The Munich Shoulder Questionnaire (MSQ): development and validation of an effective patientreported tool for outcome measurement and patient safety in shoulder surgery

ABSTRACT: BACKGROUND: Outcome measurement in shoulder surgery is essential to evaluate the patient safety and treatment efficiency. Currently this is jeopardized by the fact that most patient-reported selfassessment instruments are not comparable. Hence, the aim was to develop a reliable selfassessment questionnaire which allows an easy follow-up of patients. The questionnaire also allows the calculation of 3 well established scoring systems, i.e. the Shoulder Pain and Disability Index (SPADI), the Constant-Murley Score (CMS), and the Disabilities of the Arm, Shoulder and Hand (DASH) Score. The subjective and objective items of these three systems were condensed into a single 30-questions form and validated against the original questionnaires. METHODS: A representative collective of patients of our shoulder clinic was asked to fill in the newly designed self-assessment Munich Shoulder Questionnaire (MSQ). At the same time, the established questionnaires for self-assessment of CONSTANT, SPADI and DASH scores were handed out. The obtained results were compared by linear regression analysis. RESULTS: Fifty one patients completed all questionnaires. The correlation coefficients of the results were r = 0.91 for the SPADI, r = -0.93 for the DASH and r = 0.94 for the CMS scoring system, respectively. CONCLUSIONS: We developed an instrument which allows a quantitative self-assessment of shoulder function. It provides compatible data sets for the three most popular shoulder function scoring systems by one single, short 30-item. This instrument can be used by shoulder surgeons to effectively monitor the outcome, safety and quality of their treatment and also compare the results to published data in the literature.     

Normalization of serum bile acids after partial external biliary diversion indicates an excellent long-term outcome in children with progressive familial intrahepatic cholestasis

Background/PurposeThe surgical treatment for patients with progressive familial intrahepatic cholestasis (PFIC) is either liver transplantation (LTX) or partial external biliary diversion (PEBD). Both procedures achieve a good short-term outcome. However, the treatment strategy for these children remains controversial because the long-term outcome after PEBD is unknown. The aim of our study was to assess the long-term outcome and complications after PEBD in our institution.MethodsWe retrospectively analyzed the characteristics of all patients with PFIC undergoing PEBD in our department from 1994 to 2008. The course of serum bile acids, pruritus, and liver enzymes was assessed in a regular follow-up.ResultsTwenty-four patients underwent PEBD. Thirteen patients (54%) improved significantly, with a normalization of serum bile acids (P < .001 vs postoperatively) and lessened pruritus (P < .05 vs preoperatively) at 12 months after PEBD. None of these patients showed progression of cholestasis during a median follow-up of 9.8 years (range, 1.6-14.3 years). Partial external biliary diversion failed to normalize bile acids in 11 patients, of whom 9 required secondary LTX at a 1-year follow-up, with a median interval of 1.9 years (range, 0.5-3.8 years). All 7 patients (100%) with liver cirrhosis at the time of PEBD and 2 of 17 patients without cirrhosis (12%) required secondary LTX (P < .001).ConclusionsClinical improvement with normalization of serum bile acids within 1 year was associated with an excellent long-term outcome in patients with PEBD. The presence of liver cirrhosis at the time of PEBD indicated an unfavorable outcome. Thus, we recommend primary LTX only in PFIC patients with liver cirrhosis.     

Distal radius fractures: current concepts

Despite the frequency of distal radius fractures, the optimal treatment remains without consensus opinion. A trend toward increased distal radius fracture open reduction and internal fixation has been identified, with biomechanical and clinical studies suggesting treatment advantages of certain fixation methods over others. Well-controlled patient trials are still missing to lend objective findings to management algorithms. This article reviews the literature over the past 5 years to guide our management regarding this common upper-extremity injury.     

A randomized,controlled study of fluid management in infants and toddlers during surgery: hydroxyethyl starch 6% (HES 70/0.5) vs lactated Ringer's solution

BACKGROUND: Volume replacement with hydroxyethyl starch (HES), a synthetic colloid, is widely accepted in adults, but only few data exist regarding its use in children. The aim of this study was to assess the effect of a low molecular weight HES solution (HES 70/0.5) compared with lactated Ringer's solution (LR) on haemoglobin levels as an indirect measure of plasma expansion in infants and toddlers, and its perioperative safety. METHODS: Sixty-four patients, aged 1-38 months, were allocated randomly to receive 20 ml x kg-1 body weight of either HES 70/0.5 or LR during the first hour of urological surgery lasting >2 h. Thereafter, only LR was infused to maintain haemodynamic stability. Intraoperative blood loss and administered fluid volumes were analysed. Haemoglobin levels were determined perioperatively and intraoperatively at completion of volume loading. Changes in body weight and the incidence of postoperative oedema were assessed 24 and 48 h after surgery. For the safety analysis, patients were monitored for 72 h. RESULTS: Intraoperative haemoglobin levels decreased significantly more with HES 70/0.5 (30 +/- 10 g.l-1) compared with LR (21 +/- 12 g.l-1) (P < 0.01). The overall administered fluid volumes during surgery did not differ between groups. The postoperative changes in body weight and incidence of postoperative oedema did not differ between groups. No anaphylactoid reactions, pruritus or adverse effects were observed during the study period. CONCLUSIONS: A larger decrease in haemoglobin levels in infants and toddlers after HES 70/0.5 (20 ml.kg-1) compared with LR indicates a more effective plasma expansion. HES might be considered as a volume expander in the paediatric population.     

