Existing Challenges and Opportunities for Advancing Drought and Health Research.

PURPOSE OF REVIEW: Drought is one of the most far-reaching natural disasters, yet drought and health research is sparse. This may be attributed to the challenge of quantifying drought exposure, something complicated by multiple drought indices without any designed for health research. The purpose of this general review is to evaluate current drought and health literature and highlight challenges or scientific considerations when performing drought exposure and health assessments. RECENT FINDINGS: The literature revealed a small, but growing, number of drought and health studies primarily emphasizing Australian, western European, and US populations. The selection of drought indices and definitions of drought are inconsistent. Rural and agricultural populations have been identified as vulnerable cohorts, particularly for mental health outcomes. Using relevant examples, we discuss the importance of characterizing drought and explore why health outcomes, populations of interest, and compound environmental hazards are crucial considerations for drought and health assessments. As climate and health research is prioritized, we propose guidance for investigators performing drought-focused analyses.

The effect of heterogeneous severe drought on all-cause and cardiovascular mortality in the Northern Rockies and Plains of the United States.

Drought is a distinct and complicated climate hazard that regularly leads to severe economic impacts. Changes in the frequency and occurrence of drought due to anthropogenic climate change can lead to new and unanticipated outcomes. To better prepare for health outcomes, more research is needed to develop methodologies to understand potential consequences. This study suggests a new methodology for assessing the impact of monthly severe drought exposure on mortality in the Northern Rockies and Plains of the United States from 2000 to 2018. A two-stage model with the power prior approach was applied to integrate heterogeneous severe drought pattern and estimate overall risk ratios of all-cause and cardiovascular mortality related to multiple drought indices (the US Drought Monitor, 6- and 12-month Standardized Precipitation-Evapotranspiration Index, 6- and 12 month Evaporative Demand Drought Index). Under severe drought, the risk ratios of all-cause mortality are 1.050 (95 % Cr: 1.031 to 1.071, USDM), 1.041 (95 % Cr: 1.022 to 1.060, 6-SPEI), 1.009 (95 % Cr: 0.989 to 1.031, 12SPEI), 1.045 (95 % Cr: 1.022 to 1.067, 6-EDDI), and 1.035 (95 % Cr: 1.009 to 1.062, 12-EDDI); cardiovascular mortality are 1.057 (95 % Cr: 1.023 to 1.091, USDM), 1.028 (95 % Cr: 0.998 to 1.059, 6-SPEI), 1.005 (95 % Cr: 0.973 to 1.040, 12-SPEI), 1.042 (95 % Cr: 1.005 to 1.080, 6-EDDI), and 1.004 (95 % Cr: 0.959 to 1.049, 12-EDDI). Our results showed that (i) a model with properly accounted for heterogeneous exposure pattern had greater risk ratios if statistically significant; (ii) a mid-term (6-month) severe drought had higher risk ratios compared to longer-term (12-month) drought; and (iii) different severe droughts affect populations in a different way. These results expand the existing knowledge of drought relationship to increasing mortality in the United States. The findings from this study highlight the need for communities and policymakers to establish effective drought-prevention initiatives in this region.

The Association between Drought Exposure and Respiratory-Related Mortality in the United States from 2000 to 2018.

Climate change has brought increasing attention to the assessment of health risks associated with climate and extreme events. Drought is a complex climate phenomenon that has been increasing in frequency and severity both locally and globally due to climate change. However, the health risks of drought are often overlooked, especially in places such as the United States, as the pathways to health impacts are complex and indirect. This study aims to conduct a comprehensive assessment of the effects of monthly drought exposure on respiratory mortality for NOAA climate regions in the United States from 2000 to 2018. A two-stage model was applied to estimate the location-specific and overall effects of respiratory risk associated with two different drought indices over two timescales (the US Drought Monitor and the 6-month and 12-month Evaporative Demand Drought Index). During moderate and severe drought exposure, respiratory mortality risk ratio in the general population increased up to 6.0% (95% Cr: 4.8 to 7.2) in the Northeast, 9.0% (95% Cr: 4.9 to 13.3) in the Northern Rockies and Plains, 5.2% (95% Cr: 3.9 to 6.5) in the Ohio Valley, 3.5% (95% Cr: 1.9 to 5.0) in the Southeast, and 15.9% (95% Cr: 10.8 to 20.4) in the Upper Midwest. Our results showed that age, ethnicity, sex (both male and female), and urbanicity (both metro and non-metro) resulted in more affected population subgroups in certain climate regions. The magnitude and direction of respiratory risk ratio differed across NOAA climate regions. These results demonstrate a need for policymakers and communities to develop more effective strategies to mitigate the effects of drought across regions.

