Prolonged Loss Research Articles

Effect of Notchplasty in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Background: The effects of notchplasty on the clinical outcome after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction remain unclear. Hypothesis: Anatomic ACL reconstruction with notchplasty would result in less risk of loss of extension and would provide adequate space for better graft healing, leading to better knee stability compared with anatomic ACL reconstruction without notchplasty. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 137 patients who underwent anatomic double-bundle ACL reconstruction were included. Seventy-three patients without notchplasty were classified as the control group, and 64 patients with 2-mm notchplasty were classified as the notchplasty group. The following evaluation methods were used: loss of extension, patient’s subjective feeling of limited extension and pain at passive full extension, muscle strength, manual laxity tests, KT-1000 arthrometer measurement, patellofemoral joint findings, Tegner score, Lysholm score, subjective scores, and time to return to sports. Tearing of the reconstructed ACL and additional synovectomy were recorded. Both tibial and femoral tunnel positions were measured using 2-view radiographs: a Rosenberg and a lateral view. Results: Loss of extension was larger in the notchplasty group compared with controls (at 6 months: 0.8° vs 1.4°, P = .012; at 2 years: 0.4° vs 0.9°, P = .0053). The number of patients with a feeling of limited extension was also larger in the notchplasty group (at 6 months: 13 patients graded 1+ [somewhat limited] and 2 patients graded 2+ [very limited] vs 18 graded 1+ and 6 graded 2+, P = .015; at 2 years: 2 graded 1+ and 0 graded 2+ vs 4 graded 1+ and 5 graded 2+, P = .011). Six patients in the notchplasty group required additional synovectomy because of the prolonged loss of extension, whereas no patient in the control group required additional synovectomy. There were no differences between groups regarding muscle strength, patellofemoral findings, Lysholm score, Tegner score, subjective scores, or time to return to sports. The KT-1000 arthrometer measurement was better in the notchplasty group (1.2 vs 0.4 mm, P = .0017). However, 6 patients in the notchplasty group showed an overconstrained knee (KT-1000 measurement ≤–2 mm), compared with only 1 patient in the control group. There were no differences between groups in the other manual laxity tests or the tunnel positions. Conclusion: In anatomic double-bundle ACL reconstruction, anterior stability was improved and there were no harmful effects on patellofemoral joint findings by 2-mm notchplasty; however, notchplasty likely caused overconstrained knee, leading to a need for additional synovectomy in some patients. In contrast, anatomic double-bundle ACL reconstruction without notchplasty did not increase the incidence of loss of extension or of graft failure.

Relative bone loss during aromatase inhibitors therapy: The B-ABLE cohort.

579 Background: Estrogen deprivation induced by aromatase inhibitors (AI) leads to a rapid and prolonged bone loss and increased fracture incidence. The current study aims to evaluate AI-associated...

Acute Adult Onset Comitant Esotropia Associated with Accommodative Spasm

Acute onset comitant esotropia associated with spasm of accommodation in children and adults is a rare clinical condition. When occurring with pupillary miosis and restricted ocular motility, it is referred to as "spasm of near reflex" (SNR) and may require neurological investigation. The natural history of SNR depends on its etiology. There is little information in the literature regarding the long-term follow-up of SNR and the stability of visual signs and symptoms following cessation of treatment. We report a case of SNR in an otherwise healthy young male, and discuss the presentation, clinical investigations, management, response to treatment, and 1-year follow-up. A 23-year-old male patient reported to the clinic with sudden onset of blurred vision, inward deviation of the eyes, and binocular diplopia. On examination, he was diagnosed to have acute onset esotropia resulting from SNR. He was treated with cycloplegic medications and vision therapy. The condition resolved following 1 year and there has been no recurrence. Acute adult onset esotropia occurring with accommodative spasm responds favorably to cycloplegic medications but may need a longer course of treatment for successful resolution and stability.

