Monitoring serum concentrations for once-daily netilmicin dosing regimens

A once-daily dosing regimen for aminoglycosides is less expensive, at least as effective and possibly less toxic than multiple-daily dosing regimens. Once-daily dosing might also allow the frequency of measuring the serum concentrations of these antibiotics to be reduced since two of the major objectives of monitoring, high peak and low trough concentrations, are more likely to be achieved with this regimen. A novel strategy for monitoring serum concentrations which relies on a single sample obtained 8 h after a dose, as opposed to both trough and peak samples, is evaluated here. Serum kinetics of netilmicin were studied prospectively in 51 adult patients with initial serum creatinine concentrations of 25 μmol/L was detected in 0 of 7 patients with an 8-h concentration of 6 mg/L. The results of this study suggest that adequate information about serum netilmicin concentrations in patients receiving a once-daily dose may be derived from a sample obtained 8 h after administratio

Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications

Objective: Percutaneous iliosacral screw placement allows for minimally invasive fixation of posterior pelvic ring instabilities. The objective of this study was to describe the technique for screws in S1 and S2 using conventional C-arm and to evaluate perioperative complications. Methods: Thirty-eight consecutive patients after percutaneous pelvic ring fixation with cannulated screws in S1 and S2 using conventional C-arm fluoroscopy were analysed. Accuracy of screw placement, nerval lesions, need for second surgery, operation time, and time to full weight bearing were assessed postoperatively and during regular follow-up examinations. Results: Twenty-one patients underwent unilateral screw fixation and 17 patients underwent bilateral screw fixation. In total, 83 screws were placed. Mean age of the patients was 52±19years. Mean operation time was 16±7min/screw. Mean follow-up was 5±3months. Time to full weight bearing in 28 patients was 9±4weeks. Eight patients were still not able to support full weight bearing, partially due to concomitant injuries. Patients without concomitant injuries that affected walking were able to bear full weight after 8±4weeks (n=17). Two patients had persistent postoperative hypaesthesia. No motor weakness was apparent and no postoperative bleeding was observed. Secondary surgery due to screw malpositioning or loosening had to be performed in four patients. The presence of a screw in S2 was not indicated for perioperative complications. Conclusions: Percutaneous iliosacral screw fixation is a rapid and definitive treatment for posterior pelvic ring injuries with a low risk of secondary bleeding during posterior pelvic stabilization. The technique using standard C-arm fluoroscopy was also found to be safe for screws placed in S

Recurrent desmoids determine outcome in patients with Gardner syndrome: a cohort study of three generations of an APC mutation-positive family across 30years

Purpose: Screening of Gardner syndrome (GS) patients is tailored towards prevention of colorectal cancer (CRC). However, many patients suffer from desmoid tumors, which are challenging to treat due to invasive growth and local recurrence. The aims of our study were to determine the effectiveness of screening in GS and analyze outcome of desmoid tumors by treatment modality. Methods: This was a cohort study of a family of 105 descendants with GS. All family members who agreed were screened by endoscopy, and colorectal resection was performed upon pending malignancy. Resectable desmoids were excised, whereas large tumors were treated by a combination of brachytherapy (BT) and radiotherapy (RT). Main outcome measures were the incidence of CRC and overall and disease-specific mortality (ClinicalTrial.gov ID NCT01286662). Results: Thirty-seven of 105 family members have GS. Preventive colorectal resections were performed in 16 patients (15%), with one death due to gastric cancer. In four patients who denied screening endoscopy, invasive tumors of the colon (three patients) and stomach developed. Of 33 desmoid tumors, 10 (30%) were located in the mesentery, 17 (52%) in the abdominal wall, and 6 (18%) in extra-abdominal sites. Excision of 12 desmoids was performed in eight patients. Four desmoids were treated by BT and RT and showed full or partial remission. Conclusions: Provided adequate screening, good long-term control of colorectal tumors is achievable. However, desmoid tumors determine survival and quality of life in many patients. Our data suggest good local control using a combination of brachytherapy/radiotherapy in large desmoids unsuitable for surgical resectio

