Contributions of myofascial pain in diagnosis and treatment of shoulder pain. A randomized control trial

Background  

Rotator cuff tendinopathy and subacromial impingement syndrome present complex patomechanical situations, frequent difficulties in clinical diagnosis and lack of effectiveness in treatment. Based on clinical experience, we have therefore considered the existence of another pathological entity as the possible origin of pain and dysfunction. The hypothesis of this study is to relate subacromial impingement syndrome (SIS) with myofascial pain syndrome (MPS), since myofascial trigger points (MTrPs) cause pain, functional limitation, lack of coordination and alterations in quality of movement, even prior to a tendinopathy. MTrPs can coexist with any degenerative subacromial condition. If they are not taken into consideration, they could perpetuate and aggravate the problem, hindering diagnosis and making the applied treatments ineffective.     

Estudio epidemiológico de la anemia preoperatoria en pacientes sometidos a cirugía oncológica en España. Estudio RECIRON

Introduction

Anaemia is common in oncology patients who are going to have surgery for tumour resection. Allogenic blood transfusion has been associated with a greater incidence of postoperative complications. The aim of this study is to analyse current clinical practice as regards the preoperative treatment and conditions of these patients in Spain.

Material and method

This is an epidemiological observational study which included 472 patients from different hospitals. The data included in the clinical history was analysed: tumour location, preoperative laboratory tests, functional situation (Karnofsky index [KI]), anaemia treatment and transfusions given since the diagnosis.

Results

As regards the tumour location, 181 were urological (38.3%), 161 digestive system (34.1%), and 130 gynaecological (27.5%). The time from the initial diagnosis until surgical intervention was 6.2±6 weeks, and 19.1±23 days from the anaesthetist visit to the surgical operation. The mean pre-operative haemoglobin (Hb) was 13.1±2 g/dl. The anaemia was treated in 12.9% of the patients and 15% (69 patients) received a transfusion before surgery. A total of 28.1% patients had a KI≤80. The lowest preoperative haemoglobin levels are associated with the lowest KI.

Conclusions

Anaemia is present in a high percentage of oncology patients who are going to be surgically treated. Preoperative blood transfusion is the most common treatment. It was observed that there is sufficient preoperative time to be able to improve preparation of the patient for surgery.     

Obese Patients Have Inadequate Protein Intake Related to Protein Intolerance Up to 1 Year Following Roux-en-Y Gastric Bypass

Background: Inadequate protein intake is a concern following Roux-en-Y gastric bypass (RYGBP). The small gastric pouch and bypass restrict energy intake and may lead to insufficient protein intake and absorption, and excess loss of lean tissue. Methods:We evaluated protein intake in 93 (77 F,16 M) morbidly obese individuals (BMI = 52.0±12.9 [SD]) who underwent RYGBP at our medical center. Participants completed 24-hr food recalls and received nutritional counseling at 3, 6, and 12 months following surgery. Results: Daily energy intake (kcal/day) increased from 849±329 (SD) at 3 months to 1,101±400 at 12 months (P=.009). Protein intake also increased (g/day) from 45.6±14.2 at 3 months to 58.5±17.1 at 12 months (P=.04), and as a percentage of goal protein intake from 55.1%±23.0 at 3 months to 73.5%±38.0 at 12 months (P=.02). Although energy and protein intake increased significantly over the 12-month period, protein intake at 12 months remained significantly lower (P=.01) than the daily recommended guidelines (1.5 g/kg IBW) for a low-energy restrictive diet. Energy intake did not differ in those who reported food intolerances at 3 months (P=.77) or 6 months (P=.65), but was lower in them at 12 months (trend, P=.06). Also at 12 months, protein intake (P=.02) and percentage of protein intake goal (P=.04) were significantly lower in those with protein intolerance. Conclusions: These results suggest that postoperative patients consume insufficient amounts of protein, possibly mediated by protein intolerance. Protein supplementation following RYGBP deserves further consideration.     

