La regularización colinérgica del remodelado óseo: el riesgo de fractura de cadera en pacientes diagnosticados de Alzheimer en tratamiento con inhibidores de acetilcolinesterasa

Varios estudios recientes han demostrado la presencia receptores de acetilcolina (ACh) en el tejido óseo incluyendo varios subtipos del mismo. Se ha observado que la inhibición de estos receptores tiene un efecto negativo sobre la masa ósea y la capacidad de curación de la fractura. Sin embargo no se conocen los posibles efectos clínicos que podría tener un aumento de la señalización de la ACh sobre el hueso. Este estudio se ha diseñado para determinar si el uso de inhibidores de la acetilcolinesterasa (IAChE), fármacos utilizados en el tratamiento de la enfermedad de Alzheimer (EA), disminuye el riesgo relativo de sufrir una fractura de cadera en el paciente anciano. Material y método : Para lograr este objetivo, se diseño un estudio de casos y controles utilizando la población de pacientes con EA pertenecientes a la zona sanitaria del Hospital Regional Universitario Carlos Haya de Málaga. Los casos incluyeron a 80 pacientes con EA mayores de 75 años, que sufrieron una fractura de cadera en el periodo 1/1/2004 – 31/12/2008. Los controles fueron 2178 pacientes con EA mayores de 75 años, que no sufrieron una fractura de cadera durante el mismo período. Se aplicaron los mismos criterios de exclusión para seleccionar ambos grupos. Resultados : El OR ajustado asociado al riesgo de sufrir una fractura de cadera en los pacientes tratados con IAChE en comparación con los pacientes que no utilizaron estos medicamentos fue de 0,42 (IC del 95% intervalo de confianza [IC]: 0,24 a 0,72). El OR para los distintos tipos de IAChE fue el siguiente; rivastigmina 0,22 (IC del 95%, 0,10-0,45), donepezilo fue de 0,39 (IC del 95%, desde 0,19 hasta 0,76). Estos datos fueron ajustados a los siguientes parámetros: índice de masa corporal, el riesgo de caída, tabaquismo, estado cognitivo, grado de dependencia, grado Alzheimer, puntuación de co-morbilidad, tratamiento con inhibidores selectivos de la recaptación de la serotonina, edad y género. Nuestros resultados sugieren que el uso de IACE como el donepezilo y la rivastigmina, se asocia a una reducción del riesgo de sufrir una fractura de cadera en pacientes con EA. Comentarios y Conclusiones : Un gran numero de pacientes ancianos con EA tienen un alto riesgo desarrollar osteoporosis y como consecuencia fracturas osteoporóticas. Estos pacientes podrían beneficiarse del tratamiento con IAChE para reducir el riesgo de sufrir fracturas de cadera

Recent Advances in Epilepsy Surgery

The modern practice of epilepsy surgery requires multiple modalities of presurgical investigations such as video-EEG, intracranial EEG, high-resolution imaging, advanced functional imaging, and clinical analysis. A multidisciplinary approach is essential, including close collaboration between neurosurgeons, neurologists, neurophysiologists, neuropsychologists, neuropsychiatrists, and neuroradiologists. Candidates for epilepsy surgery require a history of seizures that are refractory to appropriate medical therapy. A meticulous selection of candidates will lead to a better chance of freedom from seizure. Epilepsy surgery includes a variety of surgical procedures including resective surgery for focal refractory seizure, which offers a significant chance of seizure freedom in temporal and extratemporal lobe epilepsy. Palliative treatment for patients who are not candidates for resective surgery, such as vagal nerve stimulation, deep stimulation, and callosotomy, offers further options. We reviewed and analyzed the recent scientific literature and forthcoming advances that will impact on the future of epilepsy surgery. This chapter on recent advances in epilepsy surgery emphasizes improved methods of assessment, a better understanding of seizures, the development of new surgical techniques, and the outcome of epilepsy surgery

Acetylcholinesterase inhibitors and risk of bleeding and acute ischemic events in non-hypertensive Alzheimer’s patients

