Shoulder periprosthetic fracture in elderly patient: a minimally invasive osteosynthesis and "off-label" treatment with teriparatide. A case report and literature review.

A case of shoulder periprosthetic fracture in elderly patient. The patient underwent a minimally invasive osteosynthesis and "off-label" treatment with teriparatide. An 80-year-old woman patient following an accidental fall reported a transverse displaced diaphyseal fracture of the right humerus, distal to the stem of the inverse prosthesis. The patient suffering from severe osteoporosis and chronic ischaemic heart disease. The patient underwent fracture osteosynthesis surgery using a Hoffmann III mono-axial external fixator. Teriparatide administered at a dosage of 20 micrograms/day, for four months. At six months from the beginning of th e hybrid treatment, a complete healing of the fracture was observed radiologically and clinically. It is possible to affirm that the use of teriparatide off-label has a positive and additive effect in promoting the healing of fractures.

Multiple congenital bilateral trigger digits in a 2-year-old child: case report.

Trigger finger is a rare condition in children. In this paper, we report on a 2-year-old boy with multiple congenital bilateral trigger digits. The patient had no history of perinatal trauma, viral or bacterial infections, or metabolic disorders. The patient was treated with physiotherapy for one year. At the one-year follow-up, the boy presented with six trigger fingers (3 on the right hand, 3 on the left hand). Neither thumb was involved. The six trigger fingers were treated surgically: first, the right-hand trigger fingers and, six months later, those of the left hand. After each operation, a 4-week brace in extension was applied to the operated hand. The symptoms were completely resolved after surgical treatment. Many authors have recommended surgical release for the treatment of trigger finger in children; empirical treatment with physiotherapy may be an option when symptoms present or appear at an older age.

Meniscal tear repaired with Fast-Fix sutures: clinical results in stable versus ACL-deficient knees.

AIM: The aim of this prospective study was to analyze the results of meniscal tears repaired with Fast-Fix All-inside suture in stable versus anterior cruciate ligament (ACL)-deficient knees. PATIENTS: Forty patients, everybody professional players, all underwent arthroscopic surgery, were divided into two groups and followed-up for at least 24 months. Group A (stable knee affected with isolated meniscal tears) consisted of 20 patients treated exclusively with Fast-Fix suture. Group B (ACL-deficient knees affected with meniscal tears) consisted of 20 patients in which we performed a Fast-Fix suture with concurrent ACL reconstruction (hamstring duplicated). Comparing both Groups together, we have noticed that the good clinical result of meniscal sutures with ACL reconstruction associated has occurred faster than isolated meniscal suture, regardless of the meniscus, the knee, and age of the patient. In fact 6 months after surgery, in Group A, there was a success by 65% against 85% for the Group B with 8.3 points International Knee Documentation Committee (IKDC) difference in favor of the latter. Whereas 24 months after surgery, the percentage was increased achieving 90% in Group A and 95% in Group B with 12.6 points IKDC difference in favor of the Group B. A statistical analysis of variable, both after 6 and 24 months, showed a significant improvement of knee conditions for patients with ACL reconstruction. CONCLUSION: In conclusion, other than observing the better results in meniscal tears with ACL-deficient knee, we observed that among all cases the best healing occurred in patients affected by meniscal longitudinal vertical tears located in Red-Red zone of external meniscus with an extension of 10 mm in ACL-deficient knee, treated with Fast-Fix suture and ACL reconstruction associated.

Rotator cuff re-tear or non-healing: histopathological aspects and predictive factors.

PURPOSE: The aim of the study was to evaluate the histopathological changes that occur in the tendon and subacromial bursal tissue in patients with rotator cuff tear trying to correlate these changes to their healing capability. METHODS: Eighty-four patients were clinically evaluated with the Constant Scale. Radiographs and MRI were performed preoperatively and ultrasound were performed postoperatively. For each patient, a biopsy of the supraspinatus tendon and subacromial bursa was performed, and the specimens were histopathologically analyzed. RESULTS: Tendons histopathological features consisted of loss of structural organization, poor or absent neoangiogenesis, chondral metaplasia, and fibrosis. Bursal features consisted of neoangiogenesis, absence of chondral metaplasia, hyperplasia/hypertrophy, and absence of necrosis. Direct correlation was seen between tendon and bursal hyperplasia and time of the onset of symptoms; between tendon chondral metaplasia, fibrosis, bursal neoangiogenesis, inflammation, and patient age; between tendon neoangiogenesis, hyperplasia, necrosis, fibrosis, bursal necrosis, inflammation, and lesion size; on the contrary, tendon fibrosis, necrosis, and bursal tissue inflammation decrease as time passes from the onset of symptoms. Tendon fibers disarray, neoangiogenesis, and inflammation decreases as the patient's age increases. Bursal tissue fibrosis decreases as lesion size increases. CONCLUSIONS: Simple histopathological techniques should be employed routinely to assess the tissue quality, with the aim to predict future clinical evolution (repair or non-repair). Comparing the histopathological data with the demographical information and the descriptive statistics, it is possible to define the RCT repair at risk and identify which RCT will be able to heal.

