Complications following implant removal in patients with proximal femur fractures - an observational study over 16 years.

BACKGROUND: Fractures of the proximal femur commonly occur but the majority of orthopaedic surgeons do not consider general hardware removal as a routine necessity. Indications and time interval for hardware removal in this special selected patient group is still controversial. Therefore we performed a retrospective study to address the following questions: 1) Is there a difference between the medically- (infection, mechanical problems, implant failure) and non-medically indicated group (patients demand, meteoro-sensitivity, foreign body sensation) in relation to complications? 2) Is there a correlation regarding time interval between implantation and removal comparing these two groups? 3) Is there a context related refracture rate? 4) Should non-medically indicated implant removal (IR) be performed due to persistent pressure from the patient? HYPOTHESIS: We hypothesized that non-medically indicated implant removals should be avoided due to a significantly higher number of associated complications. PATIENTS AND METHODS: A total of 371 consecutive patients with 424 hardware removal procedures following a proximal femur fracture, between 08/1992 and 11/2008, have been included. Study population was divided into two groups according to their indication for implant removal: medically indicated group (MIR) consisted of 299 patients (80.59%) and 72 patients (19.41%) were assigned to the non-medically indicated (NMIR) group. RESULTS: In the NMIR subgroup a total of (n = 21) 28% complications occurred compared to 11.46% in the MIR subgroup; (P < 0.005), 86.51% of IR in the MIR group were performed within 1.5 years, compared to 79.17% in the NMIR group after 2 to 3.5 years (NS). In the MIR group 1 refracture occurred, compared to 4 in the NMIR group (NS). CONCLUSION: Non-medically indicated implant removal should be avoided due to the higher complication rate of 28%. Surgeons and patients should be aware of the imminent complications and therefore implant removal should only be performed for good medical reasons. LEVEL OF EVIDENCE: Level IV. Historical case study.

Prevalence of iron deficiency across different tumors and its association with poor performance status, disease status and anemia.

BACKGROUND: Only limited data on the prevalence of iron deficiency (ID) and its correlation with clinical parameters are available in cancer. ID frequently contributes to the pathogenesis of anemia in patients with cancer and may lead to several symptoms such as impaired physical function, weakness and fatigue. PATIENTS AND METHODS: Parameters of iron status and clinical parameters were evaluated in 1528 patients with cancer who presented consecutively within a four-month period at our center. One thousand fifty-three patients had solid tumors and 475 hematological malignancies. RESULTS: ID [transferrin saturation (TSAT) < 20%] was noted in 645 (42.6%) of the 1513 patients with TSAT tests available and 500 (33.0%) were anemic. ID rates were highest in pancreatic (63.2%), colorectal (51.9%) and lung cancers (50.7%). Of the 409 iron-deficient patients in whom serum ferritin levels were available additionally to TSAT, 335 (81.9%) presented with functional ID (FID) (TSAT < 20%, serum ferritin ≥30 ng/ml) and 74 (18.1%) with absolute ID. In patients with solid tumors, prevalence of ID correlated with cancer stage at diagnosis (P = 0.001), disease status (P = 0.001) and ECOG performance status (P = 0.005). CONCLUSIONS: ID was frequently noted in cancer and was associated with advanced disease, close proximity to cancer therapy, and poor performance status in patients with solid tumors.

Elevated tryptase levels selectively cluster in myeloid neoplasms: a novel diagnostic approach and screen marker in clinical haematology.