Introduction: Acetylcholinesterase inhibitors (AChEIs) are commonly used to treat mild to moderate cases of Alzheimer disease (AD). To the best of our knowledge, there has been no study estimating the risk of bleeding and cardiovascular events in patients with non-hypertensive AD. Therefore, this study aimed to estimate the association between AChEIs and the risk of bleeding and cardiovascular ischemic events in patients with non-hypertensive AD. Methods: A nested case-control study was conducted to estimate the risk of bleeding and ischemic events (angina, myocardial infarction [MI], and stroke) in patients with AD. This study was conducted using the UK Clinical Practice Research Datalink and Hospital Episode Statistics (HES) databases. The study cohort consisted of AD patients ≥65 years of age. The case groups included all AD subjects in the database who had a bleeding or ischemic event during the cohort follow-up. Four controls were selected for each case. Patients were classified as current users or past users based on a 60-day threshold of consuming the drug. Simple and multivariable conditional logistic regression analyses were used to calculate the adjusted odds ratio for bleeding events and cardiovascular events. Results: We identified 507 cases and selected 2028 controls for the bleeding event cohort and 555 cases and 2220 controls for the ischemic event cohort. The adjusted odds ratio (OR) (95% confidence interval [CI]) for the association of AChEI use was 0.93 (0.75 to 1.16) for bleeding events, 2.58 (1.01 to 6.59) for angina, and 1.89 (1.07 to 3.33) for MI. Past users of AChEIs were also at increased risk of stroke (1.51 [1.00 to 2.27]). Discussion: This is the first study assessing the risk of bleeding and cardiovascular events in patients with non-hypertensive AD. Our findings could be of great interest for clinicians and researchers working on AD

Outcomes of "Over the Top" Anterior Cruciate Ligament Reconstruction Associated with a Lateral Extra-Articular Tenodesis in Children

Purpose: The incidence of anterior cruciate ligament (ACL) ruptures in children and adolescents has considerably increased during the last decades due to higher levels of competitive athletic activity, and early sport specialization and professionalization. Contemporary ACL reconstruction techniques have recently been subject to renewed interest in this population. The objective of this study is to report the short- and mid-term results of our physis-sparing ACL reconstruction technique using an “over the top” technique associated with a modified Lemaire procedure. (2) Methods: A retrospective series of 12 junior soccer players who presented to our clinic with a torn ACL between January 2019 and September 2021 was reviewed. The inclusion criteria were patients under 15 years with open tibial and femoral physes, with a stable contralateral knee, a minimum follow-up of 6 months, and a time frame from injury to surgery of <3 months. Patients with previous knee surgery, structural concomitant injuries, muscular, neurological, or vascular abnormalities, or hypersensitivity to metal alloys were excluded. The functional evaluation was performed using the International Knee Documentation Committee (IKDC) rating, Lysholm score, and Tegner activity level. Moreover, clinical and radiological assessments were also performed, including KT-1000 and knee X-rays. (3) Results: We identified 1 female and 11 male patients with ACL tears, with a mean age of 13.17 ± 0.9 months. Concomitant injuries include isolated vertical and bucket-handle tears of the medial meniscus, lateral meniscus tears, bilateral tear of both menisci. The mean follow-up time was 26 ± 12.6 months. The average IKDC, Lysholm and Tegner scores were 93.29 ± 11.04, 95.08 ± 13.2 and 9 ± 0.0 points, respectively. The average KT-1000 score of the participants was 0.96 ± 1.6 points. None of the included patients reported post-surgical complications or required additional surgeries. (4

Proton Pump Inhibitors and the Risk of Early Aseptic Loosening in Hip and Knee Arthroplasty

Introduction: The use of proton pump inhibitors (PPIs) has been associated with a higher risk of osteoporotic fractures and non-unions rates. However, the relation between the use of PPIs and the development of aseptic loosening in arthroplasty procedures has not been studied. The objective of this study is to analyze the relation between the use of PPIs, and the risk of early aseptic loosening in total knee arthroplasty (TKA) and total hip arthroplasty (THA). Materials and methods: A nested case-control study was conducted on patients who were subjected THA or TKA in our center between 2010 and 2014. Cases were patients subjected to revision surgery due to early aseptic loosening during the study period. Cases were matched with controls who did not require any type of revision surgery by type of joint replacement (THA/TKA), gender, age (+/− 2 years), and follow-up time (±6 months). Odds Ratios were adjusted to potential confounders. Results: The crude and adjusted ORs (95% CI) of undergoing revision surgery for aseptic loosening following primary total knee arthroplasty or total hip arthroplasty, were 6.25 (2.04–19.23) and 6.10 (1.71–21.73), respectively, for any use PPIs compared with non-users. Crude and adjusted ORs, were 11.6 (2.93–45.88) and 17.1 (2.41–121.66), respectively, for patients with a Proportion of Days Covered (PDC) for PPIs <.5 (Table 2). In addition, the crude and adjusted ORs of undergoing revision surgery, were 5.05 (1.59–16.02) and 5.01 (1.36–18.44), respectively, for patients with a PDC for PPIs ≥.5. Discussion: These results suggest that PPIs should be used with caution in patients with TKA and THA, and that the use of these drugs should not be prolonged unless there was a justifiable indication. Conclusions: The use of PPIs and was associated with a higher risk of early aseptic loosening in patients subjected to THA and TKA