Running Forward

> Give every individual the right amount of exercise, not too little and not too much.1 > > —Hippocrates Physical activity has long been tied to good health. Hippocrates was guided by his theory of balanced humors to advocate that absolutely everyone, young or old, needs exercise, but not too much. A landmark 1953 study noted that drivers of public trolleys in London had twice as many acute coronary syndromes as did conductors of the same trolleys, the only notable difference being that conductors walked as they collected tickets and drivers sat.2,3 In the decades since this seminal epidemiological observation, nearly every aspect of human physiology has been demonstrated to benefit from exercise, ranging from lung and cardiac function to cognition and aging (Figure 1). The same decades, however, have witnessed a dramatic sedentarization of the US population (despite the newfound popularity of recreational exercise). Today, the consequences of sedentary lifestyles, synergizing with dramatic increases in caloric intake, are ubiquitous and devastating. Figure 1. The many long-term benefits of regular endurance exercise. Exercise is a fundamental component of the human condition. Humans are the only primates capable of sustained long-distance running, and this behavior likely significantly shaped the evolutionary departure of humans from other primates.4 For example, the need for heat dissipation during prolonged physical activity likely favored loss of body hair and the proliferation of sweat glands, thereby considerably altering the human form.5,6 Endurance exercise thus not only is good for us but in fact is part of what defines us. Not surprisingly, the study of exercise, including its mechanics, physiology, and health benefits, has long garnered fascination. Over the last decade, new molecular techniques have ushered in a new era of exercise research, focused on understanding fundamental mechanisms. The wealth of new information is staggering. …

A murine model of airway fibrosis induced by repeated naphthalene exposure

The airway epithelium serves as a biological barrier essential for host defense against inhaled pollutants. While chronic epithelial injury, commonly associated with chronic obstructive pulmonary disease and bronchiolitis obliterans syndrome, often results in airway fibrosis, limited animal models of airway fibrosis have been established. Club cells (Clara cells) in the small airways represent an important population of epithelial progenitor cells and also the principal site of localization of the cytochrome P-450 monooxygenase system, which metabolically activates xenobiotic chemicals such as naphthalene by converting them to toxic epoxide intermediates. We hypothesized that repeated exposure to naphthalene may cause prolonged loss of club cells, triggering aberrant local epithelial repair mechanisms that lead to peribronchial fibrosis. We administered intraperitoneal injections of naphthalene to C57/BL6J mice once a week for 14 consecutive weeks. Repeated club cell injury caused by naphthalene triggered regional hyperproliferation of epithelial progenitor cells, while other regions remained denuded or squamated, resulting in fibroblast proliferation and peribronchial collagen deposition associated with upregulation of the fibrogenic cytokines transforming growth factor-β and connective tissue growth factor. The total collagen content of the lung assessed by measurement of the hydroxyproline content was also increased after repeated exposure to naphthalene. These results lend support to the relevance of repeated injury of airway epithelial cells as a trigger for resting fibroblast proliferation and airway fibrosis. This model of airway fibrosis is simple and easy to reproduce, and may be expected to advance our understanding of the pathogenesis and potential treatment of airway fibrotic disorders.

Monitoring noninvasive ventilation in neuromuscular patients: feasibility of unattended home polysomnography and reliability of sleep diaries

BackgroundIn-hospital polysomnography (PSG) often is performed to monitor neuromuscular patients under noninvasive ventilation (NIV), but success of home PSG has not been established for that purpose. Reliability of sleep diaries in neuromuscular patients is unknown. The aims of our study were to evaluate feasibility, quality, and acceptability of unattended home PSG, as well as the reliability of sleep diaries in neuromuscular patients on long-term NIV. MethodsFifty-two neuromuscular patients underwent unattended home or hospital PSG during NIV. Patients were questioned about their sleep during the PSG and their attitudes towards the procedure. ResultsOne home and one hospital PSG were scored as failure or low quality due to prolonged signal loss or sleep duration of <3h. Objective and subjective sleep duration and efficiency often showed large differences. Subjective awakenings reflected objective awakenings lasting for >4min in 86.5% patients. Preference for home PSG was expressed by 82% subjects. ConclusionsIn neuromuscular patients under NIV unattended home PSG is feasible and preferred, with a low failure rate. The degree of reliability of different parameters of subjective sleep assessment should be considered when used as a complement of nocturnal cardiorespiratory recordings.

