No Increase of Plasma Malondialdehyde after Primary Coronary Angioplasty for Acute Myocardial Infarction

Objective : Free radicals formed after coronary artery occlusion and reperfusion are assumed to produce myocardial stunning and possibly other forms of reperfusion injury as well. Malondialdehyde (MDA) is an end product in the lipid peroxidation chain reaction and is frequently used as a marker for free oxygen radical production. Increased levels of plasma MDA have been found following successful thrombolytic therapy. The aim of this study was to investigate whether plasma MDA levels also increase after successful primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI). Design : In 23 patients with AMI, treated with primary PTCA, plasma MDA was analysed using a high-performance liquid chromatography method (HPLC). The results obtained with this method were compared with those obtained with a fluorimetric assay of thiobarbituric acid reactive substances (TBARS). This assay measures MDA but with a lower specificity. Results : We found a significant decrease of plasma MDA from baseline 0.99 to 0.87 µmol/l at 30 min and to 0.90 µmol/l at 90 min following the primary PTCA ( p = 0.048 and 0.014, respectively). No significant changes in TBARS method levels were observed. Conclusion : Instead of the expected increase in MDA following reperfusion we found a significant decrease. The results from measurements of MDA and TBARS were significantly incompatible. The results raise serious doubts as to the usefulness of increased plasma levels of MDA as a marker of oxidative stress caused by coronary reperfusion in patients treated with angioplasty.     

Mitral Stenosis in Association with Aortic Valvular Disease

In a series of 47 consecutive patients with pure mitral stenosis in association with aortic valvular disease, 25 patients underwent closed mitral commissurotomy in addition to aortic valve replacement, whereas combined aortic and mitral valve replacement was performed in 22 patients. The pathology of the stenosed mitral valve and resultant left atrial stasis were more pronounced in the latter group. Valve replacements were performed under generalized hypothermia to 30°C and selective coronary artery perfusion. The advantages and disadvantages of commissurotomy in comparison with mitral valve replacement were evaluated. Commissurotomy with aortic valve replacement involved a markedly higher mortality rate, which was closely related to early and late complications from the closed mitral commissurotomy per se. The reduced risk of thrombo-embolism following preservation instead of replacement of the mitral valve hardly outweighs this excessive mortality. The late haemodynamic improvements, although slight, were definite and similar in the two groups of patients. Diminished pressure levels in the left atrium and pulmonary artery were observed both at rest and during exercise in all the 19 patients who underwent recatheterization. Three patients showed signs of slight mitral restenosis (or residual stenosis), while another required mitral valve replacement due to mitral restenosis with incompetence. Commissurotomy remains clearly indicated if the commissures split up completely and the valve leaflets, chordae tendineae and papillary muscles are in unquestionably good condition. Unfortunately, this type of mitral stenosis, particularly in association with aortic valvular disease, is seldom encountered in Sweden nowadays. Mitral valve replacement seems to be mandatory when surgery is performed for restenosis and if uncertainty exists about the immediate result of commissurotomy.     

Positive pivot shift after ACL reconstruction predicts later osteoarthrosis63 patients followed 5–9 years after surgery

Background?Rupture of the anterior cruciate ligament (ACL) may cause osteoarthrosis (OA) and functional impairment. We wanted to find out whether the degree of knee stability obtained after ACL reconstruction correlates with radiographic and clinical outcome.Patients and methods?We examined 63 patients 2 and 5–9 years after anterior cruciate ligament (ACL) reconstruction. Knee stability was assessed 2 years after surgery by recording AP laxity using radiostereometric technique (RSA) and by performing the pivot shift test. Degeneration of the knee joint was evaluated with bone scintigraphy, and radiographically. Functional outcome was assessed with Lysholm score, Tegner activity scale and with the one-leg hop test.Results?Radiographic signs of osteoarthrosis at the most recent follow-up (5–9 years) did not correlate with knee stability. Patients with positive pivot shift test 2 years after surgery showed increased scintigraphic activity of the subchondral bone at the most recent follow-up, and inferior subjective functional outcome 2 years after surgery. Knees having had meniscus resections had more often OA. Radiographical signs of OA were associated with higher scintigraphic uptake in the operated knee relative to the contralateral knee.Interpretation?The ability to obliterate the pivoting by ACL reconstruction appears to be more important than normalizing the AP laxity in order to prevent later OA.     

