Expectations and limitations due to brachial plexus injury: a qualitative study

Purpose

This study described physical and psychosocial limitations associated with adult brachial plexus injuries (BPI) and patients’ expectations of BPI surgery.

Methods

During in-person interviews, preoperative patients were asked about expectations of surgery and preoperative and postoperative patients were asked about limitations due to BPI. Postoperative patients also rated improvement in condition after surgery. Data were analyzed with qualitative and quantitative techniques.

Results

Ten preoperative and 13 postoperative patients were interviewed; mean age was 37 years, 19 were men, all were employed/students, and most injuries were due to trauma. Preoperative patients cited several main expectations, including pain-related issues, and improvement in arm movement, self-care, family interactions, and global life function. Work-related expectations were tailored to employment type. Preoperative and postoperative patients reported that pain, altered sensation, difficulty managing self-care, becoming physically and financially dependent, and disability in work/school were major issues. All patients reported making major compensations, particularly using the uninjured arm. Most reported multiple mental health effects, were distressed with long recovery times, were self-conscious about appearance, and avoided public situations. Additional stresses were finding and paying for BPI surgery. Some reported BPI impacted overall physical health, life priorities, and decision-making processes. Four postoperative patients reported hardly any improvement, four reported some/a good deal, and five reported a great deal of improvement.

Conclusions

BPI is a life-altering event affecting physical function, mental well-being, financial situation, relationships, self-image, and plans for the future. This study contributes to clinical practice by highlighting topics to address to provide comprehensive BPI patient-centered care.     

From the Cover: The precise temporal calibration of dinosaur origins

Dinosaurs have been major components of ecosystems for over 200 million years. Although different macroevolutionary scenarios exist to explain the Triassic origin and subsequent rise to dominance of dinosaurs and their closest relatives (dinosauromorphs), all lack critical support from a precise biostratigraphically independent temporal framework. The absence of robust geochronologic age control for comparing alternative scenarios makes it impossible to determine if observed faunal differences vary across time, space, or a combination of both. To better constrain the origin of dinosaurs, we produced radioisotopic ages for the Argentinian Chañares Formation, which preserves a quintessential assemblage of dinosaurian precursors (early dinosauromorphs) just before the first dinosaurs. Our new high-precision chemical abrasion thermal ionization mass spectrometry (CA-TIMS) U–Pb zircon ages reveal that the assemblage is early Carnian (early Late Triassic), 5- to 10-Ma younger than previously thought. Combined with other geochronologic data from the same basin, we constrain the rate of dinosaur origins, demonstrating their relatively rapid origin in a less than 5-Ma interval, thus halving the temporal gap between assemblages containing only dinosaur precursors and those with early dinosaurs. After their origin, dinosaurs only gradually dominated mid- to high-latitude terrestrial ecosystems millions of years later, closer to the Triassic–Jurassic boundary.The Triassic Period (252.2–201.3 Ma) is a key interval of earth history that witnessed the origin of many faunal and floral components of modern terrestrial ecosystems, and was punctuated by at least two large-scale environmental perturbations, the end-Permian and end-Triassic mass extinctions (1). These events frame the evolutionary history of nonmarine tetrapod communities during the Triassic, resulting in a long-recognized threefold division: (i) lineages that survived the end-Permian mass extinction; (ii) a wide variety of new Triassic lineages that did not survive the end-Triassic mass extinction; and (iii) the first representatives of lineages that dominated later Mesozoic and Cenozoic ecosystems (2, 3). Among the third group is arguably the most contentious of Mesozoic macroevolutionary events: the origin and rise of dinosaurs (4–8).Although dinosaurs have often been cited as a classic case of an evolutionary radiation, many disparate hypotheses have been proposed for their origin and subsequent rapid rise to global dominance (4–8). One of the major difficulties with testing these hypotheses has been the lack of precise biostratigraphically independent age constraints for early dinosaur-bearing assemblages, which would provide a firm temporal basis for comparing origin scenarios across time and space (9).Robust analysis of macroevolutionary patterns requires well-documented assemblages with fossil specimens examined in a phylogenetic context, as well as an independent, accurate, and precise geochronologic framework. As recently pointed out, analyses of the origin and early diversification of dinosaurs have suffered from an overreliance on low-resolution (both stratigraphic and taxonomic) vertebrate biostratigraphy that obscures real faunal differences in time and space (10). This situation is particularly problematic for Triassic nonmarine communities, where tetrapod composition across Pangea appears to be particularly heterogeneous (11–13). Without precise independent age control (other than vertebrate biostratigraphic correlations), it is impossible to determine if these faunal differences vary across time, space, or a combination of both.Among the many uncertainties regarding dinosaur evolution is the timing of the origin and subsequent radiation of this clade and their closest relatives (early dinosauromorphs). Contrasting hypotheses suggest they appeared anywhere between soon after the end-Permian extinction (∼252 Ma) to very close in time to the first dinosaurs (∼231 Ma) (14). This question has been put to the fore by recent discoveries of African dinosauromorphs (15) from strata thought to be early Middle Triassic in age, ∼245–242 Ma. Nonetheless, the significance of these fossils for understanding the early evolutionary history of the group is unclear as they lack a precise time framework, with the age of the strata based solely on vertebrate correlations among unconnected Gondwanan basins. This problem has been exacerbated by the recent recognition that these vertebrate index taxa may differ in age across Gondwana (16). To resolve these outstanding major issues, we examined the Agua de la Peña succession of the Ischigualasto–Villa Unión Basin in northwestern Argentina, which contains an extensive dinosaur and dinosaur-precursor record for investigating the timing of the origin and early diversification of dinosauromorphs (Fig. 1).Open in a separate windowFig. 1.Geological map of the Chañares–Gualo area in Talampaya National Park (La Rioja Province). The main fossiliferous localities are the Romer locality and Río Gualo. The latter locality is where the detailed section (SI Appendix) was measured. (Right) Generalized stratigraphic column from Río Gualo showing the sampled levels. For additional references, see SI Appendix.     