Tumor Angiogenesis

It has long been appreciated that angiogenesis can contribute to the induction or progression of several diseases, including retinopathies, arthritis, psoriasis, and cancer.1,2 Because endothelial cells typically exist in a quiescent state in normal vessels, the molecular changes required for these cells to become proliferative and invasive have long been considered potential targets for the control of both neovascularization and the accompanying pathology. To this end, over the past 3 decades, several novel effectors of angiogenesis have been characterized, ranging from growth factors, such as vascular endothelial cell growth factor (VEGF),3 to signaling effectors, such as RasGAPs,4 to cell adhesion molecules,5,6 including the αv integrins featured in the article by Steri et al.7 Nonetheless, as an aggregate, the efficacy of antiangiogenic agents has only produced a modest impact on disease.8 Article, see p 79 We and others have demonstrated that antagonists of αv integrins target and suppress pathological angiogenesis, resulting in decreased tumor growth,9,10 inflammatory disease,9,11 and retinal disease.5 In glioblastoma patients treated with these agents, some clinical efficacy was noted,12 although overall survival was not significantly impacted in recently announced phase III trials. Studies by Hynes et al showed that mice deficient in either αv or β3 showed robust blood vessel development.13,14 In fact, these animals displayed enhanced endothelial cell VEGF receptor (VEGFR) expression associated with increased tumor angiogenesis. This led the authors to conclude that αvβ3 plays a negative role in angiogenesis. How, then, can one reconcile the fact that αvβ3 antagonists suppress angiogenesis in mice and humans? In an elegant series of …

Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery.

Background and Objectives:Combining laparoscopy and enhanced recovery provides benefit to short-term outcomes after colorectal surgery. Advances in training and techniques have allowed surgeons to operate on cases that are technically challenging and associated with prolonged operative time. Laparoscopic techniques improve the outcome of enhanced recovery after colorectal surgery; however, there are no specifications on the effect of prolonged operations on the outcome. The objective was to elucidate the impact of prolonged surgery and blood loss on the outcome of enhanced recovery after surgery after laparoscopic colorectal surgery.Methods:Four-hundred patients who underwent elective colorectal resection on enhanced recovery after surgery in Yeovil District Hospital between 2002 and 2009 were retrospectively reviewed. Delayed discharge was defined as a prolonged length of stay beyond the mean in this series (≥8 days).Results:Three-hundred eighty-five patients were included. Median operative time was 180 minutes with a median blood loss of 100 mL. Conversion was not associated with a prolonged length of stay. Operative time and blood loss correlated with length of stay in a stepwise fashion. There were 2 cutoff points of operative time at 160 minutes and 300 minutes (5 hours), where risk of prolonged stay increased significantly (odds ratio [OR] = 2.02; 95% confidence interval [CI], 1.05–3.90; P = .027), and blood loss of >500 mL (OR = 3.114; 95% CI, 1.501–6.462, P = .002).Conclusions:Total operative timing impacts negatively on the outcome of enhanced recovery after laparoscopic colorectal resections with increased risk of delayed discharge seen after ∼2.5 hours and 5-hour duration.

A conceptual model of musculoskeletal disorders for occupational health practitioners

A conceptual model of musculoskeletal disorders for occupational health practitioners

Carbon monoxide poisoning in the 21st century

The world has experienced some very large shifts in the epidemiology of carbon monoxide poisoning, but it remains one of the most important toxicological global causes of morbidity and mortality. The diagnosis can be quickly confirmed with blood gases (pulse oximeters lack both sensitivity and specificity). Several strong predictors for serious neurological sequelae (prolonged loss of consciousness and elevated S100B) and reduced life expectancy (elevated troponin) are now reasonably well established. Despite this clearly defined high-risk group and extensive research into the pathophysiology, there has been little translation into better treatment. Much of the pathophysiological research has focused on hyperbaric oxygen. Yet it is apparent that clinical trials show little evidence for benefit from hyperbaric oxygen, and the most recent even raises the possibility of harm for repeated courses. More logical and promising potential antidotes have been under-researched, although recently both animal and small human studies suggest that erythropoietin may reduce S100B and prevent neurological sequelae. Major breakthroughs are likely to require further research on this and other treatments that may inhibit post-hypoxic inflammatory responses and apoptosis.

