Influence of Sex and Previous Concussion History on Postconcussive Recovery in Young Athletes.

OBJECTIVE: To determine whether concussed female athletes with a previous history of concussion have longer postconcussive recovery than that of male counterparts. DESIGN: Retrospective cohort study. SETTING: Outpatient sports medicine clinic in an academic practice. PARTICIPANTS: Male and female youth, high school, and collegiate athletes (n = 431; ages = 10-21 years) who sustained a sport-related concussion (SRC). INTERVENTIONS: The clinical courses of young athletes treated for concussion by 1 provider at an outpatient sports medicine clinic were retrospectively reviewed. MAIN OUTCOME MEASURES: Recovery time was compared after an SRC with relationship to sex and previous concussion history. RESULTS: When comparing male and female athletes with a previous history of concussion, there were no differences found (P = 0.820) in SRC recovery time. Regardless of previous concussion history, males recovered faster from an SRC compared with their female counterparts (P = 0.0002). Without regard to sex, those with no previous history of concussion recovered faster than those with a previous concussion history, although the difference was not statistically significant (P = 0.668). Athletes with a previous history of concussion were more likely to require neuropsychology referral than those with no previous concussion history (P = 0.021), and females, without regard to concussion history, were more likely to require neuropsychology referral than males (P = 0.001). CONCLUSIONS: A previous concussion history does not appear to significantly influence postconcussive recovery time in young athletes, although it does increase the probability of neuropsychological referral. Without regard to a previous concussion history, young female athletes recover slower than males from concussion and are also more likely to require neuropsychological referral.

Caregiver Burden for Patients With Severe Osteoarthritis Significantly Decreases by One Year After Total Knee Arthroplasty.

BACKGROUND: The impact of total knee arthroplasty (TKA) on patients' informal caregivers (eg, family members, friends) has gone largely ignored. The goals of this study are to measure the impact of TKA on the caregiver and identify factors contributing to higher burden. METHODS: One hundred fifty primary TKA patients and their designated caregivers were prospectively enrolled. The Caregiver Strain Index (CSI) was completed by caregivers preoperatively, at 4 weeks, and at 1 year after surgery. Additional outcomes included the Knee injury and Osteoarthritis Outcome Score for patients only and the Veterans Rand 12 Item Health Survey for both patients and caregivers. Univariate analysis and multivariate regression modeling were performed. RESULTS: Mean CSI scores at 1 year were significantly lower than preoperative values (P < .01), where lower scores indicate better results. Higher mean CSI values for younger caregivers were identified preoperatively (r = -0.21, P < .01) and at 4 weeks (r = -0.26, P < .01). There were higher mean CSI values for employed caregivers preoperatively (P = .01) and at 4 weeks (P < .01). A negative correlation was identified between CSI and the caregiver's Veterans Rand 12 Item Health Survey Mental Component Score preoperatively (r = -0.15, P = .03) and at 4 weeks (r = -1.5, P = .03). CONCLUSION: Caregiver burden nearly doubled in the early postoperative period, which was related to several caregiver and patient factors. However, the burden was close to zero by 1 year postoperatively. Thus, TKA is a beneficial intervention for both patient and caregiver.

Fluoroscopically Guided Acetabular Component Positioning: Does It Reduce the Risk of Malpositioning in Obese Patients?

