Autologous chondrocyte transplantation for osteochondritis dissecans of the talus

Eight patients with osteochondritis dissecans of the talus were reviewed. The average followup was 17.6 months (range, 8-26 months). The mean age of the patients was 31.8 years (range, 22-42 years). All patients had a preoperative examination, magnetic resonance imaging, and radiologic classification of the lesion through regular anteroposterior and lateral radiographs. Diagnostic arthroscopy and biopsies of healthy cartilage were done, which then had chondrocyte extraction and culture. After an average of 2.5 weeks, an arthrotomy, malleolar osteotomy, subchondral bone sclerosis debridement, and autologous chondrocyte transplantation were done. The postoperative treatment included nonweightbearing for 6 to 7 weeks, physiotherapy, and continuous passive motion. According to the postoperative evaluation score, all results were excellent to good with an average score of 0.6. No complications occurred. The arthroscopic reexamination of three patients at the sixth postoperative month and the radiologic evaluation of all patients showed the existence of cartilagelike tissue with complete coverage of the chondral defect. This method enables reconstructive intervention for unicompartmental defects of articular cartilage through implantation of new chondrocytes, establishment of a subchondral blood supply, and reconstruction of the articular surface.     

Orthopaedic surgery residency: comparison between the German and the North American system

AIM: On the way to the unification of the European Union (EU), Germany has passed a new medical professional education system at the 106 (th) German medical board in Cologne in 2003. The medical board has established a new residency programme for the specialty of orthopaedic surgery, which was previously separated into orthopaedic and trauma surgery. An exchange of orthopaedic surgeons within the EU is therefore less complicated. For an exchange outside the EU, an international comparison especially with the USA is warranted. METHOD: We analysed and compared the German "Assistenzarzt System" with the residency programme of the USA regarding the specialty of orthopaedic surgery and further sub-specialisation programmes. RESULTS: After evaluation of both systems, a high conformity in the basic training for orthopaedic surgery was demonstrated. However, there is a difference between the two systems regarding specialisation after residency training with the German "Oberarzt" on the one side and the American fellow system on the other side. CONCLUSION: This study demonstrates that the German orthopaedic training matches well with the American residency programs. There is potential for acknowledgement of the German title "Orthopaedic surgeon" in the USA. In some states, such as Pennsylvania, European medical specialists are given institutionally restricted work permission for limited periods of time. It remains, however, questionable if there is a general political intent for the USA to acknowledge German or European residency programs.     

Evaluation of a fast‐track programme for patients undergoing liver resection

Background:

Recent developments in perioperative pathophysiology and care have documented evidence‐based, multimodal rehabilitation (fast‐track) to hasten recovery and to decrease morbidity and hospital stay for several major surgical procedures. The aim of this study was to investigate the effect of introducing fast‐track principles for perioperative care in unselected patients undergoing open or laparoscopic liver resection.

Methods:

This was a prospective study involving the first 100 consecutive patients who followed fast‐track principles for liver resection. Catheters and drains were systematically removed early, and patients were mobilized and started eating and drinking from the day of surgery. An opioid‐sparing multimodal pain treatment was given for the first week. Discharge criteria were: pain sufficiently controlled by oral analgesics alone, patient comfortable with discharge and no untreated complications.

Results:

Median length of stay (LOS) for all patients was 5 days, with 2 days after laparoscopic versus 5 days following open resection (P < 0·001). Median LOS after minor open resections (fewer than 3 segments) was 5 days versus 6 days for major resections (3 or more segments) (P < 0·001). Simple right or left hemihepatectomies had a median LOS of 5 days. The readmission rate was 6·0 per cent and 30‐day mortality was zero.

Conclusion:

Fast‐track principles for perioperative care were introduced successfully and are safe after liver resection. Routine discharge 2 days after laparoscopic resection and 4–5 days after open liver resection may be feasible. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Relationship of the clinical response and binding of recombinant interferon alpha in patients with lymphoproliferative diseases

Patients with hairy cell leukemia (HCL) and chronic lymphocytic leukemia (CLL) were treated with recombinant interferon alpha A (rIFN- alpha A). The binding of iodinated recombinant interferon-alpha to baseline samples of peripheral blood mononuclear cells (PBMCs) from the leukemia patients was compared with clinical responsiveness to rIFN- alpha A. HCL patients (8/10) responded to rIFN-alpha A therapy, whereas none (0/10) of the CLL patients studied responded. The PBMCs from the eight responsive HCL patients bound approximately twice as much iodinated interferon as the PBMCs from nonresponsive CLL patients. This difference was due to more high-affinity receptors per cell with no difference in the affinity of the interferon-receptor interaction. However, because PBMCs from HCL patients were larger than PBMCs from CLL patients, the cell surface receptor density was similar. The leukemic cells from one of the two nonresponsive HCL patients bound iodinated interferon similarly to the cells from the responsive HCL patients, whereas the leukemic cells from the other nonresponsive HCL patient bound considerably less. The rapidity of response of the HCL patients did not correlate with the level of binding of iodinated interferon. Our results suggest that the absolute number of interferon receptors per cell may be only one of several important parameters in the response to rIFN-alpha A therapy, and that the responsiveness of a particular lymphoproliferative disease or a particular patient to rIFN- alpha A therapy cannot be predicted or explained solely by the degree of interaction between IFN and its cell surface receptor.     