Postanesthesia Persistent Amnesia in a Patient With a Prior History of Dissociative Fugue State: The Case for the Two-Hit Hypothesis

The psychiatry service was called to evaluate a patient in the outpatient procedure unit who could not remember who she was or why she was there. “Ms. R” was a 36-yearold Hispanic woman with a history of morbid obesity who underwent an upper endoscopy for evaluation of nausea and inability to tolerate oral intake 1 month after a Roux-en-Y gastric bypass for her obesity. The endoscopy demonstrated moderate stenosis at the gastrojejunal anastomosis, which did not account for the severity of her nausea. The stenosis was dilated without incident. For the procedure, Ms. R received a total of 420 mg i.v. of propofol, 100 mg i.v. of lidocaine, and 0.2 mg i.v. of glycopyrrolate. She also received a total of 200 μg i.v. of phenylephrine for a transient decrease in blood pressure to 81/45. In the recovery room, when Ms. R awoke from her conscious sedation, she had no recollection of why she was in the hospital, was disoriented to place, and, most significantly, was unable to recall her identity. She was agitated, prompting the psychiatric consultation. Ms. R was visibly frightened when any person tried to approach her, including her boyfriend of 5 years. She repeatedly asked why she was there but was unable to retain the information received. She was given 2 mg of midazolam for agitation, after which a minor improvement in behavior was observed. A repeat dose of midazolam was administered, without further improvement. Forty-five minutes after the procedure, Ms. R was still unable to recall her date of birth. Her vital signs and general physical and neurological examination were within normal limits. Her mental status examination was significant for agitation, disorientation to person and place, and extensive memory loss, which continued for the rest of the day. She repeatedly expressed the delusion that the baby she had just delivered was taken from her. She had no evidence of hallucinations. A preprocedure pregnancy test was negative. Ms. R was on a liquid diet and taking a multivitamin once daily, 1,000 μg of vitamin B12 three times a week sublingually, and calcium citrate daily. Ms. R’s past medical history included a history of gallstones as well as the Roux-en-Y gastric bypass surgery 1 month earlier, at which time her body mass index (BMI) was 47. Ms. R had received 200 mg of propofol as part of the anesthesia during the 3-hour bariatric surgery without incident. Ursodiol was begun 3 weeks before the endoscopy for nausea that developed while she was consuming a postoperative liquid diet. When her diet was advanced to soft foods, she began vomiting. She returned to a liquid diet, and the endoscopy was scheduled. Ms. R’s past psychiatric history was significant for a dissociative fugue, which occurred at the same time as her divorce 7 years earlier and for which she was psychiatrically hospitalized. She continued in individual and group treatment for 2 years after that hospitalization. She had no history of traumatic events. Because of Ms. R’s persistent amnesia and agitation, she was admitted to amedical unit for further evaluation. Results of all testing, routine laboratory tests, urine drug screen, head CT, head MRI, and EEG were normal except for ketones in the urine. Ms. R’s BMI had decreased to 40.5. She was started on a clear liquid diet and had no further nausea. The neurology consultant agreed with the psychiatrist’s diagnosis of dissociative amnesia. During her hospitalization, Ms. R slowly regained some of her memory. She vaguely remembered that she had an adult son living in another state. Ms. R could not remember how to use her cell phone. She was afraid to take a shower without supervision as she was not sure she would know what to do. She also could not recall important historical events, such as the September 2001 attacks on the World Trade Center. There was no evidence of anterograde amnesia after the first hospital day. After showing some improvement over her 6-day hospitalization, she was discharged home with her boyfriend. Two weeks after hospital discharge, Ms. R continued to recover some of her memories and to increase her activities. It was unclear, however, whether her retrograde amnesia was improving or whether she was only retaining newly learned information. She began to cook on her own and reported increased comfort around her boyfriend and her family. Ms. R was afraid to return to work because she was concerned that she would not remember how to do her job. Within 2 months of the episode, Ms. R was retrained by her employer and successfully resumed her work as a secretary. Six months after the procedure, Ms. R’s retrograde amnesia had significantly improved and she continued to form new memories without difficulty.

