Similar views on rehabilitation following hip arthroscopy among physiotherapists and surgeons in Scandinavia: a specialized care survey.

PURPOSE: The rising number of hip arthroscopies (HA) is leading to increasing numbers of patients requiring post-surgical rehabilitation; however, evidence regarding post-operative rehabilitation is currently limited. The purpose of the study was to describe and compare current rehabilitation strategies and views among surgeons and physiotherapists in Scandinavia. METHODS: Scandinavian surgeons and physiotherapists experienced with HA and post-surgical rehabilitation were asked to complete an online survey. Ninety clinicians (28 surgeons, 62 physiotherapists) responded. RESULTS: Both professions mostly rated physiotherapy as very or extremely important in the rehabilitation process. The majority advocated criteria-based or combined criteria- and time-based progression. Expected rehabilitation timelines were reported with large intra-professional variation but general inter-professional agreement. However, compared with physiotherapists surgeons expected fewer weeks on crutches and faster return to competitive sport. Surgeons more often reported use of evidence-based self-reported outcomes while physiotherapists more often evaluated readiness for return to play. CONCLUSIONS: Among surgeons and physiotherapists, physiotherapy is considered very important following HA. Generally, very similar views were held between professions. Surgeons expected reduced time on crutches and to return to competitive sports than physiotherapists. Surgeons also used evidence-based self-reported outcomes to a higher degree than physiotherapists. Being the first study to provide an overview on currently applied rehabilitation strategies following HA, results of this study may guide much needed, future research on the rehabilitation process following HA. LEVEL OF EVIDENCE: IV.

Screening mammography: a missed opportunity.

By age 80, 1/10 women will be diagnosed with breast cancer. Both positive and negative associations have been reported between alcohol consumption and breast cancer. Minority women are less likely to undergo breast cancer screening. All women admitted for alcohol detoxification in an urban setting with a high minority population were offered screening mammography, using American Cancer guidelines. Women with previously diagnosed breast cancer were excluded from the study. The mammograms were performed by standard technique in the hospital radiology department. The subjects with positive mammograms were referred for further diagnostic studies, as determined by the internist managing the patient's care. Of the 117 women admitted, 28 were excluded due to age. Only one woman, previously treated for breast cancer, was also excluded. Of the 88 women screened, abnormalities were detected in 32. The women with normal mammograms did not differ from those with abnormal studies in: (1) age; (2) years of alcohol consumption; (3) age at menarche; (4) parity; (5) age at first full term pregnancy; and (6) personal history of benign breast disease or family history of breast cancer. The alcohol detoxification unit provides a unique opportunity to screen women for breast cancer. Compliance with initial screening is high but resistance is encountered if further diagnostic studies are required to evaluate suspicious lesions. Surprisingly, in this study, the number of suspicious lesions detected was not higher than expected.

Second surgical opinion programs: dead or alive?

BACKGROUND: In the 1970s, second surgical opinion programs were established in an effort to improve medical care and to control health care costs. The cost-effectiveness of these programs has been questioned recently. STUDY DESIGN: A retrospective review was conducted of elective second-opinion surgical consultations for members of Local 32B-J of the International Service Employees Union for the years 1993-1994. Nonconfirmed consultations were reviewed against claims history data for the subsequent 2 years. Data were analyzed for rates of nonconfirmation by diagnosis and surgical specialty and for cost-effectiveness benefit. RESULTS: Of the 5,601 second surgical consultations performed, 490 procedures were not confirmed as medically necessary (9%). Claims history survey for these 490 patients for the 2 years following the consultation revealed that no operation was performed in 62%. The highest nonconfirmation rate (41%) was in plastic and reconstructive surgery, followed by gynecology (22%). The cost-benefit ratio for the program was calculated to be 1.34. CONCLUSIONS: A second surgical opinion program confers both cognitive and psychologic beneficial effects on Joint Trust Fund members and their dependents who are advised to undergo elective operations. Our current second surgical opinion nonconfirmation rate is 9%, with hysterectomy, prostatectomy, and bunionectomy among the procedures most frequently nonconfirmed. The cost-benefit ratio was estimated at 1.34.

The role of alcoholism and liver disease in the appearance of serum antibodies against acetaldehyde adducts.

