Proximal humerus reconstruction after tumour resection: biological versus endoprosthetic reconstruction

The purpose of this study was to compare the outcome, complications and survival of the three most commonly used surgical reconstructions of the proximal humerus after transarticular tumour resection. Between 1985 and 2005, 38 consecutive proximal humeral reconstructions using allograft-prosthesis composite (n = 10), osteoarticular allograft (n = 13) or a modular tumour prosthesis (n = 14) were performed in our clinic. The mean follow-up was ten years (1–25). Of these, 27 were disease free at latest follow-up (mean 16.8 years) and ten had died of disease. The endoprosthetic group presented the smallest complication rate of 21% (n = 1), compared to 40% (n = 4) in the allograft-prosthesis composite and 62% (n = 8) in the osteoarticular allograft group. Only one revision was performed in the endoprosthetic group, in a case of shoulder instability. Infection after revision (n = 3), pseudoarthrosis (n = 2), fracture of the allograft (n = 3) and shoulder instability (n = 4) were the major complications of allograft use in general. Kaplan-Meier analysis showed a significantly better implant survival for the endoprosthetic group (log-rank p = 0.002). At final follow-up the Musculoskeletal Tumour Society scores were an average of 72% for the allograft-prosthetic composite (n = 7, median follow-up 17 years), 76% for the osteoarticular allograft (n = 3, 19 years) and 77% for the endoprosthetic reconstruction (n = 10, 5 years) groups. An endoprosthetic reconstruction after transarticular proximal humeral resection resulted in the lowest complication rate, highest implant survival and comparable functional results when compared to allograft-prosthesis composite and osteoarticular allograft use. We believe that the surgical approach that best preserves the abductor mechanism and provides sufficient surgical exposure for tumour resection contributed to better functional results and glenohumeral stability in the endoprosthetic group

Servicios ecosistémicos en el Chaco Húmedo Paraguayo: retos para el manejo basado en los ecosistemas

Para contar con información necesaria para promover estrategias de gestión basada en ecosistemas, se evaluaron servicios ecosistémicos en un área ganadera en el Chaco Húmedo Paraguayo. Se estudió captura de carbono en biomasa forestal, captura de carbono en el suelo de humedales, calidad del agua de humedales, conectividad funcional de isletas forestales, valoración económica de un sistema silvopastoril basado en pasturasy bosques nativos, e infiltración y evaporación del agua en el suelo. Para ello, se aplicaron diferentes metodologías con un enfoque multidisciplinario. Los resultados informan sobre estos servicios ecosistémicos y su interacción con la ganadería, actividad instalada desde hace varias generaciones,aprovechando pastizales naturales inundables. A partir de esta evaluación, se realizaron recomendaciones para la continuidad de estos servicios, con actualización cartográfica de las unidades de vegetación. Los humedales del sitio de estudio, además de capturar carbono, se encuentran en un buen estado de conservación. La ganadería ha tenido impactos negativos ocasionales y puntuales en la calidad del agua que, sin embargo, son corregibles. Las isletas forestales del área de estudio permiten la conectividad biológica para Alouatta caraya, sin embargo, es aún necesario realizar estudios similares para otras especies. Los pastizales con palmares ofrecen un mayor valor forrajero en comparación con los pastizales con bosque, por otro lado, la captura de carbono en el bosque resultó en un valor económico que supera en más del doble al del palmar ocupando una superficie seis veces menor. Los ensayos de infiltración destacaron el papel de los bosques y árboles individuales en la mejora de este servicio, especialmente relevante para los suelos inundables de esta región. El mosaico de formaciones vegetales naturales del Chaco Húmedo plantea la necesidad del manejo basado en el conocimiento del funcionamiento de los distintos ecosistemas.In order to obtain necessary information to promote ecosystem-based management strategies, ecosystem services were assessed in a cattle rangeland in the Paraguayan Humid Chaco. Carbon sequestration in forest biomass, carbon sequestration in wetlands soil, water quality in wetlands, functional connectivity of forest islets, economic valuation of a silvopastoral system based on native savannas and forests, and infiltration and evaporation of water in the soil were studied. Different methodologies were applied with a multidisciplinary approach. Results give information about these ecosystem services and their interaction with livestock rearing, activity installed for several generations, taking advantage of frequently-flooded native savannas. From these assessments, recommendations were made for the improvement and restoration of these services, with cartographic updating of the vegetation units. Wetlands in the study site, in addition to carbon sequestration, are in a good state of conservation. Livestock rearing has had occasional and isolated negative impacts on water quality, which, nonetheless can be corrected. Forest islets present in the study area allow biological connectivity of Alouatta caraya, however, it’s still necessary to conduct similar analysis for other species. Regarding livestock production, palm groves/savannas systems offer a higher fodder value than forests/savannas, on the other hand, carbon sequestration in the forest resulted in an economic value that is more than double that of the palm groves occupying a surface six times smaller. Infiltration trials emphasized the role of individual forests and trees in improving infiltration, especially relevant to floodable soils in this region. The mosaic of natural plant formations in the Humid Chaco raises the need for a management based on the knowledge of the functioning of the different ecosystems

