Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections?

BACKGROUND: Higher complication rates have been reported for total hip arthroplasty (THA) after osteosynthesis of proximal femur fractures (PFF). This study evaluated the infection risk for conversion of internal fixation of PFF to THA by a single-staged procedure in the absence of clear infection signs. METHODS: Patients undergoing a one-staged conversion to THA (2013-2018) after prior internal fixation of the proximal femur were included. Preoperative diagnostics with laboratory results, hip aspirations as well as intraoperative microbiology and sonication were assessed. Postoperative complications were recorded as well as patient demographics, duration between initial and conversion to THA, explanted osteosynthesis and implanted THA. RESULTS: Fifty-eight patients (24 male/34 female, 62.8 ± 14.5 years) were included with a mean time of 3.8 ± 7.5 years between internal fixation and conversion to THA (45 cementless, 3 cemented, 3 hybrid and 7 hybrid inverse THAs). Preoperative mean blood level CRP was 8.36 ± 14 mg/l (reference value < 5 mg/l) and leukocyte count was 7.11 ± 1.84^3/µl (4.5-10.000^3/µl). Fifty patients had intraoperative microbiological diagnostics, with either swabs in 86.2% and/or sonication in 29.3%. Positive microbiological results were recorded in 10% (5 of 50 patients), with pathogens identified being mainly Staphylococcus. Complications after conversion occurred in 9.6% including a postoperative low-grade infection rate of 5.8% after a mean of 2.5 years. CONCLUSION: This study found a positive microbiological test result in 10% of a one-stage conversion of PFF fixation to THA. Moreover, we found a high infection rate (5.8%) for early postoperative periprosthetic joint infection. Interestingly, CRP has not been proven to be an adequate parameter for low-grade infections or occult colonized implants. Therefore, we recommend a comprehensive pre- and intraoperative diagnostic including hip aspiration, swabs and sonication when considering one-staged revision.

Can abundant colloid exclude oncocytic (Hürthle cell) carcinoma in thyroid fine needle aspiration? Cytohistological correlation of 127 oncocytic (Hürthle cell) lesions.

OBJECTIVE: The objective of the present study was to find out whether the presence or absence of certain cytological features can exclude oncocytic (Hürthle cell) carcinoma in thyroid fine needle aspiration (FNA) to minimize unnecessary surgery. METHODS: Over a 17-year period, 127 hypercellular, oncocyte-exclusive, lymphocyte-absent aspirates obtained via ultrasound-guided FNA with on-site assessment had histology slides for review. The presence or absence of six cytological features (microfollicular arrangement, discohesive single cells, small cell dysplasia, large cell dysplasia, transgressing blood vessels and colloid) and one histological feature (macrofollicular component) were determined for each case independently by two cytopathologists. RESULTS: Histology showed 12 (9.4%) cases of Hashimoto thyroiditis, 23 (18.1%) oncocytic adenomatoid nodules in nodular goitre, 66 (52.0%) oncocytic adenomas and 26 (20.5%) oncocytic carcinomas (13 minimally invasive without angioinvasion, six minimally invasive with angioinvasion, seven widely invasive). Histologically, a macrofollicular component was present in seven of 26 (26.9%) oncocytic carcinomas, including one case with abundant thin colloid. A microfollicular arrangement, discohesive single cells, small cell dysplasia, large cell dysplasia and transgressing vessels were present in oncocytic carcinoma, oncocytic adenoma and oncocytic adenomatoid nodules in nodular goitre. CONCLUSIONS: A macrofollicular component is frequently present in oncocytic carcinoma, oncocytic adenoma and oncocytic adenomatoid nodules in nodular goitre. None of the cytological features studied, including abundant colloid, can exclude oncocytic carcinoma. Oncocytic carcinoma can only be excluded by thorough histological examination of thyroidectomy specimens. A molecular marker is needed to triage oncocytic lesions in thyroid FNA.

Seizure and cognitive outcomes in children and adolescents with epilepsy treated with topiramate.

