Biochemical alterations in the trapezius muscle of patients with chronic whiplash associated disorders (WAD) – A microdialysis study

The mechanisms behind the development of chronic trapezius myalgia in patients with whiplash associated disorders (WAD) appear to involve both peripheral and central components, but the specific contribution of alterations in muscle is not clear. Female patients with WAD and involvement of trapezius (N=22) and female controls (N=20; CON) were studied during an experiment compromised of rest (baseline), 20min repetitive low‐force exercise and 120min recovery. Their interstitial concentrations of serotonin (5‐HT), glutamate, lactate, pyruvate, potassium, interleukin‐6 (IL‐6), and blood flow were determined in the trapezius muscle using a microdialysis technique. Pressure pain thresholds (PPT) over trapezius and tibialis anterior muscles were also assessed. In WAD, we found signs of generalized hypersensitivity according to PPT. The WAD group had significantly higher interstitial [IL‐6] and [5‐HT] in the trapezius than the CON. [Pyruvate] was overall significantly lower in WAD, and with lactate it showed another time‐pattern throughout the test. In the multivariate regression analysis of pain intensity [5‐HT] was the strongest regressor and positively correlated with pain intensity in WAD. In addition, blood flow, [pyruvate], and [potassium] influenced the pain intensity in a complex time dependent way. These findings may indicate that peripheral nociceptive processes are activated in WAD with generalized hypersensitivity for pressure and they are not identical with those reported in chronic work‐related trapezius myalgia, which could indicate different pain mechanisms.     

High frequency of gastrointestinal parasites in refugees and asylum seekers upon arrival in Sweden.

The results of routine screening for intestinal parasites in 1377 refugees and asylum seekers within 2 weeks of arrival in Sweden showed that protozoa, mainly Giardia intestinalis, were found in 235/1377 (17%) and helminths, mainly hookworms, in 264/1377 (19%). Intestinal parasites were more frequently recovered in refugees coming from South East Asia, Africa and Latin America (infection rates 48%, 43% and 42%, respectively) than in those from Eastern Europe (22%) and the Middle East (32%). Refugees who reported gastrointestinal symptoms were less often infected than those without symptoms (p < 0.001). Of the European refugees, 127 came from Bosnia. A high rate of hookworms was found in this group (15%), suggesting that hookworms may also be transmitted in temperate areas under special conditions. We thus identified relatively high rates of pathogens in all groups of refugees. Screening may therefore be recommended, though more for the benefit of refugees than for the prevention of further spread of the infections.     

Fibrinogen, fibrin and its degradation products in drained blood after major orthopaedic surgery.

The aim of this study was to evaluate the fibrinogen enzymatic conversion in blood collected postoperatively from a surgical wound. Ten otherwise healthy patients (aged 11-28 years) in need of surgical treatment for thoracic scoliosis were included in the study. Arterial blood preoperatively and at wound closure were compared with samples of drained blood from the wound at closure and from a collection system for autologous transfusion 2.8 +/- 1.1 h later. There was a decrease in the fibrinogen content in arterial blood from 2.17 +/- 0.35 g/l to 1.23 +/- 0.42 g/l, which followed a 40% haemodilution estimated from the blood loss of 1.6 +/- 0.9 l during the operation. Drained blood contained high concentrations of D-dimer (85 +/- 53 mg/l from the wound and 121 +/- 47 mg/l from the collection system), but no clottable fibrinogen. The Western immunoblots all visualized the same patterns; in drained blood there were split-products mainly from cross-linked fibrin, in contrast to arterial blood which contained only normal fibrinogen. This indicates a strong fibrinolysis in the surgical wound after closure, with concentrations of fibrin degradation products that may impair local coagulation, and if infused, might interfere with general haemostasis.     

Forecasting drug utilization and expenditure in a metropolitan health region

Background  

New pharmacological therapies are challenging the healthcare systems, and there is an increasing need to assess their therapeutic value in relation to existing alternatives as well as their potential budget impact. Consequently, new models to introduce drugs in healthcare are urgently needed. In the metropolitan health region of Stockholm, Sweden, a model has been developed including early warning (horizon scanning), forecasting of drug utilization and expenditure, critical drug evaluation as well as structured programs for the introduction and follow-up of new drugs. The aim of this paper is to present the forecasting model and the predicted growth in all therapeutic areas in 2010 and 2011.     

