Energy restriction or improvements in diet quality: identifying the best pathway for a longer and healthier life.

Obesity is a major risk factor for chronic non-communicable diseases (NCDs) and it has increased to epidemic proportions. Unhealthy diet represents a modifiable risk factor for both obesity and NCDs, however, there is no universal dietary intervention to improve obesity-related NCDs and particularly to reduce the risk for major adverse cardiovascular events. Energy restriction (ER) and diet quality changes, with and without ER, have been widely investigated in preclinical and clinical studies, however, the potential underlying mechanisms driving the benefits of those dietary interventions remain largely unclear. ER affects multiple metabolic, physiological, genetic, and cellular adaptation pathways associated with prolonged lifespan, particularly in preclinical models, while these benefits remain to be established in humans. Moreover, the sustainability of ER and its implementation across the different diseases remains challenging. On the other hand, diet quality with improvements, with or without ER, has been associated with more favorable long-term metabolic and cardiovascular outcomes. This narrative review will describe the role of ER and/or diet quality improvements on the risk for NCDs. It will also discuss the potential mechanisms of action underlying the potential beneficial effects of those dietary approaches.

Radiographic clues to the unstable knee: are findings of trochlear dysplasia on lateral knee radiographs reliable and predictive of patellar dislocation?

BACKGROUND: Trochlear dysplasia (TD) is a key predisposing risk factor for patellar instability (PI) and lateral patellar dislocation (LPD) injuries. It is useful to understand the reliability of radiographic findings of TD and the accuracy of knee radiographs in diagnosing patients with recent LPD. PURPOSE: The purposes of our study are to evaluate the inter-rater reliability of specific radiographic signs of PI and staging of TD between radiologists and orthopedic surgeons, and to identify which findings are associated with recent LPD. METHODS: This retrospective study comprised 336 patients aged 8 to 18 who obtained knee radiographs over a 3-year period. Two radiologists and two orthopedic surgeons, blinded to patient history, examined radiographs for indicators of PI. Using data from 19 confirmed LPD cases and 317 controls, inter-observer agreement (kappa, Pearson's correlation coefficient) was assessed, as was the odds ratio for likelihood of LPD. RESULTS: There was nearly perfect agreement between radiologists for patella-tendon ratios (Pearson's correlation coefficient 0.8377, P < 0.0001) and discrimination between normal knees and high-grade TD (kappa 0.9213, P < 0.0001). There is fair agreement between radiologists and surgeons distinguishing between normal knees and high-grade TD (kappa 0.5843, P < 0.0001). Lateral knee radiographs interpreted as high-grade TD were highly predictive of LPD (odds ratio 7.58-54.8) among all readers. CONCLUSIONS: There is high agreement between radiologists when evaluating lateral knee radiographs for signs of TD, validating the results of prior literature. Radiographic findings TD, patella alta, and effusion are variable predictors of recent LPD, greatest among patients with TD.

Increased Hip Intracapsular Pressure Decreases Perfusion of the Capital Femoral Epiphysis in a Skeletally Immature Porcine Model.

BACKGROUND: Increased intracapsular hip pressure is thought to be one of the possible etiologies of femoral head avascular necrosis after intra-articular proximal femoral fractures or acute slipped capital femoral epiphysis. The purpose of this study was to evaluate the relationship between intra-articular hip pressure (IAP) and epiphyseal perfusion pressure (EPP), and its dependency on skeletal maturity using a porcine model. METHODS: Seven female Yorkshire-hybrid pigs were used to study the direct relationship between IAP and EPP. A needle inserted into the capsule provided both IAP monitoring and saline infiltration until IAP was above mean arterial pressure (MAP). Video simultaneously documented IAP, EPP, MAP. Parameters for all trials in each hip were averaged and compared between the 2 age groups. Significance was P<0.05. RESULTS: Four young hips (in pigs 10.3±1.0 wk, 27.4±2.0 kg) and 5 older hips (21.1±0.1 wk, 89.4±7.1 kg) were studied. There was no significant difference in the MAP (50.0±11.8 and 55.5±7.0 mm Hg respectively, P=0.411) between the 2 age groups. In the older hips, biphasic EPP persisted despite increasing IAP to an average of 177 mm Hg over MAP. In the young pigs, the biphasic EPP waveform ceased with increased IAP to an average of 28 mm Hg over MAP. Biphasic waveforms returned once IAP fell to an average of 5 mm Hg over MAP. CONCLUSIONS: Increased IAP resulted in tamponade of epiphyseal perfusion in the young, but not in the older hips. An intact physis may preclude intraosseous metaphyseal vessels from penetrating the epiphysis, leaving it vulnerable to retinacular artery tamponade. CLINICAL RELEVANCE: The IAP and EPP relationship has direct clinical practice implications. Hip capsulotomy and decompression in young patients with intra-articular proximal femoral fractures and increased intracapsular pressure may decrease avascular necrosis risk.