Split skin graft reconstruction in vaginal agenesis: a long‐term follow‐up

Fifteen women who had isolated congenital vaginal agenesis reconstructed by the split skin inlay grafting technique at a mean age of 19 (0.5) years, were followed up 2–33 years after the operation. The reconstruction had been functionally successful in all patients. No patient reported dyspareunia, exceptional dryness, or disturbing vaginal discharge. All the women had established normal, stable relationships with men. Their general recollection of the hospital stay and treatment was favourable. The importance of a thorough preoperative and postoperative explanation was emphasised by the patients, as well as their wish for long term contact with a specialist in gynaecology who was well aware of their special problems. In conclusion, the good functional results have been accompanied by stable social and psychological relationships.     

Flapless, CBCT-guided osteotome sinus floor elevation with simultaneous implant installation. I: radiographic examination and surgical technique. A prospective 1-year follow-up

Background: Survival rates of implants placed in transalveolar sinus floor augmentation sites are comparable with those placed in non‐augmented sites. Flapless implant surgery can minimize postoperative morbidity, alveolar bone resorption and crestal bone loss. The use of cone beam computerized tomography (CBCT) provides 3D presentations with reduced dose exposure. Objectives: To evaluate a flapless, CBCT‐guided transalveolar sinus floor elevation technique with simultaneous implant installation. Material and methods: Fourteen consecutive patients in need of maxillary sinus floor augmentation were enrolled in this study. Preoperative CBCT with a titanium screwpost as an indicator at the intended implant position was used to visually guide the flapless surgical procedure. Twenty one implants all with a length of 10 mm and a diameter of 4.1 and 4.8 mm were inserted and followed clinically and with CBCT for 3, 6 and 12 months postoperatively. Intraoral radiographs were taken for comparison. All patients were provided with permanent prosthetic constructions 8–12 weeks after implant surgery. Results: Ten (47.6%) implants were inserted in residual bone of 2.6–4.9 mm and 11 (52.3%) implants were inserted in residual bone of 5–8.9 mm. No implants were lost after surgery and follow‐up. There was no marginal bone loss during the follow‐up verified by CBCT. The implants penetrated on average 4.4 mm (SD 2.1 mm) into the sinus cavity and the mean bone gain was 3 mm (SD 2.1 mm). Conclusion: Flapless transalveolar sinus lift procedures visually guided by preoperative CBCT can successfully be used to enable placement, successful healing and loading of one to three implants in residual bone height of 2.6–8.9 mm. There was no marginal bone loss during the 3–12 months follow‐up. To cite this article :
Fornell J, Johansson L‐Å, Bolin A, Isaksson S, Sennerby L. Flapless, CBCT‐guided osteotome sinus floor elevation with simultaneous implant installation. I: radiographic examination and surgical technique. A prospective 1‐year follow‐up.
Clin. Oral Impl. Res. 23 , 2012; 28–34.
doi: 10.1111/j.1600‐0501.2010.02151.x     

Creating room for evidence-based practice: Leader behavior in hospital wards

The integration (routinizing and sustaining) of evidence-based practice (EBP) into hospital management is a key element for improving patient safety and ensuring better patient outcomes. Hospital managers and clinical leaders play crucial roles in this integration. Interactions between leaders and integration context influence the improvement's quality, but leader-based actions that are effective for improving nursing practice remain unclear. The relationship between leaders could also either hinder or enable this implementation process. The aim of this study was to generate a theory about patterns of leader behavior that leaders are engaged in when attempting to integrate EBP in a clinical setting. We used a classic grounded theory methodology to generate a substantive EBP theory. In this study, through participant observation, we observed 63 nurses (15 specialist, 39 registered, and 9 assistant nurses). From these, five ward leaders (two head nurses, one assistant head nurse, and two teaching nurses) participated in individual interviews, and 18 clinical nurses participated in four focus groups. “Creating room for EBP” emerged as a theory for explaining the way in which the leaders attempted to resolve their main concern: How to achieve EBP treatment and care with tight resources and without overextending the nurses. Creating room for EBP encompasses a process of interactions, including positioning for, executing, and interpreting responses to EBP.     

