[Translated article] Spinopelvic dissociation: Current concepts.

INTRODUCTION: Spinopelvic dissociation is an uncommon injury, but, at the same time, very serious, since it can associate important complications with high morbidity and mortality. Its low frequency means that the experience of the specialists who have to deal with it is often very limited. OBJECTIVE: To analyze the treatment indications based in classifications and surgery techniques. METHOD: A search for scientific articles from high-impact journals was performed through international databases, such as Pubmed, Cochrane Library, Scopus, Science Direct and OVID. CONCLUSIONS: The management of the injury we are analyzing represents a challenge. The diagnosis is carried out through a meticulous anamnesis and physical examination, supported by imaging tests, where tomography acquires special relevance. The treatment is fundamentally surgical, reserved the conservative option for a few cases. Triangular fixation is nowadays considered the treatment of choice.

Spinopelvic dissociation: Current concepts. / Disociación espinopélvica, revisión de conceptos actuales.

INTRODUCTION: Spinopelvic dissociation is an uncommon injury, but, at the same time, very serious, since it can associate important complications with high morbidity and mortality. Its low frequency means that the experience of the specialists who have to deal with it is often very limited. OBJECTIVE: To analyze the treatment indications based in classifications and surgery techniques. METHOD: A search for scientific articles from high-impact journals was performed through international databases, such as Pubmed, Cochrane Library, Scopus, Science Direct and OVID. CONCLUSIONS: The management of the injury we are analyzing represents a challenge. The diagnosis is carried out through a meticulous anamnesis and physical examination, supported by imaging tests, where tomography acquires special relevance. The treatment is fundamentally surgical, reserved the conservative option for a few cases. Triangular fixation is nowadays considered the treatment of choice.

Concordancia en el diagnóstico radiológico de las fracturas del raquis toracolumbar / Concordance in the radiological diagnosis of thoracolumbar spine fractures

Introducción. Las fracturas del raquis toracolumbar son muy frecuentes y graves, siendo imprescindible su diagnóstico precoz y tratamiento adecuado para obtener buenos resultados clínicos. Para este propósito se han descrito numerosas clasificaciones e índices. Objetivo. Estudiar la validez externa de las mediciones radiográficas y de la tomografía computarizada (TC) para las clasificaciones más usadas y decidir el tipo de tratamiento que precisan. La hipótesis operativa consiste en la existencia de validez externa de las mediciones radiográficas. Material y método. Se seleccionó una muestra de pacientes con fractura toracolumbar. Tres especialistas de raquis y un médico residente realizaron mediciones sobre imágenes radiográficas anteroposterior y lateral, así como sobre cortes coronales, sagitales y axiales de TC, clasificándose las fracturas como estables o inestables, evaluándose el grado de concordancia intra e interobservador, basados en un observador estándar. Se estudiaron las variables índice sagital de Farcy, acuñamiento lateral, índice de Beck, angulación regional traumática y ocupación del canal. Resultados. Todos los indicadores estudiados, excepto el acuñamiento lateral, presentaron un alto grado de concordancia. Conclusiones. Los determinantes de inestabilidad estudiados en radiografías simples y TC que han obtenido significación estadística son fiables y precisos para caracterizar las fracturas toracolumbares y, por tanto, para indicar un tratamiento adecuado (AU)

Introduction. Thoracolumbar spine fractures are frequent and severe. Early diagnosis and appropriate treatment to obtain good clinical results is essential, with many classifications being proposed for this purpose. Objective. To determine the external validity of radiographic and computed tomography (CT) measurements for the most used classifications, and decide on the type of treatment required. The working hypothesis is the existence of external validity of radiographic measurements. Material and method. A sample of patients with thoracolumbar fracture was selected. Three spine specialists and a resident performed measurements on anteroposterior and lateral radiographic images as well as coronal, sagittal and axial CT slices. Fractures were classified as stable or unstable, evaluating the degree of intra-and interobserver agreement based on a standard observer. Sagittal index of Farcy, lateral wedging, Beck Index, traumatic regional angulation and channel occupancy were studied. Results. All indicators studied, except the lateral wedging, showed a high degree of concordance. Conclusions. Instability determinants studied with radiographs and CT, which had obtained statistical significance, are reliable and accurate for the classification of thoracolumbar fractures and, therefore, to indicate an appropriate treatment (AU)

Concordance in the radiological diagnosis of thoracolumbar spine fractures.

