Total knee arthroplasty for acute tibial plateau fractures: a survey amongst 68 Dutch orthopaedic surgeons.

In older patients with highly comminuted intra- articular tibial plateau fractures (TPFs), primary total knee arthroplasty (TKA) may be a treatment option. Our aim was to report and rank decisional factors considered by Dutch orthopaedic trauma and knee surgeons that may lead to the decision for TKA as treatment for TPFs. A survey was distributed among 141 experts on traumatology and arthroplasty of the knee. The survey assessed the likelihood of TKA surgery after TPF in various patient and radiological characteristics. The level of experience with this of each responder was also noted. Descriptive statistics were calculated for all items. 141 participants were approached and 68 responded (48.2%). Responders were not more likely to proceed with TKA based on fracture types, impaired mobility, multiple incisions for ORIF, body mass index and ASA classification. However, in patients with pre-existing osteoarthritis (OA) and age ≥ 80 a majority would be more likely to proceed with TKA, with respectively 69.1% and 50.0%. The most strongly considered factors were the presence of pre-existing OA, the age of the patient and the type of fracture, with respectively 55.9%, 51.4% and 42.6% of responders ranking it in their top three most important factors. The study showed that the presence of pre-existing symptomatic OA and age of the patient were valued highest and increased the probability of a TKA in acute TPFs.

Lever sign test shows high diagnostic accuracy for anterior cruciate ligament injuries: A systematic review and meta-analysis of 3299 observations.

PURPOSE: Injuries of the anterior cruciate ligament (ACL) are common knee injuries among active and younger patients. The Lever Sign Test (LST) is a relatively newer test, of which the accuracy is disputed in the existing literature. The aim of this study was to assess the accuracy with and without anesthesia of the Lever Sign test in the literature. METHODS: PRISMA guidelines were followed, studies were identified using PubMed, EMBASE and Google Scholar. All studies that reported accuracy of LST performed by a clinical professional were included. Integrity of ACL was confirmed using magnetic resonance imaging or arthroscopy. Sensitivity and specificity were calculated using uni- and bivariate methods. RESULTS: After inclusion, 3299 observations in 2516 patients were included from 23 studies. Mean age was 31.8 years and 64.2% were male. Without anesthesia, sensitivity was 79.2% (95% CI 68.7-86.9) and specificity was 92.0% (95% CI 82.2-96.6). An area under the curve (AUC) of 86.1% was found. With anesthesia, sensitivity was 86.6% (95% CI 68.0-95.2), specificity was 93.4% (95% CI 84.5-97.3) and the AUC was 91.6%. CONCLUSION: The Lever Sign test shows very good to excellent accuracy for ACL injury, and is a useful tool for clinical practice.

Social network analysis in pigs: impacts of significant dyads on general network and centrality parameters.

In general, one animal is considered dominant over another animal if it has won more fights than its opponent. Whether this difference in won and lost fights is significant is neglected in most studies. Thus, the present study evaluates the impact of two different calculation methods for dyadic interactions with a significant asymmetric outcome on the results of social network analysis regarding agonistic interactions of pigs in three different mixing events (weaned piglets, fattening pigs and gilts). Directly after mixing, all animals were video recorded for 17 (fattening pigs, gilts) and 28 h (weaned piglets), documenting agonistic interactions. Two calculation methods for significant dyads, that is, dyadic interactions with a clear dominant subordinate relationship in which one animal has won significantly more fights than its encounter, were proposed: pen individual limits were calculated by a sign test considering the differences of won and lost fights of all dyadic interactions in each pen; dyad individual limits were determined by a one-sided sign test for each individual dyad. For all data sets (ALL, including all dyadic interactions; PEN or DYAD, including only significant dyads according to pen or dyad individual limits), networks were built based on the information of initiator and receiver with the pigs as nodes and the edges between them illustrating attacks. General network parameters describing the whole network structure and centrality parameters describing the position of each animal in the network were calculated. Both pen and dyad individual limits revealed only a small percentage of significant dyads for weaned piglets (12.4% or 8.8%), fattening pigs (4.2% or 0.6%) and gilts (3.6% or 0.4%). The comparison between the data sets revealed only high Spearman's rank correlation coefficients (rS) for the density, that is, percentage of possible edges that were actually present in the network, whereas the centrality parameters showed only moderate rS values (0.37 to 0.75). Thus, the rank order of the animals changed due to the exclusion of insignificant dyads, which shows that the results obtained from social network analysis are clearly influenced if insignificant dyads are excluded from the analyses. Due to the fact that the pen individual limits consider the overall level of agonistic interactions within each pen, this calculation method should be preferred over the dyad individual limits. Otherwise, too many animals in the group became isolated nodes with zero centrality for which no statement about their position within the network can be made.

[An unusual case of carotid arrosion bleeding]. / Ein ungewöhnlicher Fall einer Karotisarrosionsblutung.