Anatomical Injury Clusters in Polytrauma Patients

Polytrauma is a major cause of death in young adults. The trial was to identify clusters of interlinked anatomical regions to improve strategical operational planning in the acute situation. A total of 2219 polytrauma patients with an ISS (Injury Severity Score) ≥ 16 and an age ≥ 16 years was included into this retrospective cohort study. Pearson’s correlation was performed amongst the AIS (Abbreviated Injury Scale) groups. The predictive quality was tested by ROC (Receiver Operating Curve) and their area under the curve. Independency was tested by the binary logistic regression , AIS ≥3 was taken as a significant injury. The analysis was conducted using IBM SPSS® 24.0. The highest predictive value was reached in the combination of thorax, abdomen, pelvis and spine injuries (ROC: abdomen for thorax 0.647, thorax for abdomen 0.621, pelvis for thorax 0.608, pelvis for abdomen 0.651, spine for thorax 0.617). The binary logistic regression revealed the anatomical regions thorax, abdomen pelvis and spine as per-mutative independent predictors for each other when a particular injury exceeded the AIS ≥3. The documented clusters of injuries in truncal trauma are crucial to define priorities in the polytrauma management

The calcar screw in angular stable plate fixation of proximal humeral fractures - a case study

<p>Abstract</p> <p>Background</p> <p>With new minimally-invasive approaches for angular stable plate fixation of proximal humeral fractures, the need for the placement of oblique inferomedial screws ('calcar screw') has increasingly been discussed. The purpose of this study was to investigate the influence of calcar screws on secondary loss of reduction and on the occurrence of complications.</p> <p>Methods</p> <p>Patients with a proximal humeral fracture who underwent angular stable plate fixation between 01/2007 and 07/2009 were included. On AP views of the shoulder, the difference in height between humeral head and the proximal end of the plate were determined postoperatively and at follow-up. Additionally, the occurrence of complications was documented. Patients with calcar screws were assigned to group C+, patients without to group C-.</p> <p>Results</p> <p>Follow-up was possible in 60 patients (C+ 6.7 ± 5.6 M/C- 5.0 ± 2.8 M). Humeral head necrosis occurred in 6 (C+, 15.4%) and 3 (C-, 14.3%) cases. Cut-out of the proximal screws was observed in 3 (C+, 7.7%) and 1 (C-, 4.8%) cases. In each group, 1 patient showed delayed union. Implant failure or lesions of the axillary nerve were not observed. In 44 patients, true AP and Neer views were available to measure the head-plate distance. There was a significant loss of reduction in group C- (2.56 ± 2.65 mm) compared to C+ (0.77 ± 1.44 mm; p = 0.01).</p> <p>Conclusions</p> <p>The placement of calcar screws in the angular stable plate fixation of proximal humeral fractures is associated with less secondary loss of reduction by providing inferomedial support. An increased risk for complications could not be shown.</p

Polytraumaversorgung als Bereich der hochspezialisierten Medizin

Schwerverletzte Patientinnen und Patienten werden in der Schweiz im Rahmen der interkantonalen Vereinbarung der hochspezialisierten Medizin (IVHSM) behandelt. Das Swiss Trauma Board und die dort vereinten zwölf Schweizer Traumazentren arbeiten unter anderem mit dem deutschen Traumaregister zusammen, um eine bestmögliche Behandlung der Verletzten zu gewährleisten

Introduction of the “Straight-Leg-Evaluation-Trauma-Test” as a rapid assessment for long-bone fractures in a trauma bay setting