RETRACTED ARTICLE: Volume replacement with HES 130/0.4 may reduce the inflammatory response in patients undergoing major abdominal surgery

PURPOSE: To investigate the effects of intravascular volume replacement therapy on the inflammatory response during major surgery. METHODS: Thirty-six patients scheduled for elective abdominal surgery were randomized to receive either 6% hydroxyethylstarch (130,000 Dalton mean molecular weight, degree of substitution 0.4; n = 18, HES-group) or lactated Ringer's solution (RL-group; n = 18) for intravascular volume replacement. Fluid therapy was given perioperatively and continued for 48 hr in the intensive care unit. Volume replacement was guided by physiological parameters. Serum concentrations of interleukin (IL)-6, IL-8 and IL-10 and soluble adhesion molecules (sELAM-1 and sICAM-1) were measured after induction of anesthesia, four hours after the end of surgery, as well as 24 hr and 48 hr postoperatively. RESULTS: Biometric and perioperative data, hemodynamics and oxygenation were similar between groups. On average, 4470 +/- 340 mL of HES 130/0.4 per patient were administered in the HES-group compared to 14310 +/- 750 mL of RL in the RL-group during the study period. Release of pro-inflammatory cytokines IL-6 and IL-8 was significantly lower in the HES-group [(peak values) 47.8 +/- 12.1 pg*dL(-1) of IL-6 and 35.8 +/- 11.2 pg*mL(-1) of IL-8 (HES-group) vs 61.2 +/- 11.2 pg*dL(-1) of IL-6 and 57.9 +/- 9.7 pg*mL(-1) of IL-8 (RL-group); P < 0.05]. Serum concentrations of sICAM-1 were significantly higher in the RL-group [(peak values) 1007 +/- 152 ng*mL(-1) (RL-group) vs 687 +/- 122 ng*mL(-1), (HES group); P < 0.05)]. Values of sELAM-1 were similar in both groups. CONCLUSION: Intravascular volume replacement with HES 130/0.4 may reduce the inflammatory response in patients undergoing major surgery compared to a crystalloid-based volume therapy. We hypothesize that this is most likely due to an improved microcirculation with reduced endothelial activation and less endothelial damage.     

Computer-aided detection of pulmonary embolism: Influence on radiologists’ detection performance with respect to vessel segments

The purpose was to assess the sensitivity of a CAD software prototype for the detection of pulmonary embolism in MDCT chest examinations with regard to vessel level and to assess the influence on radiologists' detection performance. Forty-three patients with suspected PE were included in this retrospective study. MDCT chest examinations with a standard PE protocol were acquired at a 16-slice MDCT. All patient data were read by three radiologists (R1, R2, R3), and all thrombi were marked. A CAD prototype software was applied to all datasets, and each finding of the software was analyzed with regard to vessel level. The standard of reference was assessed in a consensus read. Sensitivity for the radiologists and CAD software was assessed. Thirty-three patients were positive for PE, with a total of 215 thrombi. The mean overall sensitivity for the CAD software alone was 83% (specificity, 80%). Radiologist sensitivity was 77% = R3, 82% = R2, and R1 = 87%. With the aid of the CAD software, sensitivities increased to 98% (R1), 93% (R2), and 92% (R3) (p<0.0001). CAD performance at the lobar level was 87%, at the segmental 90% and at the subsegmental 77%. With the use of CAD for PE, the detection performance of radiologists can be improved.     

