Equivocal Outcomes Research Articles

OBIEKTYWNA OCENA SŁUCHU U NOWORODKÓW PODSTAWĄ DO WCZESNEJ INTERWENCJI MEDYCZNEJ

Substantial evidence supports the benefits of early intervention in infant hearing loss. Intervention can lead to the acquisition of effective communication skills and psychosocial development. Accurate diagnosis of infant hearing loss is not possible with conventional behavioral audiometry techniques. Objective auditory procedures are invaluable in the assessment of infant hearing because they do not rely on behavioral responses to sound and are unaffected by listener variables such as cognition, motivation, and language impairment. Objective hearing procedures include aural immittance measures (tympanometry and acoustic reflexes), otoacoustic emissions (OAEs), electrocochleography (ECochG), auditory brainstem response (ABR), and the auditory steady state response (ASSR). Exclusive reliance on only one or two objective auditory measures often results in equivocal outcomes. Careful analysis of findings from a comprehensive objective auditory test battery can almost always yield a precise description of auditory status; it can often lead to accurate diagnosis of auditory dysfunction within weeks of birth. The key to meaningful analysis of findings from a test battery is the recognition of patterns associated with major auditory disorders. This is not a novel concept; it is simply the modern day version of the 40-year-old cross-check principle.

Paper #9 - Posterior shoulder instability in throwing athletes: a case-matched comparison of throwers and non-throwers

Introduction: The purpose of this study was to evaluate the results of arthroscopic capsulolabral repair for the treatment of posterior shoulder instability in a throwing athlete cohort when compared to non-throwers. Methods and Materials: Forty-eight overhead throwing athletes undergoing arthroscopic posterior capsulolabral reconstruction were case matched with 48 non-throwing athletes. These cohorts were followed as they underwent posterior capsulolabral reconstruction by measuring shoulder pain, function, return to sport, and operative failures. Operative details such as intra-articular pathology and repair construct were also recorded. Results: At a mean follow up of 37 (range 12-97) months post-operatively, no statistical differences were noted between throwers and non-throwers regarding ASES scores, stability, strength, or range of motion between throwers and non-throwers. Sixty percent of throwing athletes were able to return to their pre-injury level of competitive throwing. Throwers with a discreet labral tear intra-operatively had a 10-fold increased likelihood to return to sport (OR 9.6, p = .012). Similarly, throwers that had suture anchors constructs showed a 10-fold increased likelihood of return to play compared to anchor-less repairs (OR 9.6, p = .012). Non-throwers showed no variability by labral findings or fixation techniques. Pitchers had equivocal outcomes scores when compared to other throwers, but had poorer return to play rates (50% versus 60% full return, respectively). Conclusions: Arthroscopic capsulolabral plication for unidirectional posterior shoulder instability is an effective treatment for overhead throwing athletes. Intra-operatively, achieving an adequate capsular plication and stabilizing the repair via suture anchors will give this athletic population the best odds at returning to competitive sports. Significance: Comparison study; Level of evidence, 3. This is the first study directly comparing outcomes of posterior shoulder instability managed with arthroscopic stabilization between throwing and non-throwing athletes. It is also the largest series focusing on throwing athletes reported to date.

Lateral positioning for critically ill adult patients.

Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes. To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals. We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects. We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias. We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review. Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.

Managing the surge in demand for blood following mass casualty events: Early automatic restocking may preserve red cell supply.

