Hoffa fractures are associated with concomitant soft tissue injures and a high postoperative complication rate.

INTRODUCTION: Hoffa fractures are a rare and often overlooked entity. The main goal of surgical treatment is to restore the articular surface and maintain knee function. However, current clinical data indicate heterogeneous outcomes. The aim of this multicenter study was to obtain a representative data set of patients with isolated Hoffa fractures with special emphasis on concomitant soft tissue injuries, diagnostic algorithms, treatment strategies and functional outcomes. MATERIALS AND METHODS: Participating Level I trauma centres were asked to review their internal database for isolated Hoffa fractures treated surgically between 2010 and 2020. Demographics, mechanism of injury, diagnostic and therapeutic algorithm, Letenneur classification, concomitant soft tissue injuries, and postoperative knee function and complications were analysed. RESULTS: A total of 56 patients from six participating trauma centres were included. The median age at injury was 45 years (15-94) with a median follow-up of 19 months (2-108). The most common mechanism of injury was high-energy trauma, with unicondylar lateral Letenneur type I and II fractures being the most common. Surgical treatment was independent of the type of fracture and included isolated screw fixation, combined plate and screw fixation and isolated plate osteosynthesis. Isolated screw fixation resulted in significantly better range of motion (ROM) values (p = 0.032), but the highest number of postoperative complications (n = 14/20, n.s.) compared to the other fixation techniques. The highest number of fixation failures requiring revision was observed in the plate and screw fixation group (n = 3/8, p = 0.008). Osteochondral flake fractures (n = 12/43, 27%) and lateral meniscus injuries (n = 5/49, 10%) were commonly seen in Hoffa fractures. CONCLUSIONS: Treatment of Hoffa fractures with screw fixation resulted in significantly better functional outcomes, probably due to less comminuted fractures. Concomitant cartilage, meniscal and ligamentous injuries are common and warrant preoperative recognition and management.

Incidence of postoperative complications in patellar fractures related to different methods of osteosynthesis procedures - a retrospective cohort study.

BACKGROUND: Patellar fractures have a comparatively low incidence compared to all fracture frequencies of the musculoskeletal system. However, surgical management is crucial to prevent postoperative complications that affect the knee joint. The purpose of the present study was to evaluate the incidence of postoperative complications and onset of postoperative osteoarthritis related to the chosen technique of patellar fracture management. METHODS: In a retrospective cohort study consecutive managed, isolated patella fractures were reviewed for demographic data, trauma mechanism, patella fracture type, fixation technique and postoperative complications. The results were documented radiographically and clinically and analysed statistically. The reporting followed the STROBE guidelines. RESULTS: A total of 112 patients were eligible for data evaluation. Surgical management of comminuted patellar fractures with small fragment screws showed significant fewer postoperative complications compared to other fixation techniques (8%, p < 0.043). The incidence of posttraumatic infection was significantly higher following the hybrid fixation technique with cannulated screws and tension wire than following the other analysed techniques (p = 0.024). No postoperative wound infection was observed after screw fixation or locking plate fixation. Symptomatic hardware was most frequently seen after tension-band fixation. Onset of posttraumatic osteoarthritis was most often found after the hybrid fixation technique (55%). CONCLUSION: Surgical management of patellar fractures remains crucial but fracture fixation using plating systems or small fragment screws is least associated with postoperative complications. TRIAL REGISTRATION: Trial registration number (DRKS):00027894.

Current standard of care for distal femur fractures in Germany and Switzerland.

