Conservative or operative therapy in patients with a fragility fracture of the pelvis: study protocol for a prospective, randomized controlled trial.

BACKGROUND: The incidence of fragility fractures of the pelvis is rising. Whereas the treatment for FFP type I, III, and IV is clear, the optimal treatment for FFP type II remains a topic of discussion. Traditionally these fractures have been treated conservatively. However, there is a shift toward early surgical stabilization with percutaneous screw fixation to reduce pain and promote mobility in an already frail patient population. High-quality evidence, however, is lacking. Therefore, a randomized clinical trial was designed to compare conservative management to early percutaneous screw fixation in patients with type II fragility fractures. METHODS: This is a monocenter randomized controlled trial. All patients with a FFP type II are screened for inclusion. After obtaining informed consent, patients are randomized between conservative management and surgical stabilization. Conservative management consists of early mobilization under guidance of physiotherapy and analgesics. Patients randomized for surgical treatment are operated on within 72 h using percutaneous screw fixation. The primary endpoint is mobility measured by the DEMMI score. Secondary endpoints are other dimensions of mobility, pain levels, quality of life, mortality, and morbidity. The total follow-up is 1 year. The required sample size is 68. DISCUSSION: The present study aims to give certainty on the potential benefit of surgical treatment. Current literature on this topic remains unclear. According to the volume of FFP at the study hospital, we assume that the number of patients needed for this study is gathered within 2 years. TRIAL REGISTRATION: ClinicalTrials.gov NCT04744350. Registered on February 8, 2021.

Reflexiones en torno al equipo interdisciplinario: eje y sotén en el abordaje de los trastornos neurolingüistico desde la perspectiva fonoaudiológica / Reflections on the interdisciplinary team

El objetivo de esta presentación es reflexionar acerca del rol del equipo interdisciplinario en el abordaje de los trastornos neurolingüísticas desde la perspectiva fonoaudiológica, a partir de los hallazgos de una investigación que abordó el trabajo en equipo interdisciplinario para la atención temprana del paciente afásico. El propósito perseguido es instalar en los espacios de formación de la disciplina fonoaudiológica, en particular, y en las del campo de la salud, en general, la discusión/inclusión de núcleos temáticos con una visión interdisciplinaria. En este sentido se afirma que la interacción entre los diferentes campos disciplinares debe ser incorporada como una práctica más, que debe ser aprehendida y ejercida desde el inicio de la formación de grado para un futuro beneficio de la salud y la calidad de vida de la población. Se realiza una revisión de los conceptos de disciplina, multidisciplina, interdisciplina y transdisciplina a fin de enmarcar el trabajo de equipo y se profundiza en la labor interdisciplinaria. Se describe los aportes que, desde diferentes disciplinas, confluyen en la rehabilitación del paciente afásico y la necesidad de que el equipo maneje un mismo lenguaje y trabaje de una manera integral e integrada, para lo cual es imprescindible trascender los límites de las disciplinas en aras de lograr un diálogo entre los saberes.

Several professionals, implicated in the treatment of neurolinguistic deficits/aphasia, were surveyed on the subject of the need of a team approach, who were the team members, how the team worked and how did they apply the concepts in their practice. Based on their responses, the authors establish to rigorously reflect on the role of the interdisciplinary team in the approach to the above mentioned pathology.The ultimate goal is to foster the inclusion of the concept of team approach in the institutions where speech pathology and other health care professions are taught; in view of this goal, the authors insist that the interaction between the different disciplines must be incorporated as an essential element to the clinical practice for the benefit of the client’s wellbeing.The concepts of discipline, multidiscipline, interdiscipline and transdiscipline are revised in order to provide a framework for the team, and a special emphasis is made in interdiscipline. The elements brought by each discipline to the treatment and rehabilitation of the client as well as the commonality in language and the intent to work in an integrated and full manner are presented. The most important aspect brought to the fore is the needto transcend the individual professional limits to establish a true exchange of knowledge in view of the client’s wellbeing.

[Stereotaxic brain puncture. Indications and results]. / Stereotaktische Hirnpunktionen. Indikation und Ergebnisse.

228 stereotactic biopsies for the diagnosis of brain lesions were evaluated. In 98.2% a diagnosis could be established. The diagnosis was made of brain tumor in 79.3%, of brain abscess in 7.5% and of encephalitis in 3.5% of cases. In 2.2% of the patients a pathological finding was obtained without a clear histological definition. No histological diagnosis could be made in 1.8% of the patients. A severe complication of brain biopsy occurred in 2.2% of the patients (1 death, 1 abscess, 3 increased impairments). The stereotactic procedure appears to have a low mortality and morbidity, and to be highly accurate.