BACKGROUND: Recent data suggest that tryptase, a mast cell enzyme, is expressed in neoplastic cells in myeloid leukaemias. In several of these patients, increased serum tryptase levels are detectable. MATERIALS AND METHODS: We have determined serum tryptase levels in 914 patients with haematological malignancies, including myeloproliferative disorders (n = 156), myelodysplastic syndromes (MDS, n = 241), acute myeloid leukaemia (AML, n = 317), systemic mastocytosis (SM, n = 81), non-Hodgkin's lymphoma (n = 59) and acute lymphoblastic leukaemia (n = 26). Moreover, tryptase was measured in 136 patients with non-neoplastic haematological disorders, 102 with non-haematological disorders and 164 healthy subjects. RESULTS: In healthy subjects, the median serum tryptase was 5.2 ng mL(-1). Elevated serum tryptase levels were found to cluster in myeloid neoplasm, whereas almost all patients with lymphoid neoplasms exhibited normal tryptase. Among myeloid neoplasms, elevated tryptase levels (> 15 ng mL(-1)) were recorded in > 90% of patients with SM, 38% with AML, 34% with CML and 25% with MDS. The highest tryptase levels, often > 1000 ng mL(-1), were found in advanced SM and core-binding-factor leukaemias. In most patients with non-neoplastic haematological disorders and non-haematological disorders analysed in our study, tryptase levels were normal, the exception being a few patients with end-stage kidney disease and helminth infections, in whom a slightly elevated tryptase was found. CONCLUSIONS: In summary, tryptase is a new diagnostic marker of myeloid neoplasms and a useful test in clinical haematology.

Coagulation factor XII (FXII) activity, activated FXII, distribution of FXII C46T gene polymorphism and coronary risk.

BACKGROUND: Whether factor XII (FXII) activity, its 46C>T polymorphism and activated FXII (FXIIa) are associated with coronary heart disease (CHD) remains to be determined. METHODS: FXII, FXIIa and the FXII 46C>T polymorphism were determined in a hospital-based cohort of 2615 patients undergoing coronary angiography. RESULTS: Fifty-seven per cent of the participants were identified as wild-type (46CC), 38% as heterozygous (46CT) and 5% as homozygous (46TT) for FXII 46C>T. FXII and FXIIa levels were significantly lower in carriers of the T-allele: 132 (97-151) U dL(-1) FXII in 46CC, 87 (77-99) U dL(-1) FXII in 46CT and 53 (42-67) U dL(-1) FXII in 46TT carriers (P < 0.001), and 2.8 (2.3-3.5) microg L(-1) FXIIa in CC, 2.1 (1.6-2.6) microg L(-1) FXIIa in CT and 1.2 (0.9-1.5) microg L(-1) FXIIa in TT carriers (P < 0.001; medians, lower and upper quartiles). Patients with stable CHD (n = 935), a history of myocardial infarction (n = 785) or who were suffering from acute coronary syndromes (ACS; n = 323) had significantly lower FXII levels than controls (n = 572). The differences remained statistically significant after adjustments for age, sex, diabetes mellitus, smoking, hypercholesterolemia and hypertension. Significantly reduced FXIIa levels in ACS patients lost significance once adjusted for covariates. FXII genotype was not associated with any clinical phenotype. CONCLUSION: Lower FXII activity represents an independent risk for CHD and ACS. This is not the case for FXIIa levels or the FXII 46C>T variation.

Association of low-grade inflammation with nephropathy in type 2 diabetic patients: role of elevated CRP-levels and 2 different gene-polymorphisms of proinflammatory cytokines.

BACKGROUND: Chronic inflammatory processes are thought to play a key role in the development of micro- and macrovascular complications in type 2 diabetes mellitus. An association between low -grade inflammation and type 2 diabetes has been described in some studies. We assayed the association of two frequent polymorphisms in proinflammatory cytokines: the interleukin 6 G(-174)C promoter polymorphism [IL-6G(-174)C], the exon 2 interleukin receptor antagonist insertion deletion polymorphism [IL1RA]) and serum CRP levels with the prevalence of diabetic nephropathy in patients suffering from type 2 diabetes mellitus. SUBJECTS AND METHODS: A total of 141 patients with type 2 diabetes mellitus, with and without diabetic nephropathy was genotyped for the above mentioned polymorphisms: 66 with normoalbuminuria, 31 with microalbuminuria and 44 with macroalbuminuria. CRP levels were analysed by a high sensitivity - immunnephelometric assay. RESULTS: While a significant association be-tween macroalbuminuria and CRP could be observed (p<0,015), no associations were found between IL-6G(-174)C or IL1RA genotype and any stage of nephropathy. CRP-levels were similar in the 3 different IL-6G(-174)C genotypes as well as in the 2 IL1RA genotypes. CONCLUSIONS: In type 2 diabetic subjects elevated CRP levels are associated with an increased prevalence of albuminuria. The two investigated proinflammatory polymorphisms do not seem to contribute to initiation of nephropathy in type 2 diabetic patients but we cannot exclude effects of these polymorphisms on course of nephropathy.

