Subtalar versus triple arthrodesis after intra-articular calcaneal fractures

Depending upon initial treatment, between 2 and 30% of patients with a displaced intra-articular calcaneal fracture require a secondary arthrodesis. The aim of this study was to investigate the effect of subtalar versus triple arthrodesis on functional outcome. A total of 33 patients with 37 secondary arthrodeses (17 subtalar and 20 triple) with a median follow-up of 116 months were asked to complete questionnaires regarding disease-specific functional outcome (Maryland Foot Score, MFS), quality of life (SF-36) and overall satisfaction with the treatment (Visual Analogue Scale, VAS). Patient groups were comparable considering median age at fracture, initial treatment (conservative or operative), time to arthrodesis, median follow-up, and post-arthrodesis radiographic angles. The MFS score was similar after subtalar versus triple arthrodesis (59 vs. 56 points; P = 0.79). No statistically significant difference was found for the SF-36 (84 vs. 83 points; P = 0.67) and the VAS (5 vs. 6; P = 0.21). Smoking was statistically significantly associated with a non-union (χ² = 6.60, P = 0.017). The current study suggests that there is no significant difference in functional outcome between an in situ subtalar or triple arthrodesis as a salvage technique for symptomatic arthrosis after an intra-articular calcaneal fracture. Smoking is a risk factor for non-union.     

Liver transplantation is an alternative treatment of hepatocellular carcinoma beyond the Milan criteria

Background

The decision to perform liver transplantation (LT) or liver resection (LR) for patients with hepatocellular carcinoma (HCC) who are beyond the Milan criteria remains controversial.

Methods

We retrospectively analyzed outcome data for 179 patients with HCC beyond the Milan criteria who were treated with LR (n = 135) or LT (n = 44). Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and a log-rank test was performed to compare group survival status.

Results

Patients who underwent LR group were significantly older, had a lower TNM stage, and were more likely to have unilateral disease and noncirrhotic liver. Significantly more patients in the LR group had recurrence (53.3% vs 29.5%) or died (61.5% vs 43.2%) than patients in the LT group. Recurrence-free survival rates were 11.9% for the LR group and 61.5% for the LT group. The median overall survival duration showed no statistically difference between the LR group (28.0 months) and the LT group (50.0 months).

Conclusions

LT may be the better choice for patients with HCC beyond the Milan criteria.     

Dural lesions in lumbar disc herniation surgery: incidence, risk factors, and outcome

In lumbar disc herniation surgery, dural lesions seem to be the most common complication today. Studies on incidence of and outcome after a dural lesion are mainly based on retrospective studies. In a prospective study within the framework of the Swedish Spine Register, 4,173 patients operated on for lumbar disc herniation were evaluated using pre- and 1-year postoperative protocols and complication registration. Mean patient age was 41 (18–81) years and 53% of the patients were male. 93% of the operations were performed on the two lowermost lumbar levels. The incidence of dural lesions in the material was 2.7%. In patients with previous disc surgery, the incidence was doubled, 5%, a significant increase (P = 0.02). Patients with dural lesions preoperatively had more back pain and inferior scores in general health and role emotional domains of the SF-36. These factors, however, were because they had been operated on previously, not related to the dural lesion as such. The relative improvement after surgery was similar whether a dural lesion had occurred or not. It is concluded that a dural lesion is a technical complication which must be solved at the time of surgery but which does not bear any negative implications on the long-term outcome for the patient.     

