Osteochondritis dissecans of the humeral capitellum: treatment options and differential indications

INTRODUCTION: Osteochondritis dissecans (OCD) of the capitellum is a focal condition affecting the articular cartilage and subchondral bone, typically in adolescent athletes. Limited data exists regarding the indications and expected outcomes of the various treatment methods of capitellar OCD, and the optimal treatment strategy remains controversial. Risks of progressive capitellar OCD include osteoarthritic changes and permanent elbow disability. STUDY AIMS: The objective of this literature review is to assess the data and the conclusions to be drawn from the existing literature on the differential indications for the various treatment options for capitellar OCD, using low-level meta-analysis and qualitative observations, to suggest a course of future study with the purpose of clarifying the differential treatment indications and improving the care of capitellar OCD patients. The most recent 10 years (2004-2014) of data are the focus, in order to evaluate the most modern indications, surgical techniques, surgical skills, and clinical outcomes. DISCUSSION OF PUBLISHED DATA: Ultrasound reportedly offers a high predictive value for screening baseball players for capitellar OCD, although sensitivity, specificity, and cost-effectiveness are unknown. Plain radiographs and magnetic resonance imaging (MRI) are useful diagnostic resources for making the decision to operate, but their sensitivities and specificities are imperfect. Evidence suggest that early stage OCD in physically immature patients may recover with non-operative management, while advanced stage OCD in older patients will likely achieve a better recovery with operative management. Risk factors for poor outcomes following surgical management of capitellar OCD may reportedly include patient age, physical maturity, athletic competition level, large lesion diameter and thickness, and lateral lesion location. The advantages of removal, debridement, and marrow stimulation techniques include the minimal invasiveness associated with arthroscopy. Successful fragment fixation can preserve normal articular properties, but may risk implant complications and secondary surgeries. Mosaicplasty is frequently suggested when patient or lesion characteristics seem to preclude other surgical methods, or when prior surgical treatment attempts fail, but disadvantages of mosaicplasty include the technical complexity of the procedure and the risk of donor site morbidity. CONCLUSIONS: The capitellar OCD literature has accumulated a wealth of level IV case series reporting generally satisfactory short-term results of the various surgical options. There is little need for more descriptive literature on this topic at this time. Modern treatment strategies are incomplete and poorly defined, based upon the suggestions of small case series offering disorganized, low-quality data. A study of the cost-effectiveness of ultrasound screening in high-risk athletes would be useful. A large, comparative case-control study or prospective cohort study of higher methodological quality and better standardization is needed to advance the knowledge on this topic, and classification and regression tree analysis could be applied meaningfully. With more organized data and analysis, it will become easier to take a systematic approach to treating capitellar OCD, settle clinical controversy and improve patient outcomes

Septic Arthritis of the Pediatric Shoulder: From Infancy to Adolescence

Background. Septic arthritis of the glenohumeral joint in the pediatric population (<18 yo) is not commonly described in the literature. There is a corresponding paucity of information regarding its presentation and treatment. Methods. An IRB approved review of patients treated with irrigation and debridement by the Orthopaedic Department was completed. This retrospective study includes four patients, presenting from 2005 to 2015, with septic arthritis of the shoulder. Results. The mean age (Mage) at presentation was 5 years, with a range of 1 month to 15 years. Patients presented on average after 7 days with pain and a mean temperature of 39°C, erythrocyte sedimentation rate of 66 mm/hr, a C-reactive protein level of 11.17 g/dL, and a white blood cell count of 20.2 × 103/mcL. Staphylococcus aureus, Candida albicans, and Pseudomonas aeruginosa were cultured from the wounds. All cases were treated operatively with irrigation and debridement and with antimicrobial therapy. Patients received antibiotics for an average of 6 weeks. Conclusion. Septic arthritis of the shoulder occurs in all pediatric ages. Successful treatment of septic arthritis of the shoulder was accomplished in four cases without division of the biceps sheath, with an average follow-up of 8 months

Weight management: a comparison of existing dietary approaches in a work-site setting

