[Postoperative implant-associated osteomyelitis of the shoulder: Hardware-retaining revision concept using temporary drainage]. / Postoperative implantatassoziierte Osteitis am Schultergürtel: Materialerhaltendes Revisionskonzept mit Einlage einer Dauerdrainage.

BACKGROUND: Posttraumatic and postoperative osteomyelitis (PPO) is a subgroup of bone infections with increasing importance. However, to date no standardized reoperation concept exists particularly for patients with PPO of the shoulder region. Therefore the purpose of this study was to evaluate a revision concept including débridement, irrigation, and insertion of temporary drainage with hardware retention until healing. PATIENTS AND METHODS: A total of 31 patients with PPO were included with a proximal humerus fracture (n = 14), clavicle fracture (n = 10), or AC-joint separation (n = 7). In all, 27 of these patients could be followed for > 1 year. RESULTS: Hardware retention until fracture or ligament healing could be achieved in > 83%. Six patients required follow-up débridement due to recurrent infections, but then were unremarkable. Clinical outcome showed excellent Constant scores (91.6 ± 2.8). CONCLUSION: A cost-efficient, simple, and successful revision concept for patients with PPO of the shoulder region is described.

Compliance level to Tuberculosis prophylaxis in patients undergoing therapy with tumor necrosis factor-alpha inhibitors: a cross-sectional study.

OBJECTIVE: Tumor necrosis factor-alpha (TNF-α) inhibitors are used to treat autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis, and inflammatory bowel disease. However, patients using TNF-α inhibitors are at a high risk of developing tuberculosis. Therefore, this study aimed to evaluate the compliance level of patients who were prescribed TNF-α-based tuberculosis prophylactic treatment. PATIENTS AND METHODS: The study included 135 patients who were followed up at a tuberculosis dispensary between December 2020 and June 2021 and agreed to participate in the study. The study was conducted after obtaining necessary permissions from the institution, ethics committee, and patients. Data were collected using a questionnaire and evaluated using the Medication Adherence Report Scale (MARS). The MARS scale scores range from 5 to 25, with high scores indicating a high level of "medication compliance level". RESULTS: Of the included patients, 42.2% were females, 46.7% were primary school graduates, and their mean age was 43.75±11.86 years. Additionally, 35.6% of patients had ankylosing spondylitis, among whom 54.1% had a disease duration of 1-5 years and 57.8% had been using TNF-α inhibitors for a year. Of the patients taking isoniazid (INH) for tuberculosis prophylaxis, 47.4% missed their prescribed INH doses, with "forgetfulness" being the reason in 28.9% of these patients. The patients had a mean MARS score of 15.71±6.18. CONCLUSIONS: Patients using TNF-α inhibitors were found to have "moderate" compliance levels for INH-based prophylactic therapy. It is recommended that the compliance levels of patients and factors influencing their compliance should be regularly monitored.

Impact of pre-test information on patient compliance with the spirometry protocol: a randomized controlled clinical trial.

OBJECTIVE: This study evaluated the effect of brochure-based and video-assisted information provided before spirometry on patient compliance. PATIENTS AND METHODS: This was a randomized controlled clinical trial. Before the test, subjects in intervention groups were shown a leaflet outlining the steps of the spirometry protocol and a video prepared for the same purposes. The control group was given standard routine information by the technician before spirometry. RESULTS: The study included 450 patients. We found a significant correlation between compliance status and age, female sex, being a non-smoker, having no known lung disease, investigating respiratory disease as an indication for spirometry, having first-time spirometry, and receiving pre-test information via leaflets. Variables of age, sex, smoking, indication for spirometry, diagnosis, and previous spirometry, which were found in multivariate analysis to be associated with 'compliance with the test protocol' were further processed using regression analysis which identified 'previous spirometry' as the most decisive variable affecting 'compliance with the test protocol'. CONCLUSIONS: Providing information via brochure-based and video-supported information did not contribute to compliance with the testing protocol, leading us to the conclusion that such informative tools do not provide an additional contribution. Previous spirometry experience was the most decisive parameter influencing adherence to the test protocol.