Traumatic hemorrhage is a leading preventable cause of mortality following mass casualty events (MCEs). Improving outcomes requires adequate in-hospital provision of high-volume red blood cell (RBC) transfusions. This study investigated strategies for optimizing RBC provision to casualties in MCEs using simulation modeling. A computerized simulation model of a UK major trauma center (TC) transfusion system was developed. The model used input data from past MCEs and civilian and military trauma registries. We simulated the effect of varying on-shelf RBC stock hold and the timing of externally restocking RBC supplies on TC treatment capacity across increasing loads of priority one (P1) and two (P2) casualties from an event. Thirty-five thousand simulations were performed. A casualty load of 20 P1s and P2s under standard TC RBC stock conditions left 35% (95% confidence interval, 32-38%) of P1s and 7% (4-10%) of P2s inadequately treated for hemorrhage. Additionally, exhaustion of type O emergency RBC stocks (a surrogate for reaching surge capacity) occurred in a median of 10 hours (IQR, 5 to >12 hours). Doubling casualty load increased this to 60% (57-63%) and 30% (26-34%), respectively, with capacity reached in 2 hours (1-3 hours). The model identified a minimum requirement of 12 U of on-shelf RBCs per P1/P2 casualty received to prevent surge capacity being reached. Restocking supplies in an MCE versus greater permanent on-shelf RBC stock holds was considered at increasing hourly intervals. T-test analysis showed no difference between stock hold versus supply restocking with regard to overall outcomes for MCEs up to 80 P1s and P2s in size (p < 0.05), provided the restock occurred within 6 hours. Even limited-sized MCEs threaten to overwhelm TC transfusion systems. An early-automated push approach to restocking RBCs initiated by central suppliers can produce equivocal outcomes compared with holding excess stock permanently at TCs. Therapeutic/care management study, level IV.

TREX1 Knockdown Induces an Interferon Response to HIV that Delays Viral Infection in Humanized Mice.

Despite their antiviral effect, the invivo effect of interferons on HIV transmission is difficult to predict, because interferons also activate and recruit HIV-susceptible cells to sites of infection. HIV does not normally induce type I interferons in infected cells, but does if TREX1 is knocked down. Here, we investigated the effect of topical TREX1 knockdown and local interferon production on HIV transmission in human cervicovaginal explants and humanized mice. Inexplants in which TREX1 was knocked down, HIV induced interferons, which blocked infection. In humanized mice, even though TREX1 knockdown increased infiltrating immune cells, it delayed viral replication for 3-4weeks. Similarly intravaginal application of type I interferons the day before HIV infection induced interferon responsive genes, reduced inflammation, and decreased viral replication. However, intravenous interferon enhanced inflammation and infection. Thus, in models of human sexual transmission, a localized interferon response inhibits HIV transmission but systemic interferons do not.

Institutional Experience in the Management of Hilar Liver Obstruction- A Series of 13 Cases.

Neoplastic hilar obstruction to the liver outflow presents a unique challenge to the surgeon, wherein, the balance between a curative and possibly larger resection has to be achieved against a more conservative local resection. These are often technically demanding and have thus, far produced equivocal outcomes on both ends. The present case series is on 13 patients who presented with hilar obstruction. They all underwent resections with possible curative intent. The focus of our review is on the technical nuances and the strategies we used, intra- and peri-operatively to make resections possible in these patients, who at first look were deemed inoperable. Among the 13, 10 had hilar cholangiocarcinoma (CCA) while the others had a more benign diagnosis e.g., Hydatid disease. We did not encounter any peri-operative mortality in our series. Two of our patients had to be re-explored for intra-abdominal complications. Among the 13, we encountered two deaths. The rest of the patients are still on follow-up as of April 2016. Hilar CCA continue to be rare and challenging tumours for the Hepato Pancreato Biliary (HPB) surgeon to manage. Outlooks are currently changing as we try to resect bigger and more complicated hilar liver tumours with better results.

Vibration Therapy to Prevent Bone Loss and Falls: Mechanisms and Efficacy.

A considerable volume of evidence has accumulated to suggest that whole-body vibration (WBV) may have a therapeutic role to play in the prevention of osteoporotic fracture, particularly for individuals who are unable to tolerate vigorous exercise interventions. There is moderate to strong evidence that WBV will prevent falls (likely due to enhanced neuromuscular function), but also some indication that the effects of WBV do not outstrip those of targeted exercise. Animal data indicates that WBV will also improve bone mass, including preventing loss due to hormone withdrawal, disuse and glucocorticoid exposure. Human trials, however, have produced equivocal outcomes for bone. Positive trends are apparent at the hip and spine, but shortcomings in study designs have limited statistical power. The mechanism of the vibration effect on bone tissue is likely to be mechanical coupling between an oscillating cell nucleus and the cytoskeleton. More robust dose-response human data are required before therapeutic guidelines can be developed.

