Poor Bone Mineral Density Is Associated With Increased Risk of Urological Bone Metastases.

OBJECTIVE: To investigate whether a diagnosis of precancer poor bone mineral density (PBMD) is associated with higher risk of urological cancer bone metastasis. METHODS: The PearlDiver Database was utilized to conduct a retrospective, propensity-matched cohort analysis of adult patients diagnosed with kidney, bladder, prostate, and testicular cancer with and without a prior diagnosis of PBMD, defined as osteopenia or osteoporosis. Unadjusted and adjusted odds ratios (OR) and 95% confidence intervals are used to compare the rate of newly diagnosed bone metastases between 6months and 3years of the initial cancer diagnosis between the experimental and control cohorts. RESULTS: Among 685,066 patients with urological cancers, precancer PBMD was associated with increased odds of bone metastasis at various time periods (1week, 6months, 1, 2, and 3years). The strongest association was appreciated within 1week of cancer diagnosis (kidney: adjusted odds ratio [aOR], 2.37, P <.001; bladder: [aOR], 2.37, P <.001; prostate: [aOR], 2.84, P <.001; testicular: [aOR], 4.45, P <.001). Bisphosphonates were associated with reduced risk of kidney ([aOR], 0.46, P <.001), bladder ([aOR], 0.61, P <.001), and prostate ([aOR], 0.66, P <.001) cancer bone metastasis. CONCLUSION: Our findings suggest urology patients with PBMD may be predisposed to forming bone metastases as well as presenting with metastatic disease at time of cancer diagnosis. As such, further studies are needed to elucidate whether PBMD plays a role in bone tropism and whether bone health pertains to prolonging bone-free metastasis.

Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions.

BACKGROUND: Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions. METHODS: This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years). RESULTS: Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05). CONCLUSIONS: Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA. LEVEL OF EVIDENCE: This is a level III prognostic study.

Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease.

BACKGROUND: Advanced cystic fibrosis lung disease (ACFLD) is common, is associated with reduced quality of life, and remains the most frequent cause of death in individuals with cystic fibrosis (CF). These consensus guidelines provide recommendations to the CF community on management of both common and unique issues that arise when individuals reach a state of ACFLD. METHODS: The CF Foundation assembled a multidisciplinary expert panel consisting of three workgroups: Pulmonary management; Management of comorbid conditions; Symptom management and psychosocial issues. Topics were excluded if the management considerations did not differ in ACFLD from in the overall CF population or if already addressed in other published guidelines. Recommendations were based on a systematic literature review combined with expert opinion when appropriate. RESULTS: The committee formulated twenty-three recommendation statements specific to ACFLD that address the definition of ACFLD, pulmonary and intensive care unit management, management of selected comorbidities, symptom control, and psychosocial issues. CONCLUSIONS: These recommendations are intended to be paired with previously published management guidelines for the overall CF population, with the objective of reducing practice variability and improving overall care, quality of life, and survival in those with ACFLD.

Intra-capsular complete tonsillectomy, a modification of surgical technique to eliminate delayed post-operative bleeding.

Pediatric tonsillectomy is a frequently performed procedure using a variety of surgical techniques. Despite decades of modern surgical experience and advances in tools and techniques, a consensus on which technique is superior for minimizing complications has not been established. In a 2014 study, the authors examined differing surgical techniques and devices to determine if there was a significant difference in the bleed rates based on technique and device [1]. In that study 7024 children were evaluated, of which a total of 1.4% (n = 99) of children experienced a postoperative hemorrhage that required a second surgery. There was no significant difference found between the four different techniques that were evaluated. Although the combined rates of post-operative hemorrhage requiring a second surgery was lower compared to many other published reports, we hypothesized that continued improvement in surgical techniques could eliminate post-operative hemorrhage completely. As follow up to that study, we decided on a collective change in technique, and subsequent analysis of our post-operative results with respect to only one outcome, post-operative hemorrhage requiring a second surgery. With a new standardized technique in place, we retrospectively evaluated one year of surgical outcomes. These procedures were performed using the technique of a modified and complete, intra-capsular Coblator tonsillectomy. Of the 783 tonsillectomies done in 12 months, we found there were 0 patients that had experienced a postoperative hemorrhage requiring a second surgery. Based on our previous study with a rate of 1.4% post-operative hemorrhage we would have expected to have 11 episodes of post-operative hemorrhage requiring a second surgery.