Maternal androgen excess increases the risk of pre-diabetes mellitus in male offspring in later life: a long-term population-based follow-up study.

PURPOSE: Prenatal androgen exposure could be a source of early programming, leading to the development of cardiometabolic diseases in later life. In this study, we aimed to examine cardiometabolic disturbances in males exposed to maternal androgen excess during their prenatal life. METHODS: In this prospective population-based study, 409 male offspring with maternal hyperandrogenism (MHA), and 954 male offspring without MHA, as controls, were included. Both groups of male offspring were followed from the baseline to the date of the incidence of events, censoring, or end of the study period, whichever came first. Age-scaled unadjusted and adjusted Cox regression models were applied to assess the hazard ratios (HR) and 95% confidence intervals (CIs) for the association between MHA with pre-diabetes mellitus (Pre-DM), type 2 diabetes mellitus (T2DM), pre-hypertension (Pre-HTN), hypertension (HTN), dyslipidemia, overweight, and obesity in the offspring of both groups. Statistical analysis was performed using the STATA software package; the significance level was set at P < 0.05. RESULTS: A higher risk of Pre-DM (adjusted HR: 1.46 (1.20, 1.78)) was observed in male offspring with MHA after adjustment for potential confounders, including body mass index, education, and physical activity. However, no significant differences were observed in the risk of T2DM, Pre-HTN, HTN, dyslipidemia, overweight, and obesity in males with MHA compared to controls in both the unadjusted and adjusted models. CONCLUSION: Maternal androgen excess increases the risk of Pre-DM in male offspring in later life. More longitudinal studies with long enough follow-up are needed to clarify the effects of MHA on the cardiometabolic risk factors of male offspring in later life.

[Comparison of available clinical and imaging tools to assess good positioning of a fluocinolone acetonide implant (Iluvien®) in the vitreous cavity after injection]. / Comparaison des moyens clinique et d'imagerie disponibles en pratique clinique pour objectiver la présence de l'implant d'acétonide de fluocinolone (Iluvien®) dans la cavité vitréenne après injection.

INTRODUCTION: Sustained-release corticosteroid implants are injected into the vitreous cavity using preloaded pens. The fluocinolone (FAc) implant is approximately half the size of the dexamethasone implant (Dex-I). It is simply introduced in the vitreous base rather than propelled into the vitreous cavity as is Dex-I. Verification of its positioning after injection is thus difficult by indirect ophthalmoscopy. The goal of our study is to compare the performance of available clinical and imaging tools to confirm the presence of the FAc in the vitreous cavity following injection. METHODS: Twelve eyes of 12 consecutive patients were included in a retrospective, single-center, observational study carried out at the Bordeaux University Hospital, France. All patients were injected with the FAc after pupil dilation, and presence of the implant was immediately checked by indirect biomicroscopy, wide-field retinography (Clarus®, Carl-Zeiss-Meditec, Dublin, CA, USA) and ultra-wide-field retinography (California®, Optos, Edinburgh, United-Kingdom). Seven days later, a B-mode ultrasonography (10MHz, AVISO, Quantel-medical, France) and an UBM ultrasonography (50MHz, AVISO, Quantel-medical, France) were performed. RESULTS: Indirect biomicroscopy and wide-field retinography detected 4/12 implants (33.3%). Ultra-wide-field retinophotography detected 6/12 implants (50%). All the implants seen using indirect biomicroscopy and wide-field retinography were also visualized with ultra-wide-field. B-mode ultrasonography showed 5/12 implants (41.6%) and UBM 9/12 implants (75%). Finally, one implant dislocated into the anterior chamber and was seen in the iridocorneal angle on gonioscopy. CONCLUSION: Objective confirmation of the proper positioning of the FAc implant in the vitreous cavity is mandatory. If both indirect ophthalmoscopy and anterior examination fail to detect it, ultra-wide field retinography along with UBM ultrasonography, if necessary, appear to be the two best imaging modalities to use.

