Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial

© 2017 Elsevier Ltd Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [\u3c1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians\u27 Services Incorporated

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Frequency and meaning of positive vaginal smears in the vaginal vault after effected hysterectomy

Problemstellung Während Lokalisation, Entstehungsweise und Häufigkeit des Zervixkarzinoms und seiner Vorstadien gut bekannt und klar definiert sind, ist dies beim Vaginalkarzinom und seinen Vorstadien nicht der Fall. Die vorliegende Studie stellte sich die Aufgabe, die Häufigkeit positiver zytologischer Befunde im vaginalen Blindsack zu ermitteln, besonders im Hinblick auf die Frage der Notwendigkeit zytologischer Vorsorgeuntersuchungen auch nach erfolgter Hysterektomie. Material und Methodik Hierfür waren die gynäkologischen Abstriche über einen Zeitraum von drei Jahren aus einem zytologischen Großlabor retrospektiv ausgewertet worden. Insgesamt wurden 266.618 gynäkozytologische Abstriche ausgewertet. Davon entfielen 241.956 auf Zervix- und 24.662 auf Vaginalabstriche aus dem Scheidenblindsack. Die Häufigkeit der zervikalen und vaginalen Präneoplasien und Karzinome lag in dieser Zeit bei 5.453 Fällen, die der vaginalen bei 162 Fällen. Ergebnisse Es zeigte sich, dass von 24.662 Fällen mit Abstrichen aus dem vaginalen Blindsack 162 (0,66%) positiv bewertet worden waren. Das Durchschnittsalter lag bei 58 Jahren. In dieser Altersklasse werden positive Zervixabstriche mit ca. 0,98% angegeben und sind damit nur um etwa ein Drittel häufiger. Die Häufigkeit des Auftretens eines Vaginalkarzinoms nach vorausgegangenem Uteruskarzinom war statistisch signifikant. Besonders bemerkenswert ist der relativ hohe Anteil invasiver sekundärer Vaginalkarzinome innerhalb des Positivkollektivs. Dieser war mit 6,2% höher als die Rate festgestellter Zervixkarzinome. Morphologisch spezifische HPV-Zeichen, d.h. Koilozyten, wurden in 11,7% unserer positiven Vaginalabstriche gefunden. Indirekte HPV-Zeichen (Dyskeratozyten) wurden noch häufiger, in 75,3%, beobachtet. Sie traten in dem von uns untersuchten Kollektiv also rund zehnmal häufiger auf, als im Bereich der Zervix angegeben wird. Diskussion und Schlussfolgerung Nach dem vorliegendem Ergebnis ist also davon auszugehen, dass Vorsorgeuntersuchungen nach erfolgter Hysterektomie auch weiterhin notwendig sind, um die Entstehung sekundärer Vaginalkarzinome zu verhindern.Positive vaginal smears following hysterektomy, a rare event? The resulting high incidence of positive vaginal smears and of secondary vaginal carcinomas in particular seem to the consequence of insufficient medical precaution following hysterectomy Sampling and examination of cytologic smears from the vaginal cuff frequently is neglected, because it is assumed that cancer development is hardly possible after hysterectomy. In contrast, a relatively high occurrence of so-called secondary vaginal cancer is observed in general practice Cytologic records of patients that had previosly a hysterektomy from the years 1997-99 were evaluated and the positive cases re-examined. 166 positive cases were found, 131 revealing VaIN Ia.II, 29 VaIN III , and 6 invasive vaginal carcinomas. The incidence of VaIN I-III was calculated to be 0,65%, this is only two thirds lower than that of CIN I-III. The incidence of secondary vaginal carcinoma during the observed period was found to be even equal to that of cervical cancer. About 50% of positive vaginal smears showed signs of dyskeratosis (atypical keratinisation). In all cases, the lesion was located within the central part of the vaginal cuff. This observation supports the probability of HPV-persistence rather than new infection as a causal agent

