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Deichmueller C.M.C.,Childrens Hospital Auf der Bult | Welkoborsky H.-J.,Childrens Hospital Auf der Bult | Welkoborsky H.-J.,Academic Hospital
European Archives of Oto-Rhino-Laryngology | Year: 2010

The atlanto-axial subluxation (Grisel's syndrome) is a rare complication following operative procedures and/or infections in the upper aerodigestive tract. Pathogenetically the higher flexibility of the ligaments during the inflammation causes a subluxation between axis and atlas. When the inflammation heals, this can probably result in a fixation in the rotated position. The purpose of the present study was to describe the clinical and radiological characteristics of this rare disease in children. The clinical files of 12 patients with Grisel's syndrome were examined retrospectively. The clinical files of these patients were reviewed and analyzed along with the results of radiographic and laboratory examinations. The clinical parameters were compared with the patient's therapy and outcome. Of 12 children (6 males, 6 females, average age of 7.1 years), Grisel's syndrome developed following surgery in 8 patients, and in another 4 patients following a severe in infection of the upper aerodigestive tract. The duration of complaints differed from 2 days to 6 months. All patients had a torticollis as the first symptom of atlanto-axial dislocation and three children had accompanying cervical lymphadenopathy. All patients were given antiphlogistic therapy either with diclofenac or ibuprofen. Additionally, 11 patients were treated with intravenous antibiotics (amoxicillin, ampicillin, clindamycin or cephalosporins) and 1 child with oral antibiotics. In eight patients a remission during antibiotic therapy occurred. In four cases (2 with Grisel's syndrome following surgery, 2 following infection), however, the torticollis persisted despite adequate conservative treatment and required reposition of the atlanto-axial joint along with external fixation. In all of them, starting of therapy was delayed. An early diagnosis of Grisel's syndrome and immediate therapy is most important. Grisel's syndrome must be taken under consideration in children with acute torticollis following either an infection or operative procedure in the upper aerodigestive tract. Early adequate antibiotic and antiphlogistic therapy is mandatory and leads to a high remission rate. © 2010 Springer-Verlag.


De Bruin J.L.,Medical Center | Baas A.F.,University Utrecht | Buth J.,Catharina Hospital | Prinssen M.,University Utrecht | And 6 more authors.
New England Journal of Medicine | Year: 2010

BACKGROUND: For patients with large abdominal aortic aneurysms, randomized trials have shown an initial overall survival benefit for elective endovascular repair over conventional open repair. This survival difference, however, was no longer significant in the second year after the procedure. Information regarding the comparative outcome more than 2 years after surgery is important for clinical decision making. METHODS: We conducted a long-term, multicenter, randomized, controlled trial comparing open repair with endovascular repair in 351 patients with an abdominal aortic aneurysm of at least 5 cm in diameter who were considered suitable candidates for both techniques. The primary outcomes were rates of death from any cause and reintervention. Survival was calculated with the use of Kaplan-Meier methods on an intentionto-treat basis. RESULTS: We randomly assigned 178 patients to undergo open repair and 173 to undergo endovascular repair. Six years after randomization, the cumulative survival rates were 69.9% for open repair and 68.9% for endovascular repair (difference, 1.0 percentage point; 95% confidence interval [CI], -8.8 to 10.8; P=0.97). The cumulative rates of freedom from secondary interventions were 81.9% for open repair and 70.4% for endovascular repair (difference, 11.5 percentage points; 95% CI, 2.0 to 21.0; P=0.03). CONCLUSIONS: Six years after randomization, endovascular and open repair of abdominal aortic aneurysm resulted in similar rates of survival. The rate of secondary interventions was significantly higher for endovascular repair. Copyright © 2010 Massachusetts Medical Society.


