Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations.

Our objective was to develop a clinical practice guideline (CPG) for the treatment of acute lower extremity fractures in persons with a chronic spinal cord injury (SCI). Methods: Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence. Conclusions: Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.

The effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D: a prospective randomised trial.

AIMS: To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture. PATIENTS AND METHODS: Between July 2011 and August 2013, 113 adults with a long bone fracture were enrolled in a prospective randomised double-blind placebo-controlled trial. Their serum vitamin D levels were measured and a total of 100 patients were found to be vitamin D deficient (< 20 ng/ml) or insufficient (< 30 ng/mL). These were then randomised to receive a single dose of vitamin D3 orally (100 000 IU) within two weeks of injury (treatment group, n = 50) or a placebo (control group, n = 50). We recorded patient demographics, fracture location and treatment, vitamin D level, time to fracture union and complications, including vitamin D toxicity. Outcomes included union, nonunion or complication requiring an early, unplanned secondary procedure. Patients without an outcome at 15 months and no scheduled follow-up were considered lost to follow-up. The t-test and cross tabulations verified the adequacy of randomisation. An intention-to-treat analysis was carried out. RESULTS: In all, 100 (89%) patients had hypovitaminosis D. Both treatment and control groups had similar demographics and injury characteristics. The initial median vitamin D levels were 16 ng/mL (interquartile range 5 to 28) in both groups (p = 0.885). A total of 14 patients were lost to follow-up (seven from each group), two had fixation failure (one in each group) and one control group patient developed an infection. Overall, the nonunion rate was 4% (two per group). No patient showed signs of clinical toxicity from their supplement. CONCLUSIONS: Despite finding a high level of hypovitaminosis D, the rate of union was high and independent of supplementation with vitamin D3. Cite this article: Bone Joint J 2017;99-B:1520-5.

Effectiveness of foot fasciotomies in foot and ankle trauma.

BACKGROUND: Foot compartment syndrome (FCS) has been reported to cause neuropathic pain, claw or hammer toes, and motor and sensory disturbances. The optimal treatment of FCS is controversial. The purpose of this study was to determine if foot fasciotomies improve patient outcomes in high-energy, combat-related lower extremity trauma. METHODS: Medical records of patients with documented FCS from May 2007 to January 2009 were retrospectively reviewed. Consecutive, matched control patients were identified based on similar hindfoot, mid-foot and/or forefoot injuries who did not undergo foot fasciotomy during the same period. The primary outcomes analysed were the development of claw or hammer toes and neuropathic pain. RESULTS: 19 patients with foot fasctiotomies were identified and matched with 19 controls. Median follow-up was 19.5 months (range, 3.5-47.5 months) for the combined cohorts. The most common mechanism of injury was an explosive blast. Nine fasciotomy and nine control patients sustained open foot fractures. Significantly more patients with foot fasciotomies developed claw toes (50% vs 17%, p=0.03). There were no significant differences in the development of neuropathic pain, sensory deficits, motor deficits, chronic pain, stiffness or infection. The fasciotomy patients underwent an average of 5.5 surgeries per patient versus 4 surgeries per patient in the control group. CONCLUSIONS: Fasciotomy of the foot did not prevent neuropathic pain and deformities in patients with FCS in this study.

Genistein-induced neuronal differentiation is associated with activation of extracellular signal-regulated kinases and upregulation of p21 and N-cadherin.

Neuronal differentiation in the mammalian CNS is driven by multiple events. When treated with retinoic acid (RA), hNTera-2 (NT-2) cells undergo postmitotic neuronal differentiation. Here, we show that a prolonged exposure of NT-2 cells with non-cytotoxic doses of genistein, a protein tyrosine kinase (PTK) inhibitor, induced differentiation of NT-2 cells. Additionally, genistein enhanced RA-induced neuronal differentiation by increasing the activation of extracellular signal-related kinase 1/2 (ERK1/2) via phosphorylation at Thr183 and Tyr185 in 3-7 days. Meanwhile, genistein also upregulated N-cadherin and p21 (a Cdk inhibitor), but downregulated proliferating cell nuclear antigen protein (PCNA). MEK1/2 inhibitors, such as PD98059 and U0126, reduced RA-induced ERK1/2 activity, but could not block the genistein effects. Our observations indicate that genistein-induced neuronal differentiation is not dependent of the MEK-ERK signaling cascade. Instead, genistein-upregulated ERK activation is likely due to this chemical's direct effect on chromosome and gene transcription, rather than its inhibition on tyrosine kinases. Failure of inhibition of ERK1/2 activation by the MEK1/2 inhibitors PD98059 and U0126 suggests presence of an unknown activator for ERK1/2 in neuronal cells.

The retina as a novel in vivo model for studying the role of molecules of the Bcl-2 family in relation to MPTP neurotoxicity.