PD-L1 and PD-L2 Protect The Heart In a T-Cell Receptor Transgenic Model Of Graft-Versus Host Disease

Graft-versus-host disease (GVHD) is a complication of allogeneic stem cell transplantation (alloSCT). In murine models of alloSCT, naive T cells (TN) cause GVHD while effector memory T cells (TEM) do not. To determine why TEM fail to cause GVHD, we generated a novel T-cell receptor transgenic GVHD model. In this model CD4+ TS1 T cells, which recognize an epitope of influenza hemagglutinin (HA), are transferred, along with syngeneic bone marrow, into irradiated transgenic recipients that express HA in all tissues (HA104 Tg mice). We found that TS1 TN induced early and prolonged weight loss and caused GVHD-like pathology in the skin, liver and colon. In contrast, TS1 TEM induced mild, transient weight loss and minimal pathology, demonstrating that TEM have repertoire-independent characteristics that limit their ability to induce GVHD. Post transplant analysis revealed that TS1 TEM progeny, relative to TS1 TN progeny, produced less IFN-γ, proliferated and accumulated less in the colon, and expressed higher levels of the inhibitory molecule PD-1. To investigate whether PD-1 was responsible for limiting pathogenesis by TEM, we used hosts and donor bone marrow lacking both PD-L1 and PD-L2. The absence of PD-L1/2 did not enable TS1 TEM to cause early weight loss. However, between 35 and 60 days post transplant, TS1 TEM recipients lacking PD-L1/2 rapidly began losing weight and approximately 50% died. Weight loss in TEM recipients was dependent upon lack of PD-L1/2 expression on both donor bone marrow and host cells, including radioresistant stromal cells, suggesting a possible role for PD-L1/2 expressed in tissues. Indeed, global absence of PD-L1 alone, which (in contrast to PD-L2) is expressed on parenchymal tissues, also resulted in late weight loss in recipients given TEM. To determine the reason for late weight loss, we surveyed tissue histopathology. Surprisingly, in the absence of PD-L1/2, TEM recipients did not develop exacerbated colon pathology but instead developed mononuclear infiltrates and mycocyte necrosis in the heart, accompanied by heart block and decreased cardiac output. Interestingly, heart disease was also seen in PD-L1/2 deficient TN recipients that survived to later time points, indicating that the protective role of PD-L1/2 applied more generally to GVHD induced by CD4 T cells. Strikingly, the extensive infiltrates in affected hearts were mostly comprised of non-TS1 T cells, including both CD4 and CD8 cells. These cells are likely host-derived, as severe cardiac infiltrates were seen when Rag-deficient donor BM was used to reconstitute host hematopoiesis. We therefore hypothesize that in GVHD PD-L1/2 normally prevent “allogeneic” T cell mediated damage but also protect from subsequent syngeneic T cell-mediated pathogenesis that could contribute to prolonged disease. This effect is tissue specific and could in part be due to parenchymal expression of PD-L1 in certain organs. It is possible that such mechanisms could explain more chronic phases of GVHD, which differs from acute GVHD. Ongoing depletion experiments will determine the relative contributions of donor TS1 T cells, donor bone marrow derived T cells and host T cells. Disclosures: No relevant conflicts of interest to declare.