Publisher Correction: Mapping exclusive breastfeeding in Africa between 2000 and 2017.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Mapping exclusive breastfeeding in Africa between 2000 and 2017.

Exclusive breastfeeding (EBF)-giving infants only breast-milk (and medications, oral rehydration salts and vitamins as needed) with no additional food or drink for their first six months of life-is one of the most effective strategies for preventing child mortality1-4. Despite these advantages, only 37% of infants under 6 months of age in Africa were exclusively breastfed in 20175, and the practice of EBF varies by population. Here, we present a fine-scale geospatial analysis of EBF prevalence and trends in 49 African countries from 2000-2017, providing policy-relevant administrative- and national-level estimates. Previous national-level analyses found that most countries will not meet the World Health Organization's Global Nutrition Target of 50% EBF prevalence by 20256. Our analyses show that even fewer will achieve this ambition in all subnational areas. Our estimates provide the ability to visualize subnational EBF variability and identify populations in need of additional breastfeeding support.

Post-tonsillectomy hemorrhage rates in children compared by surgical technique.

Despite the sheer number of pediatric tonsillectomies performed in the United States annually, there is no clear consensus as to which surgical technique is superior. One way to compare surgical techniques is to study the morbidity associated with each. We report postoperative hemorrhage rates, one of the frequently encountered major adverse events, as part of a retrospective chart review across four different surgical techniques. These surgeries involved either (1) Coblation, (2) Co-blation with partial suture closure of the tonsillar fossa, (3) diathermy, or (4) partial intracapsular tonsillectomy (PIT). Of the 7,024 children we evaluated, 99 (1.4%) experienced a postoperative hemorrhage that required a second surgery; hemorrhage occurred after 33 of the 3,177 Coblation-alone procedures (1.04%), 28 of the 1,633 Coblation with partial suture closure procedures (1.71%), 29 of the 1,850 diathermies (1.57%), and 9 of the 364 PIT procedures (2.47%). Statistical analysis of hemorrhage rates with each surgical technique yielded p values >0.05 in each case (Coblation alone and Coblation with partial suture closure: p = 0.29; diathermy: p = 0.47; PIT, p = 0.20). Based on these data, we conclude that none of these techniques is significantly superior in terms of decreasing the risk of post-tonsillectomy hemorrhage in children. Therefore, surgeons should continue to use the surgical procedure they are most familiar with to optimize recovery in the postoperative period.

Pediatric recurrent laryngeal nerve reinnervation: A case series and analysis of post-operative outcomes.

OBJECTIVE: To provide detailed information about recurrent laryngeal nerve (RLN) reinnervation outcomes in children using objective measures. METHODS: The records of three pediatric patients with unilateral vocal cord paralysis that underwent RLN reinnervation were retrospectively reviewed. Fundamental frequency (F0), jitter, shimmer, noise-to-harmonic ratio (NHR), and voice phonation (sustained /s/, /z/, /a/) were measured preoperatively and post-operatively at 13, 9, and 33 months (each time period corresponding to one of the three patients). RESULTS: Mean preoperative and post-operative variables were as follows: shimmer, 9.65±1.02% vs. 4.46±0.71% (p=0.01); NHR, 0.296±0.063 vs. 0.127±0.011 (p=0.04); jitter, 3.57±0.89% vs. 1.46±0.54% (p=0.08); F0, 274.6±35.4Hz vs. 282.2±70.6Hz (p=0.44); maximum phonation time, 7.46±1.40s vs. 9.79±1.84s (p=0.22); /s:z/ ratio, 1.28±0.22 vs.1.07±0.09 (p=0.26). CONCLUSIONS: There was statistically significant improvement in shimmer and NHR. Jitter improvement approached statistical significance. All other variables failed to show significant improvement among this small sample size. RLN reinnervation for pediatric patients is an option for the treatment of vocal cord paralysis. Further studies with larger cohorts are needed to show the full benefits.

Laryngotracheal separation surgery for intractable aspiration: our experience with 12 patients.