To determine the roles of different members of the family of B cell lymphoma protooncogene (Bcl-2) in relation to neurotoxin-induced neuronal degeneration, the pattern of the expression of a number of molecules of the Bcl-2 family was studied immunocytochemically in the retinas of C57BL/6J mice after intraperitoneal (IP) injection of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Three days to 12 weeks after MPTP treatment, a detectable reduction of tyrosine hydroxylase immunoreactivity in the amacrine cells was observed, with an increase of Bcl-2 expression in the Müller glial cells, and a de novo expression of Bad and Bax in the retinal ganglion cells, optic nerve fibers and plexiform layers. In contrast, a slight decrease of Bcl-x(L) immunoreactivity in the retinal ganglion cells was observed, whereas Bcl-x(S/L) immunoreactivity was increased slightly in the retinas of MPTP-treated mice compared with that of the controls. In animals that received MPTP injection, an increase in immunostaining of GFAP, glutamine synthetase, and Mac-1 (CD11b) in astrocytes, Müller cells, and microglia was invariably observed, indicating an activation or dysfunction of retinal glial cells. These findings are consistent with the current view that glial dysfunction is important in mediating the cytotoxic effect of a variety of neurotoxic molecules, including MPTP, and that different members of Bcl-2 family may have different roles as far as neuronal degeneration or neuroprotection is concerned.

[Neurogenic pulmonary edema following a grand mal seizure: a case report].

A case of neurogenic pulmonary edema following a grand mal epileptic seizure is presented. This condition is rather rare and the exact pathophysiology remains unknown, but it is believed that the event may be related to transitional increase of intracranial pressure during seizure attack. Pulmonary edema may be a serious complication of epileptic seizure. Rapid recognition and management is very important since the prognosis depends on the severity of pulmonary edema and appropriate treatment.

[Age and pulmonary function testing in predicting postoperative morbidity after thoracic surgery].

In order to evaluate whether age and pulmonary function testing may predict postoperative morbidity and mortality in the patients having received thoracic surgery, 203 patients were included in this study. Spirometry, flow volume curve, lung volume determination and arterial blood gas analysis were performed in all of them. Postoperative complications were classified into respiratory complications including pneumonia, purulent bronchitis, atelectasis, respiratory failure and so on; and non-respiratory complications including subcutaneous emphysema, internal bleeding, stump leakage, dysarrythmia and so on. Of the 117 patients over 65 years of age, 27 (23.1%) had postoperative respiratory complications, 27 (23.1%) had non-respiratory complications, and 7 (5.93%) expired postoperatively. Of the 86 patients under 65 years of age, 21 (24.4%) had postoperative respiratory complications and 9 (7.6%) had postoperative non-respiratory complications, but one expired. The incidences of postoperative mortality and non-respiratory complications were both higher in the patients over 65 years of age (p less than 0.05). Our results indicated that age is a risk factor of thoracic surgery, even if the pulmonary function testing meet the surgical criteria.

When do children avoid backwards coreference?

This study investigated the claim that very young children avoid backwards coreference in their interpretation of sentences containing pronouns. Eighty-one children ranging in age from 3;1 to 8;0 and eight adults acted out four types of pronominal sentences. Cross-sectional data and individual response patterns reveal that children initially prefer internal coreference even when such a response is disallowed for structural reasons. Avoidance of backwards coreference appears to be a late developing phenomenon characteristic of six-year-olds. Adult response patterns, which are manifested by some very young children, emerge as the dominant pattern by age seven.

Pneumothorax following cytotoxic chemotherapy in malignant lymphoma.

Pneumothorax occurring as a complication of the antitumor effect of cytotoxic chemotherapy has been reported in occasional cases of a variety of tumors. Its occurrence in malignant lymphoma has not been reported heretofore. In this report, we describe two cases of this complication in patients with malignant lymphoma and discuss the possible pathophysiologic mechanisms involved. Because pulmonary involvement with the tumor was found in both cases, pneumothorax could be attributed to the anti-tumor effect of cytotoxic agents on underlying lung involvement in patients with malignant lymphoma.

Control and coreference in early child language.

This study investigated the relationship between control and coreference using an act-out task involving 81 children ranging in age from 3.1 to 8.0 and eight adults ranging in age from 30 to 55. The results replicated previous findings in revealing five developmental stages in children's interpretation of PRO, an empty pronominal element. A significant relationship was observed in the patterns of children's interpretation of forwards sentences containing PRO and those containing overt pronouns. However, there was no relationship in the development of restrictions on control and restrictions on coreference.

When-questions: a study of how children linguistically encode temporal information.

Sixty children between the ages of 4 and 7 years and 10 adults were presented with a series of stories illustrated by five pictures in a comic strip format. Each story was followed by either a "when-," "why-," or control question. With respect to the "when"-questions, some of the stories involved causally related events while others did not. An analysis of the responses supported the hypotheses that causal relationships play an important role in the development of the ability to encode temporal relationships in response to "when"-questions.

Effects of prior context on lexical access during sentence comprehension: a replication and reinterpretation.

In a phoneme monitoring task, prior biasing context eliminates the effect of lexical ambiguity, replicating and extending the results of Swinney and Hakes (1976). It is argued, however, that the conclusions drawn by Swinney and Hakes are not justified by the data and that a different model of the effects of context on lexical processing is more theoretically plausible than theirs.