Blunt traumatic aortic transection: the endovascular experience

BACKGROUND: Thoracic aortic transection resulting from blunt trauma is usually fatal. It is almost always associated with multiple, complex, nonaortic injuries that could be adversely affected by standard surgical repair of the aorta. Endovascular stenting techniques offer these patients a less physiologically disruptive treatment option. We studied the feasibility and safety of endovascular stent graft placement for treatment of acute traumatic aortic transection. METHODS: Between 1994 and 2001, 9 patients were treated emergently for aortic transections with stent graft placement. The first patient had a custom-made prototype, and the other 8 patients had the Cook-Zenith thoracic stent graft implanted. All were polyester-covered Z-stent construction and deployed through a femoral 20- to 24-F delivery sheath. RESULTS: Stent graft placement successfully sealed the aorta in all patients. One patient died as a result of a cerebrovascular accident. One patient required a brachial thrombectomy to relieve arm ischemia. The remaining eight patients were alive and without complications during the follow-up period (mean 21 months). CONCLUSIONS: Endovascular repair for acute aortic transection is a safe, effective, and timely treatment option. It may be the treatment of choice in patients with extensive associated injuries.     

Radiology resident interpretations of on-call imaging studies: the incidence of major discrepancies

RATIONALE AND OBJECTIVES: To determine the incidence of radiology resident preliminary interpretation errors for plain film, body computed tomography, and neuroradiology (neuro)computed tomographic examinations read on call. MATERIALS AND METHODS: We retrospectively reviewed the data in a prospectively acquired resident quality assurance (QA) database dating between January 2000 and March 2007. The database comprises all imaging studies initially interpreted by an on-call resident and later reviewed by a board-certified attending radiologist who determined the level of discrepancy between the two interpretations according to a graded scale from 0 (no discrepancy) to 3 (major discrepancy). We reviewed the data with respect to resident training level, imaging modality, and variance level. Statistical analysis was performed with chi(2) test, alpha = 0.05. We compared our results with other published series studying resident and attending accuracy. RESULTS: A total of 141,381 cases were entered into the database during the review period. Of all examinations, 95.7% had zero variance, 3.3% minor variance, and 1.0% major variance. There was a slight, statistically significant increase in overall accuracy with increased resident year from 95.4% of examinations read by first-year residents (R1s) to 96.1% by fourth-year resident (R4s) (P < .0001). Overall percentages of exams with major discrepancies were 1.0% for R1s, 1.1% for second-year residents, 1.0% for third-year residents, and 0.98% for R4s. CONCLUSIONS: The majority of preliminary resident interpretations are highly accurate. The incidence of major discrepancies is extremely low and similar, even with R1s, to that of attending radiologists published in other studies. A slight, statistically significant decrease in the error rate is detectable as residents gain experience throughout the 4 years of residency.     

Endovascular stent graft repair of abdominal and thoracic aortic aneurysms: a ten-year experience with 817 patients

OBJECTIVE: On November 23, 1992, the first endovascular stent graft (ESG) repair of an aortic aneurysm was performed in North America. Following the treatment of this patient, we have continued to evaluate ESG over the past 10 years in the treatment of 817 patients. SUMMARY AND BACKGROUND DATA: Abdominal (AAA) or thoracic (TAA) aortic aneurysms are a significant health concern traditionally treated by open surgical repair. ESG therapy may offer protection from aneurysm rupture with a reduction in procedure morbidity and mortality. METHODS: Over a 10-year period, 817 patients were treated with ESGs for AAA (723) or TAA (94). Patients received 1 of 12 different stent graft devices. Technical and clinical success of ESGs was reviewed, and the incidence of procedure-related complications was analyzed. RESULTS: The mean age was 74.3 years (range, 25-95 years); 678 patients (83%) were men; 86% had 2 or more comorbid medical illnesses, 67% of which included coronary artery disease. Technical success, on an intent-to-treat basis was achieved in 93.8% of patients. Primary clinical success, which included freedom from aneurysm-related death, type I or III endoleak, graft infection or thrombosis, rupture, or conversion to open repair was 65 +/- 6% at 8 years. Of great importance, freedom from aneurysm rupture after ESG insertion was 98 +/- 1% at 9 years. There was a 2.3% incidence of perioperative mortality. One hundred seventy five patients died of causes not related to their aneurysm during a mean follow-up of 15.4 months. CONCLUSIONS: Stent graft therapy for aortic aneurysms is a valuable alternative to open aortic repair, especially in older sicker patients with large aneurysms. Continued device improvements coupled with an enhanced understanding of the important role of aortic pathology in determining therapeutic success will eventually permit ESGs to be a more durable treatment of aortic aneurysms.     