Carotid bleeding is one of the most severe complications in ear, nose and throat (ENT) surgery. It is a rare complication in patients with cancer of the head and neck after radiochemotherapy. We report the case of a 65-year-old man who suffered from cancer of the tonsils (pT2pN1M0) and was treated in 1987 with surgery and local chemotherapy. Since then he reported recurrent bleeding in the left cervical region especially during physical exertion. The patient was re-operated and during surgery the tip of a catheter was found in the external carotid artery, obviously a remnant from a catheter for intra-arterial chemotherapy. The tip was removed, the defect closed and covered with a pectoralis major muscle flap.

Use of low-molecular-weight heparin in the treatment of venous thromboembolic disease: answers to frequently asked questions. The Thrombophilia Center Investigators.

Low-molecular-weight heparins (LMWHs) represent an important therapeutic advance in the treatment of patients with venous thromboembolism. The use of LMWH has potential advantages in comparison with the use of standard unfractionated heparin (UH), including decreased binding to nonanticoagulant-related plasma proteins, greater bioavailability, longer half-life, and lower incidence of the heparin-induced thrombocytopenia syndrome. Because of the predictable anticoagulant response of LMWH when administered subcutaneously, laboratory monitoring is unnecessary, and the drug can be used to treat selected patients with venous thromboembolism in outpatient setting. Numerous studies have shown that the treatment of venous thromboembolism with LMWH is as safe and effective as that with standard UH when both are used appropriately. Allied health personnel can easily teach most patients to self-administer LMWH subcutaneously for home use. Transition of the treatment regimen to oral warfarin anticoagulation necessitates an overlap with heparin (UH or LMWH) for at least 4 to 5 days, and the international normalized ratio should ideally be 2.0 or higher for 2 consecutive days before heparin therapy is discontinued. A practical understanding of the pharmacology, risks, and benefits of LMWH in the treatment of venous thromboembolism will enhance the primary-care physician's ability to care for patients safely and cost-effectively.

[Magnetic resonance tomographic studies of paragangliomas of the glomus caroticum and glomus jugulare using Gd-DTPA]. / Kernspintomographische Untersuchungen von Paragangliomen des Glomus caroticum und Glomus jugulare mit Gd-DTPA.

The value of magnetic resonance tomography in the diagnosis of paragangliomas in the head and neck has been studied and compared with CT and angiography. Magnetic resonance tomography on its own equals the accuracy of CT, but the use of Gd-DTPA improves diagnostic accuracy. In 19 patients with a glomus jugulare tumour, MR tomography with Gd-DTPA accurately diagnosed all tumours larger than 5 mm. In seven patients with a carotid body tumour, it was possible to arrive at an exact differential diagnosis. Sensitivity was better than that of CT or of sonography. Where there is clinical suspicion of a glomus tumour, magnetic resonance tomography with Gd-DTPA should be the first investigation; if there is a positive finding, angiography should be carried out to demonstrate the circle of Willis.

[Magnetic resonance tomography in suspected acoustic neurinoma: technic and differential diagnosis]. / Kernspintomographische Untersuchungen bei Verdacht auf Akustikusneurinom. Vorgehen und differentialdiagnostische Uberlegungen.

Sixty-five patients with suspected acoustic neuromas were examined by CT and MR; the optimal diagnostic procedures are discussed. Extrameatal acoustic neuromas (11 cases) were all diagnosed by CT and MR, but only 82% of intrameatal tumours could be diagnosed by CT combined with air cisternography. Using special surface coils and the paramagnetic contrast medium Gd-DTPA, the accuracy of MR was 100%. All tumours greater than 4 mm were demonstrated. Following clinical and neurological examination, MR is the primary diagnostic method in the investigation of acoustic neuromas.

Ultrastructural localization of K+-dependent, ouabain-sensitive NPPase (Na-K-ATPase) in the guinea pig inner ear.

Ultrastructural localization of the phosphatase component of Na-K-ATPase in the inner ear of the guinea pig was studied utilizing p-nitrophenyl phosphate (NPP) as substrate. In the stria vascularis NPPase activity was restricted to the cytoplasmatic side of the basal plasma membranes of the marginal cells. In the spiral prominence enzyme activity was resolved only occasionally on the basolateral membranes of the spiral prominence epithelium, especially after longer incubation periods. The remaining inner ear tissue was unreactive. Possible transport mechanisms of potassium across the apical marginal cell membrane are discussed.

Changes in serum osmolarity influence the function of outer hair cells.