Polymorphism in the tissue factor region is associated with basal but not endotoxin-induced tissue factor-mRNA levels in leukocytes.

OBJECTIVE: Tissue factor (TF) plays a central role during disseminated intravascular coagulation (DIC) in sepsis. We hypothesized that a frequent D/I polymorphism, at nucleotide position -1208 in the promoter region, could influence TF-mRNA and downstream coagulation. METHODS: Basal- and lipopolysaccharide (LPS)-induced TF-mRNA expression, microparticle-associated TF-procoagulant activity and coagulation were determined in healthy men (n = 74) before and after endotoxin (LPS) infusion (2 ng kg(-1)). Basal values of TF-mRNA ranged between 34 and > 37.5 cycles. RESULTS: Baseline TF-mRNA levels significantly differed between genotypes: I/I carriers had almost 2-fold higher TF-mRNA levels compared to D/D carriers at baseline (P < 0.01). In accordance, higher levels of microparticle-associated TF-procoagulant activity could be seen in I/I carriers. However, the genotype did not affect basal or LPS-induced levels of prothrombin fragment F1+2, D-dimer or cytokines including tumor necrosis factor and interleukin-6. CONCLUSION: The TF-1208 polymorphism is functional in that it regulates basal TF-mRNA in circulating monocytes and circulating microparticle-associated TF-procoagulant activity in vivo, but does not influence the relative increase in TF-mRNA or coagulation activation during low-grade endotoxemia.

A polymorphism of the interleukin-6 gene promoter and idiopathic recurrent miscarriage.

BACKGROUND: Cytokines have been described to play a major role in the pathogenesis of idiopathic recurrent miscarriage (IRM). We investigated the association between IRM and a polymorphism of the interleukin-6 (IL-6) gene and IL-6 serum levels. METHODS: In a prospective case-control study, we studied 161 women with IRM and 124 healthy controls. Peripheral venous puncture, DNA extraction and PCR were employed to genotype women for the presence of a polymorphism at position -174 in the promoter region of IL-6. Serum IL-6 levels were assessed by a commercially available ELISA. RESULTS: Allele frequencies among women with IRM and controls were 63.4 and 58.1% respectively for allele G (wild type), and 36.6 and 41.9% respectively for allele C (mutant). No association between allele C and the occurrence of IRM was found (odds ratio 0.8; 95% confidence interval = 0.57-1.12; P = NS). IL-6 serum levels were not significantly different between genotypes and between the study and control groups. CONCLUSIONS: This is the first report on an IL-6 polymorphism in IRM. Although known to alter IL-6 expression, the IL-6 polymorphism investigated was not associated with IRM and alterations in IL-6 serum levels in a Middle-European Caucasian population.

[Heterotopic cystic pancreas as a growing submucous tumor close to the cardia of the stomach]. / Ektopes zystisch verändertes Pankreas als wachsender submuköser Tumor im Kardiabereich.

Ectopic pancreas, presenting as a growing submucosal tumor, is a rarity in stomach surgery. Up to now, only about 250 cases of ectopic pancreas have been described. To our knowledge this is the first report of ectopic pancreas found near the cardia. A 52 year old female patient suffered from unclear upper abdominal distress. Gastroscopy revealed a submucosal growing tumor near the cardia. The tumor was locally exceeded and histologically examined showing ectopic, cystic pancreatic tissue without signs of malignancy. Wound healing was without complications and the patient is now, two years later, free of symptoms. The preoperative diagnosis of ectopic pancreas still is rarely conclusive. Nevertheless, new techniques such as endoscopic sonography or transmucosal biopsies may provide a non-invasive alternative to surgery. However, currently, local excision with intraoperative frozen section still is the therapy of choice.

Genetic fingerprinting in mouthwashes of patients after allogeneic bone marrow transplantation.