We recently presented preliminary data indicating the presence of antibodies against acetaldehyde adducts in sera of over 70% of alcoholic patients. To assess the respective roles of liver disease and alcohol consumption as well as the specificity of this immune response, 141 patients in various stages of alcoholic and nonalcoholic liver diseases were tested by a hemagglutination assay. Sixty-three (73%) of 86 alcoholics had antibody titers above control levels (p less than 0.0001). Alcohol consumption of these individuals was significantly higher (p less than 0.001) than that of those alcoholics with normal titers. Twenty-two patients (39%) with nonalcoholic liver diseases also had elevated levels of antibodies against acetaldehyde adducts (p less than 0.0005); of these, 8 had primary biliary cirrhosis (7 in Stages III and IV), 9 had chronic active hepatitis (6 with cirrhosis) and 5 had acute (virus- or drug-induced) hepatitis. Antibody titers did not correlate with levels of transaminase or alkaline phosphatase activity, nor with bilirubin, and albumin. However, in 52 alcoholics and in nonalcoholic patients with biopsy-confirmed liver disease, the highest titers were seen in the more advanced stages of liver damage. Thus, in addition to alcohol consumption, severity of liver disease may play a role in the appearance of circulating antibodies against acetaldehyde adducts.

Serum procollagen type III N-terminal peptides and laminin P1 peptide in alcoholic liver disease.

The appearance of perivenular fibrosis on liver biopsy reflects the beginning of the fibrotic process that ultimately results in liver cirrhosis. To examine whether the fibrogenic activity can be detected by blood tests, we evaluated whole antibody radioimmunoassay (RIA) of procollagen type III N-terminal peptides (P-III-P), RIA of these peptides using Fab fragments (Fab-P-III-P), and RIA of the laminin P1 peptide in alcoholics within 1 week of alcohol abstinence. The Fab-P-III-P levels in subjects with perivenular fibrosis were significantly higher than those in patients with simple fatty liver. Values in 63% of subjects with perivenular fibrosis exceeded the upper limit of the fatty liver group. Patients with simple fatty liver had significantly lower values than nonalcoholic controls. Serum levels of P-III-P and laminin were elevated in patients with alcoholic hepatitis and correlated well with the degree of inflammation. With abstinence, Fab-P-III-P levels increased in all alcoholics. P-III-P values increased in patients with normal P-III-P values on admission. By contrast, the values of laminin decreased during abstinence. Therefore, to interpret serum levels of Fab-P-III-P, P-III-P, and laminin, the duration of abstinence must be taken into consideration. P-III-P, Fab-P-III-P and laminin measurements in the serum within 1 week of abstinence can contribute to the detection of alcoholic liver disease and the determination of its stage.

Liver fibrosis in alcoholics. Detection by Fab radioimmunoassay of serum procollagen III peptides.

Radioimmunoassays were used to measure serum levels of laminin and of procollagen III peptides, both with the intact antibody and with the Fab fragments, within one week of alcohol withdrawal in 83 alcoholics admitted for detoxification and/or treatment of concomitant medical problems. All patients underwent a diagnostic liver biopsy, which revealed simple fatty liver in 22, perivenular fibrosis in 20, septal fibrosis in 21, and cirrhosis in 20. Although all three serum measurements correlated significantly with the degree of fibrosis, only the Fab radioimmunoassay of procollagen III peptides discriminated between simple fatty liver and perivenular fibrosis in a significant number of subjects.

Balloon cytology in screening of asymptomatic alcoholics for esophageal cancer, Part I.

We assessed the feasibility of using balloon cytology to screen an asymptomatic group of alcoholics at increased risk for esophageal cancer. The results indicate that this group can be studied with minimal morbidity and that useful material can be obtained in 85% of subjects. Keratinization was present in 68% of specimens and fungus was noted in 9%. Individuals with moderate to large amounts of keratinization consumed significantly more alcohol than those without cytologic evidence of keratin. We speculate that keratinization and fungus may represent markers of enhanced malignant potential in this population.

Perivenular fibrosis as precursor lesion of cirrhosis.

Thirty-four male alcoholics underwent sequential liver biopsies as part of their evaluation. Of 19 subjects with simple fatty livers, only three showed progression of liver disease: one developed perivenular fibrosis after two years; a second showed no progression after three years, but developed perivenular fibrosis after four years; the third subject likewise showed no progression after one year, but developed incomplete cirrhosis after six years. In contrast, of 15 subjects with perivenular fibrosis at the time of the initial biopsy, 13 progressed to more severe stages of liver disease during a one- to four-year follow-up interval. Nine developed fibrosis, one developed incomplete cirrhosis and three developed cirrhosis. Thus, patients with perivenular fibrosis at the fatty liver stage are likely to progress to more severe stages of alcoholic liver disease if they continue to consume alcohol.