This 12-week open label study explored cognitive and seizure outcomes of 53 children treated with topiramate (TPM). The digit symbol test and verbal learning memory test were administered at baseline and study endpoint. Topiramate was started either in monotherapy or add-on therapy. Overall, 57% of children experienced a ≥50% seizure reduction, 36% became seizure free and cognitive testing revealed no significant changes during TPM therapy. Due to the heterogeneity of the study population, post hoc analyses were added to compare patients in initial or conversion to TPM monotherapy as well as patients who continued add-on therapy. Verbal learning memory test parameters showed neither significant differences within any subgroup comparing baseline with endpoint nor significant differences between described subgroups except for one finding. The digit symbol test revealed no differences between each subgroup between baseline and endpoint. Comparing pre-post differences, TPM monotherapy was associated with better cognitive outcomes than treatment in add-on therapy. These results have to be interpreted with caution given the short study duration and the heterogeneity of the study population. Despite these limitations, our overall results suggest that treatment with topiramate is associated with improved seizure control without significant changes in cognitive functions at the low doses tested.

Does oral antipsychotic pre-treatment influence outcome of a switch to long-acting injectable risperidone in patients with schizophrenia?

INTRODUCTION: The objective of this open-label study was to evaluate treatment benefits of risperidone long-acting injectable (RLAI) in patients with schizophrenia following direct transition from oral risperidone (RIS) compared with transition from other oral second generation antipsychotics. METHODS: Stable in- or outpatients (n=206) receiving RIS or OQAZ (olanzapine, quetiapine, amisulpride, ziprasidone) were transitioned to RLAI for 12 weeks. The primary outcome was the between-group treatment difference in change in PANSS total score from baseline to endpoint. Secondary outcomes included health-related quality-of-life and therapeutic alliance. RESULTS: Mean between-group difference in the change in PANSS total score from baseline to endpoint was -6.1 (CI: -17.6, 5.4), suggesting greater improvement in OQAZ than RIS patients. Due to the pre-specified non-inferiority margin of 5.1, it could not be concluded that OQAZ pre-treatment results in an at least non-inferior PANSS reduction versus RIS pre-treatment. Patient satisfaction with medication and change in quality-of-life subscores showed advantages for OQAZ patients. DISCUSSION: Compared to RIS pre-treatment, clinically stable patients with schizophrenia who are pre-treated with OQAZ might draw a stronger clinical benefit from direct transition to RLAI.

Trends in fracture development of the upper extremity in Germany-a population-based description of the past 15 years.

BACKGROUND: Recent studies investigating fracture development in Germany are not available especially with regard to demographic change. The primary aim of this study was to report trends in fracture development of the upper extremity in Germany between 2002 and 2017 and to evaluate changes over time. METHODS: Evaluating inpatient data from the German National Hospital Discharge Registry (International Classification of Diseases, ICD-10) between 2002 and 2017. Total count, incidences and percentage changes of the following fracture localizations were analysed: proximal humerus, distal humerus, proximal ulna, proximal radius, ulna diaphysis (including Monteggia lesion) and distal radius. Ten age groups for men and women were formed: 35-44, 45-54, 55-64, 65-74; 75-84; 85-90, and > 90 (years). RESULTS: The total count of proximal humeral fractures increased from 40,839 (2002, men/women 9967/30,872) to 59,545 (2017, men/women 14,484/45,061). Distal humeral fractures increased from 5912 (2002, men/women 1559/4353) to 6493 (2017, men/women1840/4653). The total count of forearm fractures increased from 68,636 (2002, men/women 17,186/51,450) to 89,040 (2017, men/women 20,185/68,855). Women were affected in 70-75% of all cases with rising incidences among nearly every age group in female patients. CONCLUSION: Total count of nearly every evaluated fracture increased. Also, incidences increased especially in the older female age groups. Fracture development already seems to reflect demographic changes in Germany.

[Periprosthetic fractures of the acetabulum: osteosynthesis]. / Periprothetische Frakturen des Acetabulums: Osteosynthese.