Use of Medihoney as a non-surgical therapy for chronic pressure ulcers in patients with spinal cord injury.

STUDY DESIGN: Prospective, observational study of 20 spinal cord-injured (SCI) patients with chronic pressure ulcers (PUs) using Medihoney. OBJECTIVES: To determine the effects of Medihoney by bacterial growth, wound size and stage of healing in PUs. METHODS: We treated 20 SCI adult patients with chronic PUs using Medihoney. In all, 7 patients (35%) were female, and 13 (65%) were male. The average patient age was 48.7 years (30-79). In all, 6 patients (30%) were tetraplegic and 14 (70%) were paraplegic. Also, 5 patients (25%) had grade IV ulcers and 15 patients (75%) had grade III ulcers according to the National Pressure Ulcer Advisory Panel. RESULTS: After 1 week of treatment with Medihoney, all swabs were void of bacterial growth. Overall 18 patients (90%) showed complete wound healing after a period of 4 weeks, and the resulting scars were soft and elastic. No negative effects were noted from the treatment using Medihoney. No blood sugar level derailment was documented. CONCLUSION: The medical-honey approach to wound care must be part of a comprehensive conservative surgical wound-care concept. Our study indicates the highly valuable efficacy of honey in wound management and infection control as measured by bacterial growth, wound size and healing stage.

Dynamics in children and adolescents who experience varicella zoster virus infections after haematopoietic stem cell transplantation: a case-control study.

We evaluated the incidence of varicella-zoster virus (VZV) infections, including herpes zoster (HZ), and investigated the associated risk factors for HZ and compared lymphocyte subsets of these patients at 1, 3 and 6 months following haematopoietic stem cell transplantation (HSCT) in a case-control study in children and adolescents. The incidence of HZ infection at the first year after HSCT was 17/125 (13·6%). The cumulative incidence of HZ infection was 22/125 (17·6%). Sixteen (73%) cases with HZ and 11 (32%) cases in the control group had a diagnosis of malignant disorder. No significant difference was noted between the HZ group and the control group in absolute lymphocyte number and subsets (except WBC) at the pre-transplant evaluation. Pre-transplant WBC count was statistically lower in the HZ group (P<0·05). The CD4/CD8 ratios were lower in the HZ group during the first 6 months after HSCT, and the decrease was statistically significant at 6 months compared to the control group. In conclusion, patients undergoing HSCT for a malignant disorder had a significantly higher risk of VZV infection than those with non-malignant disorders and pretransplant donor characteristics were not helpful in predicting risk of post-transplant VZV infection.

Rapid detection of Salmonella in milk by combined immunomagnetic separation-polymerase chain reaction assay.

During the past few years, milk has presented a risk of Salmonella contamination; it has been implicated as the cause in several outbreaks of salmonellosis. Because conventional detection methods require 5 to 7 d for completion and involve several subcultivation stages followed by biochemical and serological tests, rapid and sensitive methods have been sought, mainly at the DNA level. Therefore, a study including milk samples was conducted to evaluate the performance of a combination of 2 techniques--immunomagnetic separation and polymerase chain reaction (PCR)--for the detection of Salmonella. The 16-, 14-, 12-, 10-, and 8-h nonselective pre-enrichment steps before immunomagnetic separation and the high-pure DNA preparation method before PCR were used in a combined assay. Milk samples, which were found to be Salmonella-negative by a reference method, were first inoculated with Salmonella Enteritidis. Next, the shortest pre-enrichment time that is required for detection of 1 or 10 cfu of Salmonella/mL by combined immunomagnetic separation-PCR assay was found by using 16-, 14-, 12-, 10-, and 8-h incubation periods. The detection limit using a 16-, 14-, or 12-h nonselective pre-enrichment was 1 to 10 cfu/mL. However, the sensitivity decreased to 10(1) and 10(2) cfu/mL, respectively, when 10- and 8-h pre-enrichments were used. This assay, in conjunction with a 12-h pre-enrichment, proved to be rapid (overall 16 h) and sensitive (1-10 cfu/mL) for the detection of Salmonella in milk samples and promising for routine use in the detection of Salmonella in milk.