High rate of inappropriate referrals to pediatric orthopedics in an egalitarian healthcare system.

Previous studies have shown relatively high rates of inappropriate referrals to pediatric orthopedic surgery. The purpose of this study was to determine the rate of inappropriate referrals in an egalitarian healthcare system. We reviewed all 400 referrals to our pediatric orthopedic surgery practice over a 2-year period and assessed the appropriateness of each based on the American Academy of Pediatrics guidelines. A total 206 (52%) referrals were deemed appropriate. There is a high rate of inappropriate referral to pediatric orthopedic surgery even within a closed, egalitarian healthcare system. Targeted education of primary care providers may help reduce this rate.

Perceived sources of stress among Malaysian dental students.

OBJECTIVE: The study objectives were to identify the stress levels and to explore the impact of students' year of study and gender on the perceived sources of stress among Malaysian dental students. METHODS: This was a cross-sectional study involving dental students from year one to year five from private and public universities in Malaysia. The study was formally approved by the Research and Ethics Committee, International Medical University Malaysia. Dental Environment Stress (DES) questionnaire was used for data collection and the gathered data were analyzed using SPSS® version 18. The Kruskal-Wallis and the Mann-Whitney U tests were used to compare stress items across various academic years and universities. RESULTS: A total of five hundred and twenty nine (529) students participated in this study. Fear of failing the course at the end of year exams (mean stress level=5.57); concerns regarding completion of clinical work (mean=5.30); and examination results and grades (mean=5.27) were found as top stressors among dental students. Female students had higher stress scores than males with respect to personal issues, academic performance, educational environment and learning of clinical skills. Students from public universities had higher stress scores than their counterparts from private universities. CONCLUSIONS: The Malaysian dental students reported higher levels of stress. Present study identified stressors affecting dental students' academic life, and highlights the importance of stress management programs and other measures to minimize the impact of stress on both academic and personal lives of the students.

Heterotopic ossification in high-grade open fractures sustained in combat: risk factors and prevalence.

OBJECTIVES: To determine the prevalence and identify the risk factors for heterotopic ossification (HO) formation in high-grade open fractures sustained during combat and to report on the results of HO excision. DESIGN: Retrospective. SETTING: United States Army level-1 trauma center. PATIENTS/PARTICIPANTS: Seventy-six consecutive patients with 91 combat-related open Gustilo and Anderson type II and higher fractures were identified from March 1, 2003, through January 30, 2005. Fifty-nine patients with 71 fractures met criteria for study inclusion. MAIN OUTCOME MEASUREMENTS: Fractures were categorized into HO-present and HO-absent groups based on radiographic imaging. Risk factors such as injury mechanism, injury severity score (ISS), Gustilo and Anderson type, injury location, closed head injury, burn, and infection were compared between the groups. RESULTS: HO was present in 27 of 71 open fractures (38.1%). Variables associated with HO formation included ISS (p = 0.02) and injury location although infection and use of negative pressure therapy were not. Ten of 27 fractures with HO underwent excision. HO did not occur or was mild in 25 tibiae. CONCLUSIONS: HO is a common sequela of high-grade open fractures sustained in combat. High ISS and injury location to the shoulder, hip, and femur are risk factors for HO formation. The most common regions for HO excision were the elbow, forearm, and hip with mixed results. Importantly, HO did not seem to be a complication of open high-grade tibia fractures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Patient-reported adverse drug reactions and drug-drug interactions: a cross-sectional study on Malaysian HIV/AIDS patients.

OBJECTIVE: This study aimed to explore the adverse drug reactions (ADRs) reported by patients and to identify drug-drug interactions (DDIs) among human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients. SUBJECTS AND METHODS: This cross-sectional study was conducted at the Medication Therapy Adherence Clinic, Hospital Sungai Buloh, an HIV/AIDS referral centre. The patients were randomly selected and were encouraged to describe ADRs caused specifically by any of the prescribed antiretroviral drugs (ARDs). Sociodemographic characteristics were recorded from the patients' medical records. In addition data on antiretroviral treatment (ART), DDIs and other conventional medication were also documented. RESULTS: A total of 325 randomly selected HIV/AIDS patients with a mean age of 22.94 years participated in the study. The most frequently prescribed ARDs were lamivudine (64.6%), zidovudine (40.6%) and efavirenz (42.5%). Commonly reported ADRs were fatigue (54.8%), allergic reactions (41.5%), weight loss (41.5%), dry mouth (35.1%) and memory loss (35.1%). Female (87.8%), non-complementary and alternative medicine (CAM) users (87.3%) and participants below 50 years old (81.1%) were identified as having a higher prevalence of ADRs compared to males (79.6%), CAM users (78.7%) and participants aged 50 years or more (77.5%). Patient age was found to be significantly associated (p = 0.048) with the ADRs. In addition, a total of 44 cases of DDIs belonging to category D were also found in this study. CONCLUSIONS: This study enabled us to identify the most common ADRs and DDIs associated with the use of ART. Safe and effective treatment depends on the healthcare providers' knowledge of the same.