In most cases periprosthetic fractures of the acetabulum are complex injuries and are extremely challenging for the treating medical team. Over the years the frequency of this overall rare entity has increased due to demographic changes. In recent years several treatment algorithms were published and provided the possibility of developing standardized treatment concepts. The classification of the fractures and a dedicated preoperative strategy are highly important for the quality of patient-centered care. In the literature the frequency of intraoperative fractures was initially given as 0.4%; however, several studies have been published in which a far higher rate of intraoperative fractures was detected by computed tomography (CT), often referred to as so-called occult fractures. The causes are multifactorial and there is significant association with whether cement-free press-fit acetabular cups were used or cemented forms. In approximately 75% of the cases a low energy impact was the cause of the fracture. In these patients systemic processes, such as osteoporotic alterations of the bony substance or the possible presence of low-grade infections should be considered. This article gives an overview of the diagnostics, planning, challenges and osteosynthetic treatment options for periprosthetic fractures of the acetabulum.

Conversion from valproic acid onto topiramate in adolescents and adults with epilepsy.

OBJECTIVE: To explore efficacy and tolerability outcomes of topiramate (TPM) in patients with epilepsy transitioning from valproic acid (VPA) because of insufficient efficacy and/or tolerability onto TPM. METHODS: Multicenter, open label, single arm, non-interventional study examining patients (> or =12 years) with epilepsy, transitioning onto TPM from baseline mono-or combination therapy with VPA. TPM was added onto the existing antiepileptic drug (AED) treatment and started at a dose of 25 mg once daily. The dose was titrated up with 25 mg/day increments, once every 1-2 weeks, until a final dose between 50-200 mg/day was reached. Based on clinical judgment, the treating physician decided whether or not and when the existing AED treatment especially with VPA could be withdrawn. Documented were type and frequency of seizures, TPM dose, quality of life (QOLIE-10 questionnaire), subjective perception of improvement, and adverse events (AE). RESULTS: One hundred and forty-seven patients (59% women, mean age 41 years) switched from baseline VPA treatment onto TPM because of insufficient efficacy (61%) and/or poor tolerability (81%). Average duration of follow-up was 20.3 weeks with an overall discontinuation rate of 16.3% of patients, mainly because of AE (in 8.2% of 147 patients). At study endpoint, the intended shift to TPM monotherapy was achieved in 70% of patients at a median dose of 150 mg/day. A seizure reduction of > or =50% was achieved in 75% of patients in the last scheduled period (week 8-20), and 51% of patients entering that period remained seizure-free. Quality of life improved significantly as compared with baseline for all domains of QOLIE-10 (P < 0.001). Most frequent AEs were weight decrease (4.8%), paraesthesia and fatigue (4.1% each), speech disorder and headaches (2.7% each). CONCLUSIONS: In patients with epilepsy not satisfactorily treated with VPA, conversion to TPM was associated with improved seizure control as well as improvement in several aspects of quality of life.

Exploring efficacy and tolerability outcomes in patients with difficult-to-treat epilepsy receiving adjunctive topiramate at different titration rates--an exploratory study.

OBJECTIVE: To compare rapid vs regular titration of topiramate concerning efficacy and safety. MATERIALS AND METHODS: Open-label, prospective, single-center study exploring efficacy and tolerability of two adjunctive dosing regimens of topiramate (TPM) in adult patients with difficult-to-treat epilepsy. Based on investigator judgment, 21 of 50 consecutive patients received a rapid titration (starting dose 50 mg/day, stepwise increase with 50 mg/day after 3 days each until reaching the target dose), while the other 29 patients received titration according to the German prescribing information (starting dose 25 mg/day, stepwise increase with 25-50 mg/day every 7 days). Patients were observed until the target dose was reached and 3 months thereafter. RESULTS: Mean final dosages were 136 mg/day (regular titration) and 213 mg/day (rapid titration). Efficacy and tolerability measures did not differ significantly. Forty-six percent of all patients experienced a seizure reduction of > or = 50%; 14% became seizure free. No serious adverse events occurred. The most common adverse effects were tiredness (20%), memory and language difficulties (18% each), slowness in thinking and speech (10%), psychomotor disturbance (8%) and paresthesia (8%). CONCLUSIONS: This study suggests that rapid and conventional titration generate similar tolerability, safety and effectiveness in selected patients.