Fractures in myelomeningocele

BACKGROUND: In patients with myelomeningocele (MMC), a high number of fractures occur in the paralyzed extremities, affecting mobility and independence. The aims of this retrospective cross-sectional study are to determine the frequency of fractures in our patient cohort and to identify trends and risk factors relevant for such fractures. MATERIALS AND METHODS: Between March 1988 and June 2005, 862 patients with MMC were treated at our hospital. The medical records, surgery reports, and X-rays from these patients were evaluated. RESULTS: During the study period, 11% of the patients (n = 92) suffered one or more fractures. Risk analysis showed that patients with MMC and thoracic-level paralysis had a sixfold higher risk of fracture compared with those with sacral-level paralysis. Femoral-neck z-scores measured by dual-energy X-ray absorptiometry (DEXA) differed significantly according to the level of neurological impairment, with lower z-scores in children with a higher level of lesion. Furthermore, the rate of epiphyseal separation increased noticeably after cast immobilization. Mainly patients who could walk relatively well were affected. CONCLUSIONS: Patients with thoracic-level paralysis represent a group with high fracture risk. According to these results, fracture and epiphyseal injury in patients with MMC should be treated by plaster immobilization. The duration of immobilization should be kept to a minimum (<4 weeks) because of increased risk of secondary fractures. Alternatively, patients with refractures can be treated by surgery, when nonoperative treatment has failed

Body mass index and outcome in renal transplant recipients: a systematic review and meta-analysis

BACKGROUND: Whether overweight or obese end stage renal disease (ESRD) patients are suitable for renal transplantation (RT) is often debated. The objective of this review and meta-analysis was to systematically investigate the outcome of low versus high BMI recipients after RT. METHODS: Comprehensive searches were conducted in MEDLINE OvidSP, Web of Science, Google Scholar, Embase, and CENTRAL (the Cochrane Library 2014, issue 8). We reviewed four major guidelines that are available regarding (potential) RT recipients. The methodology was in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and written based on the PRISMA statement. The quality assessment of studies was performed by using the GRADE tool. A meta-analysis was performed using Review Manager 5.3. Random-effects models were used. RESULTS: After identifying 5,526 studies addressing this topic, 56 studies were included. We extracted data for 37 outcome measures (including data of more than 209,000 RT recipients), of which 26 could be meta-analysed. The following outcome measures demonstrated significant differences in favour of low BMI (<30) recipients: mortality (RR = 1.52), delayed graft function (RR = 1.52), acute rejection (RR = 1.17), 1-, 2-, and 3-year graft survival (RR = 0.97, 0.95, and 0.97), 1-, 2-, and 3-year patient survival (RR = 0.99, 0.99, and 0.99), wound infection and dehiscence (RR = 3.13 and 4.85), NODAT (RR = 2.24), length of hospital stay (2.31 days), operation duration (0.77 hours), hypertension (RR = 1.35), and incisional hernia (RR = 2.72). However, patient survival expressed in hazard ratios was in significant favour of high BMI recipients. Differences in other outcome parameters were not significant. CONCLUSIONS: Several of the pooled outcome measurements show significant benefits for ‘low’ BMI (<30) recipients. Therefore, we postulate that ESRD patients with a BMI >30 preferably should lose weight prior to RT. If this cannot be achieved with common measures, in morbidly obese RT candidates, bariatric surgery could be considered. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12916-015-0340-5) contains supplementary material, which is available to authorized users