Piperacillin/tazobactam plus amikacin versus carbapenem monotherapy as empirical treatment of febrile neutropenia in childhood hematological malignancies.

A prospective, randomized clinical trial was conducted to compare the efficacy of piperacillin/tazobactam and amikacin combination with carbapenem monotherapy for the empirical treatment of febrile neutropenic episodes of children with acute lymphoblastic leukemia or acute myeloblastic leukemia. Patients aged 2-16 years with hematological malignancies who had febrile neutropenia were randomly assigned to receive piperacillin/tazobactam (80 mg/kg piperacillin/10 mg/kg tazobactam, q6h) combined with amikacin (PTA) (7.5 mg/kg, q12h) or meropenem or imipenem (20 mg/kg, q8h) (C). Response to antimicrobial therapy, evaluated for etiological agents, was measured. Duration of fever, neutropenia, and hospitalization, mortality, and the need for additional antibiotics or antifungal drugs were compared for the treatment success between the two groups. Out of 87 febrile neutropenic episodes that were evaluable for comparison, 46 patients received PTA and 41 patients were treated with carbapenems (imipenem or meropenem). Overall, the microbiologically documented infection rate was 21.9%, with Staphylococcus epidermidis as the most common cause of bacteremia. The rate of treatment modification was 56.5% in the PTA group and 53.6% in the carbapenem group with no statistical difference (p > .05). There was no infection-related mortality during the study period. There was no difference between the two regimens for durations of fever, neutropenia, and hospitalization (p > .05 for all categories). PTA was as effective as carbapenem monotherapy as an initial empirical regimen in febrile neutropenic episodes of pediatric hematological malignancies.

Nonimmune hydrops fetalis in two cases of consanguineous parents and associated with hereditary spherocytosis and hemophagocytic hystiocytosis.

Nonimmune hydrops fetalis may occur as a result of different etiological conditions and in about one-third of cases no cause could be identified. Here, we report two cases of nonimmune hydrops fetalis associated with hereditary spherocytosis and hemophagocytic hystiocytosis. We think that babies with hydrops fetalis born of consanguineous parents should be examined for hereditary diseases, and that these rare causes should be taken into account in problematic cases.

Effect of submaximal and incremental upper extremity exercise on platelet function and the role of blood shear stress.

INTRODUCTION: Platelets are involved in the pathogenesis of atherosclerosis. Although physical exercise is recommended to prevent atherosclerosis, the effect of exercise on platelet function and the underlying mechanisms of these effects are not completely understood. Accordingly, we aimed to examine the effect of different intensities acute arm exercises on platelet function. In addition, we evaluated the effect of lipid peroxidation and fluid shear rate on platelet response. MATERIALS AND METHODS: Twenty four healthy sedentary male volunteers aged 18-24 years performed submaximal and incremental exercises by upper extremity ergometer. The shear rate in the right artery was measured by Power Doppler Ultrasound (US) at rest and immediately after exercise. Pre and postexercise maximum intensities of ADP and collagen-induced platelet aggregation were measured using the impedance technique. Bioluminescent detection of thrombin-induced platelet ATP release and measurement of thromboxane B(2) (TxB(2)) levels (as a marker of thromboxane A(2) (TxA(2)) formation) by enzyme-linked immunoassay were performed before and after exercise. RESULTS AND CONCLUSION: Shear rate increased after both submaximal and incremental exercise. Collagen-induced platelet aggregation increased after submaximal exercise, while ADP-induced aggregation and thromboxane B(2) levels did not alter with this protocol. Incremental exercise caused increased collagen and ADP-induced platelet aggregation and thromboxane B(2) levels. Neither of the protocols altered platelet ATP release. It was shown that acute upper extremity exercise increased platelet aggregation, without an increase in platelet release. Collagen-induced signalling pathways were more sensitive than those induced by ADP. The increase in thromboxane B(2) after incremental exercise implied increase in thromboxane A(2) formation and lipid peroxidation. Despite a significant correlation between platelet aggregation and thromboxane B(2) levels at rest, we found no clear-cut relationship between thromboxane A(2) formation, blood shear rate and platelet response to exercise.