Transition-Metal-Free Decarboxylative Photoredox Coupling of Carboxylic Acids and Alcohols with Aromatic Nitriles

A transition-metal-free protocol for the redox-neutral light-induced decarboxylative coupling of carboxylic acids with (hetero)­aromatic nitriles at ambient temperature is presented. A broad scope of acids and nitriles is accepted, and alcohols can be coupled in a similar fashion through their oxalate half esters. Various inexpensive sources of UV light and even sunlight can be used to achieve this C–C bond formation proceeding through a free radical mechanism

Development of a [lu-177]bpamd labeling kit and an automated synthesis module for routine bone targeted endoradiotherapy

Painful bone lesions, both benign and metastatic, are often managed using conventional analgesics. However, the treatment response is not immediate and is often associated with side-effects. Radionuclide therapy is used for pain palliation in bone metastases as well as some benign neoplasms. Endoradiotherapy has direct impact on the pain-producing bone elements, and hence, response is significant, with minimal or no side-effects. A new potential compound for endoradiotherapy is [Lu-177]BPAMD. It combines a highly affine bisphosphonate, covalently bridged with DOTA through an amide bond, with the low-energy beta(-) emitting therapeutic radiolanthanide Lu-177. For routine chemical application, an automated synthesis of this radiopharmaceutical and a Kit-type labeling procedure appears to be a basic requirement for its good manufacturing practice (GMP) based production. A Kit formulation combining BPAMD, acetate buffer, and ethanol resulted in almost quantitative labeling yields. The use of ethanol and ascorbic acid as quenchers prevented radiolysis over 48 hours. An automated synthesis unit was designed for the production of therapeutic doses of [Lu-177]BPAMD up to 5 GBq. The procedure was successfully applied for patient treatments

Intimately tracking NO pollution over the NYC - Long Island Sound land-water continuum: An integration of shipboard, airborne, satellite observations, and models

Nitrogen dioxide (NO) pollution remains a serious global problem, particularly near highly populated urbanized coasts that face increasing challenges with climate change. Yet, the combined impact of urban emissions, pollution transport, and complex meteorology on the spatiotemporal dynamics of NO along heterogeneous urban coastlines remains poorly characterized. Here, we integrated measurements from different platforms - boats, ground-based networks, aircraft, and satellites - to characterize total column NO (TCNO) dynamics across the land-water continuum in the New York metropolitan area, the most populous area in the United States that often experiences the highest national NO levels. Measurements were conducted during the 2018 Long Island Sound Tropospheric Ozone Study (LISTOS), with a main goal to extend surface measurements beyond the coastline - where ground-based air-quality monitoring networks abruptly stop - and over the aquatic environment where peaks in air pollution often occur. Satellite TCNO from TROPOMI correlated strongly with Pandora surface measurements (r = 0.87, N = 100) both over land and water. Yet, TROPOMI overall underestimated TCNO (MPD = -12 %) and missed peaks in NO pollution caused by rush hour emissions or pollution accumulation during sea breezes. Aircraft retrievals were in excellent agreement with Pandora (r = 0.95, MPD = -0.3 %, N = 108). Stronger agreement was found between TROPOMI, aircraft, and Pandora over land, while over water satellite, and to a lesser extent aircraft, retrievals underestimated TCNO particularly in the highly dynamic New York Harbor environment. Combined with model simulations, our shipborne measurements uniquely captured rapid transitions and fine-scale features in NO behavior across the New York City - Long Island Sound land-water continuum, driven by the complex interplay of human activity, chemistry, and local scale meteorology. These novel datasets provide critical information for improving satellite retrievals, enhancing air quality models, and informing management decisions, with important implications for the health of diverse communities and vulnerable ecosystems along this complex urban coastline

Fracture fixation in the operative management of hip fractures (FAITH) : an international, multicentre, randomised controlled trial

Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians' Services Incorporated