Estimating the Burden of Heat-Related Illness Morbidity Attributable to Anthropogenic Climate Change in North Carolina.

Climate change is known to increase the frequency and intensity of hot days (daily maximum temperature ≥30°C), both globally and locally. Exposure to extreme heat is associated with numerous adverse human health outcomes. This study estimated the burden of heat-related illness (HRI) attributable to anthropogenic climate change in North Carolina physiographic divisions (Coastal and Piedmont) during the summer months from 2011 to 2016. Additionally, assuming intermediate and high greenhouse gas emission scenarios, future HRI morbidity burden attributable to climate change was estimated. The association between daily maximum temperature and the rate of HRI was evaluated using the Generalized Additive Model. The rate of HRI assuming natural simulations (i.e., absence of greenhouse gas emissions) and future greenhouse gas emission scenarios were predicted to estimate the HRI attributable to climate change. Over 4 years (2011, 2012, 2014, and 2015), we observed a significant decrease in the rate of HRI assuming natural simulations compared to the observed. About 3 out of 20 HRI visits are attributable to anthropogenic climate change in Coastal (13.40% [IQR: -34.90,95.52]) and Piedmont (16.39% [IQR: -35.18,148.26]) regions. During the future periods, the median rate of HRI was significantly higher (78.65%: Coastal and 65.85%: Piedmont), assuming a higher emission scenario than the intermediate emission scenario. We observed significant associations between anthropogenic climate change and adverse human health outcomes. Our findings indicate the need for evidence-based public health interventions to protect human health from climate-related exposures, like extreme heat, while minimizing greenhouse gas emissions.

Evaluating the Sensitivity of Heat Wave Definitions among North Carolina Physiographic Regions.

Exposure to extreme heat is a known risk factor that is associated with increased heat-related illness (HRI) outcomes. The relevance of heat wave definitions (HWDs) could change across health conditions and geographies due to the heterogenous climate profile. This study compared the sensitivity of 28 HWDs associated with HRI emergency department visits over five summer seasons (2011−2016), stratified by two physiographic regions (Coastal and Piedmont) in North Carolina. The HRI rate ratios associated with heat waves were estimated using the generalized linear regression framework assuming a negative binomial distribution. We compared the Akaike Information Criterion (AIC) values across the HWDs to identify an optimal HWD. In the Coastal region, HWDs based on daily maximum temperature with a threshold > 90th percentile for two or more consecutive days had the optimal model fit. In the Piedmont region, HWD based on the daily minimum temperature with a threshold value > 90th percentile for two or more consecutive days was optimal. The HWDs with optimal model performance included in this study captured moderate and frequent heat episodes compared to the National Weather Service (NWS) heat products. This study compared the HRI morbidity risk associated with epidemiologic-based HWDs and with NWS heat products. Our findings could be used for public health education and suggest recalibrating NWS heat products.

Drought and all-cause mortality in Nebraska from 1980 to 2014: Time-series analyses by age, sex, race, urbanicity and drought severity.

BACKGROUND: Climate change will increase drought duration and severity in many regions around the world, including the Central Plains of North America. However, studies on drought-related health impacts are still sparse. This study aims to explore the potential associations between drought and all-cause mortality in Nebraska from 1980 to 2014. METHODS: The Evaporative Demand Drought Index (EDDI) were used to define short-, medium- and long-term drought exposures, respectively. We used a Bayesian zero-inflated censored negative binomial (ZICNB) regression model to estimate the overall association between drought and annual mortality first in the total population and second in stratified sub-populations based on age, race, sex, and the urbanicity class of the counties. RESULTS: The main findings indicate that there is a slightly negative association between all-cause mortality and all types of droughts in the total population, though the effect is statistically null. The joint-stratified analysis renders significant results for a few sub-groups. White population aged 25-34 and 45-64 in metro counties and 45-54 in non-metro counties were the population more at risk in Nebraska. No positive associations were observed in any race besides white. Black males aged 20-24 and white females older than 85 showed protective effect against drought mainly in metro counties. We also found that more sub-populations had higher rates of mortality with longer-term droughts compared to shorter-term droughts (12-month vs 1- or 6-month timescales), in both metro and non-metro counties, collectively. CONCLUSION: Our results suggest that mortality in middle aged white population in Nebraska shows a greater association with drought. Moreover, women aged 45-54 were more affected than men in non-metro counties. With a projected increase in the frequency and severity of drought due to climate change, understanding these relationships between drought and human health will better inform drought mitigation planning to reduce potential impacts.