Laparoscopic hiatal hernia repair with human acellular dermal matrix patch: our initial experience.

BACKGROUND: The laparoscopic repair of large hiatal hernia followed by an antireflux procedure is currently the gold standard therapy for gastroesophgeal reflux disease. However, it is recognized that recurrent hiatal herniation and wrap migration are major sources of operative failures in these patients. Some have described a reduction of such events with the placement of nonbiodegradable prosthetic patches over the primary cruroplasty. This prosthetic material may be associated with transesophageal and gastric erosions and a higher rate of postoperative dysphagia and chest pain when compared with simple suture cruroplasty alone. The aim of this study is to compare hiatal closure with a biodegradable patch (acellular dermal matrix) and simple suture curaplasty in patients undergoing laparoscopic antireflux surgery. METHODS: A total of 44 patients were prospectively enrolled in this study. Twenty-two consecutive patients undergoing large hiatal hernia repair (>5 cm) and fundoplication with primary suture cruroplasty only (group 1) were compared with 22 consecutive patients undergoing the same procedure with suture cruroplasty reinforced with an onlay acellular dermal matrix patch (group 2). The 2 groups were compared with regards to demographics, size of the hiatal hernia, pre- and postoperative symptom scores, pH studies, operative times, and hiatal hernia recurrence. RESULTS: Patients in both groups were well matched by age, weight, height, and size of hiatal hernia. There were similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring in both groups. Average operative time was 108 minutes in group 1 and 121 minutes in group 2. There were no major complications in either group. The median period of hospitalization was 1 day in both groups. Postoperative pH studies and symptoms score data were significantly improved in both groups. There was no significant difference in postoperative symptoms scores for dysphagia between the 2 groups. Two patients (one in each group) underwent esophageal dilatation for mild dysphagia postoperatively. In group 1, 2 patients (9%) had Nissen failure with hiatal hernia recurrences 6 months after surgery. There were no recurrences for the follow-up period in group 2. CONCLUSIONS: Our early results suggest that hiatal hernia repair reinforced with an acellular dermal matrix patch may reduce the incidence of recurrent herniation and wrap migration. In addition, the increase in postoperative dysphagia, chest pain, and esophageal erosions associated with nondegradable mesh has not been observed in those with an acellular dermal matrix patch to this point in our follow up. However, future investigation of the material for this particular application as well as longer follow-up is necessary.

Patients with pancreatic adenocarcinoma benefit from staging laparoscopy.

BACKGROUND: Unnecessary laparotomy in patients with advanced pancreatic cancer may both compromise the quality of life and delay the initiation of more appropriate therapy. Very often, peritoneal small liver metastases and true local status cannot be fully determined without surgery. Laparoscopy may spare laparotomy and decrease morbidity for patients with nonresectable advanced disease. The aim of this study was to determine the impact of laparoscopy in patients with potentially resectable adenocarcinoma of the pancreas. MATERIALS AND METHODS: We reviewed the records of patients undergoing pancreatic surgery at the University of Nebraska Medical Center from October 2001 to April 2005. A total of 59 patients were included in the study. All patients were staged radiographically with a high resolution helical computed tomography scan and their tumors were considered resectable. Thirty-seven patients underwent staging laparoscopy while 22 proceeded directly to laparotomy. RESULTS: Of the 37 patients who underwent laparoscopic staging, 9 (24.3%) were detected to have metastatic disease or advanced tumor; the remaining 28 (75.7%) patients with negative laparoscopy proceeded to laparotomy. Of those, 24 patients (85.7%) underwent pancreatic resection with curative intent, while 4 patients had metastatic or locally advanced disease at subsequent laparotomy which was missed on staging laparoscopy (false negative rate of 14.3%). Of the 22 patients who proceeded directly to laparotomy, 16 (72.7%) received curative Whipple resection and 6 (27.3%) were found to have advanced disease and received bypass procedures or biopsy alone. CONCLUSION: These findings suggest that staging laparoscopy is beneficial in a significant proportion of patients deemed resectable by routine noninvasive preoperative studies. We plan to add intraoperative laparoscopic ultrasound to our staging protocol in order to decrease the false negative rate.