Evaluation of platelet count, erythrocyte sedimentation rate and C-reactive protein levels in paediatric patients with inflammatory and infectious disease.

Inflammatory and infectious diseases are the major causes of morbidity and mortality. The identification of markers for the assessment of disease activity and response to treatment can improve long-term prognosis. The aim of this study was to evaluate platelet count, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) among children with inflammatory and infectious disease. This cross-sectional study was conducted in the paediatric immunology and infectious units of Shahid Madani Hospital of Khorramabad. One hundred fifty children, half boys and half girls, with diagnoses of infectious and inflammatory diseases were included in the study. Platelet count, ESR and CRP were measured at the time of hospitalization and thereafter (recovery phase). A questionnaire including demographic information, diagnosis and paraclinical data was completed. At the time of hospitalization, all 150 children had abnormal ESR, 110 (73.3%) had abnormal CRP and 12 (92%) had alterations in platelet count. At the time of discharge, one patient (0.7%) had normal ESR, 132 (88%) had normal CRP and 140 patients (93.3%) had normal platelet count. At the time of discharge, we found a significant difference between the levels of CRP and platelets in girls. This study showed that CRP level is useful during treatment follow-up. Changes in platelet count are likely to be more prevalent in girls.

Evaluation of the relationship between vitamin D levels and prevalence of urinary tract infections in children.

Urinary tract infection (UTI) is associated with increased health burden among paediatric patients. Vitamin D is known for its immunoregulatory effects, particularly antimicrobial activity. The aim of this study was to determine the relationship between vitamin D levels and UTIs in children referred to a hospital in Khorramabad, Iran. This case-control study was conducted on 258 children aged between 2 and 14 years; 44 children with UTI and 214 healthy children were enrolled. Patients were tested for UTI on the basis of signs and symptoms, and urine culture and analysis. Vitamin D levels were measured in children in both groups. According to the results, the two groups were significantly different in terms of sex (p 0.007). There was no significant difference between the mean vitamin D among the two groups. Vitamin D levels were not related to UTI by multivariate logistic regression. The relationship between the level of vitamin D and the incidence of UTI in children in accordance with age and sex had an odds ratio of 0.99, indicating that for a 1-unit increase in vitamin D, the odds of having a UTI decreased by 1, a correlation which was not statistically significant. According to the findings of this study, no significant correlation was found between UTI and vitamin D levels. However, the prevalence of UTI was higher in girls than boys.

Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery.

OBJECTIVES: Patients with recurrent instability after anterior cruciate ligament (ACL) reconstruction often present with enlarged or misplaced tunnels and bone grafting is required prior to the actual revision reconstruction. Autologous bone grafting features limited quantity and donor site morbidity. These problems may be eliminated utilizing cancellous bone allografts, but their efficiency and reliability have not been investigated systematically. The aim of the present study was to compare tunnel filling rates attained by utilizing either allogenic or autologous cancellous bone grafts. MATERIALS AND METHODS: A total of 103 consecutive patients were enrolled retrospectively. All patients suffered from recurrent instability and underwent either allogenic or autologous cancellous bone grafting. Computed tomography (CT) was carried out before and after the bone grafting procedure. Based on preoperative CT scans, positioning and maximum diameter of the femoral and tibial tunnels were determined. Tunnel filling rates were calculated as a ratio of pre- and postoperative tunnel volumes. Primary outcome was the tibial tunnel filling rate. Femoral filling rates and density of the grafted bone were assessed secondarily. RESULTS: Preoperative CT scans revealed no significant differences between the two groups regarding distribution of misplacement and widening of the femoral or tibial tunnel. Postoperative CT scans were conducted after an interval of 5.2 months. Tunnel filling rates of 74.5% (± 14.3) femoral and 85.3% (± 10.3) tibial were achieved in the allogenic compared to 74.3% (± 15.9) femoral and 84.9% (± 9.4) tibial in the autologous group. With p values of 0.85 at the femur and 0.83 at the tibia, there were no significant differences between the groups. The density of the grafted bone revealed significantly higher values in the allogenic group. CONCLUSIONS: Utilizing cancellous bone allografts in two-staged revision ACL surgery provides for sufficient and reproducible filling of enlarged or misplaced tunnels. The filling rates are comparable to those achieved with autologous bone grafting. Advantages of allografts are the unrestricted quantity and the absence of any harvesting procedure.