INTRODUCTION: Thoracolumbar spine fractures are frequent and severe. Early diagnosis and appropriate treatment to obtain good clinical results is essential, with many classifications being proposed for this purpose. OBJECTIVE: To determine the external validity of radiographic and computed tomography (CT) measurements for the most used classifications, and decide on the type of treatment required. The working hypothesis is the existence of external validity of radiographic measurements. MATERIAL AND METHOD: A sample of patients with thoracolumbar fracture was selected. Three spine specialists and a resident performed measurements on anteroposterior and lateral radiographic images as well as coronal, sagittal and axial CT slices. Fractures were classified as stable or unstable, evaluating the degree of intra-and interobserver agreement based on a standard observer. Sagittal index of Farcy, lateral wedging, Beck Index, traumatic regional angulation and channel occupancy were studied. RESULTS: All indicators studied, except the lateral wedging, showed a high degree of concordance. CONCLUSIONS: Instability determinants studied with radiographs and CT, which had obtained statistical significance, are reliable and accurate for the classification of thoracolumbar fractures and, therefore, to indicate an appropriate treatment.

Concordancia interobservador de la clasificación de Eaton-Littler de la artrosis trapeciometacarpiana / Inter-observer agreement on the Eaton-Littler classification of trapeziometacarpal joint osteoarthritis

Objetivo. Estudiar la concordancia de la clasificación radiográfica de Eaton-Littler para el diagnóstico de la artrosis de la articulación trapeciometacarpiana (ATM). La hipótesis nula consideró que la concordancia era debida al azar, y la alternativa que la concordancia no era debida al azar. Material y método. Se estudiaron las radiografías de 46 pacientes con síntomas y signos clínicos de artrosis de la ATM. Se clasificaron independientemente por 5 facultativos: tres expertos en extremidad superior, uno en radiodiagnóstico y un residente en COT de cuarto año. Se estudió la concordancia de las observaciones mediante el índice kappa global. Discusión. El diagnóstico de la artrosis de la ATM se basa fundamentalmente en la clínica, siendo la radiografía un método complementario de confirmación. La clasificación de Eaton-Littler propone 4 estadios evolutivos de la enfermedad, con una implicación terapéutica. Conclusiones. La concordancia de la clasificación radiográfica de Eaton-Littler es moderada (AU)

Objective. To study the concordance of the radiographic classification of Eaton-Littler for the diagnosis of basal thumb joint osteoarthritis (BTJO). The null hypothesis was that the concordance was due to chance and the alternative was that the concordance was not due to chance. Material and method. We have observed the x-rays of 46 patients with symptoms and clinical signs of BTJO. They were independently classified by five physicians: three experts in upper extremity, one in radiology and a fourth year resident of Orthopedics. We studied the concordance in the observations through the global Kappa. Discussion. The diagnosis of BTJO is based primarily on clinical exploration, radiology is a complementary method of confirmation. The classification of Eaton-Littler proposes 4 stages of the disease, with a therapeutic involvement. Conclusions. The concordance of the radiographic classification of Eaton-Littler is moderate (AU)

[Inter-observer agreement on the Eaton-Littler classification of trapeziometacarpal joint osteoarthritis]. / Concordancia interobservador de la clasificación de Eaton-Littler de la artrosis trapeciometacarpiana.

OBJECTIVE: To study the concordance of the radiographic classification of Eaton-Littler for the diagnosis of basal thumb joint osteoarthritis (BTJO). The null hypothesis was that the concordance was due to chance and the alternative was that the concordance was not due to chance. MATERIAL AND METHOD: We have observed the x-rays of 46 patients with symptoms and clinical signs of BTJO. They were independently classified by five physicians: three experts in upper extremity, one in radiology and a fourth year resident of Orthopedics. We studied the concordance in the observations through the global Kappa. DISCUSSION: The diagnosis of BTJO is based primarily on clinical exploration, radiology is a complementary method of confirmation. The classification of Eaton-Littler proposes 4 stages of the disease, with a therapeutic involvement. CONCLUSIONS: The concordance of the radiographic classification of Eaton-Littler is moderate.

