General short-term indomethacin prophylaxis to prevent heterotopic ossification in total hip arthroplasty

This prospective study evaluated heterotopic ossification prophylaxis with indomethacin for 14 days in 201 consecutive patients undergoing total hip arthroplasty. Ranitidine was administered concurrently to alleviate gastrointestinal side effects. None of the patients with mild gastrointestinal side effects (12%) had to suspend the prophylaxis, and no major postoperative bleeding or gastrointestinal ulcers were observed. After 12 months of follow-up, 67% of patients had no evidence of heterotopic ossification, 32% percent had grades I and 1% had grade III without clinical significance, and 0% had grade IV ossification according to Brooker's classification. These results indicate that short-term indomethacin prophylaxis is an effective, inexpensive, and easily administrated alternative to single-dose radiotherapy for nearly all patients undergoing THA.     

Effects of alprazolam on cholecystokinin-tetrapeptide-induced panic and hypothalamic-pituitary-adrenal-axis activity: a placebo-controlled study.

Cholecystokinin-tetrapeptide (CCK-4) induces panic attacks both in patients with panic disorder (PD) and healthy volunteers. It has been shown that panic elicited by CCK-4 is improved after treatment with antidepressants. Moreover, a reduction of CCK-4-induced panic has also been demonstrated after treatment with lorazepam in single subjects and after selective GABAergic treatment with vigabatrin. Although benzodiazepines are widely used as anxiolytics, no controlled study on the effects of benzodiazepines on CCK-4-induced panic symptoms is available so far. Therefore, we investigated the effects of alprazolam and placebo on CCK-4-induced panic symptoms in a double-blind, placebo-controlled study. A total of 30 healthy subjects were challenged with 50 microg CCK-4. Out of these 30 subjects, 26 showed a marked panic response to CCK-4. Subjects were rechallenged after a 7-day interval and treated with 1 mg alprazolam or placebo 1 h prior to the second CCK-4 challenge. Panic was assessed using the acute panic inventory (API) and a DSM-IV-derived panic symptom scale (PSS). Moreover, the number of reported symptoms and self-rated anxiety and arousal were recorded. We found a significant reduction of the API and PSS scores and of the number of reported symptoms compared to placebo. Moreover, compared to placebo the CCK-4-induced ACTH and cortisol release were significantly attenuated during the CCK-4 challenge after alprazolam treatment. However, also placebo treatment reduced CCK-4-induced anxiety and HPA-axis activation to a certain extent. In conclusion, our data show that alprazolam reduces CCK-4-induced panic, which supports the hypothesis of a possible interaction between the GABA and the CCK system.     

The chevron osteotomy for correction of hallux valgus. Comparison of findings after two and five years of follow-up

BACKGROUND: The chevron osteotomy, an accepted method for the correction of mild and moderate hallux valgus, is generally advocated for patients younger than the age of fifty years. The purposes of this prospective study were to compare the short-term (two-year) and intermediate-term (five-year) results of this operation with respect to patient satisfaction, flexion and extension of the metatarsophalangeal joint, maintenance of correction, and development of arthrosis and to determine whether the effectiveness of the procedure was limited by age. METHODS: Between April 1991 and September 1992, the chevron osteotomy was performed for the treatment of mild-to-moderate hallux valgus deformity in sixty-six consecutive feet. Forty-three patients (fifty-seven feet) were available for follow-up at both two and five years postoperatively. The two-year and five-year clinical assessments were based on the American Orthopaedic Foot and Ankle Society's hallux-metatarsophalangeal-interphalangeal scale. RESULTS: Between the two-year and five-year follow-up evaluations, there was only a minimal change in overall patient satisfaction, and the average score on the hallux-metatarsophalangeal-interphalangeal scale was unchanged. The passive range of motion of the first metatarsophalangeal joint decreased between the preoperative assessment and the two-year follow-up evaluation and was unchanged at the five-year follow-up evaluation. Radiographic evaluation showed no changes in the hallux valgus or intermetatarsal angle between the two-year and five-year evaluations, although the number of feet with arthrosis of the metatarsophalangeal joint increased slightly, from eight to eleven. Patients aged fifty years or older did as well as younger patients. CONCLUSIONS: At these two follow-up periods, the chevron osteotomy was found to be a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age.     