Intraoperative fluoroscopy during MPFL reconstruction improves the accuracy of the femoral tunnel position.

PURPOSE: Reconstruction of the medial patellofemoral ligament (MPFL) has been established as standard of care for patellofemoral instability. An anatomic femoral tunnel position has been shown to be a prerequisite for restoration of patellofemoral stability and biomechanics. However, the incidence of malpositioning of the femoral tunnel during MPFL reconstruction continues to be notable. Palpation of anatomic landmarks and intraoperative fluoroscopy are the two primary techniques for tunnel placement. The aim of this study was to compare the accuracy of these two methods for femoral tunnel placement. METHODS: From 2016 to 2017, 64 consecutive patients undergoing MPFL reconstruction for patelllofemoral instability were prospectively enrolled. During surgery, the presumed femoral MPFL insertion was identified by both palpation of anatomic landmarks and using fluoroscopy, both of these points were separately documented on true lateral radiographs. They were then analysed and deviations from the Schoettle's Point were measured as anterior-posterior and proximal-distal deviations. A tunnel position within a radius of 7 mm around the Schoettle's Point was designated as an "accurate tunnel position". RESULTS: Compared to the method of palpation, fluoroscopy led to significantly more anatomic femoral tunnel positoning (p < 0.0001). The mean proximal-distal and anterior-posterior distances between the femoral insertion site identified by palpation and the Schoettle's Point were 5.7 ± 4.5 mm (0.3-20.3 mm) and 4.1 ± 3.7 mm (0.1-20.3 mm), respectively, versus 1.7 ± 0.9 mm (0.1-3.6 mm) and 1.8 ± 1.3 mm (0.1-4.8 mm) for fluoroscopy, respectively. Using fluoroscopy, all femoral insertion sites were identified within a 7 mm radius around the centre of the Schoettle's Point. In contrast, only 52% (33) of femoral insertion sites identified by palpation were within this radius. These data were independent of patients' age, gender and BMI. No improvement in accuracy of femoral tunnel positions was detected over time. CONCLUSIONS: The main finding of this study was that, compared to the method of palpation of anatomic landmarks, the use of intraoperative fluoroscopy in MPFL reconstruction leads to more accurate femoral tunnel positioning. Based on these results, the use of intraoperative fluoroscopy has to be recommended for femoral tunnel placement in daily surgical practice to minimize the incidence of malpositioning and to restore native patellofemoral biomechanics. STUDY DESIGN: Level III Case-control study.

[Injuries of the anterior cruciate ligament in athletes]. / Verletzungen des vorderen Kreuzbandes bei Sportlern.

Anterior cruciate ligament ruptures represent serious injuries for athletes which are often associated with accompanying injuries and lead to relevant kinematic alterations in the femorotibial roll-glide mechanism of the knee joint. Instability resulting in recurrent giving way events, as well as instability-related meniscal and cartilage lesions can cause functional long-term impairment that may limit the athlete's career. Anterior cruciate ligament replacement is therefore considered to be the gold standard for recovery of physical performance and to prevent secondary meniscal and cartilage damage. Continuous changes in the reconstruction of the anterior cruciate ligament have led to a variety of different methods, including graft choice, fixation devices and surgical techniques, which support the consideration of individual requirements of the athlete as well as sport-specific aspects. One of the main factors for restoring stability and the physiological kinematic roll-glide mechanism of the knee is an anatomical tunnel placement as well as a stable graft fixation in the tibia and femur. By achieving of these fundamental technical requirements an early functional rehabilitation and accelerated recovery of neuromuscular skills, strength and coordination can be achieved, so that an early return to sport activities is possible.

[Emergency room management of multiple trauma : ATLS® and S3 guidelines]. / Schockraummanagement Polytrauma : ATLS® und S3-Leitlinie.