Supporting minority nursing students: 'Opportunity for Success' for Ethiopian immigrants in Israel.

AIM: To report on an Israeli academic nursing project, aimed at supporting the integration of Ethiopian immigrants into nursing studies. BACKGROUND: The representation of ethnic minorities within nursing is crucial for the provision of efficient care in diverse societies. Nevertheless, successful integration of minority students in nursing programs is not a simple task and needs developing support systems that will attract and retain students from minorities. Ethiopian Jewish immigrants and their descendants in Israel form a community of 120,000 people. Their participation in the national workforce is low, as well as their average income. METHODS: The paper is based on formative evaluation, using action research, of an academic nursing program in Israel. FINDINGS: Four main strategies identify this project: (1) a policy of institutional commitment, (2) personal relations with staff, (3) personal tutoring, and (4) cultural safety education. The project has reached success in terms of attraction, retention and students' satisfactions. The project's two main challenges, which need further concern, are: (1) giving support without labelling and (2) supporting without creating dependency. CONCLUSIONS AND INTERNATIONAL POLICY IMPLICATIONS: Appropriate strategies can enable success of minority students. Nevertheless, the amount of support needed for such programs raises two major questions: (1) To what extent should individual nursing departments be expected to bear solutions to this widely experienced problem? (2) How does focusing on one minority affect cultural safety of the overall group?

Batrachochytrium dendrobatidis in amphibians of Cameroon, including first records for caecilians.

Amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) has been hypothesised to be an indigenous parasite of African amphibians. In Cameroon, however, previous surveys in one region (in the northwest) failed to detect this pathogen, despite the earliest African Bd having been recorded from a frog in eastern Cameroon, plus one recent record in the far southeast. To reconcile these contrasting results, we present survey data from 12 localities across 6 regions of Cameroon from anurans (n = 1052) and caecilians (n = 85) of ca. 108 species. Bd was detected in 124 amphibian hosts at 7 localities, including Mt. Oku, Mt. Cameroon, Mt. Manengouba and lowland localities in the centre and west of the country. None of the hosts were observed dead or dying. Infected amphibian hosts were not detected in other localities in the south and eastern rainforest belt. Infection occurred in both anurans and caecilians, making this the first reported case of infection in the latter order (Gymnophiona) of amphibians. There was no significant difference between prevalence and infection intensity in frogs and caecilians. We highlight the importance of taking into account the inhibition of diagnostic qPCR in studies on Bd, based on all Bd-positive hosts being undetected when screened without bovine serum albumin in the qPCR mix. The status of Bd as an indigenous, cosmopolitan amphibian parasite in Africa, including Cameroon, is supported by this work. Isolating and sequencing strains of Bd from Cameroon should now be a priority. Longitudinal host population monitoring will be required to determine the effects, if any, of the infection on amphibians in Cameroon.

Challenges on the path to cultural safety in nursing education.

AIM: The purpose of this study is to identify central challenges to be addressed in cultural safety education. BACKGROUND: In recent years, the idea of cultural safety has received increased attention as a way of dealing with diversity in the nursing profession, especially in divided societies. The idea of cultural safety goes beyond recognizing and appreciating difference, to an attempt to grappling with deeper issues like inequality, conflict and histories of oppression. METHODS: The paper is based on formative evaluation, using action research, of an academic nursing programme in Israel, involving Jewish and Arab students. Part of this research dealt with the integration of cultural safety education into the curriculum. FINDINGS: The study revealed four challenges in cultural safety education: making it safe for minorities to present their culture to the majority group ('the ambassador's dilemma'), dealing with tendency of groups to deny the existence of conflict ('the one big happy family fantasy'), making dynamics of oppression discussable ('the oppressed and the oppressor') and creating conditions in which people can freely choose their individual and group identities ('the threat of identity'). CONCLUSION: Cultural safety education may be experienced as unsafe for many participants. Better understanding of the challenges of cultural safety education is necessary for making it more effective.

Teaching nursing in a situation of conflict: encounters between Palestinian-Israeli and Jewish-Israeli nursing students.