Secondary osteoporosis prevention: three‑year outcomes from a Fracture Liaison Service in elderly hip fracture patients

Hip fractures are the most serious fragility fractures due to their associated disability, higher hospitalization costs and high mortality rates. Fracture Liaison Service (FLS) programs have enhanced the management of osteoporosis-related fractures and have shown their clinical effectiveness. To analyze the effect of the implementation of a FLS model of care over the survival and mortality rates following a hip fracture. We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture before and after the implementation of the FLS in our center (between January 2016 and December 2019). Patients were followed for three years after the index date. Mortality, complications and refracture rates were compared between the two groups using a Multivariate Cox proportional hazard model. The implementation of a FLS protocol was associated with a lower all-cause one-year mortality rate and a higher survivorship in elderly hip fracture patients. However, no three-year mortality rate differences were observed between the two groups. We also found a reduction in the complication and second-fracture rates.Funding for open access charge: Universidad de Málaga / CBU

Admission criteria and academic performance in medical school.

Different variables have been used to predict the academic performance of students in medical schools. The aim of this study was to assess the effect of demographics, admission system, and high-school background on the academic performance of medical students. We conducted this longitudinal cohort study on 808 students admitted to the Faculty of. Medicine at the University of Jordan (Amman, Jordan), in the years 2012 and 2013. Admission pathway, and academic performance data were collected and analyzed. A total of 808 students [i.e., 426 (52.7%) females, and 382(47.3%) males] were identified. Admitted students were holding 17 different types of high school degrees, and were accepted through 6 different quota pathways (open competition [National unified admission], underprivileged ["Makrumah"], parallel, children of university staff, international students, and others). Students admitted through the open competition and the underprivileged quota(Makrumah) were more likely to graduate on time and had higher graduation grades while students admitted through the parallel, international and others quota were more likely to fail and had lower graduation grades. Regarding highs school degrees, the students that were more likely to graduate were those with IB and the Jordanian high school degrees. The highest graduation GPA was for IB students followed by SAT, IGCSE as well as Jordanian and Syrian high school degrees respectively. IB, Jordanian, Kuwaiti and IGSC high school grades were significantly correlated with the graduation GPA. Admission criteria such as type of high school degree and grades as well as admission pathways can predict the likelihood to graduate and the graduation GPA of medical students. Open competition and underprivileged admission pathways as well as IB, IGCSE and Jordanian high school degrees seem to be better predictors of student performance in the medical school

Could Vagus nerve stimulation influence bone remodeling?

Objectives: To investigate the effect of vagus nerve stimulation (VNS) on the bone mineral density (BMD) in epileptic patients. Methods: A prospective cohort study was conducted on individuals with refractory seizures who underwent VNS surgery between January 2012 and December 2018. BMD was measured preoperatively and between 6 months and one year after surgery. Results: Twenty-one patients (mean age (�SD)=23.6�12.3 years) were recruited for the implantation of a VNS device. The mean absolute increase in lumbar BMD in the 21 patients was 0.04�0.04 g/cm2 resulting in an overall percent increase from baseline of 4.7�6.1%. BMD increased by an amount � the least significant change (LSC) for the lumbar spine in 13 patients (61.9%). The lumbar Z score also increased in these patients from -1.22�1.15 to -0.88�1.22, P=0.006). Pre and Post VNA femoral BMD was measured in only 11 patients and, of those 3 showed a significant increase in BMD, 1 a significant decrease and 7 no change. Conclusion: The implantation of a VNS was associated with an increase in lumbar BMD. This study could lead to a new application for VNS in the treatment of osteoporosis.Scopu

Rupture of De Novo Middle Cerebral Artery Aneurysm 8 Years After the Clipping of Ruptured M1 Middle Cerebral Artery Aneurysm.