Trauma management in the emergency room is an important part of the treatment chain of the severely injured. Important decisions with respect to diagnostics and treatment must be made under time pressure. Successful trauma management in the emergency room requires a hospital tailored treatment protocol. This written protocol needs consent from all participating disciplines and must be known by all members of the resuscitation team. The ATLS® and the recently published clinical practice guidelines on multiple trauma can be of help in order to establish or update such protocols. In order to continuously evaluate and improve performance in the emergency room local quality circles are needed that truly follow that aim. Important factors are reliability of agreement between the different disciplines and continuous communication of results to the team members. In order to be successful such quality circles need people that care.

[Prevention of infection in the current treatment of open fractures: an evidence-based systematic analysis]. / Prävention von Infektionen bei offenen Frakturen heute: Ein evidenzbasierter systematischer Review.

BACKGROUND: Treatment of open fractures remains an interdisciplinary challenge. Even success and evidence of infection prevention especially of new treatment options is not clear. METHOD: A systematic search in available electronic databases over the years 1974 until 2011 was conducted. Only clinical analyses with more than 5 adult patients in the German, English or French languages were included. All studies were rated according to Centre for Evidence-Based Medicine (CEBM) criteria. RESULTS: Over 855 articles were found due to the search and after applying the exclusion and inclusion criteria 49 studies were finally assessed to contribute to the evidence-based recommendations. Grade A recommendation: early application of antibiotics against gram-positive organisms for all open fracture types, additional coverage of gram-negative organisms for type III open fractures. Early surgical debridement should be performed. Grade B recommendation: type III open fractures should be treated with antibiotics for a minimum of 72 h but not longer than 24 h after wound closure. Vacuum treatment is justified and beneficial if wound closure is not achieved. Grade C recommendation: additional local antibiotic treatment in combination with systematic antibiotics may be of benefit. Definitive wound closure should be achieved within 1 week. DISCUSSION: This evidence-based analysis shows that there is good evidence for the treatment of open fractures with antibiotics and surgical debridement. Vacuum treatment can be recommended if wound closure is not possible.

[Advanced Trauma Life Support (ATLS) in the emergency room. Is it suitable as an SOP?]. / Schockraummanagement von Schwerverletzten. Eignet sich ATLS als SOP?

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

[Are computer assisted total knee replacements more accurately placed? A meta-analysis of comparative studies]. / Sind navigierte Knieendoprothesen tatsächlich präziser implantiert? Eine Metaanalyse vergleichender Studien.

Computer-assisted surgery (CAS) has become established in many hospitals throughout the world, especially in the form of computer navigation for total knee replacement (TKR). Analysis of the studies available revealed 18 comparative studies examining the precision of implantation of knee endoprostheses following CAS and after implantation by the conventional technique. In a meta-analysis of 13 studies in which the same safe zone of +/-3 from neutral alignment was defined for the leg axis, a total of 1,784 TKR were performed. In the group of patients in whom the conventional technique was used, 75.6% (654/865) of TKR were implanted within the safe zone. In the CAS group 93.9% (863/919) of the prostheses were implanted within the safe zone (p<0.0001). The differences between the groups were statistically significant in 11 of the 13 studies, and the difference between groups for the entire patient population is highly significant. Only limited clinical results were ascertained in these comparative studies; there were no great differences between the treatment groups in clinical course.

Use of autologous radial artery for revascularization of hepatic artery thrombosis after orthotopic liver transplantation: case report and review of indications and options for urgent hepatic artery reconstruction.