BACKGROUND: Distal femur fractures occur with an incidence of 4.5/100,000 and show a prevalence of 0.4%. Causes include low-impact trauma in older patients and high-impact trauma in younger patients without pre-existing medical conditions. The aim of this study was to perform a comprehensive evaluation of trauma mechanisms, trauma-promoting factors, comorbidities, medication history and type of surgical care to provide an overview of the causes of injury and the most appropriate therapeutic approach. METHODS: In this multicenter cohort study a retrospective analysis of 229 patients who sustained a distal femur fracture between January 2011 and December 2020 was performed. Individual fracture patterns, fracture predisposing factors, concomitant disease profiles, medication history, treatment strategy and associated complications were analyzed. RESULTS: 229 patients were included in the retrospective analysis. A total of 113-type 33 A, 50-type 33 B and 66-type 33 C fractures were diagnosed, of whom 92% received a lateral locking plate osteosynthesis. There was a complication in 14.4% of all cases, of which 6.1% were attributable to infection. Significant risk factors for developing a complication were an increased BMI (29.9 ± 8.5 kg/m2; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008). CONCLUSION: In this multicenter retrospective cohort study, lateral locking plate osteosynthesis was the method of choice and was selected in over 90% of cases, regardless of the fracture classification and risk factors. A complication rate of 14.4% emphasizes the necessary analysis of patient- and care-specific risk factors and a resulting adjustment of the therapy strategy. An increased BMI (29.9 ± 8.5 kg/m2; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008) increase the risk of developing a complication and should prompt an early switch to a treatment strategy that provides more stability.

[Internal conflicts in psychoeducation for parents of children with ADHD: discours analysis]. / Tegenstrijdigheden in psycho-educatie voor ouders van kinderen met ADHD: een discoursanalyse.

BACKGROUND: Psychoeducation plays an important role in how people understand their own psychiatric classification. Since children and parents see psychoeducation as a representation of how their story is understood by the therapist, it affects the therapeutic alliance. Moreover, psychoeducation indirectly shapes the way society understands psychological differences. AIM: To understand how the classification ADHD is given meaning through psychoeducation. METHOD: We analyzed the discourse of 41 written psychoeducational materials from four different countries (USA, UK,
the Netherlands and Hungary). RESULTS: We identified five patterns, of which four contained an element of internal conflict. Notably, conflicts were found within a single thematic stance on ADHD as opposed to a conflict between parties with a different vision on ADHD. CONCLUSION: These conflicts cause confusion, misrepresentation and decontextualization of problems. Ultimately, for those diagnosed with ADHD and their parents, this may hamper their ability to understand themselves in the context of their difficulties.

[A fresh look at psychiatric disorders]. / Een veranderende kijk op psychiatrische stoornissen.

BACKGROUND: The a-theoretical approach to psychiatric disorders, introduced via dsm iii, has had a tremendous impact. It has stimulated a large body of research, facilitated by the concurrent development of new techniques in genetics, neuro-imaging and neuropsychology. However, the research results of the last twenty years or so have cast doubt on the validity of the clinical categories set out in dsm iii. AIM: To develop a new view on developmental pathways in psychopathology, clinical assessment and scientifically acceptable classification. METHOD: In this article we review the state of the art with regard to underlying endophenotypes at the level of brain and neurotransmitter functioning and neuropsychology and we consider the effect of social determinants on the developments of psychopathology. RESULTS: Our results show that neither genotypes and endophenotypes, nor brain mechanism, nor neuropsychological deviances have a one-to-one correlation with clinical categories as defined in even the dsm 5. CONCLUSION: dsm-5 provides a range of possibilities for classifying psychiatric disorders at symptom level. But these categories seem to be less distinct than was at first assumed. Recent research has shown that there is a great deal of overlap at the genetic, epigenetic and endophenotype level. This calls for more emphasis on individual assessment and diagnostics in both clinical practice and scientific research. More attention needs to be given to the dimensions of emotion and behavior, vulnerability and resilience. This type of approach, involving genotypes, endophenotypes, epigenetics and brain functioning, could help to elucidate the interaction between these various levels and/or explain the underlying mechanisms of psychiatric disorders.

Group climate and empathy in a sample of incarcerated boys.

This study examined the influence of group climate on empathy in a Dutch youth correctional facility in a sample of 59 incarcerated delinquent boys. Higher levels of empathy have been shown to be associated with less delinquent and more prosocial behaviour and may therefore be vital for successful rehabilitation and recidivism reduction. Although empathy was originally considered to be a trait, recent neurobiological research has shown that empathy has state-like properties in that levels of empathy change in response to the social environment. This study showed that differences in group climate were associated with cognitive empathy in juvenile delinquents but not with affective empathy. It is speculated that inmates' state-depressive feelings and anxiety could diminish the effects of prison group climate on affective empathy. The discussion focuses on group dynamics in youth correctional facilities. A positive prison group climate in a youth correctional facility could turn out to be a major factor contributing to effectiveness of secure institutional treatment.