BACKGROUND: Obesity has been described as an independent risk factor for acetabular component malpositioning. The purpose of this study was to determine if this could be overcome by use of fluoroscopic navigation in total hip arthroplasty (THA). METHODS: The first, postoperative, standing, anteroposterior pelvis radiographs from 1599 consecutive patients who underwent fluoroscopic-guided THAs via anterior approach during a six-year period were obtained. We retrospectively reviewed this prospectively collected data. Inclination and anteversion were measured as described by Barrack et al. Intraoperative target ranges for inclination and anteversion angles were 30°-50° and 5°-25°. Patients were divided into 3 cohorts by body mass index, nonobese (<30 kg/m2) obese (between 30 and 40 kg/m2) and morbidly obese (>40 kg/m2), looking for significant differences in acetabular component positioning. RESULTS: Of the 1599 patients, 1065 were nonobese, 506 obese, and 28 morbidly obese. Overall, average inclination was 37.7° and anteversion was 16.3°. Regarding inclination, 95.0% of cups were positioned in the safe zone, 95.7% for anteversion, and 91.2% for both inclination and anteversion. Analysis of each cohort individually revealed an average inclination of 37.5° in the nonobese, 37.9° in the obese, and 39.9° in the morbidly obese patients. For anteversion, each group's averages were 16.1°, 16.5°, and 16.0°, respectively. There was no significant relationship between a patient's body mass index and cup position for inclination (P = .867), anteversion (P = .673), or both inclination and anteversion (P = .624). CONCLUSION: Fluoroscopy is a useful tool for achieving a targeted acetabular component orientation in direct anterior THA, irrespective of patient BMI.

Closed Suction Drainage Has No Benefits in Anterior Hip Arthroplasty: A Prospective, Randomized Trial.

BACKGROUND: Many studies have challenged routine drain placement in patients undergoing total hip arthroplasty. Some studies suggest increased transfusion rate with the use of closed suction drains. The use of tranexamic acid to control surgical bleeding and aspirin for venous thromboembolism prophylaxis has gained popularity. No study has evaluated the use of drains in patients undergoing direct anterior total hip arthroplasty under these conditions. METHODS: We performed a prospective, randomized study in patients undergoing direct anterior total hip arthroplasty to evaluate whether closed suction drain placement provides any clinical benefit. Patients randomly assigned to the control group had closed suctions drains placed; patients randomly assigned to the treatment group had no drains placed. The primary outcome measures were hematoma formation, wound complications, and transfusion rates. The secondary outcome measures were estimated blood loss, decrease in hemoglobin and hematocrit levels, total hemoglobin loss, calculated blood loss, hidden blood loss, and total length of hospital stay. Differences in outcomes between groups were considered to be significant at P ≤ .05. RESULTS: There were no significant differences between groups in transfusion rate (P = .49), postoperative decrease in hemoglobin levels (P = .95), average calculated blood loss (P = .65), complications (P = .49), or length of hospital stay (P = .14). There was no hematoma formation observed in either group. CONCLUSION: Our study showed no clinical benefit or disadvantage to closed suction drainage in anterior hip arthroplasty with the concomitant use of tranexamic acid for surgical hemostasis and aspirin for venous thromboembolism prophylaxis.

The deep-breath test as a diagnostic maneuver for white-coat effect in hypertensive patients.

BACKGROUND: The white-coat effect is a common phenomenon in hypertensive patients, and there is no current useful office test to detect it. METHODS: This was a cross-sectional study. We evaluated the deep-breath maneuver at the office as a diagnostic test of the white-coat effect. Participants included 83 adult patients with uncontrolled office hypertension. We measured sensitivity, specificity, likelihood ratios of different cutoff points, area under receiver operating characteristic (ROC) curve, and 95% confidence intervals. The reference standard used was 24-hour ambulatory blood pressure monitoring. RESULTS: We included 73 patients [mean age, 58.7 +/- 9.5 years (mean +/- SD); 55% women]. The prevalence of white-coat effect was 62%. Comparing patients with white-coat effect versus those without, the deep-breath test resulted in a mean systolic blood pressure decrease of 17.8 and 10.9 mm Hg (P <.001) and a mean diastolic decrease of 6.6 and 5.4 mm Hg, respectively (P = not significant). The area under the ROC curve of systolic blood pressure change was 0.69 (95% confidence interval, 0.57 to 0.81). Interobserver agreement was very good. CONCLUSIONS: The deep-breath test can be a helpful maneuver for the detection of white-coat effect. It has no major adverse effects and it may help avoid overtreatment and unnecessary further testing procedures.