Detection of chimerism by PCR analysis of short tandem repeats (STR) in blood samples of patients who received allogeneic bone marrow transplantation (BMT) has proved to be an important method for early detection of relapse. The prerequisite for this type of analysis is knowledge of donor and recipient pretransplantation genotypes. In some cases, recipient cells from time points prior to BMT are not available and the pretransplant fingerprint cannot be determined. As BM recipients only alter their genotype in blood cells, we attempted to identify patient's pretransplantation genotypes after transplantation in mouthwash samples that contain easily accessible epithelial cells. Of 17 patients who had undergone BMT between one week and 45 months prior to analysis, DNA was isolated from mouthwash cell pellets or from epithelial cells obtained from mouthwashes. PCR analysis of STR loci in the von Willebrand and the tyrosine hydroxylase genes were performed. Even though the mouthwash cell pellets contained about 75% epithelial cells (presumably of recipient origin) and only about 25% leukocytes (presumably of donor origin), three of five patients showed donor genotype and only two patients exhibited chimeric DNA patterns, when cellular DNA was obtained by boiling of mouthwash cell pellets. Following phenol/chloroform extraction, eight of 10 DNA samples exhibited a chimeric pattern, while two of 10 DNAs showed only donor genotype. Of three patients, epithelial cells were attached to magnetic beads prior to DNA isolation. Even this DNA contained donor and recipient material. From our results it appears that blood cells serve as preferential DNA source in mouthwash samples and cannot be removed by epithelial cell separation.

Decreased susceptibility of low-density lipoproteins to in-vitro oxidation after dextran-sulfate LDL-apheresis treatment.

Low-density lipoproteins (LDL)-apheresis is a well established treatment of severe hypercholesterolemia resulting in fast clinical improvement and angiographically proven regression after 6 months of therapy. The underlying mechanisms, beside lipoprotein removal, are still under debate. Recently, oxidized LDL were shown to be of key importance in foam cell formation and atherosclerotic lesion development. We examined the influence of dextran-sulfate LDL-apheresis on the susceptibility of LDL to oxidation in 6 patients (5 males, 1 female, age: 41-60 years) suffering from severe heterozygous hypercholesterolemia or combined hyperlipidemia. LDL-apheresis influenced the oxidizability of LDL by a significant (P < 0.01) prolongation of the median of lag time (min) for LDL samples (before treatment 75, range: 31-176 versus after treatment 129.5, range 45-286). A significant (P < 0.01) difference could be also observed in the amount of conjugated dienes as expressed by the maximum rate in absorbance (before treatment 15.39, range: 5.29-21.22 versus after treatment 20.20, range 12.88-72.33). Thiobarbituric acid reactive substances (TBARS) formation was significantly decreased in LDL obtained after apheresis treatment as compared to pretreatment LDL. Electrophoretic mobility (EM) of LDL obtained before and after LDL-apheresis revealed a significant increase (P < 0.05) from a mean of 8.8 +/- 0.5 to a mean of 10.5 +/- 0.5 mm. The titers of plasma autoantibodies against oxLDL (oLAb) which varied considerably interindividually, were not influenced by LDL-apheresis treatment. Levels of F2-isoprostanes, as measured by plasma levels of 8-iso-prostaglandin-F2 alpha (8-iso-PGF2 alpha), reflecting oxidative stress, did not change, either. In summary, our findings provide evidence that even one single dextran sulfate LDL-apheresis treatment decreases LDL-oxidizability, which is an additional beneficial effect to that of lipid lowering.

Quality assurance in a large American perinatal center.

The obstetric service of Hutzel Hospital in Detroit, Michigan is responsible for approximately 7,300 deliveries annually. To monitor the quality and appropriateness of patient care, recognize and pursue opportunities for improving care, and resolve identified problems in the obstetric service as well as other clinical areas, the hospital developed a quality assurance (QA) program. The application of clinical indicators represents the principal method by which relevant QA information is obtained. These indicators are designed to identify problems in patient care. The obstetric/gynecologic QA committee analyzes the results of this indicator-based review process as well as other information (appropriateness of surgery, drug usage, transfusions, utilization of hospital resources, etc.) and reports its findings to the full staff of the Department on a monthly basis. If necessary, actions are taken to correct problems. They include lectures, individual counselling, development of guidelines, addition of personnel and/or equipment, and indicated disciplinary actions. These remedial measures have led to improvements in clinical care such as, for example, a more appropriate usage of antibiotics and oxytocin, and stricter adherence to guidelines. More important, however, are the intangible changes in practice patterns that have occurred in that physicians and other members of the health care team tend to render care with an added degree of diligence and circumspection because of their awareness that an effective monitoring process exists.