Commissioning of a commercially available system for intensity-modulated radiotherapy dose delivery with dynamic multileaf collimation.

PURPOSE: To commission commercially available equipment for intensity-modulated radiotherapy (IMRT) using dynamic multileaf collimation (DMLC). MATERIALS AND METHODS: First, the stability in leaf positioning and in realized IMRT profiles on a Varian 2300 C/D machine were determined as a function of time and gantry angle, and as a result of treatment interrupts. Second, dose distributions calculated with the CadPlan (Varian) treatment planning system, using leaf trajectories calculated with the leaf motion calculator (LMC) algorithm, were compared with distributions realized at the 2300 C/D unit. RESULTS: Day-to-day and gantry angle variations in leaf positioning and dose delivery were very small (less than 0.1-0.2 mm and 2%). The effect of treatment interrupts on measured dose distributions was less than 2%. The agreement between the final dose distribution calculated by CadPlan and the measured dose was generally within 2%, or 2 mm at steep dose gradients, using a leaf transmission value of 1.8% and a leaf separation value of 2 mm in LMC. For narrow peaks, deviations of up to 6% were observed. LMC does not synchronize adjacent leaf trajectories resulting in tongue-and-groove underdosages of up to 29% for extreme cases. CONCLUSIONS: The 2300 C/D machine is suitable for accurate and reproducible DMLC treatments. The agreement between dose predictions with LMC and CadPlan, and realized doses at this unit is clinically acceptable for most cases. However, differences between calculated and actual dose values may exist in peaked fluences or due to tongue-and-groove effects. Therefore, pretreatment dosimetric verification for each patient is recommended.

Alpha-sarcoglycanopathy previously misdiagnosed as Duchenne muscular dystrophy: implications for current diagnostics and patient care.

Differential diagnosis of limb-girdle muscular dystrophy, including alpha-sarcoglycanopathy and Duchenne muscular dystrophy, is impossible to acheive on clinical grounds alone; therefore immunohistology, Western blotting and molecular genetic analysis are manadatory for a correct diagnosis. The patient's genotype with a hitherto unknown mutation (Tyr134STOP) in exon 5 adds to the growing spectrum of mutations in the alpha-sarcoglycan gene.

Differentiating the biosynthesis of pseudomonic acids A and B.

Pseudomonic acid A (1) has been the dominant commercial pseudomonate antibiotic produced by Pseudomonas fluorescens. In specific shaken flask conditions initial fermentation accumulation of 1 is followed by preferential accumulation of the 8-hydroxy derivative, pseudomonic acid B (2). Biosynthetic probing with a pulse of [1-14C] acetate or L-[methyl-14C] methionine at early, mid and late stages of the fermentation gave relative patterns of radioactivity in 1 and 2 that are inconsistent with an assumption that 2 arises by oxidation of 1, or that 1 is formed by reduction of 2. Since [methyl-14C] methionine only labels carbons in the 12-carbon part of the pseudomonate molecule that is thought to be an early biosynthetic moiety, the evidence from radiolabelling experiments implies that preferential early oxidation of this biosynthetic intermediate causes the pathway diversion to accumulate 2 instead of 1.

Automated extraction of 11-nor-delta9-tetrahydrocannabinol carboxylic acid from urine samples using the ASPEC XL solid-phase extraction system.