Fast motility of outer hair cells (OHC) is thought to be based on a hydromechanic principle. In vitro, the function of OHCs can be disturbed by a change in the osmolarity of the culture medium. Whether changes in the serum osmolarity in vivo can also interfere with OHC motility has not been investigated as yet. Serum osmolarity of New Zealand White rabbits (n = 18) was elevated by a continuous infusion of glucose 40%, decreased by an infusion of aqua dest, or kept constant by an infusion of saline. OHC function was monitored using distortion products of otoacoustic emissions (DPOAE). Input output curves were established between 2 and 5 kHz (geometric mean of f2) with primaries of levels between 35 and 55 dB SPL. Cochlear perfusion was measured using a fluorescence microsphere method. Elevation of the serum osmolarity from 306 +/- 17 mosm/l to 365 +/- 23 induced a decrease of DPOAE between 3 and 12 dB SPL. Cochlear blood flow increased from 0.11 +/- 0.09 to 0.15 +/- 0.10 ml/min/g. When decreasing the serum osmolarity from 303 +/- 9 to 281 +/- 8 mosm/l, only slight changes of the DPOAE could be verified. As in the control group, cochlear perfusion was almost unchanged. In the control group, neither serum osmolarity nor DPOAE changed. Comparable to findings in vitro, increasing the serum osmolarity can lead to a disturbance of OHC function. In patients suffering from sudden hearing loss. dehydration due to physical or mental stress is often observed. This new and promising pathophysiological concept needs further clinical evaluation.

Cetirizine and pseudoephedrine retard, given alone or in combination, in patients with seasonal allergic rhinitis.

We compared the efficacy and safety of cetirizine (5 mg), pseudoephedrine retard (120 mg), and the combination of cetirizine (5 mg) with pseudoephedrine retard (120 mg), each given twice daily for two weeks to subjects with pollen-associated allergic rhinitis. The study was multicentre and of randomized, double-blind, parallel-group design. Five rhinitis symptoms were rated according to severity on a scale of 0 - 3, daily by patients and at each clinic visit by investigators. A total of 687 patients, aged 9 - 66 years (mean: 32 years) was randomised to treatment (cetirizine: 231; pseudoephedrine: 226; combination: 230). On entry, the three groups were comparable in relevant respects. The primary outcome measure was based on the five symptoms assessed by the patients over the 2-week treatment period. The combination was more effective, providing at least 20% more "comfortable days" (symptoms absent or at most mild) than cetirizine or pseudoephedrine given alone (median values: 53.3%, 30.8%, and 33.3%, respectively; p < 0.001). For nasal obstruction, the combination (mean score: 1.19) was more effective than cetirizine (mean score: 1.43; p = 0.0005), but there was little difference between the combination and pseudoephedrine (mean score: 1.22; not significant). Sneezing, rhinorrhoea, nasal and ocular pruritus were better controlled by combination (mean 4-symptom score: 0.77) than by pseudoephedrine alone (mean 4-symptom score: 1.12; p < 0.001) and also better than by cetirizine alone (mean 4-symptom score: 0.93; p < 0.001). No unexpected adverse reactions were observed. A combination of cetirizine and pseudoephedrine retard is well tolerated and superior to each given alone for moderate to severe allergic seasonal rhinitis, especially when nasal obstruction is a predominant symptom.

Demonstration of statistically significant correlations between 8 and 12 kHz atmospherics and sudden deafness.

In the last few years we have shown that atmospherics of different frequencies correlate with the onset of epileptic fits, heart infarcts and with the intensity of an inflammation reaction in rats. Now we show that sudden deafnesses are related (multiple R2 - 0.08) with the onset of 12 kHz in the first part of the day before the sudden deafness and the absence of 8 kHz in the first part of the day of this event.

[Possible variations of free autogenous jejunum transplantation for differential reconstruction of the oropharynx]. / Variationsmöglichkeiten der freien autogenen Jejunumtransplantation zur differenzierten Rekonstruktion des Oropharynx.

INTRODUCTION: Resections of extensive tumours, recurrences and radiodermatitides at the neck cause complex defects. Free bowel transplantation enables one-stage reconstruction. PATIENTS AND METHODS: In 35 out of 57 interdisciplinarily treated patients, small-bowel transplantation was performed for reconstruction. Thirty patients received cylinder grafts, five jejunal patch plastics. In four patients neoglottis formations according to Ehrenberger were performed. To cover soft tissue defects, two patients received scapular free flaps, eight patients a jejunal segment, incised at the anti-mesenteric side, the mucosa stripped and covered by a split skin graft. RESULTS AND CONCLUSIONS: Thirty-four grafts were viable. One patient received a successful re-transplantation. One postoperative fistula at the hypo-pharyngojejunostomy was closed by a separated jejunal segment which was primarily used as monitor, two others by pectoral flaps. Separation of a jejunal graft into two or three segments enables restoration of swallowing, voice and covering soft tissue in a one-stage procedure. The whole reconstruction necessitates only one arterial and one venous microanastomosis at the neck.