Hepatic artery thrombosis (HAT) is the most common vascular complication after orthotopic liver transplantation (OLT) and has traditionally been managed with re-OLT. However, several reports have shown that urgent revascularization is frequently an effective means of graft salvage. This most often involves hepatic artery (HA) thrombectomy and thrombolysis, with reestablishment of arterial inflow through a donor iliac artery conduit based on the supraceliac or infrarenal aorta. We report a 46-year-old man who developed HAT 13 days after OLT after angiographic splenic artery embolization to reduce splenic artery steal. A suitable donor iliac artery was not available for arterial reconstruction and could not be obtained from neighboring transplant centers. The patient underwent urgent HA thrombectomy, intrahepatic arterial thrombolysis, and revascularization using an autologous radial artery (RA) conduit based on the supraceliac aorta. The patient is alive more than 1 year after revascularization, with normal liver function and documented flow in the arterial conduit by Doppler ultrasound and arteriography. He has not developed late biliary complications or adverse sequelae of RA harvest. Autologous RA can be safely and successfully used as an aortic-based arterial conduit in urgent revascularization of HAT after OLT. RA should be considered for use in HA revascularization if an adequate donor iliac artery is not available and other potential conduits are not usable or desirable. The availability of autologous RA expands the armamentarium of vascular conduits that can be used in HA revascularization and may help minimize re-OLT for otherwise potentially salvageable liver allografts.

Further improvements in laparoscopic donor nephrectomy: decreased pain and accelerated recovery.

Fear of postoperative pain is a disincentive to living donor kidney transplantation. Laparoscopic donor nephrectomy (LDN) was developed in part to dispel this disincentive. The dramatic increase in the number of laparoscopic donor nephrectomies performed at our institution has been in part due to the reduction in postoperative pain as compared to traditional, open donor nephrectomy. We sought to further diminish the pain associated with this surgical technique. The purpose of this study was to compare the efficacy of three different postoperative pain management regimens after LDN. All living kidney donors performed laparoscopically (n=43) between September 1998 and April 2000 were included for analysis. Primary endpoints included postoperative narcotic requirements and length of stay. Narcotic usage was converted to morphine equivalents (ME) for comparison purposes. Patients received one of three pain control regimens (group 1: oral and intravenous narcotics; group II: oral and intravenous narcotics and the On-Q pump delivering a continuous infusion of subfascial bupivicaine 0.5%; and group III: oral and intravenous narcotics and subfascial bupivicaine 0.5% injection). Postoperative intravenous and oral narcotic use as measured in morphine equivalents was significantly less in group III versus groups I and II (group III: 28.7 ME versus group I: 40.2 ME, group II: 44.8 ME; P<0.05). Postoperative length of stay was also shorter for group III (1.8 days) versus group I (2.5 days) and group II (2.9 days). LDN has been shown to be a viable alternative to traditional open donor nephrectomy for living kidney donation. We observed that the use of combined oral and intravenous narcotics alone is associated with greater postoperative narcotic use and increased length of stay compared to either a combined oral and intravenous narcotics plus continuous or single injection subfascial administration of bupivicaine. The progressive modification of our analgesic regimen has resulted in decreased postoperative oral and intravenous narcotic use and a reduction in the length of stay. We recommend subfascial infiltration with bupivicaine to the three laparoscopic sites and the pfannenstiel incision at the conclusion of the procedure to reduce postoperative pain. We believe this improvement in postoperative pain management will continue to make LDN even more appealing to the potential living kidney donor.

Prognostic impact of p21/waf1/cip1 in colorectal cancer.

In addition to the tumor suppressor gene p53, Cyclin Dependent Kinases (CDK) are well known to influence the cell cycle in normal human tissues and various neoplasias as well. The purpose of our present study was to evaluate the expression of the CDK-inhibitor p21/waf1/cip1 in colorectal cancer with special emphasis on the prognostic impact. Between 1985 and 1991, 294 patients (median age, 65 years) underwent surgical operative therapy for colorectal cancer. Formalin-fixed and paraffin-embedded tumor specimens were investigated. For immunohistochemistry the Catalysed Reporter Deposition (CARD) technique was performed. The survival probability was calculated and possible prognostic risk factors were tested using multivariate analysis. The p21/ waf1/cip1 staining pattern was positive in 197 (67%) specimens and negative in 97 (33%) samples. No significant correlation could been calculated between p21/waf1/cip1 expression and other variables such as age, sex, WHO-Classification, localisation, grading, TNM-classification or UICC-stage. Patients with a positive staining reaction had a significantly better survival (p < 0.0052). Moreover, p21/waf1/cip1 was shown to be an independent prognostic parameter by multivariate analysis (p < 0.022). In contrast with these findings, the p53 tumor status had no impact on survival. P21/ waf1/cip1 appears to be an independent prognostic parameter in colorectal cancer and is associated with a favorable survival. This feature may be related to a cell cycle arrest in the G1 phase induced by p21/waf1/cip1, resulting in lower tumor cell proliferative activity.