OBJECTIVE: Laryngotracheal separation surgery (LTS) was performed as a treatment for recurrent or intractable aspiration pneumonia in 12 pediatric patients. The effectiveness of LTS surgery for preventing aspiration pneumonia, and the complications of this procedure were investigated. METHODS: A retrospective chart review, conducted at a tertiary academic hospital in conjunction with a private practice, was used to identify children who underwent Laryngotracheal Separation Surgery (LTS) from September 2001 to July 2007. The main outcome measure was the number of hospital admissions for pneumonia in the pre LTS and post LTS period. A student's t-test was used for statistical analysis. RESULTS: LTS surgery decreased the frequency of pulmonary infections and respiratory events in all patients, resulting in far fewer hospitalizations. These patients experienced an average of 5 hospital admissions for pneumonia in the 2 years prior to LTS surgery, and an average of 1.1 hospital admissions for pneumonia after the LTS surgery. There were no major complications related to the surgery. Several minor complications following surgery were easily and effectively dealt with in the perioperative period. CONCLUSIONS: LTS surgery is an effective and safe procedure in children with intractable aspiration. Parents do not perceive the care of the LTS stoma as burdensome. This procedure should be considered as an option in the surgical intervention for the management of chronic aspiration pneumonia in severely neurologically impaired children.

Postcricoid vascular lesions: histopathological and immunohistochemical diagnosis.

OBJECTIVES/HYPOTHESIS: Postcricoid vascular lesions are a rare cause of dysphagia and stridor in the pediatric population. Currently, there is no clear consensus on what type of vascular lesions are common in the postcricoid area because adequate histological or immunohistochemistry studies are lacking. This study aimed to describe the histology and immunohistochemistry of postcricoid masses in our institutions' experience, and consolidate available data on the symptoms, management, and histology of these unusual malformations with a comprehensive literature review. STUDY DESIGN: Retrospective patient and literature review. METHODS: A retrospective review of patients with postcricoid vascular lesions was performed at two pediatric tertiary care institutions. Histology and immunohistochemistry studies were performed in patients undergoing a lesion biopsy. A complete literature review of the English language was completed for cases involving vascular lesions of the postcricoid area. RESULTS: Four patients were identified in our study with postcricoid vascular lesions. All patients presented with symptoms of dysphagia and intermittent stridor. Histology and immunohistochemistry studies were performed in three patients. GLUT-1 was negative in all three patients, and CD34 was positive in all patients tested. Lewis Y antigen was performed in one patient and was negative. A description of 19 cases reported in the English literature is included. CONCLUSIONS: Patients with postcricoid vascular lesions usually present with mild to moderate feeding difficulties, and stridor or dyspnea with agitation. Histopathology and immunohistochemistry results suggest that postcricoid vascular lesions may often represent congenital vascular malformations instead of infantile hemangiomas.

Changes in load distribution in the knee after opening-wedge or closing-wedge high tibial osteotomy.

The treatment of unicompartmental osteoarthritis of the knee by high tibial osteotomy has been carried out by closing-wedge osteotomy. The advantages for opening-wedge osteotomy are ease of procedure and improved correction with comparable short-term to midterm results. It is not known how the opening-wedge high tibial osteotomy procedure alters the load distribution between the medial and lateral compartments of the knee. The current biomechanical study investigated opening-wedge vs closing-wedge osteotomies in 5 pairs of cadaver knees. The results showed that at 5 degrees osteotomy, the closing-wedge provided superior results of load transfer from medial to lateral compartment than that seen with opening-wedge, but at 10 degrees osteotomy, there was no significant difference in load transfer in the knee compartments between the 2 surgery modes.

A biomechanical study of bankart lesion fixation - biodegradable ArthroRivet tack vs. suture repair.

Bioabsorbable fixation is commonly used in soft tissue procedures performed in the shoulder. ArthroRivettrade mark tacks (referred to as rivets here), made from a copolymer of 82% poly-L-lactic acid and 18% polyglycolic acid, were developed for the Bankart procedure. Although a previous in vivo study demonstrated favorable comparison of the fixation strength and absorption characteristics of this device with that of polyglyconate bioabsorbable tacks, there have been no published biomechanical studies of this rivet in the shoulder. Fourteen shoulders were harvested from fresh-frozen cadavers of average age 74 years (46-89). Biomechanical testing was performed by measuring the energy, or work, required to anteriorly displace the humeral head 6 mm from the glenoid. Each shoulder was tested intact, vented, and before and after repair of a simulated Bankart lesion at 0, 45, and 90 degrees of abduction with and without maximal external rotation. Overall, the average work required ranged from 54.7 N-mm to 178.27 N-mm. Although the biomechanical performance of the rivet, based on resistance to anterior displacement of the humeral head, was indistinguishable from that of the suture repair, the statistical power of the test was low due to the large variance in the cadaver specimens. The results, in general, correlated well with those of previously published studies, suggesting the suitability of the bioabsorbable rivet for use in Bankart repair.