Genome-wide RNAi screen identifies ATPase inhibitory factor 1 (ATPIF1) as essential for PARK2 recruitment and mitophagy

Mitochondrial dysfunction is a hallmark of aging and numerous human diseases, including Parkinson disease (PD). Multiple homeostatic mechanisms exist to ensure mitochondrial integrity, including the selective autophagic program mitophagy, that is activated during starvation or in response to mitochondrial dysfunction. Following prolonged loss of potential across the inner mitochondrial membrane (ΔΨ), PTEN-induced putative kinase 1 (PINK1) and the E3-ubiquitin ligase PARK2 work in the same pathway to trigger mitophagy of dysfunctional mitochondria. Mutations in PINK1 and PARK2, as well as PARK7/DJ-1, underlie autosomal recessive Parkinsonism and impair mitochondrial function and morphology. In a genome-wide RNAi screen searching for genes that are required for PARK2 translocation to the mitochondria, we identified ATPase inhibitory factor 1 (ATPIF1/IF1) as essential for PARK2 recruitment and mitophagy in cultured cells. During uncoupling, ATPIF1 promotes collapse of ΔΨ and activation of the PINK-PARK2 mitophagy pathway by blocking the ATPase activity of the F1-Fo ATP synthase. Restoration of ATPIF1 in Rho0 cells, which lack mtDNA and a functional electron transport chain, lowers ΔΨ and triggers PARK2 recruitment. Our findings identified ATPIF1 and the ATP synthase as novel components of the PINK1-PARK2 mitophagy pathway and provide genetic evidence that loss of ΔΨ is an essential trigger for mitophagy.

Outcomes of Isolated Basilar Skull Fracture: Readmission, Meningitis, and Cerebrospinal Fluid Leak

To determine rates of cerebrospinal fluid (CSF) leak, meningitis, and readmission in pediatric and adult patients with isolated basilar skull fracture. Cross-sectional analysis of a statewide database. Patients with isolated basilar skull fracture (1995-2010). Patients were identified within the California Office of Statewide Health Planning and Development database using ICD-9 diagnosis codes. A total of 3563 pediatric and 10,761 adult patients met inclusion criteria. In-hospital rates of meningitis (0.48% and 0.64%, P = .3360) and CSF leak (2.33% and 1.75%, P = .0270) were similar among children and adults, respectively. Rates of 90-day meningitis (0.17% and 0.37%, P = .0714) and CSF leak (0.40% and 0.40%, P = .9823) were also similar. Thirty-day readmission was 4.6% for children compared with 12.4% for adults (P < .001). For both pediatric and adult patients, extra-axial hematoma (odds ratio [OR] [confidence interval {CI}] 1.65 [1.05-2.59] and 1.61 [1.34-1.95]) and comorbidities (OR [CI] 2.19 [1.11-4.34] and 1.28 [1.04-1.59]) were associated with significant increases in 30-day readmission. Loss of consciousness greater than 1 hour (OR, 3.05; 95% CI, 1.53-6.08) and CSF leak (OR, 3.28; 95% CI, 1.41-7.64) increased the likelihood of pediatric readmissions. Lack of insurance (OR, 0.67; 95% CI, 0.50-0.90) and female gender (OR 0.83; 95% CI, 0.70-0.99) reduced the likelihood of adult readmission. Meningitis and CSF leak following isolated basilar skull fractures are uncommon. Readmission within 30 days was more common in adults than in children. CSF leak, hematoma, and prolonged loss of consciousness increased the likelihood of readmission in children. Intracranial injury, male gender, having insurance, and comorbidities increased the likelihood of readmission in adults.

Neuropeptide Y and peptide YY protect from weight loss caused by Bacille Calmette–Guérin in mice