Effectiveness of low dose of topiramate following rapid titration in multiply handicapped children and difficult-to-treat epilepsy.

This prospective, observational, single arm, monocentric study explored efficacy and tolerability outcomes of rapid oral initiation of topimarate in children with difficult to treat epilepsy. The study population consisted of 19 multiply handicapped children (mean age 4.4 years, range 0.6-15.3 years). The observation period was 12 weeks and included 7 visits. The mean initial dose of topiramate was 1.1 mg/kg body weight/d (range: 0.66-2.67 mg/kg/d) following rapid titration. The mean final dose was 3.3 mg/kg/d (range 0.5-6.7 mg/kg/d). An at least 50% reduction of seizure frequency compared to baseline was observed in 9 of 19 patients (47.4%). Six patients (31.6%) had a slight reduction of seizure frequency (<50%) and 4 patients (21.1%) experienced an increase of seizure frequency. A total number of 29 adverse events were documented in 17 of 19 patients. Most frequently captured were fatigue (26.3% of patients), decreased appetite (15.8%) and psychiatric disturbances (15.8%). No serious adverse events were reported. These data might suggest that in certain clinical circumstances rapid dose escalation with topiramate followed by a low maintenance dose might be a good therapeutic option for pediatric patients with difficult to treat epilepsy.

[Combined posterior and anterior cruciate ligament reconstruction : Arthroscopic treatment with the GraftLink® system]. / Kombinierte Rekonstruktion des hinteren und vorderen Kreuzbandes : Arthroskopische Versorgung mit dem GraftLink®-System.

OBJECTIVE: Simultaneous arthroscopic reconstruction of the anterior and/or posterior cruciate ligament (ACL/PCL) using the GraftLink® system (Arthrex) to obtain stable treatment and good functional results. The transplant is protected by the safety belt like biomechanical GraftLink® principle, which is used to secure the intraoperatively obtained stability in the long term. INDICATIONS: ACL, PCL, or combined cruciate ligament rupture, especially multiligament injuries. Revision ACL and PCL reconstruction. CONTRAINDICATIONS: Preoperative fixed posterior tibial subluxation. Reduced range of motion (ROM) with an extension lag (extension/flexion 0­0-120° preoperatively required). Complex regional pain syndrome. High-grade atrophy of the quadriceps femoris muscle and osseous deformities. SURGICAL TECHNIQUE: Supine position with mobile leg and possible flexion of at least 120° allowing antegrade femoral bone tunnel replacement. Retrograde tunnel placement (e. g. using a retrocutter) is recommended in case of less than 120° knee flexion. Thigh tourniquet. Staging arthroscopy. Cruciate ligament reconstruction is realized by anatomic tunnel placement for the ACL/PCL using the GraftLink®. Recommended sequence of reconstruction: 1. tibial PCL tunnel, 2. femoral ACL tunnel, 3. femoral PCL tunnel, 4. tibial ACL tunnel. Hybrid fixation is recommended. Portals: High anteromedial, high anterolateral, posteromedial, posterolateral, small subvastus incision. POSTOPERATIVE MANAGEMENT: Combined cruciate ligament replacement: Gradual load and ROM increase in the PCL track. After postoperative week 5, increasing load up to full weight bearing, with extension/flexion 0­0-90° after week 7. Down training of the PCL track after week 13. Contact and competitive sports after 1 year. RESULTS: The GraftLink® system allows restoration of knee joint stability with good functional results. The procedure is especially suitable for complex situations like after knee dislocation with ACL and PCL reconstruction in 1 or 2 steps.

Conversion from carbamazepine or oxcarbazepine to topiramate in adolescents and adults with epilepsy.