A 6‐Year Exercise Program Improves Skeletal Traits Without Affecting Fracture Risk: A Prospective Controlled Study in 2621 Children

Most pediatric exercise intervention studies that evaluate the effect on skeletal traits include volunteers and follow bone mass for less than 3 years. We present a population‐based 6‐year controlled exercise intervention study in children with bone structure and incident fractures as endpoints. Fractures were registered in 417 girls and 500 boys in the intervention group (3969 person‐years) and 835 girls and 869 boys in the control group (8245 person‐years), all aged 6 to 9 years at study start, during the 6‐year study period. Children in the intervention group had 40 minutes daily school physical education (PE) and the control group 60 minutes per week. In a subcohort with 78 girls and 111 boys in the intervention group and 52 girls and 54 boys in the control group, bone mineral density (BMD; g/cm²) and bone area (mm²) were measured repeatedly by dual‐energy X‐ray absorptiometry (DXA). Peripheral quantitative computed tomography (pQCT) measured bone mass and bone structure at follow‐up. There were 21.7 low and moderate energy‐related fractures per 1000 person‐years in the intervention group and 19.3 fractures in the control group, leading to a rate ratio (RR) of 1.12 (0.85, 1.46). Girls in the intervention group, compared with girls in the control group, had 0.009 g/cm² (0.003, 0.015) larger gain annually in spine BMD, 0.07 g (0.014, 0.123) larger gain in femoral neck bone mineral content (BMC), and 4.1 mm² (0.5, 7.8) larger gain in femoral neck area, and at follow‐up 24.1 g (7.6, 40.6) higher tibial cortical BMC (g) and 23.9 mm² (5.27, 42.6) larger tibial cross‐sectional area. Boys with daily PE had 0.006 g/cm² (0.002, 0.010) larger gain annually in spine BMD than control boys but at follow‐up no higher pQCT values than boys in the control group. Daily PE for 6 years in at study start 6‐ to 9‐year‐olds improves bone mass and bone size in girls and bone mass in boys, without affecting the fracture risk. © 2014 American Society for Bone and Mineral Research.     

Transmission of LDLR Mutation From Donor Through Liver Transplantation Resulting in Hypercholesterolemia in the Recipient

Donor‐transmitted disease in organ transplantation is uncommon, but possible. The LDL receptor (LDLR), a key regulator of lipoprotein metabolism, is abundant in the liver. Mutations in the LDLR gene, leading to reduced LDLR activity, are the main cause for familial hypercholesterolemia (FH). The estimated prevalence of FH is 1/200–1/500 in the population indicating that there are 14–34 million individuals with FH worldwide. We describe a patient who developed severe hypercholesterolemia after liver transplantation (LT). The 42‐year‐old female, who was transplanted because of hepatic epithelioid hemangioendothelioma with normal liver function, exhibited an increase in plasma total cholesterol from 5.6 mmol/L (217 mg/dL) pretransplant to 11.7 mmol/L (452 mg/dL) at 6 months posttransplant. The respective increase in LDL cholesterol was from 3.30 (128 mg/dL) to 8.99 mmol/L (348 mg/dL). At 1 year, total and LDL cholesterol levels were 11.0 (425 mg/dL) and 7.81 (302 mg/dL), respectively. Sequencing of the coding region of LDLR from a liver graft biopsy revealed a splicing heterozygous mutation of LDLR, whereas no FH‐related mutation was found in DNA extracted from the patient's blood white cells. This confirmed the first reported case of a patient receiving a mutation in LDLR through LT. The case shows that a donor‐transmitted disorder should not be overlooked as a possible cause for severe hypercholesterolemia.