Background and PurposeImmune challenge of mice with Bacille Calmette–Guérin (BCG) has been reported to cause transient weight loss and a behavioural sickness response. Although BCG-induced depression involves the kynurenine pathway, weight loss occurs independently of this factor. Because neuropeptide Y (NPY) and peptide YY (PYY) are involved in the regulation of food intake, we hypothesized that they play a role in the BCG-induced weight loss.Experimental ApproachMale wild-type, PYY knockout (PYY−/−), NPY knockout (NPY−/−) and NPY−/−;PYY−/− double knockout mice were injected with vehicle or BCG (approximately 108 colony-forming units per mouse), and their weight, locomotion, exploration and ingestion were recorded for 2 weeks post-treatment.Key ResultsDeletion of PYY and NPY aggravated the BCG-induced loss of body weight, which was most pronounced in NPY−/−;PYY−/− mice (maximum loss: 15%). The weight loss in NPY−/−;PYY−/− mice did not normalize during the 2 week observation period. BCG suppressed the circadian pattern of locomotion, exploration and food intake. However, these changes took a different time course than the prolonged weight loss caused by BCG in NPY−/−;PYY−/− mice. The effect of BCG to increase circulating IL-6 (measured 16 days post-treatment) remained unaltered by knockout of PYY, NPY or NPY plus PYY.Conclusions and ImplicationsThese data show that NPY and PYY are both required to protect from the action of BCG-evoked immune challenge to cause prolonged weight loss and disturb energy balance. The findings attest to an important role of NPY and PYY in orchestrating homeostatic reactions to infection and immune stimulation.

Tail vaccination in cats: a pilot study.

Feline injection site sarcomas affect 1-10 cats per every 10,000 vaccinated and are associated with high mortality. Radical resection may be curative, but is often associated with prolonged recovery, disfigurement and loss of function when tumors occur at currently recommended injection sites. The objective of this study was to assess alternatives to currently recommended vaccination sites in terms of preference by oncology practitioners, ease of injection and serological responses. Surgical, radiation and medical oncology practitioners were surveyed regarding their preference for vaccination sites based on the ease of tumor resection. A six-point Likert scale was used to measure each cat's behavioral reaction to vaccination when injected subcutaneously in the distal hind limb or the distal tail. Serum collected before and 1-2 months after vaccination was tested for antibody titers against feline panleukopenia virus (FPV) and rabies virus (RV). The preferred sites for vaccination by 94 oncology practitioners were below the stifle (41%) and the tail (30%). There were no significant differences in the cats' behavioral reaction to vaccination below the stifle (n = 31) and in the distal tail (n = 29). Of the cats seronegative for FPV at the time of vaccination, 100% developed protective antibody titers (≥40) against FPV 1-2 months following vaccination. For cats seronegative for RV, all but one cat (tail vaccine) developed acceptable antibody titers (≥0.5 IU/ml) against RV. Tail vaccination was well tolerated and elicited similar serological responses to vaccination in the distal limbs.

Fall incidents unraveled: a series of 26 video-based real-life fall events in three frail older persons

BackgroundFor prevention and detection of falls, it is essential to unravel the way in which older people fall. This study aims to provide a description of video-based real-life fall events and to examine real-life falls using the classification system by Noury and colleagues, which divides a fall into four phases (the prefall, critical, postfall and recovery phase).MethodsObservational study of three older persons at high risk for falls, residing in assisted living or residential care facilities: a camera system was installed in each participant’s room covering all areas, using a centralized PC platform in combination with standard Internet Protocol (IP) cameras. After a fall, two independent researchers analyzed recorded images using the camera position with the clearest viewpoint.ResultsA total of 30 falls occurred of which 26 were recorded on camera over 17 months. Most falls happened in the morning or evening (62%), when no other persons were present (88%). Participants mainly fell backward (initial fall direction and landing configuration) on the pelvis or torso and none could get up unaided. In cases where a call alarm was used (54%), an average of 70 seconds (SD=64; range 15–224) was needed to call for help. Staff responded to the call after an average of eight minutes (SD=8.4; range 2–33). Mean time on the ground was 28 minutes (SD=25.4; range 2–59) without using a call alarm compared to 11 minutes (SD=9.2; range 3–38) when using a call alarm (p=0.445).The real life falls were comparable with the prefall and recovery phase of Noury’s classification system. The critical phase, however, showed a prolonged duration in all falls. We suggest distinguishing two separate phases: a prolonged loss of balance phase and the actual descending phase after failure to recover balance, resulting in the impact of the body on the ground. In contrast to the theoretical description, the postfall phase was not typically characterized by inactivity; this depended on the individual.ConclusionsThis study contributes to a better understanding of the fall process in private areas of assisted living and residential care settings in older persons at high risk for falls.