Frequency of hyperprolinemia in alcoholic liver cirrhosis: relationship to blood lactate.

In alcohol-induced liver injury, hyperprolinemia has been proposed as a marker of fibrogenesis probably secondary to hyperlactacidemia. However, some studies of plasma proline in alcoholics with cirrhosis have reported normal rather than increased levels. In order to evaluate the frequency of hyperprolinemia in alcoholic liver disease and its relationship to blood lactate, we measured plasma proline levels in 145 subjects including 91 alcoholics with a spectrum of liver disease as well as 22 nonalcoholics with liver injury unrelated to alcohol. We also studied baboons fed alcohol as 50% of total calories for 1 to 4 years. Among alcoholics only 21/91 had elevated proline values. Elevations were most frequent among patients with severe hepatic decompensation (3/8), in patients with alcoholic hepatitis on liver biopsy (5/17), and in those with acute alcohol-related withdrawal, with alcohol still present in the blood (4/9). Patients with liver disease unrelated to alcohol but severe in nature also has elevations in proline (3/3). Only 4/28 patients with cirrhosis due to alcohol had elevated values, and none of the baboons fed alcohol had hyperprolinemia whether withdrawn from alcohol or not. Hyperlactacidemia was associated with hyperprolinemia, but so were depressed serum albumin values and prolongations of the prothrombin time, suggesting a general association with severe liver disease. These results reveal that hyperprolinemia occurs infrequently in patients with alcohol-induced cirrhosis and therefore does not appear to be a sensitive marker of hepatic fibrosis in these patients.

Perivenular fibrosis in alcoholic liver injury: ultrastructure and histologic progression.

Twenty alcoholic patients underwent sequential biopsy of the liver as part of their medical evaluation. Of the 10 patients with simple fatty liver, 9 showed no progression of the histologic lesion after 1-2 yr. By contrast, of 10 patients with perivenular fibrosis, of the 9 who continued to drink all showed progression. Laboratory parameters did not distinguish between these two groups at the time of initial biopsy. The ultrastructure of the perivenular lesion was evaluated in 11 patients. The thickness of the perivenular rim was variable, but there was a good correlation between the thickness of the perivenular rim and the number of mesenchymal cells surrounding the venules (correlation coefficient r = 0.7634, p less than 0.001). Myofibroblasts represented the most common cell type but there was also infiltration with other mononuclear cells. Collagen fibers surrounding myofibroblasts were observed in the perivenular fibrotic area. Thus, in the group of alcoholics who were investigated in this study, myofibroblast proliferation and collagen deposition around the terminal hepatic venule represent the first apparent lesions in the sequence of events leading to alcoholic cirrhosis.

Plasma glutamate dehydrogenase: clinical application in patients with alcoholic liver disease.

The time course of plasma glutamate dehydrogenase (GDH) elevation was studied in 42 male alcoholics admitted for alcohol detoxification or for the treatment of medical complications of alcoholism and in 2 volunteers consuming 2 g/kg/day of ethanol under metabolic ward conditions. GDH values were usually highest during or immediately after cessation of drinking; thereafter, they fell rapidly toward the normal range. Early GDH values correlated well with liver histology in 37 patients who subsequently underwent diagnostic liver biopsy.

Alcohol-related diseases and carcinogenesis.

Possible mechanisms whereby alcohol abuse and alcohol-related diseases may promote the development of cancer are analyzed. The mechanisms discussed include: (a) contact-related local effects on the upper gastrointestinal tract; (b) the presence of low levels of carcinogens in alcoholic beverages; (c) induction of microsomal enzymes involved in carcinogen metabolism; (d) various types of cellular injury produced by ethanol and its metabolites and their relationship to cancer, particularly in the liver; (e) the nutritional disturbances frequently associated with alcohol abuse. The relationship between alcohol-induced cirrhosis and hepatocellular carcinoma is also discussed, and case histories of patients seen at the Bronx Veterans Administration Medical Center with hepatocellular carcinoma in the absence of cirrhosis are reviewed. Data are presented demonstrating the induction, by chronic ethanol consumption, of microsomal enzymes which convert procarcinogens to carcinogens. These data were derived from experiments in which the ability of microsomes isolated from liver, intestine, and lung tissues of ethanol-fed and control rats to activate several test carcinogens was examined in the Ames Salmonella-mutagenicity test. The hypothesis is presented that ethanol-mediated induction of enzyme systems which activate procarcinogens to carcinogens in various tissues contributes to the enhanced incidence of cancer in the alcoholic.