Oddens J.R.,Robert Bosch GmbH | Sylvester R.J.,European Organization for Research and Treatment of Cancer | Brausi M.A.,New Estense S Agostino Hospital Ausl | Kirkels W.J.,Erasmus Medical Center | And 5 more authors.
European Urology | Year: 2014

Background Although maintenance bacillus Calmette-Guérin (BCG) is the recommended treatment in high-risk non-muscle-invasive bladder cancer (NMIBC), its efficacy in older patients is controversial. Objective To determine the effect of age on prognosis and treatment outcome in patients with stage Ta T1 NMIBC treated with maintenance BCG. Design, setting, and participants A total of 957 patients with intermediate- or high-risk Ta T1 (without carcinoma in situ) NMIBC were randomized in European Organization for Research and Treatment of Cancer (EORTC) trial 30911 comparing six weekly instillations of epirubicin, BCG, and BCG plus isoniazid followed by three weekly maintenance instillations over 3 yr. Outcome measurements and statistical analysis Cox multivariate proportional hazards regression models were used to assess the relative importance of age for recurrence, progression, overall survival, and NMIBC-specific survival with adjustment for EORTC risk scores. Results and limitations Overall, 822 eligible patients were included: 546 patients in the BCG with or without INH arms and 276 in the epirubicin arm. In patients treated with BCG with or without INH, 34.1% were >70 yr of age and 3.7% were >80 yr. With a median follow-up of 9.2 yr, patients >70 yr had a shorter time to progression (p = 0.028), overall survival (p < 0.001), and NMIBC-specific survival (p = 0.049) after adjustment for EORTC risk scores in the multivariate analysis. The time to recurrence was similar compared with the younger patients. BCG was more effective than epirubicin for all four end points considered, and there was no evidence that BCG was any less effective compared with epirubicin in patients >70 yr. Conclusions In intermediate- and high-risk Ta T1 urothelial bladder cancer patients treated with BCG, patients >70 yr of age have a worse long-term prognosis; however, BCG is more effective than epirubicin independent of patient age. Patient summary Intravesical bacillus Calmette-Guérin for non-muscle-invasive bladder cancer is less effective in patients >70 yr of age, but it is still more effective than epirubicin. © 2014 European Association of Urology.


Erken H.Y.,Anadolu Medical Center | Akmaz I.,Anadolu Medical Center | Takka S.,Academic Hospital | Kiral A.,Anadolu Medical Center
Journal of Hand Surgery: European Volume | Year: 2015

We performed a retrospective review of 12 patients with dorsal oblique and transverse amputations of the distal thumb who were treated with a volar cross-finger flap from the index finger. The mean patient follow-up period was 28 months postoperatively (range: 19-43 months). There were no instances of flap loss, infection, or donor site complication in our series. The mean Semmes-Weinstein monofilament testing scores on the injured thumb and the donor site were 0.65 g (range: 0.16-2 g) and 0.51 g (range: 0.16-1 g), respectively. The mean 2-point discrimination testing scores on the injured thumb and the donor site were 4.5 mm (range: 3-8 mm) and 4.3 mm (range: 3-7 mm), respectively. This study suggests that the volar cross-finger flap using the index finger is a reliable technique in repairing dorsal oblique and transverse amputations of the distal thumb.Type of study/level of evidence: Therapeutic IV © The Author(s) 2014.


Erken H.Y.,Anadolu Medical Center | Takka S.,Academic Hospital | Akmaz I.,Academic Hospital
Journal of Hand Surgery | Year: 2013

Purpose We report our experience, treatment protocol, and 2-year follow-up results of 24 fingertip replantations treated using the artery-only technique without vein or nerve repair. Methods We performed a retrospective review of 24 patients who had undergone fingertip replantation at the same center between 2005 and 2011. All patients in this study had complete fingertip amputation at or distal to the distal interphalangeal joint of the fingers or interphalangeal joint of the thumb. Patients with incomplete and complete amputations who had undergone vein and/or nerve repair along with artery repair were excluded. All patients received the same protocol including removal of the nail at the surgery and intravenous heparin 70 U/kg administered at the time of arterial anastomosis. After surgery, the nailbed was mechanically made to bleed with a sterile needle and mechanically scrubbed with a heparin-saline gauze. All patients received the same postoperative medical treatment protocol until physiological outflow was restored. Successful replantation was confirmed with clinical observation. Results Twenty-one of the 24 fingertip replantations (88%) were successful. The mean length of hospital stay was 7 days (range, 4-9 d). Fifteen of 22 patients required blood transfusion. The average amount of blood transfusion was 1.2 U (range, 0-3 U). Conclusions This study shows that the described technique and protocol reconstructed circulation without vein anastomosis and with a high success rate. Furthermore, adequate sensory recovery without any nerve repair had occurred by the 2-year follow-up. Type of study/level of evidence Therapeutic IV. © 2013 by the AmericanSociety for Surgery of the Hand. All rights reserved.