Minor Traumatic Brain Injury: A Primer for the Orthopaedic Surgeon

Minor traumatic brain injury (mTBI) is a major public health problem. The Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control label it a "silent epidemic." Subtle signs and symptoms of mTBI, including headache, fatigue, and memory loss, are often seen in conjunction with musculoskeletal trauma. Although sometimes evident immediately, mTBI may not manifest until patients return to work and their personal lives. In the patient with acute concurrent mTBI, skeletal management must be based on either a period of observation to rule out evolving neurologic symptoms or, when warranted, the recommendations of a neurosurgeon. Such input is particularly important when mTBI is associated with a prolonged loss of consciousness or posttraumatic amnesia. In the outpatient setting, when concern for mTBI exists weeks after an injury, familiarity with and referral to locally available mTBI specialists and programs can facilitate proper care. Armed with this knowledge, the orthopaedic surgeon has an opportunity to positively influence outcomes and help provide crucial care that extends beyond the management of musculoskeletal injuries.

Krankheitsbilder in der Pneumologie

The diagnosis and treatment of granulomatous lung diseases is challenging. This article describes two of these entities: (1) eosinophilic vasculitis with polyangiitis which is clinically characterized as a combination of bronchial asthma and eosinophilic granulomatous vasculitis. Antoneutrophil cytoplasmic antibodies are present in approximately 40 % of patients. Treatment with steroids is sufficient in patients with isolated pulmonary manifestation but extrapulmonary manifestations, e.g. heart, central nervous system (CNS), kidneys and gastrointestinal tract warrant combined immunosuppression with prednisolone and cyclophosphamide. (2) In Germany tuberculosis is an orphan disease with an incidence of 5.3/100,000 in the year 2011. Prolonged cough, night sweats and weight loss should be considered suspicious of tuberculosis. Microbiological diagnosis has been improved by gene and PCR technology. The traditional Mendel-Mantoux skin test has widely been replaced by the interferon gamma release assay (IGRA). Standard treatment of non-resistant mycobacterium tuberculosis is based on a combination of isonizide, rifampicine, pyrazinamide and ethambutol for 2 months followed by 4 months of isoniazide plus rifampicine. Therapy resistant, multiple drug resistant (MDR) and extensively drug resistant (XDR) tuberculosis bacteria should be treated by experienced specialists.

Interplay between ABA and phospholipases A2 and D in the response of citrus fruit to postharvest dehydration

The interplay between abscisic acid (ABA) and phospholipases A2 and D (PLA2 and PLD) in the response of citrus fruit to water stress was investigated during postharvest by using an ABA-deficient mutant from 'Navelate' orange named 'Pinalate'. Fruit from both varieties harvested at two different maturation stages (mature-green and full-mature) were subjected to prolonged water loss inducing stem-end rind breakdown (SERB) in full-mature fruit. Treatment with PLA2 inhibitor aristolochic acid (AT) and PLD inhibitor lysophosphatidylethanolamine (LPE) reduced the disorder in both varieties, suggesting that phospholipid metabolism is involved in citrus peel quality. Expression of CsPLDα and CsPLDβ, and CssPLA2α and CssPLA2β was studied by real-time RT-PCR during water stress and in response to ABA. CsPLDα expression increased in mature-green fruit from 'Navelate' but not in 'Pinalate' and ABA did not counteract this effect. ABA enhanced repression of CsPLDα in full-mature fruit. CsPLDβ gene expression decreased in mature-green 'Pinalate', remained unchanged in 'Navelate' and was induced in full-mature fruit from both varieties. CssPLA2α expression increased in mature-green fruit from both varieties whereas in full-mature fruit only increased in 'Navelate'. CssPLA2β expression increased in mature-green flavedo from both varieties, but in full-mature fruit remained steady in 'Navelate' and barely increased in 'Pinalate' fruit. ABA reduced expression in both after prolonged storage. Responsiveness to ABA increased with maturation. Our results show interplay between PLA2 and PLD and suggest that ABA action is upstream phospholipase activation. Response to ABA during water stress in citrus is regulated during fruit maturation and involves membrane phospholipid degradation.