Reconstruction of limited soft-tissue defect with open tibial fracture in the distal third of the leg: a cost and outcome study.

This study was conducted to analyze the cost and outcome of free-tissue transfers versus local muscle flaps for reconstruction of limited soft-tissue defects associated with tibial fractures in the distal third of the leg. Twelve adult patients underwent either free (n = 6) or local muscle (n = 6) flap reconstruction were retrospectively reviewed. Total operative time for local muscle flap reconstruction was 215 +/- 47 minutes compared with 450 +/- 90 minutes (P < 0.0002) for free-muscle transfer. Median length of hospital stay after reconstruction was 7 days for local muscle flap compared with 9 days for free-muscle transfer. Total cost of the local muscle flap procedure was US dollars 11,729 +/- US dollars 4460 compared with US dollars 19,989 +/- US dollars 3295 (P < 0.0004) for free-flap reconstruction. Five of 6 patients in each group had excellent soft-tissue contours. Fracture healing was evident in all patients of each group. Thus, a local muscle flap for reconstruction of a limited distal tibial wound appears to be more cost-effective than free-tissue transfer because of equivocal outcomes achieved but at approximately half of the cost.

Complications of short versus long cephalomedullary nail for intertrochanteric femur fractures, minimum 1 year follow-up.

Hip fractures are becoming increasingly common resulting in significant morbidity, mortality and raising healthcare costs. Both short and long cephalomedullary devices are currently employed to treat intertrochanteric hip fractures. However, which device is optimal continues to be debated as each implant has unique characteristics and theoretical advantages. This study looked to identify rates of complications associated with both long and short cephalomedullary nails for the treatment of intertrochanteric hip fractures. We retrospectively reviewed charts from 2006 to 2011, and we identified 256 patients were identified with AO class 31.1-32.3 fractures. Sixty were treated with short nails and 196 with long nails. Radiographs and charts were then analysed for failures and hardware complications. Catastrophic failure and hardware complication rates were not statistically different between short or long cephalomedullary nails. The overall catastrophic failure rate was 3.1 %; there was a 5 % failure rate in the short-nail group compared with a 2.6 % failure rate in the long-nail group (p = 0.191). There was a 3.33 % secondary femur fracture rate in the short-nail group, compared with none in the long-nail cohort (p = 0.054). The rate of proximal fixation failure was 1.67 % for the short-nail group and 2.0 % in the long-nail group (p = 0.406). Our data suggests equivocal outcomes as measured by similar catastrophic failure rate between both short and long cephalomedullary nails for intertrochanteric femur fractures. However, there was an increased risk of secondary femur fracture with short cephalomedullary nails when compared to long nails that approached statistical significance.

Improving clinical services: be aware of fuzzy connections between principles and strategies.

This article is a response to Alan Kamhi's treatise on improving clinical practices for children with language and learning disorders by focusing on what is known about learning (see Kamhi, 2014, article in this issue). Descriptive methods are used to discuss general learning principles and the fact that they do not always translate readily into effective language intervention practices. The authors give examples of 2 instances in which popular intervention strategies should have worked but did not. The authors also summarize what they learned about their own approach to contextualized language intervention for teaching priority goals related to narration and the Common Core State Standards (CCSS; National Governors Association Center for Best Practices, & Council of Chief State School Officers, 2010). Even theoretically sound, well-intentioned, and carefully implemented interventions can result in equivocal outcomes. When they do, careful attention to the evidence and willingness to rethink strategy often serves to right the course.

Remote conditioning or erythropoietin before surgery primes kidneys to clear ischemia-reperfusion-damaged cells: a renoprotective mechanism?