Does fixed-angle plate osteosynthesis solve the problems of a fractured proximal humerus?: A prospective series of 87 patients

Background and purpose There is considerable controversy about the treatment of complex, displaced proximal humeral fractures. Various types of head-preserving osteosynthesis have been suggested. This prospective case series was designed to evaluate the perioperative and early postoperative complications associated with fixed-angle implants and to record outcome after bone healing.Patients and methods Fractures of the proximal humerus were stabilized surgically in 87 patients (mean age 64 (16–93) years) by application of a fixed-angle plate (65 PHILOS, 22 T-LCP). There were 34 2-segment fractures, 42 3-segment fractures, and 11 4-segment fractures, including 7 dislocation fractures. Follow-up assessment after a minimum of 12 months was based on the Constant, UCLA, and DASH scores and on radiographs.Results Postoperative complications included soft tissue problems (n = 9), humeral head necrosis (n = 9), screw perforation (n = 11), secondary displacements (n = 14), and delayed fracture healing (n = 4). Treatment outcomes recorded on the various scores were very good in 60–82% of the cases.Interpretation Screw perforation of fixed-angle implants has replaced the complications of secondary displacement and implant loosening after using conventional plates. Even with the use of fixed-angle implants, fractures of the proximal humerus are associated with a high complication rate and sometimes poor outcome.     

The Bankart repair versus the Putti-Platt procedure: A randomized study with WOSI score at 10-year follow-up in 62 patients

Background and purpose This randomized study compared clinical results after surgery for posttraumatic shoulder instability with either an anatomical repair or an older, less anatomical but commonly used method. The less anatomical procedure has been considered quicker and less demanding, but it has been questioned regarding the clinical result. We therefore wanted to compare the clinical outcome of the two different procedures. Our hypothesis was that the anatomical repair would give less residual impairment postoperatively.Methods Patients with anterior posttraumatic shoulder instability were consecutively randomized on the day before surgery to either a Bankart repair using Mitek GI/GII anchors combined with capsular imbrication (B) (n = 33) or a Putti-Platt procedure (P) (n = 33). Follow-up was performed by examination at 2 years and using a self-evaluation score at 10 years.Results At the 2-year follow-up, we found no difference in muscle strength between patients treated with the two surgical methods and there were no statistically significant differences in the Rowe scores (mean 90 units for both groups). Compared to preoperatively, the decrease in external rotation 2 years after surgery was 10 degrees in the P group and 3 degrees in the B group (p = 0.03). 10 years after surgery, 62 of 66 patients replied to a questionnaire sent by mail. It included a self-evaluating quality of life score for shoulder instability (WOSI) for evaluation of their shoulder function. In the P group 15 patients and in the B group 19 patients reported they had experienced either a redislocation or a subluxation with a new feeling of shoulder instability. Mean WOSI score was similar in the P and B groups: 80% and 83%, respectively. The WOSI score was 87% for patients with stable shoulders (n = 28) and 77% for those with unstable shoulders (n =34) (p = 0.005).Interpretation With assessment of pain and general shoulder function, only a small difference was found between the two methods. The WOSI scores for stable shoulders indicated that some shoulders still had impaired function even though the shoulders had become stable.     

Obesity, hypertension, carbohydrate disorders and the risk of chronic diseases. Is there any epidemiological evidence for integrated prevention programmes?

The major cause of coronary heart disease, hypertension, non-insulin-dependent diabetes and obesity in adults in developed countries appears to be the result of risk factors that are introduced by way of their life-styles. Many developing countries are also noting increases in morbidity and mortality from these diseases. There is increasing evidence of common risk factors in the aetiology of these chronic disorders and two or more of these diseases may coexist in the same subjects. This evidence provides a strong rationale for a community-based, integrated approach to the primary prevention of such non-communicable diseases by the reduction of the level of risk factors. This may be achieved by community-based programmes which stress the importance of a healthy life-style, such as the practice of good nutrition, weight reduction in the obese, increased physical activity, the avoidance of stress and a reduction in alcohol and cigarette consumption.