Burden of blood transmitted infections in substance users admitted for inpatient treatment in Singapore and the associated factors

INTRODUCTION

There is a paucity of local data on the prevalence of blood transmitted infections (BTIs), such as hepatitis B, hepatitis C and human immunodeficiency virus (HIV) infections, among illicit drug users. This study aimed to examine the prevalence of BTIs among substance-dependent inpatients and identify the factors associated with BTIs.

METHODS

We conducted a retrospective case note analysis of 170 inpatients who had a history of substance dependence and were seen at the National Addictions Management Service, Singapore, between 1 June 2009 and 31 May 2010.

RESULTS

The majority of the 170 inpatients were male (88.2%) and Chinese (58.2%). The mean age of the patients was 43.1 years, and the main drug of abuse was opioids (86.5%). BTIs were found in 70 (41.2%) inpatients; the prevalence of hepatitis B, hepatitis C and HIV infections was 3.7%, 39.6% and 0%, respectively. Lifetime intravenous drug use, but not needle-sharing, was more common among inpatients who were positive for BTIs (p < 0.01). Logistic regression analysis showed that lifetime intravenous drug use (OR 4.3, 95% CI 1.7–10.8, p < 0.01) was the only significant predictor of BTI.

CONCLUSION

41.2% of the substance users seeking help were positive for at least one BTI. Lifetime intravenous drug users were found to be more than four times more likely to have a BTI. Early detection and prevention is essential to improve prognosis.     

www.Accurate Information for Varicose Vein patients.com?

INTRODUCTION

The aim of this study was to review the information available to the public regarding the treatment of varicose veins on dedicated UK-based websites.

PATIENTS AND METHODS

Websites were identified by using the Google® search engine. All identified websites were examined, noting the range of treatments explained and their stated potential complications. Website ownership was also recorded.

RESULTS

A total of 49 websites were identified, belonging to individual physicians (21), private clinics or groups (15), national institutions (4) and device/drug manufacturers (4). Five websites were simply redirecting portals and, hence, were excluded from further analysis. Treatment methods discussed were conventional surgery (32), endovenous laser [EVLA] and/or radiofrequency ablation [RFA] (31), and ultrasound-guided foam sclerotherapy [UGFS] (27). Only 19 websites (43%) discussed all treatment methods. Complications mentioned following surgery were: cutaneous nerve damage (56%), recurrence (56%), infection (53%), bleeding (41%) and venous thrombo-embolism (38%). Complications following EVLA/RFA were: cutaneous nerve damage (42%), recurrence (42%), venous thrombo-embolism (39%) and burns (35%). Complications following UGFS were: pigmentation (59%), venous thrombo-embolism (48%), ulceration (41%), recurrence (41%), allergy (26%) and visual disturbance (26%).

CONCLUSIONS

Over 50% of the websites examined did not mention all the management methods now available for varicose veins. More importantly, the majority of the websites did not warn of the common complications of intervention. Currently, information on the Internet cannot be relied upon to supplement informed consent and may actually generate unrealistic patient expectations.     