PURPOSE: This research examines the ways Palestinian-Israeli and Jewish-Israeli nursing students, who study together in one group in an academic school of nursing situated in northern Israel, perceive each other and the relationships among them. DESIGN: The study is based on semi-structured interviews with undergraduate students. The cohort consists of 46 students, 20 of whom participated in the study. FINDINGS: The students perceive themselves as divided into two separate groups according to nationality. Cooperation between the groups related to their study duties is described as generally satisfying, but little expressive communication and scarce social relations occur across these two groups. Students provided their perceptions of 'the others' to explain this social distance. IMPLICATIONS: We discuss the challenges of the situation for nursing educators and some strategies for coping with these challenges.

The establishment of an academic nursing faculty: action research in Israel.

AIM: The aim of this paper is twofold: to conceptualize tensions related to the academization of nursing, and to analyse a case study, describing how such tensions were dealt with in the process of establishing a new nursing department. BACKGROUND: This paper represents the first stage of a case study of the transformation of a hospital-based nursing school into an academic programme, carried out as a joint venture between a local hospital school and a college in northern Israel. METHODS: This paper is based on action research. The participants were 19 members of the new academic faculty and 3 members of an action research center. FINDINGS: The three inter-related tensions surfaced in the research process are: (1) the status of nursing and nurses, (2) the role of research and critical thinking in nursing education and practice, and (3) the characteristics of students, who should enroll in and graduate from nursing programmes, or in other words, the character of the 'ideal nurse'. CONCLUSIONS: An action research process enables new teams to put tensions on the table so they can be openly addressed through ongoing reflection, inquiry, learning, evaluation and redesign.

Signal integration in lipopolysaccharide (LPS)-stimulated murine macrophages.

Using a panel of LPS-inducible genes, selected for the capacity of their products to contribute to endotoxicity, normal macrophages were compared to macrophages deficient in CD14, CD11b/CD18, or TLR4 to elicit gene expression in response to Escherichia coli LPS or the LPS mimetic, Taxol. All genes were TLR4-dependent. At low doses of LPS or Taxol, all genes were also CD14-dependent; however, IP-10 and ICSBP remained poorly inducible even at much higher concentrations. A distinct subset of genes (COX-2, IL-12 p40, and IL-12 p35) was CD11b/CD18-dependent. NF-B translocation and MAPK phosphorylation were dysregulated in receptor-deficient macrophages. In contrast to E. coli LPS, a Porphyromonas gingivalis LPS preparation was found to be TLR2-, rather than TLR4-dependent, and resulted in differential expression of genes within the panel. These data suggest that: (i) TLR4 is necessary, but not sufficient, to induce the full repertoire of genes examined; (ii) CD14 and CD11b/CD18 facilitate signaling for induction of select subsets of genes that are also TLR4-dependent; and (iii) signaling through TLR2 versus TLR4 differs quantitatively/qualitatively. These data support an LPS signaling complex on murine macrophages that minimally includes CD14, CD11b/CD18, and TLR4 to respond to E. coli LPS to elicit the full spectrum of gene expression.

Signaling by toll-like receptor 2 and 4 agonists results in differential gene expression in murine macrophages.

Lipopolysaccharide (LPS) derived from the periodontal pathogen Porphyromonas gingivalis has been reported to differ structurally and functionally from enterobacterial LPS. These studies demonstrate that in contrast to protein-free enterobacterial LPS, a similarly purified preparation of P. gingivalis LPS exhibited potent Toll-like receptor 2 (TLR2), rather than TLR4, agonist activity to elicit gene expression and cytokine secretion in murine macrophages and transfectants. More importantly, TLR2 stimulation by this P. gingivalis LPS preparation resulted in differential expression of a panel of genes that are normally induced in murine macrophages by Escherichia coli LPS. These data suggest that (i) P. gingivalis LPS does not signal through TLR4 and (ii) signaling through TLR2 and through TLR4 differs quantitatively and qualitatively. Our data support the hypothesis that the shared signaling pathways elicited by TLR2 and by TLR4 agonists must diverge in order to account for the distinct patterns of inflammatory gene expression.

Cutting edge: repurification of lipopolysaccharide eliminates signaling through both human and murine toll-like receptor 2.