Mapping Heat Vulnerability Index Based on Different Urbanization Levels in Nebraska, USA.

Heatwaves cause excess mortality and physiological impacts on humans throughout the world, and climate change will intensify and increase the frequency of heat events. Many adaptation and mitigation studies use spatial distribution of highly vulnerable local populations to inform heat reduction and response plans. However, most available heat vulnerability studies focus on urban areas with high heat intensification by Urban Heat Islands (UHIs). Rural areas encompass different environmental and socioeconomic issues that require alternate analyses of vulnerability. We categorized Nebraska census tracts into four urbanization levels, then conducted factor analyses on each group and captured different patterns of socioeconomic vulnerabilities among resultant Heat Vulnerability Indices (HVIs). While disability is the major component of HVI in two urbanized classes, lower education, and races other than white have higher contributions in HVI for the two rural classes. To account for environmental vulnerability of HVI, we considered different land type combinations for each urban class based on their percentage areas and their differences in heat intensifications. Our results demonstrate different combinations of initial variables in heat vulnerability among urban classes of Nebraska and clustering of high and low heat vulnerable areas within the highest urbanized sections. Less urbanized areas show no spatial clustering of HVI. More studies with separation on urbanization level of residence can give insights into different socioeconomic vulnerability patterns in rural and urban areas, while also identifying changes in environmental variables that better capture heat intensification in rural settings.

Drought severity and all-cause mortality rates among adults in the United States: 1968-2014.

BACKGROUND: Little is known about the effect of drought on all-cause mortality, especially in higher income countries such as the United States. As the frequency and severity of droughts are likely to increase, understanding the connections between drought and mortality becomes increasingly important. METHODS: Our exposure variable was an annual cumulative drought severity score based on the 1-month, county-level Standardized Precipitation Evapotranspiration Index. The outcome variables of demographic subgroup-specific all-cause mortality count data per year were obtained from the National Vital Statistics System. Any counts below 10 deaths were censored in that demographic group per county. We modeled county-stratum-year mortality using interval-censored negative binomial regression with county-level random intercepts, for each combined age-race-sex stratum either with or without further stratification by climate regions. Fixed effects meta-regression was used to test the associations between age, race, sex, and region with the drought-mortality regression coefficients. Predictive margins were then calculated from the meta-regression model to estimate larger subgroup (e.g., 'race' or 'sex') associations of drought with mortality. RESULTS: Most of the results were null for associations between drought severity and mortality, across joint strata of race, age, sex and region, but incidence rate ratios (IRRs) for 17 subgroups were significant after accounting for the multiple testing; ten were < 1 indicating a possible protective effect of drought on mortality for that particular subpopulation. The meta-regression indicated heterogeneity in the association of drought with mortality according to race, climate region, and age, but not by sex. Marginal means of the estimated log-incidence rate ratios differed significantly from zero for age groups 25-34, 35-44, 45-54 and 55-64; for the white race group; and for the South, West and Southwest regions, in the analysis that included wet county-years. The margin of the meta-regression model suggested a slightly negative, but not statistically significant, association of drought with same-year mortality in the overall population. CONCLUSIONS: There were significant, heterogeneous-direction associations in subpopulation-stratified models, after controlling for multiple comparisons, suggesting that the impacts of drought on mortality may not be monolithic across the United States. Meta-regression identified systematic differences in the associations of drought severity with all-cause mortality according to climate region, race, and age. These findings suggest there may be important contextual differences in the effects of drought severity on mortality, motivating further work focused on local mechanisms. We speculate that some of the estimated negative associations of drought severity with same-year mortality could be consistent with either a protective effect of drought on total mortality in the same year, or with a delayed health effect of drought beyond the same year. Further research is needed to clarify associations of drought with more specific causes of death and with sublethal health outcomes, for specific subpopulations, and considering lagged effects occurring beyond the same year as the drought.

[Role of en face OCT in the diagnosis of syphilitic placoid chorioretinitis]. / Apport de l'OCT en face dans le diagnostic de la syphilis phacoïde oculaire.