Acute kidney injury is common, serious with no specific treatment. Ischemia-reperfusion is a common cause of acute kidney injury (AKI). Clinical trials suggest that preoperative erythropoietin (EPO) or remote ischemic preconditioning may have a renoprotective effect. Using a porcine model of warm ischemia-reperfusion-induced AKI (40-min bilateral cross-clamping of renal arteries, 48-h reperfusion), we examined the renoprotective efficacy of EPO (1,000 iu/kg iv.) or remote ischemic preconditioning (3 cycles, 5-min inflation/deflation to 200 mmHg of a hindlimb sphygmomanometer cuff). Ischemia-reperfusion induced significant kidney injury at 24 and 48 h (χ(2), 1 degree of freedom, >10 for 6/7 histopathological features). At 2 h, a panel of biomarkers including plasma creatinine, neutrophil gelatinase-associated lipocalin, and IL-1β, and urinary albumin:creatinine could be used to predict histopathological injury. Ischemia-reperfusion increased cell proliferation and apoptosis in the renal cortex but, for pretreated groups, the apoptotic cells were predominantly intratubular rather than interstitial. At 48-h reperfusion, plasma IL-1β and the number of subcapsular cells in G2-M arrest were reduced after preoperative EPO, but not after remote ischemic preconditioning. These data suggest an intrarenal mechanism acting within cortical cells that may underpin a renoprotective function for preoperative EPO and, to a limited extent, remote ischemic preconditioning. Despite equivocal longer-term outcomes in clinical studies investigating EPO as a renoprotective agent in AKI, optimal clinical dosing and administration have not been established. Our data suggest further clinical studies on the potential renoprotective effect of EPO and remote ischemic preconditioning are justified.

Are Results of Surgical Treatment for Calcaneal Fractures better than Nonoperative Treatment?

ABSTRACT The methods of treatment of displaced intra-articular calcaneal fractures (DIACFs) have always been surrounded by controversies, whether operative treatment is better or conservative. Some randomized controlled trials (RCTs) have been published comparing the operative vs conservative management options for DIACFs, but the conclusions are varied, with some of them supporting operative treatment while others showing equivocal results. To get some clarity on this subject, we reviewed 9 RCTs and 4 meta-analyses to evaluate the evidence that was present for both operative and nonoperative methods of management. Most studies report equivocal outcomes of operatively and nonoperatively managed DIACFs when looked at; however on stratification of groups, the evidence seemingly points towards better functional results in the operated patients who do not develop a complication, but poorer outcomes in patients with more severe injury patterns (higher Sanders’ Type). Complications were associated with both groups; no differentiation between closed and open fractures is made in most studies, leading to slightly higher rate of complications in the operated group (probably due to open cases inclusion); nevertheless the difference was not found significant. Despite a high level of interest in calcaneal fractures, the current evidence in published literature does not support a specific management protocol for DIACFs, although detailed analysis points to importance of patient selection, surgeon experience and soft tissue status. As of today, there is a need for larger randomized trials, which should also clarify the role of extensile approach vis a vis Minimally Invasive Surgery, to address this question and bring out a conclusive answer. How to cite this article Dhillon MS, Gahlot N. Are Results of Surgical Treatment for Calcaneal Fractures better than Nonoperative Treatment? J Foot Ankle Surg (Asia-Pacific) 2014; 1(1):17-23.

Does source of funding and conflict of interest influence the outcome and quality of spinal research?