Purpose Lower extremity long bone fractures can constitute a substantial source of bleeding in the polytraumatized patient and should be diagnosed in the primary survey as fast as possible. Standardized clinical assessment tools for fracture detection in the trauma bay, however, are lacking. We propose the “Straight-Leg-Evaluation-Trauma-Test” (SILENT-test) as a rapid assesment tool for the lower extremity. The aim of this prospective diagnostic study was to evaluate the efficacy of this test in a standardized preclinical setting. Methods Medical professionals with different levels of experience performed clinical fracture diagnotics in four human cadavers with two femur- and two tibia shaft fractures. The SILENT-test (ST) and conventional fracture testing (CS) were performed. A cross-over design was used and participants were randomly allocated and blinded. Accuracy, subjective clinical applicability, and clinical performance of both tests were measured and compared. Results A total of 440 clinical tests were performed by 55 examiners. For femoral fractures, ST had a positive predictive value (PPV) of 0.97 (95% CI 0.93 to 0.99), a specificity of 0.91 (95% CI 0.80 to 0.97) and a sensitivity of 0.96 (95% CI 0.92 to 0.99). CS had a PPV of 0.97 (95% CI 0.93 to 0.99), a specificity of 0.93 (95% CI 0.82 to 0.98) and a sensitivity of 0.89 (95% CI 0.83 to 0.93). ST was significantly more feasible (8.05 ± 1.48 vs. 5.91 ± 2.09) had a significantly greater certainty (8.32 ± 1.84 vs. 7.89 ± 2.01) and was significantly faster (7.73 ± 6.61 vs 14.50 ± 11.11 s). Conclusion Preclinical evaluation of the SILENT-test showed equal accuracy compared to conventional fracture testing, while being significantly faster and significantly more clinically applicable. Prospective diagnostic clinical studies are justified to hopfully improve trauma care

Use of Imatinib in the Prevention of Heterotopic Ossification

Background: Heterotopic ossification (HO) is a common complication following orthopedic and trauma surgery, which may have substantial negative effects on the postoperative outcome. Angiogenesis appears to play a critical role in heterotopic ossification. One of the involved signaling molecules is platelet-derived growth factor (PDGF) which may be inhibited by imatinib. Questions/Purposes: Our goal was to prevent HO by pharmacologically interfering with the molecular signaling pathways involved in the developmental process. We hypothesized that by administering a proven inhibitor of PDGF expression, heterotopic bone formation may be prevented. Methods: The effect of imatinib on HO formation was studied in a murine model which reliably produces islets of HO within the soft tissue following Achilles tenotomy. The control group underwent Achilles tenotomy only. The imatinib group received imatinib mesylate. After trial completion, the limbs were harvested and scanned by micro-CT. Heterotopic bone volume was then identified and quantified. Results: The mean volume of heterotopic bone formed in the control group was 0.976mm3 compared to 0.221mm3 in the imatinib group. The volume of HO in the treatment group was reduced by 85% compared to the control group. Conclusions: The administration of imatinib was associated with a significantly reduced volume of HO. This may be due to the inhibitory effect of imatinib on the PDGF signaling pathway during development of HO. Clinical Relevance: The successful reduction of HO formation following imatinib administration has led to further insight concerning the pathogenesis of HO which in the future may lead to new clinical approaches towards the prevention of H

Treatment of femoral neck fractures in elderly patients over 60 years of age - which is the ideal modality of primary joint replacement?

BACKGROUND: Femoral neck fractures in the elderly are frequent, represent a great health care problem, and have a significant impact on health insurance costs. Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques. METHODS: The Pubmed database was searched for all articles on femoral neck fracture and for the reconstruction options presented in this review using the search terms "femoral neck fracture", "unipolar hemiarthroplasty", "bipolar hemiarthroplasty", and "total hip arthroplasty". In addition, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcome and complications of the distinct reconstruction options. RESULTS: THA yields the best functional results in patients with displaced femoral neck fractures with complication rates comparable to HA. THA is beneficially implanted using an anterior approach exploiting the internervous plane between the tensor fasciae latae and the sartorius muscles allowing for immediate full weight-bearing. Based on our findings, bipolar hemiarthroplasty, similar to unipolar hemiarthroplasty, cannot restorate neither anatomical nor biomechanical features of the hip joint. Therefore, it can only be recommended as a second line of defense-procedure for patients with low functional demands and limited live expectancy. CONCLUSIONS: THA is the treatment of choice for femoral neck fractures in patients older than 60 years. HA should only be implanted in patients with limited life expectanc