人类白细胞抗原-DRB1基因多态性与山西省家族性乙型肝炎预后的相关性研究

目的探讨人类白细胞抗原（human lymphoeyte antigen,HLA）-DRB1等位基因多态性与山西省家族性乙型肝炎临床转归及乙型肝炎病毒（HBV）复制状态的相关性。方法采用前瞻性临床流行病学研究方法,以山西省家族性乙型肝炎家庭中的295位成员为研究对象,将其分为健康对照组、慢性无症状携带（ASC）组、慢性乙型肝炎（CHB）组及肝硬化组。采用聚合酶链反应．序列特异性寡核苷酸探针技术（polymerase chain reaction—sequence specific oligonucleotide probe,PCR—SSOP）结合荧光磁珠流式检测技术,进行HLA—DRB1等位基因检测。采用,检验或Fisher’s确切概率计算法比较HLA—DRB1各等位基因频率在各组间以及在HBV DNA不同载量下的分布情况,组间计量资料比较采用方差分析,相关疾病的等位基因风险率以相对危险系数（RR）表示。结果HLA—DRB＊04基因频率在健康对照组为0．159,明显高于ASC组（0．069）和CHB组（0．079）,差异具有统计学意义（χ^2分别为4．892和4．072,P值均〈0．05）;HLA—DRB1＊07等位基因在CHB组和肝硬化组的频率分别为0．131和0．154,明显高于健康对照组（0．049）,差异具有统计学意义（χ^2值分别为4．140和5．529,P值均〈0．05）;HLA—DRB1＊13等位基因频率在健康对照组为0．037,高于CHB组（0）,2组比较差异具有统计学意义（χ^2=3．316,P〈0．05）。HLA—DRB1＊15等位基因频率在ASC组为0．206,在肝硬化组为0．115,2组比较差异具有统计学意义（χ^2=4．287,P〈0．05）。其他各等位基因频率在各组间差异无统计学意义。患者年龄在ASC、CHB及肝硬化3组间的差异有统计学意义（F=33．38,P〈0．01）;HBV DNA阳性组的HLA—DRB1＊07基因频率（0．167）高于HBV DNA阴性组（0．096）（χ^2=5．268,P=0．002）。结论HLA—DRB1＊07与家族性HBV易感性有关,可能是山西省家族性乙型肝炎易感基因或连锁基因。HLA—DRBI＊04及HLA—DRB1＊13与家族性乙型肝炎抗性相关,可能是山西省家族性乙型肝炎抗性基因。     

Outcome of traumatic extradural haematoma in Hong Kong

AIM: Traumatic extradural haematoma (EDH) is a neurosurgical emergency and timely surgical intervention for significant EDH is the gold standard. This study aims to determine the incidence and mortality of consecutive patients with traumatic EDH admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH), a University Hospital Trauma Centre in Hong Kong. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data for all consecutive trauma cases admitted through the ED during 2001-2004. EDH was diagnosed by CT in all cases. Both primary and delayed onset EDH were included, as were patients with combined EDH and other intracranial lesions (e.g. subdural haematoma). Age, sex, cause of injury, associated intracranial lesions, skull fracture, Glasgow Coma Scale, pupil reactivity, treatment, length of stay and clinical outcome were determined. RESULTS: Two thousand and two hundred and eight patients were in the trauma registry for 2001-2004. Total 1080 head injured patients; 89 patients had traumatic EDH, mean of 1.9 patients per month. Seventy (79%) patients were male, with a mean age of 37.7 years. Fifty (56%) patients were from road traffic crashes, 27 (30%) sustained falls, 10 (11%) had direct head trauma. On admission, 62 (70%) patients were GCS 13-15, 9 (10%) GCS 9-12 and 18 (20%) GCS 3-8. Sixty-six (74%) patients had a skull fracture. Thirty (34%) patients underwent neurosurgical operation. Overall, nine patients (10%) died; eight patients were GCS<8; five had bilateral fixed and dilated pupils; one had a single fixed and dilated pupil. Four patients died after neurosurgical operation, three of whom had fixed dilated pupils and were GCS 3 prior to surgery. Median length of hospital stay for survivors was 10.4 days. CONCLUSION: Survival from traumatic EDH was 90% (80/89) and 91% (73/80) of survivors had a Glasgow Outcome Score of 4 or 5 (good or moderate). The combination of bilateral fixed dilated pupils and GCS 3 suggests severe primary brain injury. Emergency evacuation of intracranial haematomas is unlikely to improve the outcome for these patients. Even in an urban environment with short prehospital times and rapid access to neurosurgery, outcome in patients who are GCS 3 following EDH is likely to be poor.     

Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial

Objective: To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients with traumatic brain injury (TBI).

Design and methods: Sixty-eight patients (age 12-65 years) with moderate-to-severe TBI were included. They were randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had passed.

Outcome and results: No significant differences were found in the Functional Independence Measure (FIM) (primary outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score at the third month (47% vs. 19%, p = 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second (28% vs. 8%, p = 0.034) and third months (34% vs. 14%, p = 0.044).

Conclusions: Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up recovery rather than changed the final outcome.     