Background/contextThere has been longstanding controversy surrounding the influence of funding source on the conduct and outcome of medical research. In 2011, a systematic review of the use of recombinant bone morphogenetic protein-2 revealed underreporting of unfavorable outcomes in some industry-sponsored trials. We hypothesize that Industrial funding and the presence of potential conflict of interest will be associated with low levels of evidence (LOE) and greater proportions of favorable outcomes in spinal research. PurposeThe aim of this study is to investigate the association between funding source and potential conflict of interest on the LOE and study outcome in the current spinal research. Study design/settingSystematic review of all the spinal publications in five leading spinal, orthopedics, neurosurgery, and general medical journals during 2010 (print and online). Supplements were included. Outcome measureOutcome and the LOE of research papers. MethodsTwo reviewers independently assessed all publications. Commentaries, editorials, letters, open operating theatres, case reports, narrative reviews, and study protocols were excluded. The self-reported potential conflict of interest and type of funding was extracted from each paper. Funding type was classified as foundation, industry, public, intramural, multiple (including industry), multiple (without industry), and unfunded. The outcome of each study was classified as favorable, unfavorable, equivocal, or not applicable. Clinical publications were ranked using the LOE guidelines produced by the Oxford Center for Evidence-Based Medicine. ResultsOverall, 1356 papers were analyzed, out of which 864 were suitable for LOE grading. There was good interobserver reliability for assignment of LOE grade, κ=0.897 (p<.01) and study outcome κ=0.804 (p<.01). A significant association was found between LOE and source of funding (p<.01). Industry-funded studies had the greatest proportion of level IV evidence (65%). There was a significant association between the funding source and study outcome (p=.01). The proportion of industry-funded studies with favorable outcomes (88%) was higher than that of publicly and foundation-funded studies (73% and 74%, respectively). The associated odds ratio for reporting favorable outcomes in industry-funded studies compared with studies with public and foundation funding was 2.7 (95% confidence interval [CI], 1.4–5.3), and 2.6 (95% CI, 1.3–5.2), respectively. A significant association between LOE and study outcome (p<.01) was also identified. Level I studies had the highest proportions of unfavorable (14%) and equivocal (23%) outcomes. Level IV studies had the highest proportion of favorable outcome (85%). There was no association between self-reported conflict of interest and LOE (p=.83) or study outcome (p=.25). ConclusionWe demonstrated a significant association between source of funding, study outcome, and LOE in spinal research. A large proportion of industry funded research was shown to provide level IV evidence and report favorable outcome.

Long-term Morbidity of Martius Labial Fat Pad Graft in Vaginal Reconstruction Surgery

To assess the long-term morbidity of Martius labial fat pad (MLFP) interposition in vaginal reconstruction procedures at a tertiary institution. After institutional review board approval, medical records of consecutive women in a prospective surgical database requiring MLFP as part of their vaginal reconstruction were reviewed for demographics, indications for MLFP, complications, and outcomes, with minimum of 6 months follow-up. Three MLFP groups were compared as follows: (1) vesicovaginal fistula, (2) bladder outlet obstruction, and (3) others. Patients were contacted by mailed survey and/or structured telephonic interview with Quality of Life score, validated Female Sexual Function Index questionnaire, and a specific question addressing Martius harvest site, that is, "pain or numbness in labia". Between 1996 and 2011, 122 women met inclusion criteria, with 25 excluded for lack of follow-up details or death. Mean age was 54 years (range, 19-78), with mean BMI 28 kg/m(2) (range, 19-43) and mean follow-up of 85 months (range, 6-202). Indications for MLFP included vesicovaginal fistula (20), bladder outlet obstruction (60), and others (17) (bladder neck closures, urethral diverticulum, and excision of duplicate urethra). No perioperative complications were recorded. Of the 97 women, 79 (81%) had normal sensation, with 5 (5%) reporting pain and 13 (14%) reporting numbness, respectively. Nine (7%) reported distortion of labia majora. Of the 29 women reporting sexual activity, only 26 (27%) responded to Female Sexual Function Index questionnaires with equivocal sexual function outcomes between all 3 surgical groups. The MLFP has minimal early and delayed morbidity at mean 7 years follow-up.