Thomsen-Friedenreich antigen presents as a prognostic factor in colorectal carcinoma: A clinicopathologic study of 264 patients.

BACKGROUND: Up to now, the expression of the tumor-associated Thomsen-Friedenreich (TF) antigen in colorectal carcinoma has not been thoroughly investigated with particular emphasis on its correlation with established clinicopathologic characteristics and classifications as well as its prognostic relevance. METHODS: Formalin fixed, paraffin embedded specimens from 264 patients with colorectal carcinoma were stained using an avidin-biotin complex-peroxidase assay. As primary monoclonal antibodies (MAbs), A78-G/A7, which binds to TFalpha and TFbeta antigen irrespective of its carrier, and BW835, which detects TFalpha on MUC1 repeat peptide, were applied. RESULTS: MAbs A78-G/A7 and BW835 labeled 64.8% and 58. 0%, respectively, of carcinomas. None of the binding patterns correlated with gender, tumor localization, or growth type. Only BW835 reactivity exhibited a significant correlation with increasing pTNM staging and histologic grading. Staining of the MAb A78-G/A7 was significantly stronger in carcinomas that contained a mucinous component. In univariate survival analysis, in addition to pTNM staging and histologic grading, reactivity with A78-G/A7 as well as BW835 were significantly correlated with lower survival probability. Multivariate analysis according to the Cox proportional hazards model revealed only pTNM staging, histologic grading, and A78-G/A7 staining to be independent prognostic factors. CONCLUSIONS: According to these results, TF disaccharide represents a cancer-associated antigen in colorectal carcinoma that exhibits qualities of a prognostic marker. As demonstrated by BW835 staining, it is obviously coexpressed with MUC1 peptide core in a great number of cases. These results suggest that TF, in addition to MUC1, might also serve as a useful target antigen in the treatment of patients with colorectal carcinoma.

Laparoscopic donor nephrectomy: impact on an established renal transplant program.

The current disparity of viable organs and patients in need of a transplant has been an impetus for innovative measures. Live donor renal transplantation offers significant advantages compared with cadaveric donor transplantation: increased graft and patient survival, diminution in incidence of delayed graft function, acute tubular necrosis (ATN), and reduction in waiting time. Notwithstanding these gains live donors continue to be underutilized and account for only approximately one quarter of all renal transplants performed in the United States. It has been felt that inherent disincentives to live donation have slowed its growth. These include degree and duration of postoperative pain and convalescence, child care concerns, cosmetic concerns, and time until return to full activities and employment. In an attempt to curtail the disincentives to live donation, laparoscopic live donation (laparoscopic donor nephrectomy; LDN) was developed. The purpose of this study was to compare the results of our first 25 laparoscopic nephrectomies (performed over a 10-month period from September 1998 through July 1999) with the previous 25 standard open donor nephrectomies (ODNs) completed over the past 3 years. We conducted a retrospective review of all donor nephrectomies and recipient pairs performed over the past 3 years. End points included sex, operative time, length of stay, immediate and long-term renal function, and willingness to donate. There were no differences in demographics of the ODN versus the LDN group. The average length of stay was 2.48+/-0.72 days for the LDN versus 4.08+/-0.28 days for the ODN. ODN and LDN have comparable short- and long-term function with no delayed graft function and no complications. Growth of living donor transplant has increased from 16 per cent of all kidney transplants performed in 1995 to 23 per cent in 1999. We conclude that LDN is a viable alternative to the standard donor operation. LDN has had a positive impact on the donor pool by minimizing disincentives to live donation. With the initiation of our laparoscopic program the number of LDNs has increased. Presently the live donor pool is the most viable alternative to significantly increase the number of kidneys for transplantation.