OBJECTIVE: To explore effectiveness, tolerability and changes in quality of life in patients with epilepsy converting to topiramate (TPM) from carbamazepine (CBZ) or oxcarbazepine (OXC) due to insufficient effectiveness and/or tolerability. METHODS: A multicenter, open-label, non-interventional trial was used to examine patients (> or = 12 years) with epilepsy, changing to TPM monotherapy from baseline mono- or combination therapy with CBZ or OXC. TPM was added to the existing antiepileptic drug (AED) treatment and started at a dose of 25 mg once daily. The dose was titrated up with 25 mg/day increments, once every 1-2 weeks, until a final dose between 50 and 200 mg/day was reached. On the basis of clinical judgment, the treating physician decided whether or not the existing AED treatment with CBZ or OXC could then be withdrawn. Type and number of seizures, preferred TPM dose, quality of life (QOLIE-10 questionnaire), subjective perception of improvement and adverse events (AE) were documented. RESULTS: 140 patients (53.5% women, mean age 47 years) decided to switch to TPM due to insufficient effectiveness (75% of patients) and/or poor tolerability (80%) of the CBZ/OXC treatment. Average duration of follow-up was 24 weeks with an overall discontinuation rate of 19.3%, mainly due to AEs (12.1%). At study endpoint, the intended shift to TPM monotherapy was achieved in 73% of patients at a median TPM dose of 100 mg/day. A seizure reduction of > or = 50% was achieved in 91% of patients in the last scheduled period (weeks 12-26); 62% of patients entering that period remained seizure free. Quality of life at endpoint improved significantly when compared with baseline for all domains of QOLIE-10 (P < 0.001). Most frequent AEs (reported by > or = 5% of patients) were paresthesia (9.3%), weight loss (7.9%), convulsions (5.7%) and memory disorders (5.0%). CONCLUSION: In patients with epilepsy, previously not satisfactorily treated with CBZ or OXC, conversion to TPM may result in an improvement in seizure control as well as in quality of life.

Epilepsy outcomes in elderly treated with topiramate.

OBJECTIVES: To explore effectiveness, tolerability and quality of life in elderly patients with epilepsy treated with topiramate. METHODS: One year, open-label, flexible-dosing clinical trial. RESULTS: One hundred and seven patients (mean age 69 years, 53% men) were studied during 273 +/- 141 days. The average final dose in monotherapy was 98 mg/day vs 153 mg/day in adjunctive treatment. Mean monthly cumulative seizure frequency decreased from 3.7 +/- 15 to 1.6 +/- 7.7 (n = 101, P < 0.0001), 78% of patients with seizures at baseline (n = 102) achieved at least 50% reduction in seizure frequency, 44% were seizure-free throughout the trial. Total scores on the quality of life in epilepsy inventory (QOLIE-31) improved from 57 +/- 17 to 68 +/- 18 (n = 64, P < 0.0001). The most frequently reported adverse events included convulsions, dizziness and tiredness. CONCLUSIONS: Elderly patients treated with topiramate showed marked reductions in seizures, good tolerability and significant improvements in several aspects of quality of life.

Evidence supporting nutritional interventions for persons in early stage Alzheimer's disease (AD).

The purpose of this paper is to grade research evidence supporting nutritional interventions for persons with early stage dementias and to report the recommendations of a consensus panel. Thirty four studies were reviewed in the areas of dietary restriction, antioxidants, and Mediterranean diet with strong support from epidemiological studies found in all three areas. The body of evidence to support nutritional interventions in the prevention and treatment of AD is growing and has potential as a treatment modality following translational studies.

Optimage central organised image quality control including statistics and reporting.

Quality control of medical imaging systems is performed using dedicated phantoms. As the imaging systems are more and more digital, adequate image processing methods might help to save evaluation time and to receive objective results. The developed software package OPTIMAGE is focusing on this with a central approach: On one hand, OPTIMAGE provides a framework, which includes functions like database integration, DICOM data sources, multilingual user interface and image processing functionality. On the other hand, the test methods are implemented using modules which are able to process the images automatically for the common imaging systems. The integration of statistics and reporting into this environment is paramount: This is the only way to provide these functions in an interactive, user-friendly way. These features enable the users to discover degradation in performance quickly and document performed measurements easily.