Training Adaptation and Heart Rate Variability in Elite Endurance Athletes: Opening the Door to Effective Monitoring

The measurement of heart rate variability (HRV) is often considered a convenient non-invasive assessment tool for monitoring individual adaptation to training. Decreases and increases in vagal-derived indices of HRV have been suggested to indicate negative and positive adaptations, respectively, to endurance training regimens. However, much of the research in this area has involved recreational and well-trained athletes, with the small number of studies conducted in elite athletes revealing equivocal outcomes. For example, in elite athletes, studies have revealed both increases and decreases in HRV to be associated with negative adaptation. Additionally, signs of positive adaptation, such as increases in cardiorespiratory fitness, have been observed with atypical concomitant decreases in HRV. As such, practical ways by which HRV can be used to monitor training status in elites are yet to be established. This article addresses the current literature that has assessed changes in HRV in response to training loads and the likely positive and negative adaptations shown. We reveal limitations with respect to how the measurement of HRV has been interpreted to assess positive and negative adaptation to endurance training regimens and subsequent physical performance. We offer solutions to some of the methodological issues associated with using HRV as a day-to-day monitoring tool. These include the use of appropriate averaging techniques, and the use of specific HRV indices to overcome the issue of HRV saturation in elite athletes (i.e., reductions in HRV despite decreases in resting heart rate). Finally, we provide examples in Olympic and World Champion athletes showing how these indices can be practically applied to assess training status and readiness to perform in the period leading up to a pinnacle event. The paper reveals how longitudinal HRV monitoring in elites is required to understand their unique individual HRV fingerprint. For the first time, we demonstrate how increases and decreases in HRV relate to changes in fitness and freshness, respectively, in elite athletes.

Novel object recognition is not affected by age despite age-related brain changes

Age-related memory impairments show a progressive decline across lifespan. Studies have demonstrated equivocal results in biological and behavioral outcomes of aging. Thus, in the present study we examined the novel object recognition task at a delay period that has been shown to be impaired in aged rats of two different strains. Moreover, we used a strain of rats, Fisher 344XBrown Norway, which have published age-related biological changes in the brain. Young (10 month old) and aged (28 month old) rats were tested on a standard novel object recognition task with a 50-minute delay period. The data showed that young and aged rats in the strain we used performed equally well on the novel object recognition task and that both young and old rats demonstrated a righthanded side preference for the novel object. Our data suggested that novel object recognition is not impaired in aged rats although both young and old rats have a demonstrated side preference. Thus, it may be that genetic differences across strains contribute to the equivocal results in behavior, and genetic variance likely influences the course of cognitive aging.

Satisfactory outcomes with usage of extended criteria donor (ECD) kidneys in re-transplant recipients

The use of extended criteria donor (ECD) kidneys have increased substantially and the benefit recognized in certain populations. Our institution has maintained a policy of aggressively utilizing ECD kidneys, even among those who have failed a previous transplant. Previous reports on the benefit of ECD in re-transplants have shown equivocal outcomes. We sought to determine if our experience would support or refute this finding. This is a retrospective study of 19 ECD re-transplants between 2002 and 2010. We compared 1 and 3 year outcomes with 95 patients with standard criteria donor (SCD) re-transplant and 169 patients with first time transplant using ECD kidneys. Outcomes and demographics were evaluated including delayed graft function (DGF), HTN, DM, cold ischemia time (CIT), BMI, donor age and prior allograft nephrectomies using a Cox Proportional Hazard model. We compared patient and graft survival using the log rank test. Patient survival were similar among the first time ECD and ECD re-transplant groups at 1 year (p=0.9547) and at 3 years (p=0.8287). Graft survival was also similar between first time ECD and ECD re-transplant groups at 1 year (p=0.4781) and at 3 years (p=0.8519). As expected, SCD re-transplant had better outcomes than the other groups. 1 and 3 years graft and patient survival among first time ECD transplants and ECD re-transplants are similar. As the list of patients on dialysis is ever growing, it may be prudent to aggressively explore the utility of using ECD kidneys in re-transplant patients.