Prevention of urethral stricture formation after transurethral resection of the prostate: a controlled randomized study of Otis urethrotomy versus urethral dilation and the use of the polytetrafluoroethylene coated versus the uninsulated metal sheath

Stricture formation after transurethral prostatectomy was studied in a randomized clinical trial including 185 patients. The patients were allocated to either a 2-day urethral catheter-dilation or internal Otis urethrotomy and to an operation with either a polytetrafluoroethylene coated or an uninsulated metal resectoscope. Urethral stricture was defined as an obstruction resulting in a maximum urine flow rate of less than 15 ml. per second and not permitting the passage of a 21F cystoscope. The frequency of urethral strictures was significantly lower after Otis internal urethrotomy (4 per cent) than after a 2-day urethral catheter dilation (16 per cent). The incidence of stricture formation was similar in patients operated on with a polytetrafluoroethylene coated (8 per cent) and with an uninsulated metal (12 per cent) resectoscope sheath. The incidence of stricture formation was unrelated to age, duration of preoperative and postoperative catheterization, operating time and presence of urinary tract infection.     

Loads on the lumbar trunk during level walking

The goal of this study was to estimate the loads internal to the lumbar trunk that arise during level walking. To do this, (a) trunk muscle activities were calibrated in terms of muscle contraction force levels in a set of isometric exertions; (b) trunk muscle myoelectric activities were measured during level walking; and then (c) the muscle contraction forces that arose during walking were calculated from these measurements and calibrations. Lumbar trunk muscle myoelectric activities were quantified in 10 healthy young males. Myoelectric activities were monitored using eight bipolar surface electrode pairs placed around the trunk at the level of the third lumbar vertebrae. The subjects first performed four static weight-resisting tasks to calibrate muscle force/activity relationships. They then traversed a 8.25 m walkway three times each at cadences of 72 and 120 steps/min. A biomechanical model incorporating 22 lumbar trunk muscles was used to predict muscle contraction forces for the calibration tasks. Predicted forces were linearly correlated with the measured myoelectric activities for these tasks. The regression equations were then interpolated to estimate the muscle contraction forces from the myoelectric data during gait. Peak contraction forces for the iliocostalis muscles were calculated to be approximately 55 N per side, corresponding to total erector spinae peak contractions on the order of 140 N per side. For the other six muscles that were monitored, contraction forces were less than 15 N per side. This suggests that peak net reaction moments and peak spine compressions on the lumbar trunk during these walking tasks were on the order of 15 Nm and 1.2 times body weight, respectively.     

Plasma sRAGE is independently associated with increased mortality in ARDS: a meta-analysis of individual patient data

Purpose

The soluble receptor for advanced glycation end-products (sRAGE) is a marker of lung epithelial injury and alveolar fluid clearance (AFC), with promising values for assessing prognosis and lung injury severity in acute respiratory distress syndrome (ARDS). Because AFC is impaired in most patients with ARDS and is associated with higher mortality, we hypothesized that baseline plasma sRAGE would predict mortality, independently of two key mediators of ventilator-induced lung injury.

Methods

We conducted a meta-analysis of individual data from 746 patients enrolled in eight prospective randomized and observational studies in which plasma sRAGE was measured in ARDS articles published through March 2016. The primary outcome was 90-day mortality. Using multivariate and mediation analyses, we tested the association between baseline plasma sRAGE and mortality, independently of driving pressure and tidal volume.

Results

Higher baseline plasma sRAGE [odds ratio (OR) for each one-log increment, 1.18; 95% confidence interval (CI) 1.01–1.38; P?=?0.04], driving pressure (OR for each one-point increment, 1.04; 95% CI 1.02–1.07; P?=?0.002), and tidal volume (OR for each one-log increment, 1.98; 95% CI 1.07–3.64; P?=?0.03) were independently associated with higher 90-day mortality in multivariate analysis. Baseline plasma sRAGE mediated a small fraction of the effect of higher ΔP on mortality but not that of higher V_T.

Conclusions

Higher baseline plasma sRAGE was associated with higher 90-day mortality in patients with ARDS, independently of driving pressure and tidal volume, thus reinforcing the likely contribution of alveolar epithelial injury as an important prognostic factor in ARDS. Registration: PROSPERO (ID: CRD42018100241).

     

Prevalence of screening in patients newly diagnosed with colorectal cancer in Ontario.

OBJECTIVES: The primary objective was to determine the proportion of individuals with a new diagnosis of colorectal cancer (CRC) in Ontario in whom the cancer was screen detected. The secondary objectives were to determine the cancer stage at diagnosis and the indications for the procedure in patients who received their first colonoscopy. PATIENTS AND METHODS: Individuals admitted to a hospital with a new diagnosis of CRC were randomly selected after stratifying by hospital type (teaching or community). The Canadian Institute for Health Information's Discharge Abstract Database was used to identify individuals with a first diagnosis of CRC during calendar year (CY) 2000, and Ontario Health Insurance Plan data were used to identify people 50 to 74 years of age who had their first colonoscopy during CY 2000. Up to 20 individuals were selected for each group (CRC or colonoscopy) in each of seven randomly selected community hospitals and three randomly selected teaching hospitals. Data were abstracted from the hospital charts. RESULTS: The hospital charts of 152 patients with a new diagnosis of CRC were examined. Of the 133 patients in whom screening status could be determined, eight had screen-detected cancers (6.0%). Of the 99 patients (65% of the sample) in whom stage could be determined, 43 (43.4%) had advanced disease (tumour-node-metastasis stage III or IV) at diagnosis. The hospital charts of 184 patients who underwent their first colonoscopy were examined. Of the 175 patients in whom the indication for colonoscopy could be determined, 45 underwent the procedure for screening purposes, 10 were for diagnostic workup of anemia and 120 for evaluation of symptoms. CONCLUSIONS: The low proportion (6%) of screen-detected CRC and the high proportion of patients (43.4%) with advanced disease at diagnosis reflect the lack of an organized screening program.