Intrarenal Doppler findings of upstream renal artery stenosis: a preliminary report.

To diagnose 60% or greater diameter-reducing stenosis of the renal artery (RAS), color Doppler imaging (CDI) and angiography were performed on 44 hypertensive and 16 normotensive cases. In this prospective, double-blind study we evaluated the related intrarenal waveform changes. In both the right and left kidneys of normotensive cases, at the level of interlobar arteries, the results indicated a symmetric finding in peak systolic/end diastolic velocities (S/D), pulsatility index (PI) and resistive index (RI) ratios. The results in the stenotic kidneys among the hypertensive group indicated that index values were significantly lower in the stenotic kidneys than those of the contralateral kidneys, the kidneys of control and nonstenotic hypertensive cases. To quantify this observation we suggest "perfusion indexes," which require more studies on a greater number of hypertensive cases. It was concluded that measuring the index values of intrarenal arterial waveforms is easier and more accessible in diagnosing RAS than obtaining those of the main renal artery.

Abscess formation due to dropped gallstone after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is a popular treatment modality of symptomatic gallstones with decreased major complications and shortened hospital stay. Complications following laparoscopic cholecystectomy, most of them involving strictures of biliary tract have been well described in recent reports. However, there are only a few reported cases about dropped gallstones after the procedure, all of which were opaque and easily demonstrated with multiple imaging modalities. An unusual complication of laparoscopic cholecystectomy; abscess formation due to a dropped non-opaque gallstone is described in which diagnosis was suggested with the combination of ultrasound and computed tomography findings and confirmed by surgery.

Evaluation of renal morphology and vascular function by color flow Doppler sonography immediately after extracorporeal shock wave lithotripsy.

Thirteen male and seven female patients with renal calculi were evaluated by color flow Doppler sonography (CFDS) for renal morphology and function before and after receiving 1000 to 2350 shocks with the Dornier MPL 9000 lithotripter. No significant morphologic change was encountered except for renal enlargement thought to be secondary to edema induced by shock wave application. Similarly, no significant differences were recorded in the systolic and diastolic flow rates or pulsatility (PI) or resistive (RI) indices of the renal vessels before and after treatment (P > 0.05). Color flow Doppler sonography appears to be a safe, noninvasive, and reliable means of evaluating kidneys subjected to extracorporeal shock wave lithotripsy.

A case of Whipple's disease complicated by fatal hepatitis.

Whipple's disease was diagnosed in a 42-year-old woman by the histological examination of a mesenteric lymph node taken at laparotomy, and the electron microscopic examination of a peroral intestinal biopsy specimen. She responded well to tetracycline therapy, but succumbed to fatal hepatitis ten weeks after the diagnosis of Whipple's disease

Deep venous thrombosis of the extremity diagnosed by color Doppler ultrasonography after isolated limb perfusion.

AIM: Isolated limb perfusion (ILP) is used to treat locally advanced sarcoma and melanoma of the extremities. ILP is associated with a 1.7% to 10% incidence of deep venous thrombosis (DVT). The aim of the study was to examine the effect of ILP on the peripheral venous system and to evaluate the diagnostic accuracy of color Doppler ultrasonography (US). METHODS: A total of 26 patients with locally advanced sarcoma or melanoma of the extremities received a total of 38 ILP. The patients were evaluated preoperatively and postoperatively by color Doppler US as a noninvasive venous measurement. We used a color Doppler US system (SSA-270A, Toshiba) with a 7.5-MHz linear transducer for gray-scale imaging and a 5-MHz vascular transducer for color Doppler imaging. RESULTS: Seventeen patients underwent single ILP while the others were treated with multiple ILPs. Color Doppler US showed a reflux flow in three (7.9%) patients and DVT occurred subsequently in these patients. CONCLUSIONS: Color Doppler US is a noninvasive and clinically useful diagnostic technique in the diagnosis of extremity DVT. We recommend anticoagulant therapy in patients with reflux on ultrasonographic examination.