Risk factors for surgical site infection after major breast operation

BACKGROUND: Understanding surgical site infection (SSI) risk factors after breast operation is essential to develop infection-prevention strategies and improve surgical outcomes. METHODS: We performed a retrospective case-control study with subjects selected from a cohort of mastectomy, breast reconstruction, and reduction surgical patients between January 1998 and June 2002 at a university-affiliated hospital. SSI cases within 1 year after operation were identified using ICD-9-CM diagnosis codes for wound infection and complication or positive wound cultures, or both. Medical records of 57 patients with breast SSI and 268 randomly selected uninfected control patients were reviewed. Multivariate logistic regression was used to identify independent risk factors for SSI. RESULTS: Significant independent risk factors for breast incisional SSI included insertion of a breast implant or tissue expander (odds ratio [OR] = 5.3; 95% CI, 2.5 to 11.1), suboptimal prophylactic antibiotic dosing (OR = 5.1; 95% CI, 2.5 to 10.2), transfusion (OR = 3.4; 95% CI, 1.3 to 9.0), mastectomy (OR = 3.3; 95% CI, 1.4 to 7.7), previous chest irradiation (OR = 2.8; 95% CI, 1.2 to 6.5), and current or recent smoking (OR = 2.1; 95% CI, 0.9 to 4.9). Local infiltration of an anesthetic agent was associated with substantially reduced odds of SSI (OR = 0.4; 95% CI, 0.1 to 0.9). CONCLUSIONS: Suboptimal prophylactic antibiotic dosing is a potentially modifiable risk factor for SSI after breast operation. SSI risk was increased in patients undergoing mastectomy and in patients who had an implant or tissue expander placed during operation. This information can be used to develop a specific risk stratification index to predict SSI and infection-preventive strategies tailored for breast surgery patients.     

Mechanism of vascular smooth muscle cells activation by hydrogen peroxide: role of phospholipase C gamma.

BACKGROUND: Hydrogen peroxide (H2O2) formation is a critical factor in processes involving ischaemia/ reperfusion. However, the precise mechanism by which reactive oxygen species (ROS) induce vascular damage are insufficiently known. Specifically, activation of phospholipase C gamma (PLCgamma) is a probable candidate pathway involved in vascular smooth muscle cells (VSMC) activation by H2O2. METHODS: The activation of human venous VSMC was measured as cytosolic free calcium mobilization, shape change and protein phosphorylation, focusing on the role of tyrosine phosphorylation-activated PLCgamma. RESULTS: The exposure of VSMC to exogenous H2O2 caused a rapid increase in cytosolic free calcium concentration ([Ca2+]i), and induced a significant VSMC shape change. Both effects were dependent on a tyrosine kinase-mediated mechanism, as determined by the blockade of short-term treatment of VSMC with the protein tyrosine kinase inhibitor, genistein. Giving further support to the putative role of phospholipase C (PLC)-dependent pathways, the [Ca2+]i and VSMC shape change response were equally inhibited by the specific PLC blocker, 1-(6-((17-beta-methoxyestra-1,3,5(10)trien-17-yl)amino)hexyl)-1H-pyrrole-2,5-dione (U73122). In addition, U73122 had a protective effect against the deleterious action (24 h) of H2O2 on non-confluent VSMC. As a further clarification of the specific pathway involved, the exposure to H2O2 significantly stimulated the tyrosine phosphorylation of PLCgamma with a concentration- and time-profile similar to that of [Ca(2+)](i) mobilization. CONCLUSIONS: The present study reveals that H(2)O(2) activates PLCgamma on VSMC through tyrosine phosphorylation and that this activation has a major role in rapid [Ca(2+)](i) mobilization, shape-changing actions and damage by H(2)O(2) in this type of cells. These findings have direct implications for understanding the mechanisms of the vascular actions of H(2)O(2) and may help to design pharmacologically protective strategies.