Anesthesia-related maternal mortality in Michigan, 1972 to 1984.

We reviewed maternal deaths in the state of Michigan occurring from 1972 through 1984. There were 15 maternal deaths in which anesthesia was considered the primary cause and 4 deaths in which anesthesia was a contributory factor. Complications of regional anesthesia were the main cause of death during the early part of the period, whereas the inability to accomplish endotracheal intubation emerged as the principal cause of death in recent years. Eleven of the 15 patients had undergone cesarean section. Obesity was a risk factor in 12 patients, in an equal number of patients the risk factor was the emergent nature of the operation, and hypertensive disease was a risk factor in eight. Thirteen of the 15 deaths occurred in black patients.

PIP: A review of all maternal deaths occurring in Michigan in 1972-84 uncovered 15 deaths in which anesthesia was considered the primary cause and an additional 4 deaths in which anesthesia was a contributory factor. Overall, anesthesia-related deaths contributed 6.9% of the direct maternal mortality in the state during the period under review. The mean age of the 15 women was 24 years (range, 16-34 years). 13 of the 15 deaths involved black women, resulting in an anesthesia-related mortality rate of 4.26/100,000 live births for blacks compared to only 0.14/100,000 among whites. The causes of deaths attributable to anesthesia were pulmonary complications in 1 case, cardiac complications in 9 cases, central nervous system complications in 2 cases, and reactions to spinal or lumbar puncture in 3 cases. Complications of regional anesthesia were the main cause of death during the early part of the study period, while the inability to accomplish endotracheal intubation has been the principal cause in recent years. 11 women had undergone cesarean section. Risk factors included obesity in 12 cases, the emergent nature of the operation in 12 cases, and hypertensive disease in 8 cases. All 3 of these risk factors were present in 40% of the women who died, at least 2 were present in 80%, and at least 1 was present in 93%. Specific steps recommended to reduce the incidence of anesthesia-related maternal mortality include the use of regional anesthesia where indicated, development of a plan to deal with airway problems, use of up-to-date equipment and monitoring instruments, and use of antacids.

Effect of general anesthesia on fertilization and cleavage of human oocytes in vitro.

To determine whether anesthesia affects in vitro fertilization (IVF), the authors examined 3 1/2 years' experience with IVF. Anesthesia length significantly predicted fertilization and cleavage at stage 0 of stepwise multiple logistic regression analysis, but not at the final step. Oocyte grade, retrieval order, and a quadratic term for grade remained significant for fertilization; cleavage, order, the interaction of order and grade, and the quadratic term for grade remained significant. Order correlated with anesthesia (r = 0.675, P less than 0.001). Also inherent in order are CO2 pneumoperitoneum, increased prolactin, decreased gonadotropins, ovarian trauma, and time. First oocytes of equivalent grade from contralateral ovaries were compared. Fertilization rates were equivalent, but significantly fewer mature oocytes from the second ovary cleaved. Anesthetic agents and CO2 appear to adversely affect fertilization and cleavage in vitro.

Use of spinal anesthesia in laparoscopy for in vitro fertilization.

Regional anesthesia, in selected cases, is a useful alternative method of providing anesthesia for the retrieval of oocytes when general anesthesia is not indicated. We report our experience in managing anesthesia in four patients in whom we used a subarachnoid block. Ova were obtained in three patients, and two became pregnant and delivered healthy full-term infants. Although the high pregnancy rate was noted with delight, it is clearly a statistical happenstance. It would be interesting, however, to carry out prospective studies to determine whether a relationship between the incidence of pregnancy and anesthetic method might exist.

Gastric perforation during pelvic laparoscopy.

Gastric perforation is one of the recognized hazards of pelvic laparoscopy. Two such instances of perforation are presented and the role of gastric distention in causing this complication is examined. This article also reviews the literature and outlines the measures which can be taken to prevent and treat this complication.