INTRODUCTION: This is a retrospective case series of three patients presenting with syphilitic chorioretinitis. The diagnosis of syphilis rests on the ophthalmologic clinical exam as well as serologic confirmation. We studied the en face and SD-OCT images upon first consultation and after one month of antibiotic treatment with penicillin G. RESULTS: Four eyes of three male patients between 40 and 60 years of age all diagnosed with syphilitic placoid chorioretinitis were studied by en face OCT. Visual acuities upon initial presentation were unrecordable. On all the en face OCT examinations of the three patients, numerous small hyperreflective oval lesions were observed within the ellipsoid line and the retinal pigment epithelium around the macula. These lesions corresponded to small elevated nodules in the retinal pigment epithelium and interruptions in the ellipsoid line observed on SD-OCT. One month after treatment for neurosyphilis, the visual acuity had improved, and the outer retinal lesions had partially reversed in these eyes. CONCLUSIONS: We documented the characteristic lesions of syphilitic placoid chorioretinitis by en face OCT. En face OCT allows a more precise approach to the outer retina for diagnosis and follow-up as well as in understanding the pathophysiology of the disease.

Surpass Streamline Flow-Diverter Embolization Device for Treatment of Iatrogenic and Traumatic Internal Carotid Artery Injuries.

Iatrogenic and traumatic cerebral internal carotid artery injuries are uncommon but potentially lethal complications. Direct surgical repair of ICA injuries may be difficult in an acute setting. However, endovascular treatment with a flow-diverter embolization device is a feasible alternative technique that we experienced. In this clinical report, we describe demographic data, radiographic images, lesion characteristics, endovascular procedure notes, postprocedural hospital course, and follow-up digital subtraction angiography of 5 patients. At least 6-month follow-up was available in all patients without occurrence of rebleeding and other complications.

Peroxisome proliferator-activated receptor gamma expression in peripheral blood mononuclear cells and angiopoietin-like protein 4 levels in obese children and adolescents.

PURPOSE: The peroxisome proliferator-activated receptor γ (PPARγ) is highly expressed in adipose tissue and functions as transcriptional regulator of metabolism and adipocyte differentiation. Angiopoietin-like protein 4 (ANGPTL4), a central player in various aspects of energy homoeostasis, is induced by PPARγ. The aim of this study was to evaluate ANGPTL4 plasma levels and PPARγ gene expression in peripheral blood mononuclear cells (PBMCs) of children and adolescents with obesity and their association with metabolic parameters. METHODS: Seventy children and adolescents (35 obese and 35 age- and gender-matched control subjects), were selected. PBMCs were separated and their total RNA was extracted. After cDNA synthesis, PPARG gene expression was analyzed by real-time PCR. Relative differences in gene expression were calculated by ΔCt method using ß-actin as a normalizer. Serum ANGPTL4 and insulin were measured using ELISA, and insulin resistance (IR) was calculated by the homeostatic model assessment of insulin resistance (HOMA-IR). Fasting plasma glucose (FPG), triglyceride, total cholesterol, LDL-C and HDL-C were also measured. RESULTS: The expression of the PPARG gene as well as the plasma ANGPTL4 levels were significantly diminished in obese subjects as compared to control ones. However, they were not significantly different in obese children with IR compared to obese children without IR or in those with or without metabolic syndrome. A significant positive correlation was found between PPARγ and ANGPTL4 (r = 0.364, p = 0.002). PPARγ expression levels were also significantly correlated with FPG (r = -0.35, p = 0.003). CONCLUSION: PPARγ is decreased in childhood obesity and may be responsible for diminished ANGPTL4 levels.

THE ASSOCIATION OF PLASMA LEVELS OF miR-34a AND miR-149 WITH OBESITY AND INSULIN RESISTANCE IN OBESE CHILDREN AND ADOLESCENTS.