The rare malformation of nasal aplasia]

BACKGROUND: After presenting two sisters with the rare form of congenital arrhinia, this syndrome is reviewed, an explanation of the pathogenesis is offered and the therapeutic options of the functional and aesthetic reconstruction are discussed. DISCUSSION: In cases of congenital arrhinia different degrees of respiratory distress, cyanotic episodes, and impaired food intake are described. Therefore after birth respiration and food intake need to be monitored to alleviate the situation through intubation or tracheotomy. The following conclusions could be made based on the literature overview. Little is known about the pathophysiology and a great variety of therapeutic interventions and reconstruction solutions with a wide spectrum of complications are described. Due to the numerous forms of complications, which need to be compared with the reconstructive results, indications for surgical reconstruction of the airway and plastic reconstruction of the nose during childhood must be defined very stringently. CONCLUSION: One method to achieve a satisfactory plastic result is with an osseointegrated prosthesis. This facial prosthesis can be inserted without complications and can guarantee an adequate result, whereas no impairment of maxillofacial development was noted.     

Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons

Because malunion (usually with dorsal elevation of the first metatarsal) has been reported after the treatment of severe hallux valgus deformities by proximal osteotomies, the current study was designed to compare the sagittal stability of six different metatarsal shaft osteotomies: the proximal crescentic, proximal chevron, Mau, Scarf, Ludloff, and biplanar closing wedge osteotomies. A plate was used in the biplanar closing wedge osteotomy; all others used screws for fixation. Ten fresh-frozen, human anatomic lower extremity specimens were used for each osteotomy. Failure loads were measured as units of force (newtons) and converted to pressure (kilopascals). Then the F-Scan system, which uses a thin insole to measure plantar pressure, was used to evaluate the pressure under the first metatarsal of seven volunteers using four types of shoes. According to the results, in patients with normal bone stock who are compliant, any of the four shoe types tested may be used after a Ludloff, Scarf, biplanar wedge (plantar screw fixation), or Mau osteotomy, but the wedge-based shoe should be used after a proximal crescentic or chevron osteotomy or for patients with severe osteopenic bone.     

Endoscopy in Barrett's oesophagus: adherence to standards and neoplasia detection in the community practice versus hospital setting

Objective. Potential process differences between hospital and community‐based endoscopy for Barrett’s oesophagus have not been examined. We aimed at comparing adherence to guidelines and neoplasia detection rates in medical centres (MC) and community practices (CP). Design. Retrospective analysis. Setting. All histologically confirmed Barrett cases seen over a 3‐year period in six MC and 19 CP covering a third of all upper gastrointestinal endoscopies (n = 126 000) performed annually in Berlin, Germany. Main outcome measure. Rate of relevant neoplasia (high‐grade intraepithelial neoplasia or more) in both settings in relation to adherence to standards. Results. Of 1317 Barrett cases, 66% were seen in CP. CP patients had a shorter mean Barrett length (2.6 cm vs. 3.8 cm; P < 0.001) with fewer biopsies taken during an examination (2.5 vs. 4.1 for Barrett length ≤2 cm; P < 0.001). CPs also provided fewer complete esophagogastroduodenoscopy documentation (25.1% vs. 57.8%, P < 0.001). Neoplasias were found more commonly in MCs compared to CPs (9.2% vs. 0.8%; P < 0.001). However, on exclusion of all referred patients with known neoplasia (65%) or those examined for other reasons (27.5%), the detection rate at MCs decreased to 1.3%, not different from the one seen at CPs (0.8%, P = 0.43). Only 13% were found during surveillance, but 57% were diagnosed at an early stage. Conclusions. Referral bias and not better adherence to guidelines could explain the higher neoplasia prevalence in Barrett’s oesophagus at hospital centres. Despite a generally poor adherence to guidelines, most neoplasias found were at an early and potentially curable stage.     

Clinical impact of thrombotic microangiopathy on the outcome of patients with acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

The impact of thrombotic microangiopathy (TMA) on outcome was studied in 148 patients with acute graft-versus-host disease (GVHD) (> or =grade II). The Blood and Marrow Transplant Clinical Trials Network's definition for TMA was used to diagnose definite TMA. Probable TMA was diagnosed when none of the features of nephropathy and neurologic abnormalities associated with definite TMA were present. Overall, TMA developed in 43 (29%) patients; 16 definite and 27 probable. The occurrence of TMA, the maximum grade of acute GVHD and initial treatment failure were associated with shorter overall and GVHD-specific survival. The development of probable as well as definite TMA affected the survival of patients with acute GVHD adversely. These results show the clinical impact of TMA on patients with acute GVHD, and suggest that the proposed definitions and grading of TMA may need to be modified.