[All sudden hearing losses are not alike. Away from infusion therapy?]. / Hörsturz ist nicht gleich Hörsturz. Weg von der Infusionstherapie?

The number of patients requiring treatment for acute functional disorders of the inner ear has increased over the last decades. The diagnosis sudden loss of hearing is made when the cause of a precipitous hearing impairment cannot be determined with clinical diagnostic means. In the large majority of such cases, the pathogenesis is unclear, with vascular, viral and autoimmune processes most commonly being considered. Against this background, numerous polypragmatic therapeutic measures are employed. In general treatment of sudden loss of hearing employs a combination of several drugs with perfusion-promoting or anti-inflammatory effects. However, the efficacy of such an approach has not been established. The present article discusses a number of known ideas on the pathogenesis of this condition, together with the associated therapeutic strategies, and reports on the importance of nitrogen oxide (NO), which as recent studies appear to show, plays an important role in the physiology of the cochlea.

[Otorhinolaryngological aspects of high altitude medicine]. / HNO-ärztliche Aspekte der Höhenmedizin.

The World Health Organisation estimates that about 40 million tourists every year climb to high (2,500-5,300 m) and extremely high altitudes (5,300-8,850 m). Thus altitude sickness and other health risks are increasing accordingly and so this fact requires clarification and advice for tourists in order to reduce the risks. That applies to the otolaryngologist, too. The non-traumatic health risks all result from the atmospheric conditions at high altitudes, in particular due to the lower atmospheric pressure. The partial pressure of oxygen (pO2), the temperature and the partial pressure of water vapour decrease continuously with increasing altitude and at the summit of the highest mountain on earth, Mt. Everest, the pO2 is reduced by two-thirds, from 212 to about 70 hPa. The temperature drops on average 6.5 degrees C per 1,000 m and at -20 degrees C 1 m3 of air contains at most just about 1 g of water vapour. The shortage of oxygen above 2500 m cannot be compensated for at once. Respiratory alcalosis, followed by hyperventilation, improves the alveolar loading of red blood cells (RBC) with oxygen, however, it also reduces the ventilatory drive from the central CO2-chemosensors as well from the peripheral O2-chemosensors located in the carotid bodies. Not until the alcalosis has been balanced by a renal secretion of bicarbonate, does the pO2-driven ventilatory stimulus normalize and the relative increase of RBC as a result of altitude diuresis improve and complete the acclimatisation. Up to an altitude of 4,000 m this adaptation takes several days to one week and up to 5,000 m up to 2 weeks. If acclimatisation has not taken place or has been insufficient, acute mountain sickness may develop. It is a harmless disorder, although it noticeably affects people physically and mentally and in some rare cases it might even develop into a life-threatening high-altitude edema in the brain or in the lung. Hematocrit values of up to 58 or even 60% at great altitudes are quite usual. Up to an altitude of 7,500 m the distortion product signals of the otoacustic emissions decrease not only between 1,000 and 1,500 Hz, but also between 3,000 and 4,000 Hz. The reduction of the inner ear signals, however, is reversible and disappears after descent. For the vestibular organ high altitudes do not mean a risk, either. 70% of all infections suffered by trekkers and climbers affect the upper airways. The cold, dry mountain air damages the mucociliary apparatus and thus leads a disposition towards acute recurrences in climbers suffering from chronic inflammations of the tonsils, the paranasal sinuses and the middle ear. In the oxygen-poor air these recurrences do not heal at all, or only very slowly, but also often tend to have a rather more complicated course.

[Adverse effects of drugs on the hearing organ]. / Medikament-Nebenwirkungen auf das Hörorgan.

Many different classes of drugs are known to produce ototoxicity. They include such commonly used agents as salicylates and diuretics but the most important of them are the ototoxic antibiotics, particularly those of the aminoglycoside group. The toxic effects result from an initial selective damaging to the organ of Corti (hair cells) or the secretory cells of the stria vascularis. Both damaging mechanisms are dose-dependent. The ototoxic risk of the different drugs is described.

[Electron microscopy cytochemical studies on electrolyte transport in the lateral cochlear wall]. / Elektronenmikroskopisch-zytochemische Untersuchungen zum Elektrolyttransport in der seitlichen Schneckenwand.

The results of electronmicroscopic-cytochemical studies on the localization of the membrane-bound enzymes Na-K-ATPase and adenylcyclase in the lateral cochlear wall are presented. Their functional significance in cochlear ion and fluid transport is discussed.

Cytochemical localization of adenylcyclase in the lateral wall of the inner ear.

The cytochemical localization of adenylcyclase in the lateral cochlear wall was studied using a modification of the Reik -Howell method. All the cell membranes of the stria vascularis and spiral prominence cells, except the vascular endothelium, showed a low enzyme activity. In the marginal cell and spiral prominence epithelium facing the endolymph, this activity was limited to the perilymphatic membrane sections. The results are discussed.