Toll-like receptor (TLR) 2 has recently been associated with cellular responses to numerous microbial products, including LPS and bacterial lipoproteins. However, many preparations of LPS contain low concentrations of highly bioactive contaminants described previously as "endotoxin protein," suggesting that these contaminants could be responsible for the TLR2-mediated signaling observed upon LPS stimulation. To test this hypothesis, commercial preparations of LPS were subjected to a modified phenol re-extraction protocol to eliminate endotoxin protein. While it did not influence the ability to stimulate cells from wild-type mice, repurification eliminated the ability of LPS to activate cells from C3H/HeJ (Lpsd) mice. Additionally, only cell lines transfected with human TLR4, but not human or murine TLR2, acquired responsiveness to both re-extracted LPS and to a protein-free, synthetic preparation of lipid A. These results suggest that neither human nor murine TLR2 plays a role in LPS signaling in the absence of contaminating endotoxin protein.

The "Canadian model" in the international context.

The focus of this commentary is on the relevance of the Canadian experience for developing countries. It highlights the growing urgency poor countries face in preserving their major human and social capital--community solidarity and family care. Developing countries face a double burden of disease--communicable and non-communicable diseases alike, with very few, and often shrinking, resources. While poorer countries will be able to learn about the essential elements of home-based care from the examples of Canada and other industrialized countries, they do need to develop their own systems based upon their economic, social, political and cultural realities. The primary health care system would seem to provide a foundation for the provision of long-term care on a sustainable and cost-effective basis. In contrast to the often-prevailing practice in developed countries, home-based care services could be integrated into the overall health and social system. Functional disability, regardless of disease aetiology or age of the care recipient, as well as the needs of family caregivers would thus become the defining elements of service eligibility. While the question remains open as to how much poor countries can learn from the experience of others, developing countries do have the opportunity to initiate a rational process where they first provide support to communities and informal caregivers and help to maintain patients in their homes and only later develop other service elements.

Cutting edge: inflammatory signaling by Borrelia burgdorferi lipoproteins is mediated by toll-like receptor 2.

The agent of Lyme disease, Borrelia burgdorferi, produces membrane lipoproteins possessing potent inflammatory properties linked to disease pathology. The recent association of toll-like receptors (TLR) 2 and 4 with LPS responses prompted the examination of TLR involvement in lipoprotein signaling. The ability of human cell lines to respond to lipoproteins was correlated with the expression of TLR2. Transfection of TLR2 into cell lines conferred responsiveness to lipoproteins, lipopeptides, and sonicated B. burgdorferi, as measured by nuclear translocation of NF-kappaB and cytokine production. The physiological importance of this interaction was demonstrated by the 10-fold greater sensitivity of TLR2-transfected cells to lipoproteins than LPS. Futhermore, TLR2-dependent signaling by lipoproteins was facilitated by CD14. These data indicate that TLR2 facilitates the inflammatory events associated with Lyme arthritis. In addition, the widespread expression of lipoproteins by other bacterial species suggests that this interaction may have broad implications in microbial inflammation and pathogenesis.

An evaluation of WHA resolution 45.5: health human resource implications.

The World Health Assembly approved resolution WHA45.5 in 1992. This paper reports the findings of an evaluation of the implementation of this resolution using a survey technique. A total of 150 WHO Member States responded, for a 79% response rate. Findings suggest that the greatest strides worldwide have been made in education. While the data show that progress has been made at the country level, far more action is needed to strengthen nursing and midwifery if these cost-effective resources are to play a decisive role in improving the extent and quality of services, especially as delivered to people in the greatest need.

Human resources for health--challenges for the 21st century.

A quality health workforce is critical for the development of health systems and the delivery of health services. Although significant resources have been devoted to this area, imbalances persist in most countries. There is a growing recognition that to address current demographic, epidemiological, technological and socioeconomic changes, approaches to human resources for health development must be more comprehensive. While education and training of health personnel is a crucial element, the areas of policy development, planning and management of human resources must receive appropriate attention. Health sector reform initiatives have not included human resources development as an integral part in their processes, which has led to failures of reforms in some cases. Human resources for health must have a more prominent place on the political agenda of countries. It is apparent that to meet current and future challenges, partnerships between the many actors must be established.