Commissioning and constancy protocols for digital angiographic units.

During the European Concerted Action SENTINEL 'Safety and Efficacy for New Techniques and Imaging using New Equipment to Support European Legislation', protocols for commissioning and constancy tests for dynamic digital flat detectors angiography units have been developed in order to harmonise practice among the European counties. The commissioning protocol includes measurements on X-ray tube and generator, patient and detector radiation dose and image quality. The constancy protocol is based on the dose and image quality measurements. The commissioning protocol was tested by SENTINEL partners who expressed an interest in checking their dynamic digital systems using this protocol. The results of basic tests are reported.

QA/acceptance testing of DEXA X-ray systems used in bone mineral densitometry.

New developments in dual energy X-ray absorptiometry (DEXA) imaging technology [fan beam and cone beam (CB)] result in higher exposure levels, shorter scan times, increased patient throughput and increased shielding requirements. This study presents the results of a European survey detailing the number and location of DEXA systems in SENTINEL partner states and the QA (quality assurance) currently performed by physicists and operators in these centres. The results of a DEXA equipment survey based on an in-house developed QA protocol are presented. Measurements show that the total effective dose to the patient from a spine and dual femur DEXA examination on the latest generation DEXA systems is comparable with a few microSv at most. Scatter measurements showed that the use of a mobile lead screen for staff protection was necessary for fan and CB systems. Scattered dose from newer generation systems may also exceed the exposure limits for the general public so structural shielding may also be required. Considerable variation in the magnitude and annual repeatability of half value layer was noted between different models of DEXA scanners. A comparative study of BMD (bone mineral density) accuracy using the European Spine Phantom highlighted a deviation of up to 7% in BMD values between scanners of different manufacturers.

Quality control measurements for fluoroscopy systems in eight countries participating in the SENTINEL EU coordination action.

Quality control (QC) is becoming increasingly important in relation to the introduction of digital medical imaging systems using X rays. It was, therefore, decided to organise and perform a trial on image quality and physical measurements. The SENTINEL toolkit for QC measurements of fluoroscopy systems containing equipment and instructions for their use in the assessment of dose and image quality circulated among participants in the trial. The participants reported on their results. In the present contribution, the impact of the trial on the selected protocols is presented. The Medical Physics and Bioengineering protocol appeared to be useful for QC, and also for digital systems. The protocol needs an additional section, or an addition to each section, to state compliance with the requirements. The circular cross-sections of the Leeds test objects need adaptation for rectangular flat panel detector (FPD) systems. Only one participant was able to perform the monitor test using MoniQA. This is due to the fact that assistance is required from the suppliers of the X-ray systems. This problem needs to be solved to apply MoniQA in practice.

Patient dose in interventional radiology: a European survey.

Patient doses for a few common fluoroscopy-guided procedures in interventional radiology (IR) (excluding cardiology) were collected from a few radiological departments in 13 European countries. The major aim was to evaluate patient doses for the basis of the reference levels. In total, data for 20 procedures for about 1300 patients were collected. There were many-fold variations in the number of IR equipment and procedures per population, in the entrance dose rates, and in the patient dose data (total dose area product or DAP, fluoroscopy time and number of frames). There was no clear correlation between the total DAP and entrance dose rate, or between the total DAP and fluoroscopy time, indicating that a number of parameters affect the differences. Because of the limited number of patients, preliminary reference levels were proposed only for a few procedures. There is a need to improve the optimisation of IR procedures and their definitions and grouping, in order to account for their different complexities.

[Trochanteric and subtrochanteric fractures]. / Per- und subtrochantäre Femurfrakturen.

Proximal femoral fractures are one of the most common fractures, particularly in older people. The most common cause is a falling event due to dizziness and gait insecurity. In most cases prompt surgical treatment is necessary to achieve early mobilization and to reduce the risk of mortality. The aim is a stable osteosynthesis and patient-centered care. A great variety of implants are available for this purpose. Furthermore, perioperative management is important to prevent further problematic events, such as delirium, reoccurrence of falling events and to diagnose and adequately treat a pre-existing osteoporosis.