The analysis of 11-nor-delta9-tetrahydrocannabinol-carboxylic acid (THCCOOH, the major metabolite of cannabis) in urine with gas chromatography and mass spectrometry (GC-MS) and solid-phase extraction (SPE) sample preparation is well documented. Automated SPE sample preparation of THCCOOH in urine, although potentially advantageous, is to our knowledge poorly investigated. The objective of the present study was to develop and validate an automated SPE sample-preparation step using ASPEC XL suited for GC-MS confirmation analysis of THCCOOH in urine drug control. The recoveries showed that it was not possible to transfer the protocol for the manual SPE procedure with the vacuum manifold to the ASPEC XL without loss of recovery. Making the sample more lipophilic by adding 1 mL 2-propanol after hydrolysis to the urine sample in order to overcome the problem of surface adsorption of THCCOOH led to an extraction efficiency (77%) comparable to that reached with the vacuum manifold (84%). The reproducibility of the automated SPE procedure was better (coefficient of variation 5%) than that of the manual procedure (coefficient of variation 12%). The limit of detection was 1 ng/mL, and the limit of quantitation was 4 ng/mL. Precision at the 12.5-ng/mL level was as follows: mean, 12.4 and coefficient of variation, 3.0%. Potential carryover was evaluated, but a carryover effect could not be detected. It was concluded that the proposed method is suited for GC-MS confirmation urinalysis of THCCOOH for prisons and detoxification centers.

Analysis of low concentration sufentanil citrate/bupivacaine hydrochloride admixtures, using solid phase extraction followed by high-performance liquid chromatography.

A method has been developed for the quantitative determination of low concentrations of sufentanil citrate (1.0 microg/ml), in the presence of bupivacaine hydrochloride (0.125%), in the quality control of pharmaceutical preparations. The main problem in analysis of this combination is the low concentration of sufentanil citrate in the presence of relatively high concentrations of bupivacaine hydrochloride. This paper describes the validation of a HPLC method of sufentanil citrate in an admixture with bupivacaine hydrochloride using solid phase extraction (SPE). The optimized method shows good linearity, precision and accuracy. The limits of detection (0.09 microg/l) and quantification (0.29 microg/l) for sufentanil citrate are lower than the maximal accepted limits. This method is currently used in stability studies.

Cranial computed tomography in the emergency evaluation of adult patients without a recent history of head trauma: a prospective analysis.

OBJECTIVES: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. METHODS: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection. X2 recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. RESULTS: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age > or = 60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94-100%) and 31% specific (95% CI: 28-33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8-13%) and 100% (95% CI: 98-100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed. CONCLUSION: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high- and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.

Pentamidine aerosols and environmental contamination: health-care workers at risk.

In our hospital safety guidelines are available for the handling of pentamidine in the day-care department, but no safety ventilation cabin is used because only one patient a day has been treated, The number of patients to be treated, however, is growing, resulting in the need to treat more than one patient a day. To determine the environmental contamination and exposure of health-care workers during and after aerosolised pentamidine treatment of more than one patient with the acquired immunodeficiency syndrome a day a high-performance liquid chromatographic method is used for the detection and quantification of pentamidine. High volume air samples were taken before, immediately after and the day after a treatment session of up to three patients. Also, sediment samples and personal air samples close to the mouth of the health-care workers were taken. Immediately after a treatment session the air in the room contains 1.0-99.7 micrograms pentamidine per m3 of air. Before and the morning after treatment no pentamidine could be detected in the air. Sediment samples vary in detectable amounts of pentamidine from < 5 to 1165 micrograms. pentamidine/cm2. The personal air samples also show a large variation in quantities of pentamidine: < 5-170 ng a filter. When large amounts of pentamidine in the high volume air samples are found high amounts of pentamidine on the sediment samples and the personal air samples are found as well. This means that the patients treated should be instructed well on how to use the nebulizer correctly and be monitored during treatment. Additional safety measures (for example the use of a safety ventilation cabin) should be taken when more than one patient is treated a day.

Knowledge-based decision support for patient monitoring in cardioanesthesia.

An approach to generating 'intelligent alarms' is presented that aggregates many information items, i.e. measured vital signs, recent medications, etc., into state variables that more directly reflect the patient's physiological state. Based on these state variables the described decision support system AES-2 also provides therapy recommendations. The assessment of the state variables and the generation of therapeutic advice follow a knowledge-based approach. Aspects of uncertainty, e.g. a gradual transition between 'normal' and 'below normal', are considered applying a fuzzy set approach. Special emphasis is laid on the ergonomic design of the user interface, which is based on color graphics and finger touch input on the screen. Certain simulation techniques considerably support the design process of AES-2 as is demonstrated with a typical example from cardioanesthesia.