Bergqvist D.,Academic Hospital
Expert Review of Hematology | Year: 2013

Evaluation of: Beyer-Westendorf J, Lützner J, Donath L et al. Efficacy and safety of thromboprophylaxis with low-molecular-weight heparin or rivaroxaban in hip and knee replacement surgery. Findings from the ORTHO-TEP registry. Thromb. Haemost. 109(1), 154-163 (2013). From the ORTHO-TEP registry on joint replacement arthroplasty (hip and knee) from Dresden, Germany, three periods of different prophylactic regimens have been compared. In the present paper, results from low-molecular-weight heparin and rivaroxaban have been analyzed, with rivaroxaban showing a benefit concerning both effect and side effects. Clinical end points are used, the results being in line with published data from randomized studies. Inclusion in the registry of consecutive patients is important to illustrate generalizability of results obtained in randomized trials. This review discusses the problem with using historical comparisons to draw firm conclusions. © 2013 Expert Reviews Ltd.


Hofer S.,Innsbruck Medical University | Benzer W.,Academic Hospital | Oldridge N.,University of Wisconsin - Milwaukee | Oldridge N.,Rush University Medical Center
International Journal of Cardiology | Year: 2014

Aims Self-reported health-related quality of life (HRQL) and changes in HRQL have been shown to predict mortality and/or adverse events in patients with coronary artery disease. MacNew Heart Disease HRQL questionnaire scores were examined as predictors of 4-year all-cause mortality. Methods Following referral for angioplasty in 385 patients with coronary artery disease, data were analyzed for differences in all-cause mortality by MacNew Global and subscale baseline and 1- and 3-month change scores (deteriorated ≥ 0.50; unchanged (- 0.49 to + 0.49); and improved ≥ 0.50 points). Results Mean baseline, 1-month, and 3-month MacNew Global and subscale scores were similar in survivors and non-survivors. Mean 1- and 3-month Global and emotional subscale and mean 1-month social subscale change scores decreased more in non-survivors than survivors. Compared with patients whose Global MacNew HRQL scores improved at one month, 4-year all-cause mortality hazard ratio (HR) was higher in patients whose HRQL deteriorated (HR, 1.70, 95% CI, 1.09, 2.65; p = 0.021). Compared with patients whose Global MacNew HRQL improved at three months, 4-year all-cause mortality was higher in both patients whose HRQL had deteriorated (HR, 2.07, 95% CI, 1.29, 3.32; p = 0.003) and patients with unchanged HRQL (HR, 2.62, 95% CI, 1.11, 6.17; p = 0.028). Conclusions A deterioration of ≥ 0.50 points in MacNew HRQL Global scores at both one and three months is predictive of 4-year all-cause mortality. Serial HRQL information may be useful to identify patients at higher risk for adverse cardiac events and mortality and may have implications for determining follow-up frequency and treatment in individual patients. © 2014 Elsevier Ireland Ltd.


Murray V.,Karolinska Institutet | Norrving B.,Lund University | Sandercock P.A.G.,University of Edinburgh | Terent A.,Academic Hospital | And 2 more authors.
Journal of Internal Medicine | Year: 2010

