA+ and an increased percentage and absolute number of CD8+HLA-DR+ cells. A type 1 response was observed in the patients unstimulated cells, indicated by an increase in IFN--producing CD8+, IL-2-producing CD4+ T cells, and a decrease in IL-4-producing CD4+ and CD8+ T cells. Similar results were obtained in the patients at follow-up. Taken together, these results suggest a chronic in vivo stimulation of CD4+ and CD8+ T cells in PAPS patients exhibiting a type 1 polarization. Changes of cellular immunity may contribute to the pathogenesis of the clinical manifestations of the syndrome and might be proven to be useful targets for therapeutic interventions in the future.     

Aspergillus fumigatus abscesses of the thyroid with obstruction of the esophagus.

Thyroid invasion by Aspergillus spp. can occur with invasive aspergillosis, although it is rarely diagnosed antemortem. We describe a case of multiple thyroid abscesses from A. fumigatus that caused esophageal obstruction in a patient with myelodysplasia. Despite aggressive antifungal treatment, the outcome was rapidly fatal.     

Bichat guidelines for the clinical management of brucellosis and bioterrorism-related brucellosis

Interest in Brucella species as a biological weapon stems from the fact that airborne transmission of the agent is possible. It is highly contagious and enters through mucous membranes such as the conjunctiva, oropharynx, respiratory tract and skin abrasions. It has been estimated that 10-100 organisms only are sufficient to constitute an infectious aerosol dose for humans. Signs and symptoms are similar in patients whatever the route of transmission and are mostly non-specific. Symptoms of patients infected by aerosol are indistinguishable from those of patients infected by other routes. Regimens containing doxycycline plus streptomycin or doxycycline plus rifampin are effective for most forms of brucellosis. Isolation of patients is not necessary. Trimethoprim-sulfamethoxazole and fluoroquinolones also have good results against Brucella, but are associated with high relapse rates when used as monotherapy. The combination of ofloxacin plus rifampicin is associated with good results. Even if there is little evidence to support its utility for post-exposure prophylaxis, doxycycline plus rifampicin is recommended for 3 to 6 weeks.