Guía europea de hipertensión / European guide of hypertension

Estas guías fueron elaboradas por un comité de expertos reunido por la Sociedad Europea de Hipertensión y la Sociedad Europea de Cardiología y han sido avaladas por la Sociedad Internacional de Hipertensión. Fueron prperadas sobre la base de la mejor evidencia disponible sobre el manejo de la hipertensión arterial con un objetivo principalmente educacional más que prescriptivo. El comité ha tratado de no dar reglas rígidas que pudieran restringir el criterio de manejo de los pacientes individuales quiénes difieren en características personales, médicas y culturales. (AU)

Guía europea de hipertensión / European guide of hypertension

Estas guías fueron elaboradas por un comité de expertos reunido por la Sociedad Europea de Hipertensión y la Sociedad Europea de Cardiología y han sido avaladas por la Sociedad Internacional de Hipertensión. Fueron prperadas sobre la base de la mejor evidencia disponible sobre el manejo de la hipertensión arterial con un objetivo principalmente educacional más que prescriptivo. El comité ha tratado de no dar reglas rígidas que pudieran restringir el criterio de manejo de los pacientes individuales quiénes difieren en características personales, médicas y culturales.

Influence of new evidence on prescription patterns.

BACKGROUND: It is currently accepted that no drug can enter clinical practice without proved efficacy in clinical trials. Improving patient care requires that the results of clinical evaluation be translated into practice. Results of studies are conflicting, but there is support that well-executed, clinically relevant randomized trials published in highly visible clinical journals can have an effect on patterns of medical practice. METHODS: We evaluated the potential impact of the publication in a leading journal of different drug studies (metformin, alendronate, terazosin, and finasteride) on the prescription behavior of generalists and specialists. Using a health maintenance organization (HMO) prescription drug database, we analyzed the incidence of new prescriptions written by generalists and specialists from a university-affiliated HMO before and after the publication date of the studies. RESULTS: The proportions of new prescriptions changed between a 6-month period before publication and a 6-month period after publication. The rate for alendronate increased from 31.7% to 43.2% of all prescriptions for specialists (P = NS) and from 8.8% to 38.9% for generalists (P < .01). The rate for metformin increased from 26.7% to 46.4% for specialists (P = .04) and from 7.9% to 24.2% for generalists (P < .01). The rate for alpha1-blockers decreased from 48.7% to 38.9% (P = NS) for specialists and increased from 20.7% to 60% for generalists (P < .01). The rate for finasteride decreased from 40.9% to 19.64% for specialists (P < .01) and from 22.11% to 11.3% for generalists (P = .01). CONCLUSIONS: The change in the prescription patterns of all physicians showed a clear temporal association with the publication of new evidence. The greater change observed for generalists could be explained by their lower baseline use of the drugs and a more conservative behavior that might defer the adoption of new treatments until they are supported by strong evidence published in major journals.

Diagnóstico y rastreo de enfermedades de transmisión sexual / Diagnosis and screening of sexually transmitted diseases

En la presente guía se revisan algunos puntos importantes de utilidad para el médico de atención primaria en las enfermedades de transmisión sexual (ETS) más comunes e importantes: clamydia, gonococo, herpes genital, sífilis, HPV, hepatitis B e HIV. Se evalúan las recomendaciones de rastreo en distintas poblaciones y los tests diagnósticos indicados

Diagnóstico y rastreo de enfermedades de transmisión sexual / Diagnosis and screening of sexually transmitted diseases

En la presente guía se revisan algunos puntos importantes de utilidad para el médico de atención primaria en las enfermedades de transmisión sexual (ETS) más comunes e importantes: clamydia, gonococo, herpes genital, sífilis, HPV, hepatitis B e HIV. Se evalúan las recomendaciones de rastreo en distintas poblaciones y los tests diagnósticos indicados