Effect of hormone replacement therapy on ocular hemodynamics in postmenopausal women.

PURPOSE: To evaluate the effect of hormone replacement therapy on ocular hemodynamics in postmenopausal women. METHODS: Ocular Doppler ultrasonography was performed in 20 postmenopausal women on hormone replacement therapy (HRT) and in 20 women without treatment, as the control group. Central retinal artery (CRA), posterior ciliary artery (PCA) and ophthalmic artery (OA) flow velocities and vascular resistances were measured prospectively by a radiologist blinded to the therapy. There were no associated systemic or ocular diseases or any medication history. RESULTS: The mean age of the patients on HRT was 50.05 +/- 4.5 yrs (range 44-62). The mean age of the control group was 52.8 +/- 4.09 yrs (range 46-65). The mean duration of HRT was 1.6 +/- 1.4 yrs (range 3 months - 5 years). There were no differences between the groups in terms of flow velocities, vascular resistivities or pulsatility indices of OA, CRA and PCA (p>0.05). CONCLUSIONS: HRT is essential in postmenopausal women for relief of vasomotor symptoms, cardioprotection and prevention of osteoporosis. Even though vaso-occlusive complications of hormone preparations have been reported, we did not observe any changes in ocular hemodynamics detectable with Doppler ultrasonography.

Aneurysms of the portal venous system. Gray-scale and color Doppler ultrasonographic findings with CT and MRI correlation.

Two cases of incidentally detected aneurysms involving the portal venous system are described with emphasis on gray-scale and color Doppler ultrasonographic (US) findings. Appearing on US as anechoic masses showing direct luminal continuity with the right portal vein and superior mesenteric vein, the lesions displayed spectral findings characteristic of portal venous system on color Doppler US. Dynamic helical computed tomography (CT) demonstrated simultaneous enhancement with the portal system, while the aneurysms were hypointense owing to flow void on T1-weighted spin-echo magnetic resonance (MR) images.

Sialographic and ultrasonographic analyses of major salivary glands.

Seventy patients with major salivary gland diseases (60 parotis, 10 submandibular) were examined both with sialography and ultrasonography. The clinical and histopathological results were compared with radiological interpretations. Sialography was found to be 60% accurate for the diagnosis of salivary gland tumors and cysts and 63% for the diagnosis of inflammatory diseases. Ultrasonography diagnosed 95% of the tumors and 63% of inflammatory diseases accurately.

Regional cerebral blood flow changes in chronic alcoholism using Tc-99m HMPAO SPECT. Comparison with CT parameters.

Twenty-eight patients were studied for regional cerebral blood flow changes as a result of chronic alcoholism. After the administration of 550 to 600 MBq Tc-99m HMPAO, tomographic slices were obtained using a SPECT camera. Eight regions per hemisphere were drawn on each transaxial section, and tracer redistribution was calculated for each region. Region-to-whole slice ratios were determined for each patient. Patients had significantly decreased frontal/whole slice (1 +/- 0.02) ratios in comparison with a normal group (p less than 0.01). Twenty-four out of 26 patients (85.7%) demonstrated abnormal rCBF. Eighteen out of 28 (64.3%) showed activity lower in the left hemisphere than in the right. Using CT parameters, 60% of the patients had either sulcal widening and/or ventricular enlargement. The frontal region and the left hemisphere were more affected by alcohol than other regions. More cerebral blood flow changes than morphologic changes were found caused by alcoholism.

[High bone consolidation rates after humeral head-preserving revision surgery in non-unions of the proximal humerus]. / Hohe knöcherne Ausheilungsraten nach kopferhaltender Revision von proximalen Humeruspseudarthrosen.

