Complete Great Toe Sesamoid Excision: A Case Series

Background: Hallux sesamoids notably contribute to the biomechanics of the great toe. Although frequently ignored or forgotten, injury to the hallux sesamoids can be debilitating. Conservative management remains the initial approach for symptomatic sesamoid disorders, but surgical excision is an option. We performed a retrospective case series to examine the preoperative characteristics and postsurgical outcomes of patients who underwent great toe sesamoidectomy. Methods: We reviewed medical records of patients who underwent great toe sesamoidectomy performed by a single surgeon (RAM) during a 10-year period (26 patients, 28 procedures). Data collected included smoking status, prior first ray surgical treatment, highlevel athlete participation, diagnosis, preoperative treatment, length of time from symptoms to treatment, and visual analogue scale (VAS) pain score at final follow-up. Results: The average length of symptoms before operative treatment was about 3 years. Pain at final postoperative visit averaged 1.35 (range, 0-7), with 23 of 26 patients rating pain 0 to 3 measured on a 10-point VAS. Additionally, eight of the nine patients in high-level athletics returned to sports. There were no surgical site infections or wound complications. Two patients with underlying nerve disorders required procedures for treating late-appearing cock-up deformities and great toe metatarsophalangeal pain. Conclusions: The complete excision of the great toe sesamoid should be judiciously considered for recalcitrant pain attributable to the hallux sesamoids

Multimodal Analgesia in Orthopaedic Surgery and Presentation of a Comprehensive Postoperative Pain Protocol: A Review

Rising opioid use in the United States has now been termed an epidemic. Opioid use is associated with considerable morbidity, mortality, and cost to the healthcare system. Orthopaedic surgeons play a key role in the opioid epidemic by prescribing postoperative narcotics. Although our understanding of the quantity of narcotics to prescribe postoperatively for analgesia is progressing, there is still a paucity of data focused on routine postoperative pain protocols. The purpose of this article is to review the current options for both opioid and non-opioid analgesia and put forth a multisubspecialty orthopaedic protocol of postoperative pain. On the basis of study findings and the individual experiences of surgeons within our orthopaedic department, our comprehensive pain protocol includes the following considerations: use of non-steroidal antiinflammatory drugs on an individual basis, limited use of benzodiazepines, use of diazepam in only pediatric patients undergoing major procedures, lower doses of gabapentin after hip and knee arthroplasty, higher doses of gabapentin after spine procedures, general use of oxycodone owing to its accessibility, use of isolated opioids rather than combined forms, and close collaboration with anesthesiologists for determining use of peripheral nerve block. Our resultant comprehensive pain protocol can provide orthopaedic surgeons with a framework to build upon, which will benefit greatly from future studies that examine narcotic use with specific procedures

Patient Compliance With Follow-Up After Open Reduction and Internal Fixation for Treating Malleolar Ankle Fractures: A Retrospective Review

Background: Compliance with follow-up after orthopaedic procedures is variable and does not always occur as recommended. Various factors such as medical, financial, cultural, and logistical reasons may contribute to this lack of compliance. The purpose of this study was to determine follow-up compliance of patients who had undergone open reduction and internal fixation (ORIF) for treating closed malleolar ankle fractures. Methods: Medical records of patients who underwent ORIF for treating closed malleolar ankle fractures by the senior author (RAM) were reviewed to evaluate compliance with postoperative follow-up (n = 267). Inclusion criteria were patients with isolated, acute, closed fractures (n = 229). Patients were considered to have followed up appropriately if they returned to clinic after a removable cast boot was issued at 4 to 8 weeks postoperatively. A 2-tailed t test was performed to analyze age and visual analogue scale score at the time of obtaining the removable cast boot. Chi-square testing was performed to analyze the other variables studied. Results: Of the 229 patients included, a total of 183 complied with follow-up whereas 46 did not. Younger age, male sex, and living greater than 160.9 km (100 mi) from the hospital were statistically significant variables associated with decreased compliance with follow-up. Conclusions: In our patient population, 80% of patients followed up in clinic as scheduled. The remaining 20% did not adhere with scheduled followup either before or after obtaining a removable cast boot. Younger age, male sex, and living greater than 100 miles from the hospital were associated with decreased compliance. Consideration should be paid to these factors when treating patients with ankle fractures

Natriuretic peptides and integrated risk assessment for cardiovascular disease: an individual-participant-data meta-analysis