&lt;b&gt;OBJECTIVES:&lt;/b&gt; (1) To compare the effectiveness a 2512 kJ (600 kcal) daily energy deficit diet (ED) with a 6279 kJ (1500 kcal) generalized low-calorie diet (GLC) over a 24 week period (12 weeks weight loss plus 12 weeks weight maintenance). (2) To determine if the inclusion of lean red meat at least five times per week as part of a slimming diet is compatible with weight loss in comparison with a diet that excludes lean red meat. DESIGN: Randomized controlled trial. &lt;b&gt;SETTING:&lt;/b&gt; Large petrochemical work-site. &lt;b&gt;PARTICIPANTS:&lt;/b&gt; One-hundred and twenty-two men aged between 18 and 55 y. &lt;b&gt;MAIN OUTCOME MEASURES:&lt;/b&gt; Weight loss and maintenance of weight loss. &lt;b&gt;INTERVENTION:&lt;/b&gt; Eligible volunteers were randomized to one of the four diet=meat combinations (ED meat, ED no meat, GLC meat, GLC no meat). One-third of subjects in each diet/meat combination were randomized to an initial control period prior to receiving dietary advice. All subjects attended for review every 2 weeks during the weight loss period. For the 12 week structured weight maintenance phase, individualized energy prescriptions were re-calculated for the ED group as 1.4 (activity factor)x basal metabolic rate. Healthy eating advice was reviewed with subjects in the GLC group. All subjects were contacted by electronic mail at 2 week intervals and anthropometric and dietary information requested. &lt;b&gt;RESULTS:&lt;/b&gt; No difference was evident between diet groups in mean weight loss at 12 weeks (4.3 (s.d. 3.4) kg ED group vs 5.0 (s.d. 3.5) kg GLC group, P=0.34). Mean weight loss was closer to the intended weight loss in the 2512 kJ (600 kcal) ED group. The dropout rate was also lower than the GLC group. The inclusion of lean red meat in the diet on at least five occasions per week did not impair weight loss. Mean weight gain following 12 weeks weight maintenance was þ1.1 (s.d. 1.8) kg, P&lt;0.0001. No differences were found between groups. &lt;b&gt;CONCLUSIONS:&lt;/b&gt; This study has shown that the individualized 2512 kJ (600 kcal) ED approach was no more effective in terms of weight loss than the 6279 kJ (1500 kcal) GLC approach. However the ED approach might be considered preferable as compliance was better with this less demanding prescription. In terms of weight loss the elimination of red meat from the diet is unnecessary. The weight maintenance intervention was designed as a low-input approach, however weight regain was significant and weight maintenance strategies require further development

Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: a systematic review

Aims: In pregnant smoking cessation trial participants, to estimate (1) among women abstinent at the end of pregnancy, the proportion who re-start smoking at time-points afterwards (primary analysis) and (2) among all trial participants, the proportion smoking at the end of pregnancy and at selected time-points during the postpartum period (secondary analysis). Methods: Trials identified from two Cochrane reviews plus searches of Medline and EMBASE. Twenty-seven trials were included. The included trials were randomized or quasi-randomized trials of within-pregnancy cessation interventions given to smokers who reported abstinence both at end of pregnancy and at one or more defined time-points after birth. Outcomes were validated biochemically and self-reported continuous abstinence from smoking and 7-day point prevalence abstinence. The primary random-effects meta-analysis used longitudinal data to estimate mean pooled proportions of re-starting smoking; a secondary analysis used cross-sectional data to estimate the mean proportions smoking at different postpartum time-points. Subgroup analyses were performed on biochemically validated abstinence. Results: The pooled mean proportion re-starting at 6 months postpartum was 43% [95% confidence interval (CI) = 16–72%, I2 = 96.7%] (11 trials, 571 abstinent women). The pooled mean proportion smoking at the end of pregnancy was 87% (95% CI = 84–90%, I2 = 93.2%) and 94% (95% CI = 92–96%, I2 = 88%) at 6 months postpartum (23 trials, 9262 trial participants). Findings were similar when using biochemically validated abstinence. Conclusions: In clinical trials of smoking cessation interventions during pregnancy only 13% are abstinent at term. Of these, 43% re-start by 6 months postpartum

A qualitative evidence synthesis of employees' views of workplace smoking reduction or cessation interventions

Background The need to reduce smoking rates is a recognised public health policy issue in many countries. The workplace offers a potential context for offering smokers’ programmes and interventions to assist smoking cessation or reduction. A qualitative evidence synthesis of employees’ views about such programmes might explain why some interventions appear effective and others not, and can be used to develop evidence-based interventions for this population and setting. Methods A qualitative evidence synthesis of primary research exploring employees’ views about workplace interventions to encourage smoking cessation, including both voluntary programmes and passive interventions, such as restrictions or bans. The method used was theory-based “best fit” framework synthesis. Results Five relevant theories on workplace smoking cessation were identified and used as the basis for an a priori framework. A comprehensive literature search, including interrogation of eight databases, retrieved 747 unique citations for the review. Fifteen primary research studies of qualitative evidence were found to satisfy the inclusion criteria. The synthesis produced an evidence-based conceptual model explaining employees’ experiences of, and preferences regarding, workplace smoking interventions. Conclusion The synthesis suggests that workplace interventions should employ a range of different elements if they are to prove effective in reducing smoking among employees. This is because an employee who feels ready and able to change their behaviour has different needs and preferences from an employee who is not at that stage. Only a multi-faceted intervention can satisfy the requirements of all employees

A before-after implementation trial of smoking cessation guidelines in hospitalized veterans

Abstract Background Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA) hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM) to improve inpatient smoking cessation. Specific objectives The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention. Design Pre-post study design in four VA hospitals Participants Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day. Intervention The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy), computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units. Outcomes The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the intervention and baseline periods, we will use random effects logistic regression models, which take the clustered nature of the data within nurses and hospitals into account. We will assess attitudes of staff nurses toward cessation counseling by questionnaire and will identify barriers and facilitators to implementation by using clinician focus groups. To determine the short-term incremental cost per quitter from the perspective of the VA health care system, we will calculate cessation-related costs incurred during the initial hospitalization and six-month follow-up period. Trial number NCT00816036http://deepblue.lib.umich.edu/bitstream/2027.42/112349/1/13012_2009_Article_190.pd