BACKGROUND: Fractures of the subcapital and proximal humerus shaft region are common fractures of the human skeleton. Their treatment should provide an early functional after-care of the shoulder joint, that is prone to arthrofibrosis. Although the upper extremity is not weight-bearing the occurrence of proximal humerus non-unions leads to severe impairment with inability to work and restrictions of activity of daily life. The aim of this study was to investigate whether an operative revision of proximal humerus non-unions with reosteosynthesis and application of distant autologous bone grafts can lead to sufficient bone healing. The second aim was to find out whether patients achieved an acceptable functional outcome, as alternatively patients could be treated by reconstruction with a shoulder prosthesis. PATIENTS AND METHODS: 27 patients (female = 15, male = 12) with reosteosynthesis of the proximal humerus and proximal humeral shaft due to non-union after initially operative fracture treatment were included between 2008 and 2014. Average age of patients was 56 years (23-87), 48% had no comorbidities, while 52% of the patients had at least 1 comorbidity such as diabetes, hypertension or nicotine abusus. The mean number of prior surgical intervention was 1.2 (1-3). The mean time between initial surgery and re-osteosynthesis was 12.3 months. Patients with signs of infection pseudarthrosis were excluded. The initial type of osteosynthesis was with plates (n = 16; thereof PHILOS Plate n = 14), and intramedullary nails (T2, Targon Nail, PHN, Seidel Nail; n = 11). Revision surgery was done with plate osteosynthesis (n = 26; thereof PHILOS Plate n = 4; LC Plate n = 10; angle plate n = 12). In 23 patients (89%) a distant bone transplantation was done from the iliac crest, and 1 patient received allogenous bone. Three patients (11%) received bone morphogenetic protein 7 (BMP 7) in combination with distant bone graft. Intraoperative swabs from the pseudarthrosis area showed no bacterial pathogen after 14 days of incubation. DASH score and Constant score were used to evaluate the functional outcome after revision surgery. Bone healing was determined by standard X-rays and evaluated by a modified radiological score. RESULTS: 89% of the patients could be followed for an average of 28 months and the radiological follow-up was at 9 months. The radiological score showed very good (50%), or good results, and a sufficient bone healing was shown in 25 of 27 patients (93%). The pseudarthrosis revision surgery failed in two cases (n = 1 persisting non-union; n = 1 humeral head necrosis after re-operation with angle plate). DASH scores provided a mean of 40 ± 28.8 with a range from 0-97 points, and the results from the Constant score provided 45 ± 25.4. The analysis with variation of age showed a trend for better results in female patients < 60 years of age. As complications after bone graft 3 patients had persistent local dysesthesia (11%), in one case fracture of the iliac bone occurred that healed with conservative treatment. CONCLUSION: The pseudarthrosis revision surgery with humeral head preserving re-osteosynthesis with bone transplantation is an effective treatment for non-unions of the proximal humerus and the proximal humeral shaft and the current results showed high bone consolidation rates. As the functional results remained limited after revision an individual treatment decision should be made concerning the most appropriate therapy. While a shoulder prosthesis may be considered in the aged patient, a revision strategy with reosteosynthesis should be considered particularly in younger patients.

Synthesis of 3,6-disubstituted 7H-1,2,4-triazolo[3,4-b]-1,3,4-thiadiazines as novel analgesic/anti-inflammatory compounds.

In this study, a new class of 4-amino-3-substituted-1,2,4-triazole-5-thiones (1-4) and their corresponding condensed derivatives 3,6-disubstituted 7H-1,2,4-triazolo[3,4-b]-1,3,4-thiadiazines (1a-4c) were synthesized and evaluated for their analgesic/anti-inflammatory activities. All synthesized compounds were also tested for their gastric toxicity and antioxidant activity on acute administration. Most of the compounds showed significant activity in both carrageenan-induced oedema and acetic acid-induced writhing tests besides negligible gastrointestinal toxicity. The compounds showing less ulcerogenic effect also showed less lipid peroxidation (LPO) level. Most promising results were obtained with the compounds that placed a fluoro or a chloride on the phenyl ring at the sixth position of the fused ring.