A Feasibility Study of Low-Cost, Self-Administered Skin Care Interventions in Patients With Head and Neck Cancer Receiving Chemoradiation

Current evidence for the management of radiation skin toxicities demonstrates equivocal outcomes using a variety of interventions, leaving substantial gaps in knowledge. Skin toxicities can lead to treatment delays, infection, pain, and increased costs for the patient. Patients with head and neck cancers receiving chemoradiation (N = 100), a population particularly vulnerable to disruptions in skin integrity, were enrolled into a prospective, descriptive study. Data collection was conducted and photographs were taken at baseline and weekly throughout treatment. Patients received skin care kits, instructions, and a diary to record adherence. Skin toxicity was measured and validated by at least three observers using serial photographs with 100% interrater agreement. Data were analyzed using descriptive statistics, graphs, and bivariate analysis. Adherence to both washing and moisturizing was consistently high. Although a correlation existed between the radiation dose and skin toxicity at week 6, no correlation existed between skin toxicity and adherence. Given the rate of grade 3 toxicities at week 6 and product costs, this proved to be an affordable regimen to which patients could easily adhere. Positive patient outcomes can be promoted through teaching and reinforcement of self-care measures to reduce skin toxicity.

Anabolic Steroids and Cardiovascular Risk

Recent reports from needle exchange programmes and other public health initiatives have suggested growing use of anabolic steroids (AS) in the UK and other countries. Data indicate that AS use is not confined to body-builders or high-level sportsmen. Use has spread to professionals working in emergency services, casual fitness enthusiasts and subelite sportsmen and women. Although the precise health consequences of AS use is largely undefined, AS use represents a growing public health concern. Data regarding the consequences of AS use on cardiovascular health are limited to case studies and a modest number of small cohort studies. Numerous case studies have linked AS use with a variety of cardiovascular disease (CVD) events or endpoints, including myocardial infarction, stroke and death. Large-scale epidemiological studies to support these links are absent. Consequently, the impact of AS use upon known CVD risk factors has been studied in relatively small, case-series studies. Data relating AS use to elevated blood pressure, altered lipid profiles and ECG abnormalities have been reported, but are often limited in scope, and other studies have often produced equivocal outcomes. The use of AS has been linked to the appearance of concentric left ventricular hypertrophy as well as endothelial dysfunction but the data again remains controversial. The mechanisms responsible for the negative effect of AS on cardiovascular health are poorly understood, especially in humans. Possibilities include direct effects on myocytes and endothelial cells, reduced intracellular Ca2+ levels, increased release of apoptogenic factors, as well as increased collagen crosslinks between myocytes. New data relating AS use to cardiovascular health risks are emerging, as novel technologies are developed (especially in non-invasive imaging) that can assess physiological structure and function. Continued efforts to fully document the cardiovascular health consequences of AS use is important to provide a clear, accurate, public health message to the many groups now using AS for performance and image enhancement.

Surgery for recurrent malignant gliomas: Feasibility and perioperative outcomes

Surgery for recurrent gliomas is often undertaken in select cases. Equivocal oncological outcomes of such surgeries are responsible for much of the controversy surrounding its role. Adding to the dilemma is the perceived increased morbidity associated with redo surgeries. Lack of studies and absence of uniformity in reporting outcomes is partly responsible for this. We evaluated our perioperative outcomes in recurrent malignant gliomas with the aim of documenting these objectively. A consecutive prospectively maintained database was queried for all redo surgeries in malignant gliomas performed at our referral neuro-oncology center. Demographic, clinical, surgical, and perioperative details were retrieved. Perioperative outcomes were objectively categorized as neurological (major/minor, transient/prolonged), regional, and systemic complications, along with overall morbidity and mortality. A similar analysis was performed for all craniotomies for intra-axial tumors. Forty-one surgeries for recurrent malignant gliomas (from a database of 196 craniotomies for all intra-axial tumors) were evaluated. Neurological worsening occurred in 22.2% (12.2% major), whereas 44% showed improvement in the pre-existing deficits. Besides, regional and systemic complications occurred in 14.2% and 4.8%, respectively. Overall morbidity was 29.3% (major in 14.6%) and mortality was 2.4%. Though not significant on multivariate analysis, prior treatment was an important predictor of increased regional complications. Neurological morbidity after surgery for recurrent gliomas is acceptable. Surgery also provides a high chance of restoration of neurological function. Though regional complications can be significant and need to be given cognizance when reporting perioperative outcomes, they are not alarmingly high. Careful case selection can ensure optimization of these outcomes.