The role of macrophage colony-stimulating factor in patients with acute myocardial infarction: a pilot study

We assessed whether macrophage colony-stimulating factor (M-CSF) levels are associated with left ventricular systolic dysfunction (LVSD) in patients with acute myocardial infarction (AMI). We studied 56 patients with AMI (mean age: 67 ± 12 years) and identified those with clinical (Killip class >II) or echocardiographic signs (ejection fraction ≤45%) of LVSD. We evaluated the established cardiovascular risk factors and measured several cardiovascular biomarkers, including M-CSF. Serum M-CSF concentrations (pg/mL) were significantly increased in patients with both clinical and echocardiographic signs of LVSD (460 ± 265 vs 290 ± 210, P = .0103 and 493 ± 299 vs 287 ± 174, P = .0028, respectively). We found a significant inverse association between M-CSF and ejection fraction (r = -.351, P = .0079). Logistic regression analysis revealed that, among all evaluated clinical and biochemical parameters, the stronger predictor of LVSD was M-CSF (odds ratios 2.1, 95% confidence interval 1.1-2.9, P = .0168). This is the first study reporting plasma M-CSF levels as independent determinants of low LV ejection fraction and clinical LV dysfunction in patients with AMI.     

Ex Vivo Lung Perfusion Increases the Pool of Lung Grafts: Analysis of Its Potential and Real Impact on a Lung Transplant Program

Background

Among the strategies to increase the number of lung transplants, ex vivo lung perfusion (EVLP) represents a novel technique to expand the donor pool.

Methods

Data from donors referred to our center were retrospectively analyzed to identify grafts that could potentially be potentially reconditioned by EVLP and for comparison with those obtained by clinical application of EVLP program in our center.

Results

Among 75 rejected lungs, 23 organs have been identified as potentially treatable with EVLP with a hypothetic increase of lung transplant activity of 53%. After the introduction of the EVLP program in our center, lung transplantation with reconditioned grafts was performed in 7 (23%) patients with a 30% increase in transplant procedures.

Conclusion

Although less than expected, EVLP increased the number of lungs suitable for transplantation.     

Economic impact of childhood obesity on health systems: a systematic review

The primary purpose of this study is to analyse the costs related to childhood obesity (CO) with reference to different models of healthcare systems. A systematic review of the economic impact of CO on healthcare systems was conducted by searching the main electronic scientific databases. Cost-of-illness (COI) analyses of children aged under 18 years who had been diagnosed as overweight or obese published up to July 2010 were considered. Short- and long-term consequences of CO were taken into account. In order to appraise the quality of the included studies, the British Medical Journal referees' checklist was used. About 3,844 COI analyses were initially found and 10 were finally considered in the current review: two studies referred to Beveridge and eight referred to Voluntary health insurance models. No studies have been conducted within a Bismarck model. Six studies considered in-patient costs, four studies estimated outpatient and primary care costs and seven studies considered pharmaceutical costs. The average quality of the included analyses was medium. The analysis confirmed the significance of CO related costs and the heterogeneity among available studies, which made it impossible to compare the different healthcare models.     

Adult-onset mitochondrial movement disorders: a national picture from the Italian Network

Journal of Neurology - Both prevalence and clinical features of the various movement disorders in adults with primary mitochondrial diseases are unknown. Based on the database of the...     

Medial unicompartmental knee arthroplasty in the ACL-deficient knee

Symptomatic osteoarthritis (OA) of the knee develops often in association with anterior cruciate ligament (ACL) deficiency. Two distinct pathologies should be recognised while considering treatment options in patients with end-stage medial compartment OA and ACL deficiency. Patients with primary ACL deficiency (usually traumatic ACL rupture) can develop secondary OA (typically presenting with symptoms of instability and pain) and these patients are typically young and active. Patients with primary end stage medial compartment OA can develop secondary ACL deficiency (usually degenerate ACL rupture) and these patients tend to be older. Treatment options in either of these patient groups include arthroscopic debridement, reconstruction of the ACL, high tibial osteotomy (HTO) with or without ACL reconstruction, unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). General opinion is that a functionally intact ACL is a fundamental prerequisite to perform a UKA. This is because previous reports showed higher failure rates when ACL was deficient, probably secondary to wear and tibial loosening. Nevertheless in some cases of ACL deficiency with end-stage medial compartment OA, UKA has been performed in isolation and recent papers confirm good short- to mid-term outcome without increased risk of implant failure. Shorter hospital stay, fewer blood transfusions, faster recovery and significantly lower risk of developing major complications like death, myocardial infarction, stroke, deep vein thrombosis (as compared to TKA) make the UKA an attractive option, especially in the older patients. On the other hand, younger patients with higher functional demands are likely to benefit from a simultaneous or staged ACL reconstruction in addition to UKA to regain knee stability. These procedures tend to be technically demanding. The main aim of this review was to provide a synopsis of the existing literature and outline an evidence-based treatment algorithm.