Human insulin allergy: four case reports.

Insulin allergy was not uncommon in the past, but has lowered with the introduction of human recombinant insulin. Human recombinant insulin allergy is a rare condition, now reported in less than 1% of treated patients. However, it is a serious condition that requires an immediate allergological work-up. In this study, we describe 4 cases of IgE-mediated reaction to human recombinant insulin, emphasizing some practical aspects in diagnosis and treatment.

Immediate breast reconstruction in two stages using anatomical tissue expansion.

Over the last four years, 43 modified radical mastectomies and 13 simple mastectomies were done for 56 patients with breast cancer followed by immediate reconstruction in two stages using anatomical tissue expansion. In 49 patients a permanent prosthesis was successfully implanted while three patients refused a further operation, and four required removal of the expander. Complications were seen in 21 cases, including infection (n = 4), Baker III-IV contractures (n = 5), radiodermitis with breast distorsion (n = 3), and seroma (n = 2). Four patients required removal of the expander, and no further attempts were made to reconstruct the breast. All 10 patients given radiotherapy developed some kind of complication. After a mean follow up of 2.5 years (range 6-48 months), the aesthetic result was rated 6.9 and patient satisfaction 7.8 on a 0-10 scale. We concluded that immediate breast reconstruction with anatomical tissue expansion gives predictable aesthetic results, which satisfied most patients. Although the complication rate is high, it does not exceed complication rates associated with mastectomy alone or delayed reconstruction. At present, only patients undergoing preoperative or postoperative radiotherapy and hesitant patients are not considered to be candidates for this procedure.

Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgery: a 10-year analysis.

Infection of a median sternotomy wound is a rare though potentially fatal complication. Despite early diagnosis and proper treatment, prognosis is poor because of the chance of mediastinal spread of the infection and the poor physical state of these patients. Muscle repair is superior to more conservative surgical options such as sternal resuturing with mediastinal irrigation. During the last 10 years, complications--including sternal infections and dehiscences--have been encountered in 172/4725 median sternotomy wounds after cardiac surgery procedures (4%). Thirty-four patients (of whom 30 had acute sternal infections and four chronical sternal infections) underwent aggressive sternal debridement followed by muscle flap closure. Seventy-two muscle flaps were carried out, a pectoralis major bilateral muscle flap being the most common either alone or in combination with a rectus abdominis muscle flap. Five perioperative deaths (15%) were recorded. Of the 29 surviving patients, 25 patients (74%) were free of infection and four (12%) developed recurrence of the infection after a mean follow up of 3 years (range 49 days-8 years). We conclude that although muscle repair is not free of complications, it is reliable in reducing mediastinitis-related morbidity and mortality.

On the rationality of decision-making studies: Part 2: Divergent rationalities.

A study of treatment decision making in an Anishinaabe community in Manitoba, Canada was designed to be comparable with an earlier project carried out in a Mexican town. One objective was to compare the resulting decision models. For both communities, a decision-making perspective was compatible with how individuals talked about actions taken in response to illness, and it proved to be a useful means for learning about the process of seeking care. At the same time, a decision-modeling approach is better suited to explaining treatment actions taken in the Mexican community than in the Anishinaabe community. I suggest that this finding reflects the variable potentiality, in the Anishinaabe community, for affliction and its treatment to be constructed within a cultural framework in which the underlying assumptions differ from those implicit in studies of decision modeling.

On the rationality of decision-making studies: Part 1: Decision models of treatment choice.

With reference to both critiques and empirical studies, the theoretical and methodological grounding of anthropological research on medical decision making is examined in this article, giving particular attention to the construction and evaluation of cognitively oriented decision models. A decision-modeling study carried out in the Mexican village of Pichátaro (in conjunction with James C. Young) frames an exploration of some of the tensions and points of contention about the aims and designs of cognitively oriented studies of decision modeling. While a decision model can provide a reasonably good guide to an understanding of treatment actions and the culturally based rationality that underlies them, such models fall short when they are oriented primarily around predicting treatment accounts. They should also attend to the jointly cultural, personal, social, and cognitive constructive processes through which meaning is conferred upon the occurrence of illness.

The illness known as "twisted mouth" among the Nêhinaw (Cree).

This paper is based on interviews with two individuals who talked about their experiences with a condition known as "twisted mouth." While the biomedical label of Bell's palsy is often applied to such cases, the appropriateness of this label is not explored here. Rather, the focus is on how Nêhinaw (Cree) cultural understandings frame the experience of and response to illness, even when biomedical practitioners were consulted. The interviews were carried out by the first author using the Nêhinaw language as much as possible. Subtle linguistic clues within the interviews point to the pervasiveness of Nêhinaw cultural understandings.

Mutation in the avrBs1 Avirulence Gene of Xanthomonas campestris pv. vesicatoria Influences Survival of the Bacterium in Soil and Detached Leaf Tissue.