Structural basis of neurogenic bladder dysfunction. II. Myogenic basis of detrusor hyperreflexia

PURPOSE: We describe the ultrastructure of detrusor smooth muscle in long-standing neurogenic bladder dysfunction in the human. MATERIALS AND METHODS: Detrusor biopsies were obtained from (15 female and 31 male) patients 7 to 96 years old with neurogenic bladder dysfunction for less than 1 to 43 years. Of the patients 9 had meningomyelocele, 25 spinal cord injury and 12 brain disorder. Urodynamically, all patients had detrusor hyperreflexia (neurogenic detrusor overactivity) in addition to bladder outlet obstruction in 4, impaired detrusor contractility in 19, decreased bladder compliance in 4, and detrusor-sphincter dyssynergia in 24. Ultrastructural changes in detrusor, including those associated with detrusor overactivity, impaired detrusor contractility and bladder outlet obstruction, were evaluated qualitatively and quantitatively. RESULTS: Intermediate junctions of muscle cells were absent or reduced in 45 biopsies, which instead had dominant intimate cell appositions with much narrower junctional gaps. A greater than 2 intimate cell apposition-to-intermediate junction ratio was present in 45 biopsies (98%), and intimate cell apposition linked chains of 5 muscle cells or greater in all biopsies (100%). Muscle cell degeneration was observed in 34 biopsies from 20 of 27 patients (74%) with normal contractility and 14 of 19 (74%) with impaired detrusor contractility. No particular changes were associated with functional bladder outlet obstruction due to detrusor-sphincter dyssynergia. CONCLUSIONS: The ultrastructural complete dysjunction pattern is a feature of hyperreflexia as well as nonneuropathic detrusor overactivity of various etiology. A greater than 2 intimate cell apposition-to-intermediate junction ratio had 98% sensitivity but its specificity remains to be determined. The lack of relationship between muscle cell degeneration and detrusor contractility probably reflects limitations of urodynamic measurement of contractility in patients with spinal cord injury and meningomyelocele.     

Intra-articular ganglion cysts of the cruciate ligaments: case report and review of the literature

BACKGROUND: A ganglion can arise as a cystic lesion from a tendon sheath or a joint capsule and contain a glassy, clear, and jelly-like fluid. They can occur within muscles, menisci, and tendons. Intra-articular ganglion cysts of the knee joint are rare. We report on three ganglion cysts of the cruciate ligaments: Two were intercruciate, and one was located around the posterior cruciate ligament. METHODS: The clinical diagnosis was established using magnetic resonance imaging. All patients were treated successfully using arthroscopic debridement by basket punch and shaver. Subsequent histological examination confirmed the diagnosis. RESULTS: All three patients were asymptomatic at the postoperative follow-up of 16-36 months. CONCLUSION: A review of the literature reveals a controversial discussion about the clinical significance as well as the etiology of ganglion cysts arising from the cruciate ligaments. These case reports show that an intra-articular ganglion cyst of the cruciate ligaments is difficult to diagnose. A cyst does not necessarily have to be associated with specific clinical symptoms or a previous trauma. Preoperatively, MRI is essential when diagnosing ganglion cysts of the knee joint. An intra-articular ganglion cyst of the knee joint can be successfully treated by arthroscopy.     

Skin tuberculosis with atypical mycobacteria 8 years after combined pancreas-kidney transplantation

We report on a Mycobacterium marinum infection in a diabetic woman 8 years after undergoing a combined pancreas-kidney transplantation. This is, to our knowledge, the first case report on an isolated skin infection with atypical mycobacteria after simultaneous pancreas-kidney transplantation. A genetic probe categorization revealed an infection with M. marinum. Skin tuberculosis caused by M. marinum is an uncommon complication in kidney or pancreas-kidney transplant recipients, hence the diagnosis can be delayed.     

Use of diffusion-weighted magnetic resonance imaging in differentiating purulent brain processes from cystic brain tumors

OBJECT: Brain abscesses and other purulent brain processes represent potentially life-threatening conditions for which immediate correct diagnosis is necessary to administer treatment. Distinguishing between cystic brain tumors and abscesses is often difficult using conventional imaging methods. The authors' goal was to study the ability of diffusion-weighted (DW) magnetic resonance (MR) imaging to differentiate between these two pathologies in patients within the clinical setting. METHODS: Diffusion-weighted MR imaging studies and calculation of the apparent diffusion coefficient (ADC) values were completed in a consecutive series of 16 patients harboring surgically verified purulent brain processes. This study group included 11 patients with brain abscess (one patient had an additional subdural hematoma and another also had ventriculitis), two with subdural empyema, two with septic embolic disease, and one patient with ventriculitis. Data from these patients were compared with similar data obtained in 16 patients matched for age and sex, who harbored surgically verified neoplastic cystic brain tumors. In patients with brain abscess, subdural empyema, septic emboli, and ventriculitis, these lesions appeared hyperintense on DW MR images, whereas in patients with tumor, the lesion was visualized as a hypointense area. The ADC values calculated in patients with brain infections (mean 0.68 x 10(3) mm2/sec) were significantly lower than those measured in patients with neoplastic lesions (mean 1.63 x 10(3) mm2/sec; p < 0.05). CONCLUSIONS: Diffusion-weighted MR imaging can be used to identify infectious brain lesions and can help to differentiate between brain abscess and cystic brain tumor, thus making it a strong additional imaging modality in the early diagnosis of central nervous system purulent brain processes.