Anticoagulation-related intracranial extracerebral haemorrhage.

From January 1981 to June 1986 116 patients with anticoagulation-related intracranial haemorrhage were referred to hospital. Seventy six of these haemorrhages were extracerebral, 69 were in the subdural and seven in the subarachnoid space. No epidural haemorrhages were identified. Compared with non-anticoagulation-related haematomas, the risk of haemorrhage was calculated to be increased fourfold in men and thirteenfold in women. An acute subdural haematoma, mostly due to contusion, was more frequently accompanied by an additional intracerebral haematoma than a chronic subdural haematoma. Trauma was a more important factor in acute subdural haematomas than in chronic. Almost half of the patients (48%) had a history of hypertension, more than a third (35%) had heart disease and about one fifth (18%) were diabetic. Headache was the most frequent initial symptom. Later decreased level of consciousness and focal neurological signs exceeded the frequency of headache. Three patients with subarachnoid haemorrhage and nine patients with acute subdural haematomas died, while those with chronic subdural haematomas all survived and had at the most mild, non-disabling sequelae. Myocardial infarction (22%), pulmonary embolism (20%), and arterial disease (20%) were the most frequent reasons for anticoagulant treatment. Critical review based on established criteria for anticoagulation treatment suggests there was no medical reason to treat a third of these patients. The single most useful measure that could be taken to reduce the risk of anticoagulation-induced intracranial haemorrhage would be to identify patients who are being unnecessarily treated and to discontinue anticoagulants.

Preventive therapy of herpes labialis associated with trigeminal surgery.

Acyclovir was shown to limit herpes simplex reactivation in a controlled trial to prevent herpes labialis after surgical intervention for trigeminal neuralgia. Of 14 patients receiving acyclovir, unambiguous herpes labialis developed in only one, compared with 12 of 16 in the placebo group.

[Ventriculo-peritoneal cerebrospinal fluid drainage in the treatment of hydrocephalus]. / Die ventrikulo-peritoneale Liquordrainage in der Behandlung des Hydrocephalus.

From January 1980 to December 1984 67 patients with hydrocephalus were treated with v-p shunts at the University Hospital, Berne. 61.2% had obstructive hydrocephalus and 38.3% communicating hydrocephalus. They were followed up for 2 to 6 years. Apart from clinical examination, computerized tomography was the single most important procedure for diagnostic purposes as well as for follow-up. This was not true in the case of communicating hydrocephali treated with an antisiphon device. 8 patients had serious early complications, with two fatal cases. There were not late complications. 90% of the clinical symptoms were improved or cured. V-p shunt is a technically simple and clinically effective operation, but in view of a complication rate of 12% the indication requires critical assessment.

Nontraumatic spinal epidural and subdural hematomas.

Ten patients with a nontraumatic spinal extramedullary hematoma are reported, nine of the hematomas localized in the epidural space. Seven of the patients were taking anticoagulant drugs and five showed signs of liver disease, mostly due to alcoholism. The invariable first symptom was an intense local pain in the spine, followed in all but one case by radicular irradiation and in all by bladder disturbances and sensory and motor deficits of the spinal cord or cauda equina. All the patients had myelography to verify the spinal mass and were operated on as fast as possible. The outcome depended mainly on the preoperative neurologic status. If there was only an incomplete sensory and motor lesion before the operation, the patients recovered fairly well or completely. The patients who did not become capable of walking again were completely paralytic preoperatively.

The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage.

A consecutive series of 32 adult patients with chronic subdural hematoma was studied in respect to postoperative cerebral reexpansion (reduction in diameter of the subdural space) after burr-hole craniostomy and closed-system drainage. Patients with high subdural pressure showed the most rapid brain expansion and clinical improvement during the first 2 days. Nevertheless, a computerized tomography (CT) scan performed on the 10th day after surgery demonstrated persisting subdural fluid in 78% of cases. After 40 days, the CT scan was normal in 27 of the 32 patients. There was no mortality and no significant morbidity. Our study suggests that well developed subdural neomembranes are the crucial factors for cerebral reexpansion, a phenomenon that takes at least 10 to 20 days. However, blood vessel dysfunction and impairment of cerebral blood flow may participate in delay of brain reexpansion. It may be argued that additional surgical procedures, such as repeated tapping of the subdural fluid, craniotomy, and membranectomy or even craniectomy, should not be evaluated earlier than 20 days after the initial surgical procedure unless the patient has deteriorated markedly.