CONTEXT: MicroRNAs (miRNAs) are short noncoding RNAs involved in posttranscriptional regulation of gene expression that influence various cellular functions including glucose and lipid metabolism and adipocyte differentiation. OBJECTIVE: The aim of this study was to evaluate the levels of miR-34a and miR-149 and their relationship with metabolic parameters in obese children and adolescents. DESIGN: Seventy children and adolescents were enrolled in the study. Plasma levels of microRNAs were evaluated by real-time PCR using SYBR green and analyzed by ΔCt method. Plasma concentrations of visfatin and insulin were measured by ELISA method. Glucose and lipid profile were determined colorimetrically. HOMA-IR was calculated and used as an index of insulin resistance (IR). RESULTS: miR-34a was significantly lower in subjects with insulin resistance compared to obese children with normal insulin sensitivity. There was an inverse relationship between miR-34a levels and both insulin and HOMA-IR. On the other hand, miR-149 was significantly correlated with visfatin. There was no significant difference in miR-34a and miR-149 between obese and normal weight subjects. CONCLUSIONS: miR-34a is associated with insulin and HOMA-IR and thus seems to be involved in IR. miR-149 is inversely associated with visfatin levels which could be indicative of anti-inflammatory effect of this miRNA.

Body Composition and Epicardial Fat in Type 2 Diabetes Patients Following Insulin Detemir Versus Insulin Glargine Initiation.

The aim of the study was to compare body composition and epicardial fat thickness changes in insulin-naïve inadequately controlled patients with type 2 diabetes following basal insulin initiation with detemir vs. glargine. Six-month, open-label, interventional randomized pilot study was conducted. Dual-energy X-ray absorptiometry and echocardiography were used to estimate the body composition and epicardial fat thickness respectively. Thirty-six patients in the detemir group and 20 in the glargine group completed the study. Study groups baseline characteristics were comparable. At 6 months, for similar glycemic control, those on detemir significantly gained less total weight (0.6±2.5 vs. 4.2±4.1 kg, p=0.004), total fat mass (0.9±2.2 vs. 2.9±2.4 kg, p=0.02), and truncal fat mass (0.8±1.5 vs. 2.1±1.7 kg, p=0.02), with a loss in truncal lean mass (- 0.8±1.9 kg vs. 0.3±1.7 kg; p=0.02). EFT significantly decreased from baseline in both group (detemir - 1.7±0.52-mm, glargine - 1.1±1.6-mm; p<0.05, without significant difference inter-groups). Within the detemir group, epicardial fat thickness change correlated with truncal fat and total fat mass changes (r=0.65, p=0.06 and r=0.60, p=0.07). In conclusion, detemir resulted in less fat mass gain, a trend for a more pronounced epicardial fat thickness reduction when compared with glargine.

Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?

INTRODUCTION: Management of combined anterior or posterior cruciate ligament and posterolateral corner tears is still poorly codified. The aim of this study was to evaluate functional outcome after complete surgical treatment. MATERIALS AND METHODS: This retrospective multicenter study included 53 patients. Mean age was 29.8 yrs. (15-49). The anterior and posterior cruciate ligaments were involved in respectively 48 and 5 cases. Mean time to surgery was 25.6 months (0-184), and in 10 cases less than 21 days. Nine patients were sedentary workers and 29 non-sedentary (13 laborers). All ligament injuries were treated surgically. Mean follow-up was 49 months (12-146). Last follow-up assessment used IKDC, Lysholm and KOOS scores. RESULTS: At last follow-up, IKDC score graded 14 patients A, 25 B, 8 C and 6 D, versus 0 A, 4 B, 25 C, 22 D and 2 ungraded preoperatively. Mean subjective IKDC and Lysholm scores were respectively 72.8 (11.5-100) and 77.5 (37-100). Mean KOOS scores (pain, symptoms, daily life, sports, quality of life) were respectively 78 (3-100), 70 (25-100), 88 (47-100), 53 (0-100) and 50 (0-100). Posterolateral laxity was corrected in all but two cases. All sedentary workers and 86.7% of non-sedentary workers could return to work. The job had to be changed in 10% of cases overall, but in 25% of cases for laborers. DISCUSSION: The present results are comparable with those of the literature. The strategy of combined surgical treatment showed functional efficacy, usually associated with return to work except for some laborers. There was a non-significant trend in favor of acute-phase ligament reconstruction. LEVEL OF EVIDENCE: IV (retrospective series).

Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: a systematic review.