Surgical Intervention for Malignant Fibrous Histiocytoma of the Lung: Report of a Case

Malignant fibrous histiocytoma (MFH) of the lung is rare, accounting for less than 0.2% of all pulmonary neoplasms, and an optimal treatment strategy has not yet been elucidated. We encountered a 62-year-old male patient with MFH of the lung who underwent a resection of the lymph node of recurrence 7 months after a lobectomy. We herein review 93 cases of pulmonary MFH in the literature, and discuss the surgical treatment for this disorder with special reference to lymph node involvement. Lymphogenic metastasis was observed in 14 of 72 cases (19%) who underwent surgical treatment. The 5-year survival rates for these reported patients with and without surgical treatment were 43% and 0% (P = 0.01) and the 5-year survival rates for “resected” patients with and without lymph node metastasis were 27% and 49%, respectively (P = 0.03). A complete resection with the systematic dissection of regional lymph nodes is therefore considered to positively contribute to the survival of patients with primary pulmonary MFH.     

Prognosis Scores of Tokuhashi and Tomita for Patients With Spinal Metastases of Renal Cancer

Background Retrospective evaluation of the prognosis scores of Tokuhashi and Tomita for life expectancy in 37 consecutive patients with spinal metastases secondary to renal cancer who underwent surgery. The score of Tokuhashi, composed of six parameters, each rated from zero to two, has been proposed in 1990 for the prognostic assessment of patients with spinal metastases. In 2001, Tomita et al. created another prognostic score, composed of three parameters, growth behaviour of the primary tumor (slow, moderate and rapid) and the evidence of visceral and bony metastases. Methods Thirty-seven patients, surgically treated for vertebral metastases secondary to renal cancer were studied. The scores according to Tokuhashi and Tomita were calculated for each patient. Results Applying the Tokuhashi Score for the estimation of life expectancy of renal cancer patients with vertebral metastases was found to provide very reliable results with a statistically high significance. The analysis according to Tomita showed no correlation between predicted and real survival. The statistical analysis did not show any significance. Conclusion For surgical decisions in renal cancer patients with spinal metastases, the prognostic score of Tokuhashi appears to be much more valuable than the Tomita score.     

超早期磁共振血管成像无大血管闭塞的急性缺血性卒中患者的预后

目的研究超早期磁共振血管成像(MRA)无大血管闭塞的急性缺血性卒中患者的临床结局及预测结局的因素。方法选择超早期(发病6 h内)完成急诊磁共振成像(MRI)检查且MRA无大血管闭塞的急性缺血性卒中患者31例,收集其临床及影像学数据,在MRI检查前完成NIHSS评分,随访发病后24 h的NIHSS评分及3个月时mRS评分。结果31例患者中28例MRI弥散加权成像(DWI)提示梗死灶,治疗后24 h时NIHSS显著改善者17例,3个月随访mRS0-2分者28例,未发现预测结局的因素。结论超早期MRA无大血管闭塞的急性缺血性卒中患者中大部分DWI可见责任梗死灶,即使未溶栓,大多数患者临床结局也较好。     

Measuring common outcome measures and their concepts using the International Classification of Functioning, Disability and Health (ICF) in adults with burn injury: a systematic review

Purpose

To identify and quantify the health related concepts contained in the most common outcome instruments used in adult burn care, and to compare the content of these instruments based on their linkage to the International Classification of Functioning, Disability and Health (ICF). The ICF has been validated as a reference tool by the World Health Organization and is a framework that incorporates physical, emotional, environmental and social aspects of daily functioning.

Methods

Electronic searches of MEDLINE, EMBASE CINAHL, PsychINFO and the Cochrane Library from 2003 onwards were carried out using a predetermined search strategy. Specific characteristics of the included studies and data pertaining to the outcome instruments were extracted. Two reviewers independently categorised the underlying concepts contained in the most commonly used outcome measures and linked them to ICF categories using standardised linkage rules.

Results

Out of a total 132 included studies, 151 outcome instruments were identified. Of these, 14 frequently used generic and burn-specific instruments were selected for linkage to the ICF. From the 381 items contained in the 14 instruments, 356 concepts were extracted and subsequently linked to 99 ICF categories. Nearly 46% of the concepts were linked to body function and 20% to activities and participation, whereas only a few concepts were formally linked to health condition, body structures and personal or environmental factors.

Conclusion

The ICF proved highly useful for the content comparison of frequently used generic and burn-specific instruments. The results may provide clinicians and researchers with new insights when selecting health-status measures for clinical studies in those with burn injury.