BACKGROUND: Guidelines for primary prevention of cardiovascular diseases focus on prediction of coronary heart disease and stroke. We assessed whether or not measurement of N-terminal-pro-B-type natriuretic peptide (NT-proBNP) concentration could enable a more integrated approach than at present by predicting heart failure and enhancing coronary heart disease and stroke risk assessment. METHODS: In this individual-participant-data meta-analysis, we generated and harmonised individual-participant data from relevant prospective studies via both de-novo NT-proBNP concentration measurement of stored samples and collection of data from studies identified through a systematic search of the literature (PubMed, Scientific Citation Index Expanded, and Embase) for articles published up to Sept 4, 2014, using search terms related to natriuretic peptide family members and the primary outcomes, with no language restrictions. We calculated risk ratios and measures of risk discrimination and reclassification across predicted 10 year risk categories (ie, <5%, 5% to <7·5%, and ≥7·5%), adding assessment of NT-proBNP concentration to that of conventional risk factors (ie, age, sex, smoking status, systolic blood pressure, history of diabetes, and total and HDL cholesterol concentrations). Primary outcomes were the combination of coronary heart disease and stroke, and the combination of coronary heart disease, stroke, and heart failure. FINDINGS: We recorded 5500 coronary heart disease, 4002 stroke, and 2212 heart failure outcomes among 95 617 participants without a history of cardiovascular disease in 40 prospective studies. Risk ratios (for a comparison of the top third vs bottom third of NT-proBNP concentrations, adjusted for conventional risk factors) were 1·76 (95% CI 1·56-1·98) for the combination of coronary heart disease and stroke and 2·00 (1·77-2·26) for the combination of coronary heart disease, stroke, and heart failure. Addition of information about NT-proBNP concentration to a model containing conventional risk factors was associated with a C-index increase of 0·012 (0·010-0·014) and a net reclassification improvement of 0·027 (0·019-0·036) for the combination of coronary heart disease and stroke and a C-index increase of 0·019 (0·016-0·022) and a net reclassification improvement of 0·028 (0·019-0·038) for the combination of coronary heart disease, stroke, and heart failure. INTERPRETATION: In people without baseline cardiovascular disease, NT-proBNP concentration assessment strongly predicted first-onset heart failure and augmented coronary heart disease and stroke prediction, suggesting that NT-proBNP concentration assessment could be used to integrate heart failure into cardiovascular disease primary prevention. FUNDING: British Heart Foundation, Austrian Science Fund, UK Medical Research Council, National Institute for Health Research, European Research Council, and European Commission Framework Programme 7

Cuidados biomédicos de saúde em Angola e na Companhia de Diamantes de Angola, c. 1910-1970

Pretende-se caracterizar a prestação de cuidados biomédicos em Angola durante a atividade da Companhia de Diamantes de Angola. Uma análise comparativa de políticas e práticas de saúde pública de vários atores coloniais, como os serviços de saúde da Companhia, sua congénere do Estado e outras empresas coloniais, revelará diferenças de investimento na saúde, isto é, instalações e pessoal de saúde, e tratamentos. Este escrutínio bem como as condições de vida iluminarão o carácter idiossincrático e central dos serviços de saúde da Companhia em termos de morbimortalidade em Angola, e a centralidade destes para as representações de um império cuidador

Effects of eight neuropsychiatric copy number variants on human brain structure

Many copy number variants (CNVs) confer risk for the same range of neurodevelopmental symptoms and psychiatric conditions including autism and schizophrenia. Yet, to date neuroimaging studies have typically been carried out one mutation at a time, showing that CNVs have large effects on brain anatomy. Here, we aimed to characterize and quantify the distinct brain morphometry effects and latent dimensions across 8 neuropsychiatric CNVs. We analyzed T1-weighted MRI data from clinically and non-clinically ascertained CNV carriers (deletion/duplication) at the 1q21.1 (n = 39/28), 16p11.2 (n = 87/78), 22q11.2 (n = 75/30), and 15q11.2 (n = 72/76) loci as well as 1296 non-carriers (controls). Case-control contrasts of all examined genomic loci demonstrated effects on brain anatomy, with deletions and duplications showing mirror effects at the global and regional levels. Although CNVs mainly showed distinct brain patterns, principal component analysis (PCA) loaded subsets of CNVs on two latent brain dimensions, which explained 32 and 29% of the variance of the 8 Cohen’s d maps. The cingulate gyrus, insula, supplementary motor cortex, and cerebellum were identified by PCA and multi-view pattern learning as top regions contributing to latent dimension shared across subsets of CNVs. The large proportion of distinct CNV effects on brain morphology may explain the small neuroimaging effect sizes reported in polygenic psychiatric conditions. Nevertheless, latent gene brain morphology dimensions will help subgroup the rapidly expanding landscape of neuropsychiatric variants and dissect the heterogeneity of idiopathic conditions

The Influence of Manga on the Graphic Novel

This material has been published in The Cambridge History of the Graphic Novel edited by Jan Baetens, Hugo Frey, Stephen E. Tabachnick. This version is free to view and download for personal use only. Not for re-distribution, re-sale or use in derivative works. © Cambridge University PressProviding a range of cogent examples, this chapter describes the influences of the Manga genre of comics strip on the Graphic Novel genre, over the last 35 years, considering the functions of domestication, foreignisation and transmedia on readers, markets and forms