BACKGROUND: Combined injuries to the posterolateral corner and cruciate ligaments are uncommon. The heterogeneity of injury patterns in many studies complicates the assessment of outcomes. OBJECTIVE: To assess the prognosis and functional outcomes after surgery for combined injuries to the posterolateral corner and to the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL). MATERIAL AND METHODS: We systematically reviewed the literature for articles reporting outcomes 1 year or more after surgery for combined injuries to the posterolateral corner and ACL (n=4) or PCL (n=9). Patients with bicruciate injuries were not studied. RESULTS: Overall, 65% of patients were IKDC A or B after surgery. The mean Lysholm score improved from 67 to 90. Mean time to surgery was 4.43 months in the group with ACL tears and 18.4 months in the group with PCL tears, and mean follow-up was 34.4 and 40.7 months in these two groups, respectively. In the groups with ACL and PCL tears, the proportions of patients classified as IKDC A or B at last follow-up were 81.6% and 81.0%, respectively, whereas 88% and 99% of patients, respectively, were IKDC grade C or D before surgery. The mean Lysholm score improved from 77 to 92 in the group with ACL tears and from 65 to 89 in the group with PCL tears. Improvements in laxity ranged from 28% to 79% in the group with PCL tears. DISCUSSION: Most of the articles selected for our review provided level III or IV evidence. Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears. Full reconstruction seems the best strategy in patients with combined ACL/posterolateral corner injuries. Outcomes were also good but more variable in the group with PCL/posterolateral corner injuries. The time to surgery, which reflected the time to diagnosis, was shorter in patients with ACL than with PCL tears in addition to the posterolateral corner injury. LEVEL OF EVIDENCE: Level III (systematic literature review).

Audit of rapid access introduction reveals high prevalence of prostate cancer in Western Region.

INTRODUCTION: Men with symptoms suggestive of prostate cancer are now directly referred by their general practitioners to rapid access prostate assessment clinics (RAPACs). This service implements recommendations outlined by the National Cancer Control Programme. The RAPAC was introduced at Galway University Hospital, Galway, Ireland in June 2009, aiming to structure GP referral of patients with suspected prostate cancer to a urology service. AIMS: The aims of this study are to assess our initial experience with particular emphasis on access times, patient demographics, detection rates and treatment outcomes. METHODS: Data on all patients presenting to the RAPAC during the preliminary 2-year period have been gathered prospectively and analysed using standard parametric analysis methods. RESULTS: A total of 1,106 patients were reviewed at 278 clinic sessions during the initial 2-year period. The average waiting time to first clinic visit was 18 days (12-39 days). The mean age of referral to the clinic is 65 years (44-88 years). The mean PSA is 16.31 g/dL (0.4-845 g/dL). Of the 1106 patients undergoing TRUS biopsies, 503 (45.5 %) patients were diagnosed with prostate cancer. Further analysis patient demographics and cancer grading is presented in the article. Seventy-one patients (14.1 %) underwent radical retropubic prostatectomy. Sixty-seven patients (13.3 %) are being followed on an active monitoring programme, whilst 235 (56.7 %) received primary treatment with external beam radiotherapy and 68 (13.5 %) received brachytherapy. CONCLUSION: This data highlight the necessity of a RAPAC to streamline the provision of prostate cancer services in the west of Ireland.

Effect of G-Coat Plus on the mechanical properties of glass-ionomer cements.

BACKGROUND: Although various mechanical properties of tooth-coloured materials have been described, little data have been published on the effect of ageing and G-Coat Plus on the hardness and strength of the glass-ionomer cements (GICs). METHODS: Specimens were prepared from one polyacid-modified resin composite (PAMRC; Freedom, SDI), one resin-modified glass-ionomer cement; (RM-GIC; Fuji II LC, GC), and one conventional glass-ionomer cement; (GIC; Fuji IX, GC). GIC and RM-GIC were tested both with and without applying G-Coat Plus (GC). Specimens were conditioned in 37 °C distilled water for either 24 hours, four and eight weeks. Half the specimens were subjected to a shear punch test using a universal testing machine; the remaining half was subjected to Vickers Hardness test. RESULTS: Data analysis showed that the hardness and shear punch values were material dependent. The hardness and shear punch of the PAMRC was the highest and GIC the lowest. Applying the G-Coat Plus was associated with a significant decrease in the hardness of the materials but increase in the shear punch strength after four and eight weeks. CONCLUSIONS: The mechanical properties of the restorative materials were affected by applying G-Coat Plus and distilled water immersion over time. The PAMRC was significantly stronger and harder than the RM-GIC or GIC.