ABSTRACT The role of the avrBs1 avirulence gene of Xanthomonas campestris pv. vesicatoria in survival of the bacterium was investigated by testing two strains that differ in the structure and function of the gene in 37 different soil types of Barbados and detached leaf tissue of four pepper genotypes. One strain carried a mutation in the avrBs1 gene and lacked avirulence activity, while the other expressed wild-type avrBs1 activity. In 30 to 32 soil types and all leaf tissue tested, the mutant strain persisted longer and more abundantly than the wild-type strain over a 2- to 6-week period. During this time, the mutant strain generally replaced the wild-type strain completely in soil initially infested with a mixture of equal amounts of each strain and by a factor of 6.7 in similarly infested pepper leaves. Nine selected soil factors, namely pH, clay and cation content, and percent nitrogen, carbonates, carbon, K(+), Na(+), and Ca(2+) did not affect bacterial survival significantly.

Intracultural variation in causal accounts of diabetes: a comparison of three Canadian Anishinaabe (Ojibway) communities.

This paper presents a methodological approach for examining variation and consensus both within and between research settings and for addressing issues of generalizability and replicability. The comparison is based on how individuals diagnosed with diabetes and living in three Canadian Anishinaabe (Ojibway) communities explain diabetes and talk about their responses to the illness. Two kinds of interview format are used--an open-ended explanatory model type interview and a more structured, true-false, interview, amenable to analysis with cultural consensus theory. The responses given in both interviews converge on a set of explanations which can be found in all three communities, although differences occur in how these explanations are framed and emphasized. Implications of these differences and how these accounts relate to how individuals respond to diabetes are discussed. It is argued that the analysis of both interview formats leads to a deeper and more finely nuanced representation of understandings about causes of diabetes across the three communities than could be achieved by using one alone.

Metastatic tumours of the hand. Report of six additional cases.

Six metastatic tumours of the hand are reported. Five were located in long bones of the hand and one in the soft tissues without bone involvement. The primary tumours arose in the lung, kidney, hard palate, larynx and pharynx. Treatment was palliative and consisted of amputation for distal lesions and local excision and/or radiation for proximal lesions when symptomatic. Short-term prognosis was poor with a median survival of 7 months. In two patients, hand metastases were the first sign of malignant disease.

Congenital radioulnar synostosis. Surgical correction by derotational osteotomy.

We have evaluated 4 cases of congenital proximal radioulnar synostosis corrected by proximal derotational osteotomy. Surgery was only indicated in cases with more than 60 degrees of pronation. Mean age at the time of surgery was 7 years and 4 months and mean postoperative follow-up time was 8 years. Forearm position after surgery ranged from 15 to 0 degrees of pronation. Aesthetic and functional improvement was achieved in all cases. No complications were observed the Surgical technique is reviewed.

Individual or societal responsibility? Explanations of diabetes in an Anishinaabe (Ojibway) community.

In recent years, many aboriginal communities in North America have experienced increasing rates of maturity onset diabetes. This paper is based on interviews held with individuals diagnosed with diabetes in an Anishinaabe community in Manitoba, Canada. The varying ways people account for their own case of diabetes and the increase in diabetes generally are described. Although people talk about diabetes as a result of individual dietary choices, much of the discourse links diabetes to environmental and societal changes.

Chronic illness of the temporomandibular joints as experienced by support-group members.

PURPOSE: For temporomandibular disorders, the clinical situation is one of considerable etiologic, diagnostic, and therapeutic uncertainty. Using interview data, this report describes this condition and the search for care from the perspective of sufferers who are support-group members. PARTICIPANTS AND METHODS: Thirty-two individuals participated; all were members of a support group for individuals with long-term problems attributed to the temporomandibular joints and/or the surrounding masticatory muscles. Using a structured, open-ended interview format, this study investigated how individuals understand and give meaning to their symptoms, their patterns of care seeking, and the consequences of the illness on their lives. The participants also completed several structured questionnaires. RESULTS: For these support-group members, symptoms extended beyond the jaw and surrounding area, with extensive musculoskeletal involvement and resulting dysfunctions that have far-reaching consequences for the sufferers' lives. Primary care physicians are often consulted, especially early in the illness history. They also provide ongoing care and are asked for guidance when patients seek specialized treatment. A striking aspect of the findings from the interviews is the complex and costly pattern of health care seeking. This extended search for effective treatment is examined with reference to culturally based understanding, shared by patients and clinicians, about the nature of illness.

Narrative representations of chronic illness experience: cultural models of illness, mind, and body in stories concerning the temporomandibular joint (TMJ).

The narratives individuals told about their experiences with an illness they have come to understand as TMJ, a problem linked to the temporomandibular joints of the jaw, are complex. Each is embedded within a unique set of life circumstances and guided by individual schemas and explanatory models. Each recounts how persons have come to make sense of perplexing symptoms that are not easily categorized and treated within the North American health care system. Yet, in spite of their distinctiveness, the reconstructed narratives are not independent of shared cultural schemas, such as those relating to mind and body, and other shared models, such as the model for TMJ, which individuals come to adopt as a consequence of treatment and interaction with others. The consistent emergence of themes concerning the mind and body within and across narratives attest to their salience for understanding the narratives related here. While describing the effect of illness on individual lives, narratives also illuminate how shared understanding shape the interpretation and construction of individual experience.