BACKGROUND Development and rupture of a de novo intracranial aneurysm is rare. Little is known regarding its etiology and the appropriate timing of follow-up angiograms after surgical clipping or coiling. CASE REPORT We present a case report of a 39-year-old male smoker with history of hypertension who developed a de novo aneurysm 8 years after surgical clipping of an aneurysm in the middle cerebral artery in the same segment. He presented with neck rigidity and drowsiness. Laboratory analysis did not show blood dyscrasia. Brain computerized tomography showed right temporal lobe hematoma and 4-vessel angiogram demonstrated de novo aneurysm in the same segment of the M1 middle cerebral artery, which was confirmed by intraoperative microsurgical findings. We review the literature on such cases and discuss the pathophysiology, diagnosis, and treatment of this condition. De novo aneurysm, although rare, can develop within days to as long as 10 years after surgical clipping or coiling. CONCLUSIONS This rare case of de novo aneurysm supports follow-up imaging of patients after initial surgical clipping for up to 10 years

Proximal Femoral Nail Antirotation (PFNA) length and postoperative complications: a retrospective cohort study

Objetivos: Los clavos proximales de fémur fueron diseñados para realizar una cirugía mínimamente invasiva y reducir la tasa de complicaciones en pacientes con fracturas de fémur proximal. Planteamos la hipótesis que el tamaño de estos clavos influye en las complicaciones postoperatorias. Material y Métodos: Realizamos un estudio de cohortes retrospectivas en pacientes con fracturas de fémur proximal que fueron sintetizadas con un PFNA durante el periodo comprendido entre enero de 2012 y marzo de 2014. La siguiente información fue recogida de nuestra base de datos informática: longitud del implante, duración de la cirugía, hemoglobina postoperatoria, necesidad de transfusión, estancia hospitalaria, presencia de complicaciones y mortalidad. Los pacientes fueron seguidos durante un año después de la cirugía. Resultados: Un total de 400 pacientes fueron incluidos en este estudio. La edad media de los pacientes fue de 80.45 ± 0.53 años; 98 (24.5%) pacientes fallecieron durante el periodo de seguimiento. El tiempo quirúrgico fue de 38.70±0.68, 50.31±1.88 y 66.92±3.44 minutos, para los pacientes con clavos de 170, 200 y 240 mm respectivamente (P0.05). La diferencia de hemoglobina pre y postoperatoria fue menor en pacientes intervenidos con clavos de 170 mm comparado con 200 y 240 mm [2.43±0.08 g/dl; 2.81±0.16 g/dl; y 2.50±0.06 g/dl, respectivamente (P0.01)]. Comparado con los clavos de 170 mm, las odd ratios para la necesidad de transfusión fueron 2.83 (1.57-5.10) paa clavos de 200 mm, y 2.58 (1.26-5.30) para clavos de 240 mm. La longitud del clavo no afectó a la estancia hospitalaria, presencia de cut-out y la tasa de mortalidad. Conclusiones: El uso de clavos proximales más largos está asociado con un incremento de la duración de la cirugía, menos niveles de hemoglobina postoperatorios y mayores tasas de transfusión. La longitud del implante no influye en las tasas de cut-out y mortalidad.Objectives: Proximal femoral nails were developed to perform minimally invasive surgery and reduce the complication rates in patients with proximal femoral fractures. We hypothesize that the length of these nails may influence the surgical outcome. Methods: We conducted a retrospective cohort study on patients with proximal femoral fractures who were treated with a PFNA during the period between January 2012 and March 2014. The following information was withdrawn from our local computerized database: nail length, duration of surgery, postoperative hemoglobin level, transfusion requirements, hospital stay, presence of surgical complications and mortality. Patients were followed for one year after surgery. Results: A total of 400 cases were included in this study. The mean age was 80.45 ± 0.53 years; 98 (24.5%) patients died during the follow-up period (one year). The surgical time was 38.70±0.68, 50.31±1.88 and 66.92±3.44 min, for patients with 170, 200, and 240 mm nails, respectively (P0.05). The change in the preoperative to postoperative hemoglobin levels was lower in patients operated with 170 nails compared to 200 and 240 nails [2.43±0.08 g/dl; 2.81±0.16 g/dl; and 2.50±0.06 g/dl, respectively (P0.01)]. Compared to 170 nails the odd ratios for postoperativ transfusions were 2.83 (1.57-5.10) for 200 nails, and 2.58 (1.26-5.30) for 240 nails. The nail length did not affect hospital stay, presence of cut-out, or mrtality rate. Conclusions: The use of longer proximal nails is associated with increased surgical duration, lower postoperative hemoglobin levels and higher transfusion rates. The implant length did not influence the cut-out or mortality rates