Murray V, Norrving B, Sandercock PAG, Terént A, Wardlaw JM, Wester P (Karolinska Institutet Danderyd Hospital, Stockholm; Department of Neurology, Lund, Sweden; Division of Clinical Neurosciences, Edinburgh, UK; Acute and Internal Medicine, Uppsala; Umeå Stroke Centre, Umeå; Sweden). The molecular basis of thrombolysis and its clinical application in stroke (Review). J Intern Med 2010; 267: 191-208. The rationale for thrombolysis, the most promising pharmacological approach in acute ischaemic stroke, is centred on the principal cause of most ischaemic strokes: the thrombus that occludes the cerebral artery, and renders part of the brain ischaemic. The occluding thrombus is bound together within fibrFibrinolysis acts by activation of plasminogen to plasmin; plasmin splits fibrinogen and fibrin and lyses the clot, which then allows reperfusion of the ischaemic braThrombolytic agents include streptokinase (SK) and recombinant tissue-type plasminogen activator (rt-PA) amongst others under test or development. SK is nonfibrin-specific, has a longer half-life than tissue-type plasminogen activator (t-PA), prevents re-occlusion and is degraded enzymatically in the circulation. rt-PA is more fibrin-specific and clot-dissolving, and is metabolized during the first passage in the liver. In animal models of ischaemic stroke, the effects of rt-PA are remarkably consistent with the effects seen in human clinical trials. For clinical application, some outcome data from the Cochrane Database of Systematic Reviews which includes all randomized evidence available on thrombolysis in man were used. Trials included tested urokinase, SK, rt-PA, pro-urokinase, or desmoteplase. The chief immediate hazard of thrombolytic therapy is fatal intracranial bleeding. However, despite the risk, the human trial data suggest the immediate hazards and the apparent substantial scope for net benefit of thrombolytic therapy given up to 6 h of acute ischaemic stroke. So far the fibrin-specific rt-PA is the only agent to be approved for use in stroke. This may be due to its short half-life and its absence of any specific amount of circulating fibrinogen degradation products, thereby leaving platelet function intact. The short half-life does not leave rt-PA without danger for haemorrhage after the infusion. Due to its fibrin-specificity, it can persist within a fibrin-rich clot for one or more days. The molecular mechanisms with regards to fibrin-specificity in thrombolytic agents should, if further studied, be addressed in within-trial comparisons. rt-PA has antigenic properties and although their long-term clinical relevance is unclear there should be surveillance for allergic reactions in relation to treatment. Although rt-PA is approved for use in selected patients, there is scope for benefit in a much wider variety of patients. A number of trials are underway to assess which additional patients - beyond the age and time limits of the current approval - might benefit, and how best to identify them. © 2010 Blackwell Publishing Ltd.


Hull R.D.,University of Calgary | Liang J.,University of Calgary | Bergqvist D.,Academic Hospital | Yusen R.D.,University of Washington
Thrombosis and Haemostasis | Year: 2014

Surgeons consider the benefit-to-harm ratio when making decisions regarding the use of anticoagulant venous thromboembolism (VTE) prophylaxis. We evaluated the benefit-to-harm ratio of the use of newer anticoagulants as thromboprophylaxis in patients undergoing major orthopaedic surgery using the likelihood of being helped or harmed (LHH), and assessed the effects of variation in the definition of major bleeding on the results. A systematic literature search was performed to identify phase II and phase III studies that compared regulatory authority-approved newer anticoagulants to the low-molecular-weight heparin enoxaparin in patients undergoing major orthopaedic surgery. Analysis of outcomes data estimated the clinical benefit (number-needed-to-treat [NNT] to prevent one symptomatic VTE) and clinical harm (number-needed-to-harm [NNH] or the NNT to cause one major bleeding event) of therapies. We estimated each trial's benefit-to-harm ratio from NNT and NNH values, and expressed this as LHH = (1/NNT)/(1/NNH) = NNH/NNT. Based on reporting of efficacy and safety outcomes, most studies favoured enoxaparin over fondapari-nux, and rivaroxaban over enoxaparin. However, when using the LHH metric, most trials favoured enoxaparin over both fondaparinux and rivaroxaban when they included surgical-site bleeding that did not require reoperation in the definition of major bleeding. The exclusion of bleeding at surgical site which did not require reoperation shifted the benefit-to-harm ratio in favour of the newer agents. Variations in the definitions of major bleeding may change the benefit-to-harm ratio and subsequently affect its interpretation. Clinical trials should attempt to improve the consistency of major bleeding reporting. © Schattauer 2014.


Yazici H.,Academic Hospital
Bulletin of the Hospital for Joint Diseases | Year: 2015

It had been shown that authors do not frequently acknowledge the limitations of the work that lead to scientific articles. Limitations of scientific reports are mainly of two kinds. First is the frank acknowledgment by the authors, with its reasons, of the category in which their article best belongs, like original, confirmatory, exploratory, and so forth. Second is an open discussion of validity. This second limitation might be more involved than generally considered. We also had the impression that the relative lack of self-critique was more true for articles in basic science. A formal survey of three leading rheumatology journals confirmed our hypothesis. The possible reasons for this relative lack in basic sciences is discussed as well as is how best to voice limitations. © 2015, J. Michael Ryan Publishing Inc. All rights reserved.

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