Ethics and constitutional government.

The term ethics refers to a set of principles that govern acceptable, proper conduct. Attacks on the Constitution of the United States pose the most serious breach of ethics today. Our country was founded as a republic, not as a democracy. Our Founding Fathers' main concern was to protect citizens from the power of the federal government, so constitutionally, the central government has little or no authority over individual citizens except on federal property. One of the major problems today is the fact that we now have professional politicians. This is due in large part to the lure of financial gain from countless special interest groups. This would change under constitutional law because the federal budget would decrease drastically. Article 1 states that all legislative power is vested in Congress. Congress has only 18 enumerated powers, and almost half of these pertain to defense of the country. Many of our current problems are due to regulatory agencies that have become independent fiefdoms with unconstitutional legislative, as well as executive and judicial, powers. The regulatory agency most relevant to medicine, both clinical care and research, is the FDA. It is now obvious that its basic structure needs to be changed or abolished because its actions are identical to those inherent in authoritarian systems. Constructive change could come from Congress, but it would be most desirable if the Supreme Court would take the lead and reestablish the authority of the Constitution as the Supreme Law of the Land. The FDA's function could be limited to the determination of safety, but preferably its mission would be altered to that of product certification. Defenders of the current system claim that such a drastic change would be too dangerous and their prime example is thalidomide. But it is now known that the market has already solved that problem prior to the government-imposed sanctions. Realistically, market forces and their ramifications, including our legal system, provide the most effective methods of protecting the public from harmful drugs and devices. Fortunately, a model for miracles is available. It is New Zealand, which had become increasingly socialistic after WW II. As a result, they had become noncompetitive, and with the formation of the European Union, they lost their major market exports. In order to survive they made some astounding changes in the mid-1980s. They studied every agency that depended on government funding and transferred much of this work over to the private sector. They turned the remaining agencies into profit-making enterprises. These agencies had cost the government about $1 billion/year. Now, they produce about $1 billion in revenue and taxes. Without question, a return to constitutional government would be an invigorating stimulus to bioengineering research in the future. It would flourish. The eminence of this country did not develop from a strong central government. It is due to its absence, but we are rapidly reaching a point of no return.

A biomechanical study of simulated femoral neck fracture fixation by cannulated screws: effects of placement angle and number of screws.

The angle of placement of hip screws to fix femoral neck fractures is still a controversial subject, and it must be addressed. In the study reported here, we compared the relative stiffness of fixation of simulated Pauwels type III femoral neck fractures fixed with either 2 or 3 cannulated screws implanted at 135 degrees, 145 degrees, and 150 degrees. Each femur was fixed with 2 or 3 cannulated screws and tested under axial loading and anteroposterior (AP) bending. Then each femur was fatigued to 1000 cycles and tested to failure. Fourteen femurs were tested. Results showed that axial stiffness values were not statistically different at different angles. AP bending stiffness of the high-angle (150 degrees) construct was significantly higher than that of either of the other 2 constructs (for 2 screws only). Two-screw fixation appears to be adequate; adding a third screw may not be necessary.

Assessment of immunologic mechanisms for flare reactions to Synvisc.

Intraarticular injection of Synvisc for treatment of knee pain sometimes results in an acute local reaction (flare). We tested the hypothesis that the flare was a Type-1 hypersensitivity reaction as manifested by the presence of Synvisc antibodies in the synovial fluid and serum and by an increase in the concentration of the mast-cell enzyme tryptase in the synovial fluid. Our second objective was to determine whether the ratio of CD4+ to CD8+ lymphocytes in the synovial fluid was increased, as would be expected in a Type-4 hypersensitivity reaction. The study population was a prospective, consecutive series of 16 patients who had a flare, and 20 control patients. We found no differences in product-specific antibodies in the synovial fluid or serum between patients with flares and patients without flares. The mean tryptase level in the synovial fluid of patients with flares, 3.8 +/- 0.8 microg/L, was not different from the corresponding level in the control patients. The CD4+/CD8+ ratio in the synovial fluid was more than eight times greater in patients with flares. Flares that sometimes occur after treatment with Synvisc are probably not Type-1 (antibody-mediated) hypersensitivity reactions, but may be Type-4 (cell-mediated) hypersensitivity reactions.

Percutaneous plate fixation of comminuted ulnar fractures.

The superficial location of ulnar fractures allows minimally invasive insertion of percutaneous plates, which improves stability and creates a friendly healing environment.